Gastrointestinal dysmotility in a patient with advanced lung cancer: paraneoplastic or drug-induced?

A 75-year-old man was hospitalised for bronchoscopy with biopsy due to a suspicious pulmonary mass at chest tomography. He had significant dyspnoea, constipation, nausea, vomiting, anorexia and a 33% loss of weight in the past 3 months. Biopsy revealed a pulmonary squamous cell carcinoma, which was inoperable. Tramadol used at home for 3 months was replaced by morphine on admission. The patient remained constipated despite prokinetics and laxatives, leading to the diagnostic hypothesis of paraneoplastic motility disorder and opioid-induced constipation. Abdominal tomography ruled out the possibility of mechanical obstruction. As complications, the patient presented superior vena cava syndrome and opioid (morphine) intoxication. The patient died a few days later. The management of this case highlights the importance of multidisciplinary care and the challenges of palliative oncology care. Paraneoplastic motility disorder must always be considered among the mechanisms of intestinal dysfunction in patients with advanced oncological disease.

Delphi consensus on strategies in the management of opioid-induced constipation in cancer patients.

BACKGROUND: Opioid-induced constipation (OIC) is a frequent and bothersome adverse event related with opioid therapy in cancer patients. Despite the high prevalence, medical management of OIC is often uncertain. The current project aimed to investigate expert opinion on OIC management and provide practical recommendations to improve the clinical approach of OIC in cancer patient. METHODS: A modified Delphi method was conducted involving 46 different physicians experts in OIC. Using a structured questionnaire of 67 items this project intended to seek consensus on aspects related to diagnosis, treatment, and quality of life of cancer patients suffering with OIC. RESULTS: After two rounds, a consensus was reached in 91% of the items proposed, all in agreement. Agreement was obtained on OIC definition (95.7%). Objective and patient-reported outcomes included in that definition should be assessed routinely in clinical practice. Responsive to symptom changes and easy-to-use assessment tools were recommended (87.2%). Successful diagnosis of OIC requires increase clinicians awareness of OIC and proactivity to discuss symptoms with their patients (100%). Successful management of OIC requires individualization of the treatment (100%), regular revaluation once is established, and keeping it for the duration of opioid treatment (91.5%). Oral Peripherally Acting µ-Opioid Receptor Agonists (PAMORAs), were considered good alternatives for the treatment of OIC in cancer patients (97.9%). This drugs and laxatives can be co-prescribed if OIC coexist with functional constipation. CONCLUSIONS: The panelists, based on their expert clinical practice, presented a set of recommendations for the management of OIC in cancer patients.

Opioid-Induced Constipation in Oncological Patients: New Strategies of Management.

OPINION STATEMENT: Cancer-associated pain has traditionally been treated with opioid analgesics, often in escalating doses. Opioid-induced constipation (OIC) is a common problem associated with chronic use of opioid analgesics. Typical treatment strategies to alleviate constipation are based on dietary changes, exercise, and laxatives. However, laxatives have a nonspecific action and do not target underlying mechanisms of OIC. This article will review prevalent, clinical presentation and recommendations for the treatment of OIC. An independent literature search was carried out by the authors. We reviewed the literature for randomized controlled trials that studied the efficacy of laxatives, naloxone, and naloxegol in treating OIC. Newer strategies addressing the causal pathophysiology of OIC are needed for a more effective assessment and management of OIC. Finally, traditional recommended therapies are appraised and compared with the latest pharmacological developments. Future research should address whether naloxegol is more efficacious by its comparison directly with first-line treatments, including laxatives.

[Analysis of the European Consensus on the treatment of opioid-induced constipation analgesic drugs.] / Analisi del consensus europeo sul trattamento della stipsi indotta da farmaci analgesici oppiacei.

Until recently, conclusive data on clinical presentation, diagnosis and therapy of the opioid-induced constipation (OIC) were not available. Lately, some phase II and III prospective studies, evaluating the efficay of several old and new laxatives in cancer and non-cancer patients, make their mechanisms of action easier to understand and lead healthcare institutions to determine homogeneous guidelines for OIC, with the use of diagnostic and treatment algorithms. On May 2018, management recommendations from a panel of 7 European experts on OIC was published on United European Gastroenterology Journal. They discussed on different aspects of OIC: (a) definitions and diagnostic criteria; (b) pathophysiology; (c) clinical evaluation; (d) patient reported outcome measures; (e) initial standard laxatives; (f) specific treatments; (g) pragmatic recommendations. Later, a multi-disciplinary panel consisting of experts in neurogastroenterology, oncology and palliative medicine gave their external input. This statement will help clinicians to harmoniously treat OIC, according to clear guidelines, resulted from phase II and III prospective studies. Nevertheless, the constipation is rarely due to opioids consumption alone. More often, different factors contribute to induce constipation, including diet, immobility, other drugs, pain during evacuation, comorbidities, gastrointestinal obstacles, especially in advanced cancer patients. Therefore, management of OIC always needs to be tailored to the individual patient based on their overall clinical picture.