Mu-opioid antagonists for opioid-induced bowel dysfunction.
BACKGROUND
Opioid-induced bowel dysfunction (OBD) is characterized by constipation, incomplete evacuation, bloating, and increased gastric reflux. OBD occurs both acutely and chronically, in multiple disease states, resulting in increased morbidity and reduced quality of life.


OBJECTIVE
To compare the efficacy and safety of traditional and peripherally active opioid antagonists versus conventional interventions for OBD.


METHODS
We searched MEDLINE, the Cochrane Central Register of Controlled Trials and EMBASE in January 2007. Additional reports were identified from the reference lists of retrieved papers.


METHODS
Studies were included if they were randomized controlled trials that investigated the efficacy of mu-opioid antagonists for OBD.


METHODS
Data were extracted by two independent review authors and included demographic variables, diagnoses, interventions, efficacy, and adverse events.


RESULTS
Twenty-three studies met inclusion criteria and provided data on 2871 opioid antagonist-treated patients. The opioid antagonists investigated were alvimopan (nine studies), methylnaltrexone (six), naloxone (seven), and nalbuphine (one). Meta-analysis demonstrated that methylnaltrexone and alvimopan were better than placebo in reversing opioid-induced increased gastrointestinal transit time and constipation, and that alvimopan appears to be safe and efficacious in treating postoperative ileus. The incidence of adverse events with opioid antagonists was similar to placebo and generally reported as mild-to-moderate.


CONCLUSIONS
Insufficient evidence exists for the safety or efficacy of naloxone or nalbuphine in the treatment of OBD. Long-term efficacy and safety of any of the opioid antagonists is unknown, as is the incidence or nature of rare adverse events. Alvimopan and methylnaltrexone both show promise in treating OBD, but further data will be required to fully assess their place in therapy.
McNicol
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New England Medical Center, Pharmacy and Anesthesia, Box #420, 750 Washington Street, Boston, MA 02111, USA. ewanmcnicol@comcast.net
Boyce
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Schumann
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Carr
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D003248:Constipation / Q000139:chemically induced / Q000188:drug therapy; D003672:Defecation / Q000187:drug effects; D005765:Gastrointestinal Agents / Q000627:therapeutic use; D006801:Humans; D007410:Intestinal Diseases / Q000139:chemically induced / Q000188:drug therapy*; D009266:Nalbuphine / Q000627:therapeutic use; D009270:Naloxone / Q000627:therapeutic use; D009271:Naltrexone / Q000031:analogs & derivatives / Q000627:therapeutic use; D009292:Narcotic Antagonists / Q000627:therapeutic use*; D009293:Opioid-Related Disorders / Q000188:drug therapy*; D010880:Piperidines / Q000627:therapeutic use; D000644:Quaternary Ammonium Compounds / Q000627:therapeutic use; D017450:Receptors, Opioid, mu / Q000037:antagonists & inhibitors
D005765:Gastrointestinal Agents; D009292:Narcotic Antagonists; D010880:Piperidines; D000644:Quaternary Ammonium Compounds; D017450:Receptors, Opioid, mu; C032257:methylnaltrexone; D009270:Naloxone; D009271:Naltrexone; C419502:alvimopan; D009266:Nalbuphine