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. OBJECTIVES: To compare the efficacy and safety of traditional and peripherally active opioid antagonists versus conventional interventions for OBD. SEARCH STRATEGY: 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. SELECTION CRITERIA: Studies were included if they were randomized controlled trials that investigated the efficacy of mu-opioid antagonists for OBD. DATA COLLECTION AND ANALYSIS: Data were extracted by two independent review authors and included demographic variables, diagnoses, interventions, efficacy, and adverse events. MAIN 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. AUTHORS' 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.