Laxatives for the management of constipation in palliative care patients
Sübutlu məlumatların xülasələri
02.08.2017 • Sonuncu dəyişiklik 02.08.2017
Editors
There is insufficient evidence on the effect of laxatives and their differences in the treatment of patients in palliative care.
A Cochrane review included 5 studies with a total of 370 subjects. All participants were at an advanced stage of disease and were cared for within a palliative care setting. All participants had a cancer diagnosis, apart from four participants (5% of sample) in one study. The laxatives studied were lactulose, senna, co-danthramer, misrakasneham, docusate and magnesium hydroxide with liquid paraffin.
Studies either compared the effectiveness of two different laxatives, or compared the laxative with an active control.
No differences in effectiveness were demonstrated in:
lactulose compared with senna;
senna plus lactulose compared with magnesium hydroxide plus liquid paraffin;
misrakasneham compared with senna;
docusate plus senna compared with placebo plus senna. There was a significant difference (P value <0.01) in the subgroup of 17 participants receiving strong opioid analgesia that favoured senna plus lactulose compared with co-danthramer plus poloxamer in stool frequency and overall participants took fewer rescue medications (9/51 in senna plus lactulose group compared with 19/51 in co-danthramer plus poloxamer group). However, there was no difference between the laxatives in participants' overall assessment of their bowel function.
Four studies report that a few (one to three) participants experienced adverse effects. The most common adverse effects were nausea, vomiting, diarrhoea and abdominal pain. In the study comparing senna plus lactulose with magnesium hydroxide plus liquid paraffin, one participant from each group withdrew because of intolerable nausea and gripping abdominal pain.
Most participants had a cancer diagnosis; participants with other diagnoses included advanced cardiovascular disease, AIDS and dementia. The average age of participants ranged from 61 to 72 years. Studies either compared the effectiveness of two different laxatives (lactulose, senna, danthron combined with poloxamer, misrakasneham and magnesium hydroxide combined with liquid paraffin), compared methylnaltrexone with a placebo (2 studies) or different doses of methylnaltrexone (1 study). In the methylnaltrexone placebo-controlled trials an undisclosed proportion of participants continued to take conventional laxatives. The effectiveness of methylnaltrexone was not compared with a laxative and none of the trials compared a laxative with a placebo; all comparisons were made between different laxatives.Evidence was inconclusive in studies comparing the different laxatives. Evidence on subcutaneous methylnaltrexone was clearer; there was a significant difference favouring methylnaltrexone in rescue-free laxation within four (OR 6.95, 95% CI 3.83 to 12.61; 2 studies, n=278) and 24 hours (OR 5.42, 95% CI 3.12 to 9.41) of the first dose of methylnaltrexone in patients with opioid-induced constipation despite taking conventional laxatives. The proportion of participants that had a laxation response at 4 hours ranged from 48% to 62% in the methylnaltrexone trial groups and 13% to 15% in the placebo groups. At 24 hours it was 52% to 68% in the active trial arms and 8% to 27% in the placebo groups. In combined analyses there was no difference in the proportion experiencing side effects, although significantly more participants in the methylnaltrexone groups suffered flatulence (22/165 versus 7/123) and dizziness (12/165 versus 2/123). No evidence of opioid withdrawal was found. In one study severe adverse events, commonly abdominal pain, were reported that were possibly related to methylnaltrexone. A serious adverse event considered to be related to the methylnaltrexone also occurred; this involved a participant having severe diarrhoea, subsequent dehydration and cardiovascular collapse.
Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment), by indirectness (studies only measured effects in the short term) and by imprecise results (few patients).
Ədəbiyyat
- Candy B, Jones L, Larkin PJ et al. Laxatives for the management of constipation in people receiving palliative care. Cochrane Database Syst Rev 2015;(5):CD003448. .."?>