DÄ internationalArchive46/2009The Pathophysiology, Diagnosis and Treatment of Constipation: Confusion

Correspondence

The Pathophysiology, Diagnosis and Treatment of Constipation: Confusion

Dtsch Arztebl Int 2009; 106(46): 766-7. DOI: 10.3238/arztebl.2009.0766b

Zerbe, I

LNSLNS As “appropriate therapeutic management” for opioid induced constipation, the author names a combination of oxycodone with naloxone, or methylnaltrexone, and finally (!) laxatives. I have several comments:

Every textbook stresses the importance of routine early administration of laxatives when opioid treatment is started, in order to treat any constipation—a common side effect of opioid treatment—consistently from the outset or even to avoid its development completely (1). Laxatives should therefore be named in the first place among the recommendations.

Changing the way of application or opioid rotation often results in the desired success (2).

No mention was made of constipation as an important gastrointestinal symptom in patients with advanced tumor disease and the differentiation from chronic subileus/ileus resulting in modified therapeutic consequences. Lubricant laxatives—often used in palliative care—are not mentioned at all.

Oxycodone/naloxone in the treatment of severe acute (especially postoperative) and chronic pain are justifiably of great importance as they cause little constipation in clinical practice, but the licensed daily dosage is restricted to 80 mg oxycodone/40 mg naloxone. In patients with severe pain, this is not sufficient in many cases. Further, oxycodone is not the suitable opioid for all patients.

The combination tilidine/naloxone at WHO step II is not mentioned at all, although it has been on the market for years and bears almost no risk of causing constipation (3).

Methylnaltrexone is expensive and licensed only if conventional laxative therapy fails, so that a more differentiated discourse and weighting is necessary. Within the footnote, the emphasis on methylnaltrexone together with oxycodone/naloxone as the “only measures that have been shown to be effective in randomized, controlled studies” serves to confuse readers rather than offering a rational basis for decisions.
DOI: 10.3238/arztebl.2009.0766b


Dr. med. Ingo Zerbe
St. Josef-Krankenhaus
Koblenzer Str. 23
54411 Hermeskeil, Germany
i.zerbe@t-online.de

Conflict of interest statement
The author declares that no conflict of interest exists according to the Guidelines of the International Committee of Medical Journal Editors.
1.
Bausewein C: Arzneimitteltherapie in der Palliativmedizin. 1. Deutsche Auflage. München: Urban & Fischer 2005: 15ff.
2.
Bausewein C: Arzneimitteltherapie in der Palliativmedizin. 1. Deutsche Auflage. München: Urban & Fischer 2005: 173.
3.
Wörz R: Differenzierte medikamentöse Schmerztherapie. 2. Auflage. München: Urban & Fischer 2001: 190.
4.
Müller-Lissner S: The pathophysiology, diagnosis and treatment of constipation [Obstipation – Pathophysiologie, Diagnose und Therapie]. Dtsch Arztebl Int 2009; 106(25): 424–32. MEDLINE
1. Bausewein C: Arzneimitteltherapie in der Palliativmedizin. 1. Deutsche Auflage. München: Urban & Fischer 2005: 15ff.
2. Bausewein C: Arzneimitteltherapie in der Palliativmedizin. 1. Deutsche Auflage. München: Urban & Fischer 2005: 173.
3. Wörz R: Differenzierte medikamentöse Schmerztherapie. 2. Auflage. München: Urban & Fischer 2001: 190.
4. Müller-Lissner S: The pathophysiology, diagnosis and treatment of constipation [Obstipation – Pathophysiologie, Diagnose und Therapie]. Dtsch Arztebl Int 2009; 106(25): 424–32. MEDLINE