Effect of opioids for breathlessness in heart failure: a systematic review and meta-analysis

Abstract

BackgroundFor the treatment of breathlessness in heart failure (HF), most textbooks advocate the use of opioids. Yet, meta-analyses are lacking.MethodsA systematic review was performed for randomised controlled trials (RCTs) assessing effects of opioids on breathlessness (primary outcome) in patients with HF. Key secondary outcomes were quality of life (QoL), mortality and adverse effects. Cochrane Central Register of Controlled Trials, MEDLINE and Embase were searched in July 2021. Risk of bias (RoB) and certainty of evidence were assessed by the Cochrane RoB 2 Tool and Grading of Recommendations Assessment, Development and Evaluation criteria, respectively. The random-effects model was used as primary analysis in all meta-analyses.ResultsAfter removal of duplicates, 1180 records were screened. We identified eight RCTs with 271 randomised patients. Seven RCTs could be included in the meta-analysis for the primary endpoint breathlessness with a standardised mean difference of 0.03 (95% CI −0.21 to 0.28). No study found statistically significant differences between the intervention and placebo. Several key secondary outcomes favoured placebo: risk ratio of 3.13 (95% CI 0.70 to 14.07) for nausea, 4.29 (95% CI 1.15 to 16.01) for vomiting, 4.77 (95% CI 1.98 to 11.53) for constipation and 4.42 (95% CI 0.79 to 24.87) for study withdrawal. All meta-analyses revealed low heterogeneity (I2in all these meta-analyses was <8%).ConclusionOpioids for treating breathlessness in HF are questionable and may only be the very last option if other options have failed or in case of an emergency.PROSPERO registration numberCRD42021252201.

Symptom burden and relief in palliative care units of German Comprehensive Cancer Center and other hospitals

“…They may also be beneficial for patients who suffer from other diseases than cancer in particular when no other Standard Operating Procedures are available. The use of a Standard Operating Procedure must be critically reflected in each individual case, since the pathophysiology of, e.g., symptoms can be very different and not all strategies can be transferred 1 to 1 to others, e.g., more careful administration of opioids in cardiac insufficiency (Gaertner et al 2023 ).…”

Should opioids be used for breathlessness and in whom? A PRO and CON debate of the evidence

“…In other conditions than COPD, the available evidence is limited. A systematic review in cancer and a systematic review in heart failure did not show a beneficial effect of opioids for breathlessness 27 28 . Unfortunately, studies included in these reviews often are small, of low quality, and use different opioids and routes of administration, which makes interpretation of findings difficult 27 28 .…”

“…A systematic review in cancer and a systematic review in heart failure did not show a beneficial effect of opioids for breathlessness 27 28 . Unfortunately, studies included in these reviews often are small, of low quality, and use different opioids and routes of administration, which makes interpretation of findings difficult 27 28 . A study including 23 people with pulmonary arterial hypertension and a trial including 36 patients with fibrotic interstitial lung diseases (ILDs) failed to show a beneficial effect 21 , 29 .…”

Palliativmedizinische Aspekte in der klinischen Akut- und Notfallmedizin sowie Intensivmedizin

“…Ultrafiltration) nicht mehr ausreichen, kann eine Therapie mit Opioiden initiiert werden. Opioide können Symptome minimieren und die körperliche Leistungsfähigkeit verbessern und sollten nur in therapierefraktären Fällen angewandt werden [89]. Die Gabe von Sauerstoff kann jedoch ausschließlich bei hypoxischen Patienten zur Symptomlinderung beitragen [75].…”