Laxatives for the management of constipation in people receiving palliative care

Abstract

BackgroundThis article describes the second update of a Cochrane review on the effectiveness of laxatives for the management of constipation in people receiving palliative care. Previous versions were published in 2006 and 2010 where we also evaluated trials of methylnaltrexone; these trials have been removed as they are included in another review in press. In these earlier versions, we drew no conclusions on individual effectiveness of different laxatives because of the limited number of evaluations. This is despite constipation being common in palliative care, generating considerable suffering due to the unpleasant physical symptoms and the availability of a wide range of laxatives with known differences in effect in other populations. ObjectivesTo determine the effectiveness and differential efficacy of laxatives used to manage constipation in people receiving palliative care. Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library), MEDLINE, EMBASE, CINAHL and Web of Science (SCI & CPCI-S) for trials to September 2014. Selection criteriaRandomised controlled trials (RCTs) evaluating laxatives for constipation in people receiving palliative care. Data collection and analysisTwo authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. Main resultsWe identified five studies involving the laxatives lactulose, senna, co-danthramer, misrakasneham, docusate and magnesium hydroxide with liquid paraffin. Overall, the study findings were at an unclear risk of bias. As all five studies compared different laxatives or combinations of laxatives, it was not possible to perform a meta-analysis. There was no evidence on whether individual laxatives were more effective than others or caused fewer adverse effects. Laxatives for the management of constipation in people receiving palliative care (Review)

Efficacy of pharmacological therapies for the treatment of opioid-induced constipation: systematic review and network meta-analysis

“…Less than 50% of patients with OIC report a satisfactory therapeutic effect of laxatives13 and this is supported by evidence from an updated Cochrane review, which failed to demonstrate any evidence of a beneficial effect of laxatives in OIC 12. As a result, there is a clear need for cost-effective treatments, particularly given the continued increase in opioid prescribing worldwide 3 4.…”

“…As a result, a substantial proportion of patients with OIC use over-the-counter or prescription laxatives, in an attempt to alleviate their symptoms 8. However, a previous Cochrane review revealed that there is little evidence to support a benefit of laxatives in this patient group,12 which is mirrored by surveys of patients, where less than 50% report a satisfactory effect 13…”

Assessment and management of constipation for patients receiving palliative care in specialist palliative care settings: A systematic review of the literature

“…However, the findings of this review are inconclusive regarding the most effective pharmacological treatment of constipation. This is supported by the systematic review by Candy on the effectiveness of laxatives, which found limited evidence to support the use of one laxative over another (36). Instead, it was suggested that the choice be made based on patient preference and circumstance, followed by cost effectiveness when no clear patient preference was evident (34).…”

Managing Constipation in Adults With Cancer

“…The range of normal bowel movements (BMs) in healthy people is arbitrarily defined as three BMs per day to three per week (Candy et al, 2015). In general, constipation occurs because prolonged bowel transit allows more water to be absorbed from feces through the bowel wall, which leads to hard, dry, and difficult-to-pass stools (Twycross, Sykes, Mihalyo, & Wilcock, 2012).…”

“…Bulking Agents: Soluble (e.g., psyllium, pectin) and insoluble (methylcellulose) fiber products induce a stretch reflex in the intestinal wall, which increases propulsive activity, water absorption, and bacterial proliferation in the colon, leading to softer and larger stool masses and easier BMs (Candy et al, 2015;Costilla & Foxx-Orenstein, 2014;Larkin et al, 2008;Wald, 2007). Bulk laxatives are not effective for already-constipated cancer patients, especially those taking opioid analgesics or anticholinergic drugs.…”