Less nausea, emesis, and constipation comparing hydromorphone and morphine? A prospective open-labeled investigation on cancer pain

Abstract

Symptom control in outpatients with cancer pain may be complicated by a symptom controlling medication. Particularly, antiemetics revealed potentially constipating effects. Despite lower opioid doses, morphine provided a better pain control but produced more side effects. Comparing hydromorphone with morphine, it remains unclear if fewer incidences of constipation and nausea in the hydromorphone group were related to pharmacodynamic effects or to a less effective pain control with significantly higher NRS for pain. However, the conversion factor of oral hydromorphone and morphine needs to be questioned.

Definitions and Outcome Measures of Clinical Trials Regarding Opioid-induced Constipation

“…The definition in 3 studies (19%) was based completely on the criterion < 3 spontaneous bowel movements per week. 14 18,21,34 consistently used the same definition for OIC in all their publications. This definition combines stool frequency with a PROM: (a) a stool-free interval of >72 hours; and (b) Numerical Rating Scale value >4 of the patients' judgment of the severity of OIC.…”

“…69 Therefore, other publications prefer a more patient-centered definition, combining objective measures such as bowel movement (or stool) frequency with PROMs such as pain (during defecation) or feeling "bloated." [11][12][13]17,18,21,27,28,33,34 It is especially well known within the field of palliative care that not every symptom reported as a PROM necessarily needs to be treated. A prominent example is cancer-related anorexia in advanced stages of the disease.…”

“…(ii) hard stools at least 25% of the time; (iii) incomplete evacuation at least 25% of the time; (iv) 2 or fewer bowel movements per week Irving et al 27 Patients were also required to have a recalled history of opioid-induced bowel dysfunction, defined as decreased BM frequency associated with opioid medication and at least 1 other BM symptom (such as hard stools or straining to pass a stool) Iyer et al 12 Constipation during the screening period was defined as <3 RFBMs per week (no laxative use within 24 h before any bowel movement) that were associated with 1 or more of the following: (a) a Bristol Stool Form Scale score (15) of 1 or 2 for at least 25% of the bowel movements; (b) straining during at least 25% of the bowel movements; (c) a sensation of incomplete evacuation after at least 25% of the bowel movements Jansen et al 28 Patients were also required to have a recalled history of opioid-induced bowel dysfunction, defined as decreased BM frequency associated with opioid medication, and at least 1 other BM symptom (such as hard stools, or straining to pass a stool) Ishihara et al 29 Constipation was defined as the lack of stools for >3 d in a week (23) Chamberlain et al 30 In addition, inclusion criteria required constipation defined as either <3 bowel movements during the preceding week, and no clinically significant bowel movement (investigator determined) within 24 h before the first study drug dose, or no clinically significant bowel movement within 48 h before the first dose Wirz et al 21 The definition of constipation is that it is a subjective symptom involving complaints of decreased stool frequency 19,31,32 but for pragmatic reasons, we defined constipation as a stool-free interval of >72 h in combination with an NRS score for constipation >4 Portenoy et al 33 Reported ongoing constipation, defined as >2 d with no bowel movement and a score of Z3 on a 5-point scale assessing constipation-related distress Webster et al 13 Opioid-induced bowel dysfunction was defined as a history of decreased bowel movement frequency since initiating opioid therapy and Z1 of the following symptoms: incomplete evacuation, hard stools, or straining, in Z25% of bowel movements Wirz et al 34 For pragmatic reasons, we defined constipation in outpatients by the detection of a stool-free interval of >72 h in combination with a NRS of constipation >4…”

The effects of hydromorphone on astrocytic responses in cerebral ischemia

“…Hydromorphone, one of the first choice opioids as per the European guideline [25], is widely used in the management of acute or chronic cancer pain, in both, children and adults [25]. As compared to morphine, hydromorphone has certain advantages in clinical settings, such as lesser nausea and vomiting [26], and lower histamine release [27]. To demonstrate its protective effect, we used hydromorphone to reduce oxidative stress-related injury [28].…”

The Role of Opioid Analgesics in the Treatment of Pain in Cancer Patients

“…Due to glucuronidation, the risk of hydromorphone pharmacokinetic interactions with other drugs seems to be low (Sarhill et al, 2001). Adverse effects are similar to those of morphine; however, hydromorphone less frequently induces nausea and vomiting, constipation, itching, and probably more slowly develops tolerance to analgesia (Wirz et al, 2008). In comparative studies conducted in cancer patients with pain hydromorphone displays similar analgesic efficacy to morphine (Miller et al, 1999) and oxycodone (Hagen and Babul, 1997).…”