Naloxegol versus Methylnaltrexone for Opioid-Induced Constipation in Critically Ill Patients

Abstract

Background: Constipation impacts 58% to 83% of critically ill patients and is associated with increased time on mechanical ventilation, delirium, and increased length of stay (LOS) in the intensive care unit (ICU). Objective: The purpose of this study was to evaluate the efficacy of enteral naloxegol (NGL) versus subcutaneous methylnaltrexone (MNTX) for the management of opioid-induced constipation (OIC) in critically ill patients. Methods: A retrospective analysis was conducted on adult patients admitted to the ICU who received a parenteral opioid infusion for at least 4 hours and experienced no bowel movement (BM) within the 48-hour period preceding the administration of NGL or MNTX. The primary outcome was time to first BM from the start of NGL or MNTX therapy. Secondary outcomes included number of BMs 72 hours following NGL or MNTX administration, ICU LOS, and cost-effectiveness. Results: After exclusion criteria were applied, 110 and 51 patients were included in the NGL and MNTX groups, respectively. With a 10% noninferiority margin, NGL was noninferior to MNTX (Wald statistic = 1.67; P = 0.047). Median time to first BM was 23.7 hours for NGL and 18.3 hours for MNTX patients. Median LOS was 14 days (NGL) and 12 days (MNTX), and the average number of BMs in 72 hours was 3.9 for NGL and 3.8 for MNTX. Using wholesale acquisition cost (WAC), the cost per BM for NGL and MNTX was $21.74 and $170.00, respectively. Conclusion and relevance: This study determined that NGL and MNTX had similar time to BM. NGL appears to be a safe and effective alternative with cost-saving potential in treating OIC in critically ill patients.

A Systematic Review of Naldemedine and Naloxegol for the Treatment of Opioid-Induced Constipation in Cancer Patients

“…While conducting studies on symptom management in cancer patients seems difficult and fraught with recruitment challenges, head-to-head comparisons of laxatives versus PAMORAs or different PAMORASs against each other are even rarer, even in patients with non-cancer pain who are easier to recruit. We only found one retrospective study comparing oral naloxegol with subcutaneous methylnaltrexone [ 48 ]; however, this study was conducted in seriously ill patients in an intensive care unit setting and included only 30 cancer patients (15% of patients in the naloxegol group and 28% in the naltrexone group had cancer). They found that both drugs increased SBMs and that naloxegol was non-inferior to subcutaneous methylnaltrexone at a significantly reduced cost.…”