Kanser Hastalarında Kabızlık Yönetim
Özet
Kabızlık, kanser hastalarının %40-90'ında görülen ve sıklıkla yetersiz tedavi edilen önemli bir morbidite sebebidir. Roma-4 kriterlerine göre barsak hareketlerinde zorlanma, sert/topaklı dışkı ve haftada 3'ten az dışkılama gibi semptomlarla tanımlanan bu tabloya, ağrı tedavisinde kullanılan opioidler, antiemetikler ve vinka alkaloidleri gibi kemoterapötikler yol açmaktadır. Detaylı öykü, dijital rektal muayene ve Victoria Bağırsak Performans Ölçeği gibi metotlarla tanı konulduktan sonra tedavi aşamasına geçilir. İlk adımda hasta mahremiyetinin sağlanması, hidrasyon ve fiziksel aktivite gibi yaşam tarzı değişiklikleri önerilirken, ilerleyen dönemde polietilen glikol ve laktuloz gibi osmotik laksatifler ile sinameki ve bisakodil gibi stimülan laksatifler tercih edilir. Opioidlerin yol açtığı kabızlıkta (OIC) ise tolerans gelişmediği için proflaktik laksatif başlanmalı, dirençli vakalarda ise kan-beyin bariyerini geçmeden sadece periferik reseptörleri inhibe eden metilnaltreksor, naloksegol ve naldemedin gibi yeni nesil periferik u-opioid reseptör antagonistlerine (PAMORA) başvurulmalıdır.
Constipation is a significant cause of morbidity observed in 40-90% of cancer patients and is frequently undertreated. Defined by Rome-4 criteria through symptoms such as straining during defecation, lumpy/hard stools, and fewer than three bowel movements per week, this clinical picture is induced by opioids used in pain management, antiemetics, and chemotherapeutics like vinca alkaloids. Following diagnosis via detailed history, digital rectal examination, and scales such as the Victoria Bowel Performance Scale, the treatment process is initiated. While lifestyle modifications including ensuring patient privacy, hydration, and physical activity are recommended in the first step, osmotic laxatives like polyethylene glycol and lactulose, alongside stimulant laxatives such as senna and bisacodyl, are preferred in later stages. In opioid-induced constipation (OIC), since tolerance does not develop, prophylactic laxatives must be prescribed, and in refractory cases, next-generation peripheral u-opioid receptor antagonists (PAMORAs) like methylnaltrexone, naloxegol, and naldemedine, which selectively inhibit peripheral receptors without crossing the blood-brain barrier, should be utilized.
Referanslar
Sykes N.P. Constipation and Diarrhoea.in: Doyle D. Hanks G.W.C. Cherny N. Calman K. Oxford Textbook of Palliative Medicine. 3. Oxford University Press, Oxford2004: 483-496.
Mearin F, Lacy BE, Chang L, Chey WD, Lembo AJ, Simren M, Spiller R. Bowel Disorders. Gastroenterology. 2016 Feb 18:S0016-5085(16)00222-5. doi: 10.1053/j.gastro.2016.02.031. Epub ahead of print. PMID: 27144627.
Tack J.Drossman D.A.What’s new in Rome IV?.J Neurogastroenterol Motil. 2017; 29: e13053.)
Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol 2011; 106:1582.
Müller-Lissner SA, Kamm MA, Scarpignato C, Wald A. Myths and misconceptions about chronic constipation. Am J Gastroenterol 2005; 100:232.
Sandler RS, Jordan MC, Shelton BJ. Demographic and dietary determinants of constipation in the US population. Am J Public Health 1990; 80:185.
Larkin P.J, Sykes N.P, Centeno C.The management of constipation in palliative care: clinical practice recommendations.Palliat Med. 2008; 22: 796-807
Staats P.S, Markowitz J, Schein J. Incidence of constipation associated with long-acting opioid therapy: a comparative study. South Med J. 2004; 97: 129-134).
Van Lancker A, Velghe A, Van Hecke A. Prevalence of symptoms in older palliative cancer patients: a systematic review and meta-analysis. J Pain Symptom Manage. 2014; 47: 90-104).
Glare P, Walsh D, Sheehan D. The adverse effects of morphine: A prospective survey of common symptoms during repeated dosing for chronic cancer pain. Am J Hosp Palliat Care 2006; 23: 229–235.
Tuteja AK, Biskupiak J, Stoddard GJ, et al. Opioid-induced bowel disorders and narcotic bowel syndrome in patients with chronic non-cancer pain. Neurogastroenterol Motil 2010; 22: 424–e96.
Drewes AM, Munkholm P, Simren M, et al. Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–recommendations of the Nordic Working Group. Scand J Pain 2016; 11: 111–122.)
P. J. Larkin, N. I. Cherny , D. La Carpia et all. Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Annals of Oncology 29 (Supplement 4): iv111–iv125, 2018 doi:10.1093/annonc/mdy148 Published online 17 July 2018.
Farmer AD, Drewes AM, Chiarioni G at all. Pathophysiology and management of opioid-induced constipation: European expert consensus statement. United European Gastroenterol J. 2019 Feb;7(1):7-20. doi: 10.1177/2050640618818305. Epub 2018 Dec 14. Erratum in: United European Gastroenterol J. 2019 Mar;7(2):178. PMID: 30788113; PMCID: PMC6374852.
Talley N.J. Serotoninergic neuroenteric modulators. Lancet. 2001; 358: 2061-2068
Sharma RK. Vincristine and gastrointestinal transit. Gastroenterology 1988; 95:1435.
Legha SS. Vincristine neurotoxicity. Pathophysiology and management. Med Toxicol 1986; 1:421.
Dimopoulos MA, Eleutherakis-Papaiakovou V. Adverse effects of thalidomide administration in patients with neoplastic diseases. Am J Med 2004; 117:508.
Thorpe D.M. Management of opioid-induced constipation. Curr Pain Headache Rep. 2001; 5: 237-240
Clark K, Currow D.C, Talley N.J. The use of digital rectal examinations in palliative care inpatients. J Palliat Med. 2010; 13: 797.
Downing G.M, Kuziemsky C,Lesperance M et al. Development and reliability testing of the Victoria Bowel Performance Scale (BPS). J Pain Symptom Manage. 2007; 34: 513-522
Argoff C.E, Brennan M.J, Camilleri M et al. Consensus recommendations on initiating prescription therapies for opioid-induced constipation. Pain Med. 2015; 16: 2324-2337
Common Terminology Criteria for Adverse Events (CTCAE), Version 5.0, November 2017, National Institutes of Health, National Cancer Institute. Available at: https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf (08.02.2022 tarihinde erişildi)
Davies A, Leach C, Caponero R, Dickman A, Fuchs D, Paice J, Emmanuel A. MASCC recommendations on the management of constipation in patients with advanced cancer. Support Care Cancer. 2020 Jan;28(1):23-33. doi: 10.1007/s00520-019-05016-4. Epub 2019 Aug 9. PMID: 31396746.
Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003; 349:1360.
Davies A, Leach C, Caponero R, et al. MASCC recommendations on the management of constipation in patients with advanced cancer. Support Care Cancer 2020; 28:23.
Dupont C, Campagne A, Constant F. Efficacy and safety of a magnesium sulfate-rich natural mineral water for patients with functional constipation. Clin Gastroenterol Hepatol 2014; 12:1280.
Connolly M. Larkin P.J. Managing constipation: a focus on care and treatment in the palliative setting. Br J Community Nurs. 2012; 17 (62-64, 66-67): 60
Clinical Practice Guideline: Bowel Care. King Edward Memorial Hospital, Perth, Western Australia; http://kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionc/1/c1.2.pdf (22 November 2017, date last accessed).
Niv G, Grinberg T, Dickman R et al. Perforation and mortality after cleansing enema for acute constipation are not rare but are preventable. Int J Gen Med. 2013; 6: 323-328
Rentea R.M, Fehring C.H. Rectal colonic mural hematoma following enema for constipation while on therapeutic anticoagulation. J Surg Case Rep. 2017; 2017: rjx001.
Araghizadeh F. Fecal impaction. Clin Colon Rectal Surg. 2005 May;18(2):116-9. doi: 10.1055/s-2005-870893. PMID: 20011351; PMCID: PMC2780143.
Pappagallo M. Incidence, prevalence, and management of opioid bowel dysfunction. Am J Surg 2001;182:S11–8)
Panchal SJ, Müller-Schwefe P, Wurzelmann JI.. Opioid-induced bowel dysfunction: Prevalence, pathophysiology and burden. Int J Clin Pract 2007;61:1181–7.
Mesía R, Virizuela Echaburu JA, Gómez J, Sauri T, Serrano G, Pujol E. Opioid-Induced Constipation in Oncological Patients: New Strategies of Management. Curr Treat Options Oncol. 2019 Dec 19;20(12):91. doi: 10.1007/s11864-019-0686-6. PMID: 31853656; PMCID: PMC6920224.
Mearin F, Lacy BE, Chang L, et al. Bowel disorders. Gastroenterology 2016; doi: 10.1053/j.gastro.2016.02.031.
Plaisance L, Ellis JA. Opioid-induced constipation. Management is necessary but prevention is better. Am J Nurs 2002; 102: 72–73.
Poulsen JL, Brock C, Olesen AE, Nilsson M, Drewes AM. Clinical potential of naloxegol in the management of opioid-induced bowel dysfunction. Clin Exp Gastroenterol. 2014;7:345–358.
Candy B, Jones L, Goodman ML, et al. Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev 2011, pp. CD003448
Webster L, Chey WD, Tack J, et al. Randomised clinical trial: The long-term safety and tolerability of naloxegol in patients with pain and opioid-induced constipation. Aliment Pharmacol Ther 2014; 40: 771–779.
Farmer AD, Drewes AM, Chiarioni G, De Giorgio R, O'Brien T, Morlion B, Tack J. Pathophysiology and management of opioid-induced constipation: European expert consensus statement. United European Gastroenterol J. 2019 Feb;7(1):7-20. doi: 10.1177/2050640618818305. Epub 2018 Dec 14. Erratum in: United European Gastroenterol J. 2019 Mar;7(2):178. PMID: 30788113; PMCID: PMC6374852.
