Reactions 1444 - 23 Mar 2013

SOpioids

Refractory constipation with secondary bowelpseudo-obstruction, treated with methylnaltrexonebromide: case report

A woman developed refractory opioid-induced constipation(OIC) with secondary bowel pseudo-obstruction followingtreatment with tramadol, fentanyl, buprenorphine, morphineand oxycodone [dosages not stated]. She was treated withmethylnaltrexone bromide.

The 59-year-old woman, "MTHP", had a history ofhypothyroidism, fibromyalgia and metastatic lungadenocarcinoma treated with chemotherapy. She had anapproximate 2-year history of bone pain, which had respondedpoorly to high-dose oxycodone, and persistent OIC that hadbeen difficult to manage. During those 2 years, she had beentreated in succession with the following opioids: tramadol[route not stated], transdermal fentanyl, transdermalbuprenorphine, oral morphine, oral oxycodone. She hadundergone successive opioid rotations (OR) due to theappearance of OIC [duration of treatments to reaction onsetand age at reaction onset not clearly stated] and the absence ofan effective analgesic. At the time of assessment, she wastaking approximately 320mg/24h of slow-release oxycodone.

The patient often received laxatives with enemas to producebowel movements. Upon examination, she also had painfuland thrombosed external haemorrhoids. Due to the existenceof vertebral and sacroiliac metastases, she received palliativeradiotherapy. She also received approximately 450mg/24h ofcontinuous SC parenteral morphine OR and methylnaltrexonebromide in conjunction with laxatives. She regained normalintestinal movement and had bowel movements every48 hours. Her haemorrhoids were treated with an excellentresponse. She underwent OR with oral morphine until she wasdischarged. Subsequently, she developed acute abdominalsymptoms. X-ray results were compatible with a mechanicalintestinal obstruction. Methylnaltrexone bromide waswithdrawn. She had an opioid-induced intestinal pseudo-obstruction. Methylnaltrexone bromide was resumed withserum therapy, enemas and metoclopramide. Morphine wasswitched to parenteral methadone with the aim of improvingher OIC and incipient delirium. She improved rapidly and wasdischarged. A month later, she was readmitted due topneumonia-related respiratory failure. She died due to a lunghaemorrhage despite antibacterial therapy. Of note, her OIChad been kept under control with treatment until the time ofher death.

Author comment: We present a case of benign bowelpseudo-obstruction secondary to extreme or refractory OIC.Nunez Olarte JM, et al. Refractory opioid-induced constipation with secondaryintestinal pseudo-obstruction resolved with methylnaltrexone. Medicina Paliativa17: 75-79, No. 2, 2010 [Spanish; summarised from a translation] -Spain 803084566

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Reactions 23 Mar 2013 No. 14440114-9954/10/1444-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved