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DRUG SELECTION PERSPECTIVES

Pharmacologic Options to Prevent Postoperative Ileus

Senior Pharmacist, Center for Drug Policy, Partner's Healthcare, Needham, MA

Elissa V Klinger, MS

Project Manager, Center for Drug Policy, Partner's Healthcare

Prabashni Reddy, PharmD

Director, Center for Drug Policy, Partners Healthcare

Reprints: Dr. Reddy, Center for Drug Policy, Partners Healthcare,115 Fourth Ave., Needham, MA 02494, fax 781/433-3604

OBJECTIVE: To summarize the evidence on pharmacologic options in preventing postoperative ileus (POI).

DATA SOURCES: The Cochrane Database of Reviews and OVID databases and Food and Drug Administration (FDA) Web site were searched (1950-April 2009) using the term postoperative ileus.

STUDY SELECTION AND DATA EXTRACTION: Meta-analyses and randomized controlled trials were included for review. The FDA Web site was searched for clinical reviews and label information for drugs indicated for the prevention of POI.

DATA SYNTHESIS: Three meta-analyses, 2 on gum-chewing and 1 on alvimopan, and 18 clinical trials were identified. Only gum chewing and alvimopan were effective in preventing POI. Gum chewing reduced the time to first flatus and bowel movement (weighted mean difference 21h; p = 0.0006 and 33h; p = 0.0002, respectively). In one meta-analysis, gum chewing significantly reduced length of stay (LOS) by 2.4 days (p < 0.00001) but this was not replicated in the second meta-analysis. Alvimopan shortened the time to reach a composite endpoint of solid food intake, plus/minus flatus, and bowel movement (93 vs 105 h; p < 0.001). A higher incidence of myocardial infarction was observed in a 12-month study of alvimopan for the treatment of opioid-induced bowel dysfunction, but not in studies in patients undergoing bowel resection. Alvimopan decreased the time to written hospital discharge order (hazard ratio 1.35; p < 0.01), while the significance of a reduction in LOS (0.2-1.3 days) was not reported.

CONCLUSIONS: Gum chewing and alvimopan are effective in preventing POI, but given safety concerns and higher cost with alvimopan, gum chewing may be preferred.

Key Words: alvimopan, gum-chewing, ileus, postoperative

Published Online, July 14, 2009. www.theannals.com, DOI 10.1345/aph.1M121