Naloxegol/opioid analgesics
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Naloxegol/opioid analgesics Acute opioid withdrawal syndrome secondary to drug interaction and opioid-induced constipation: case report
A 56-year-old man developed opioid-induced constipation (OIC) while receiving oxycodone and fentanyl for pain control in metastatic pancreatic neuroendocrine tumour. Additionally, he developed acute opioid withdrawal syndrome secondary to oxycodone withdrawal following concomitant administration of naloxegol for OIC and oxycodone/naloxone for pain control in metastatic pancreatic neuroendocrine tumour [not all routes, dosages, duration of treatments to reaction onsets and outcomes stated]. The man, who had pancreatic neuroendocrine tumour with lymph node, bone and liver metastases, underwent a surgery. Additionally, he had been receiving unspecified somatostatin analogues, radiofrequency for liver metastases, radionucide (lutecium) and chemotherapy with streptozocin, doxorubicin, everolimus and sunitinib. However, due to poor pain control from liver and bone metastasis, he started receiving oxycodone 40mg twice a day, transmucosal fentanyl (for episodic pain) along with paracetamol [acetaminophen], insulin, metoclopramide and omeprazole. However, he developed OIC secondary to oxycodone and fentanyl. The man was treated with naloxegol for 3 weeks for OIC. However, he presented again with constipation and worsening pain. Hence, oxycodone was switched to oxycodone/naloxone 60mg/30mg (divided in 40/20mg pill and 20/10mg pill) two times a day. Approximately 15–30 minutes following oxycodone/naloxone pill intake, he developed immediate and severe agitation, anxiety, sweating, tachycardia, disorientation, yawning and restless legs. His symptoms were corresponding to a moderate grade in the clinical opiate withdrawal scale. He was hospitalised and treated with midazolam with little improvement. The diagnosis of acute opioid withdrawal syndrome was confirmed, and it was attributed to the additive effect of opioid receptor antagonism with both naloxegol and oxycodone/naloxone. The plasma free concentration of one of the antagonists was increased due to pharmacodynamic synergism and more of it crossed the blood brain barrier leading to withdrawal syndrome. Thereafter, he was treated with morphine leading to rapid clinical improvement. Subsequently, a brain CT scan indicated normal results. He remained under clinical observation for 24 hours. The treatment was again switched to oxycodone at a same dose, and naloxegol was continued. Eventually, he was discharged without any symptoms. At an outpatient follow-up 1 month later, he had no further episodes. Olmo M, et al. Acute opioid withdrawal syndrome from naloxone/naloxegol interaction. BMJ Supportive and Palliative Care : 11 Aug 2020. Available from: URL: http:// 803500640 doi.org/10.1136/bmjspcare-2020-002387
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Reactions 12 Sep 2020 No. 1821
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