Prevention of Opioid-induced Constipation in Patients With Advanced Cancer (OMAMA)

November 19, 2024 updated by: Lia van Zuylen, Amsterdam UMC, location VUmc

OMAMA-study - Prevention of Opioid-induced Constipation in Patients With Advanced Cancer

More than 70% of patients with cancer in the palliative phase have pain that often requires treatment with opioids (morphine-like agents). Constipation occurs in 59% of patients treated with opioids. Opioid-induced constipation (OIC) has consequences that range from daily discomfort with social insecurity and disability to intestinal obstruction. It leads to limitations in self-management, a reduced quality of life and a risk of the need for more care. In the guideline "Diagnosis and treatment of pain in patients with cancer" it is recommended to start preventively with an osmotic laxative such as macrogol/electrolytes or magnesium hydroxide when starting opioids. Macrogol/electrolytes has been proven to be effective for OIC, but is sometimes perceived by patients as unpleasant due to its taste. Magnesium hydroxide, which is less commonly prescribed for OIC, has a neutral taste. Although it is mentioned in the guideline, it is not studied for the treatment of OIC and also not officially registered for this. To support the advice of the guideline and to prove that a choice is possible, it is important to investigate whether there are differences in effectiveness and/or side effects between macrogol/electrolytes and magnesium hydroxide in the prevention of OIC.

The aim of this study is to compare macrogol/electrolytes with magnesium hydroxide in the prevention of opioid-induced constipation in patients with cancer in the palliative (incurable) phase, who start opioids because of pain. The choice of laxative is determined by drawing lots (randomisation). After two weeks, its effect will be assessed and will be presented as the percentage of patients who have not developed constipation after starting opioids. If the laxative, as assigned by lot, is described as satisfactory by the patient, the patient can continue with the drug that the patient used, after the study through regular prescription.

The investigators will ask the patients in the study about their satisfaction with the laxative used, any side effects and the degree of pain. Furthermore, the appeal to care for possible constipation will be examined. Because the best attainable quality of life in the palliative phase is the objective of all care, the investigators will also measure this perceived quality with a questionnaire in this study. The results of this study will lead to the best achievable prevention of opioid constipation in patients with cancer in the palliative phase.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Study Type

Interventional

Enrollment (Estimated)

330

Phase

  • Phase 4

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

  • Netherlands
      • Groningen, Netherlands, 9713 GZ
        • Recruiting
        • University Medical Center Groningen
        • Contact:
      • Groningen, Netherlands, 9728 NT
        • Recruiting
        • Martini Hospital Groningen
        • Contact:
      • Utrecht, Netherlands, 3584 CX
    • Flevoland
    • Gelderland
      • Arnhem, Gelderland, Netherlands, 6815 AD
      • Nijmegen, Gelderland, Netherlands, 6525 GA
    • Noord-Brabant
      • 's Hertogenbosch, Noord-Brabant, Netherlands, 5223 GZ
        • Recruiting
        • Jeroen Bosch ziekenhuis
        • Contact:
    • Noord-Holland
      • Amsterdam, Noord-Holland, Netherlands, 1081 HV
        • Recruiting
        • Amsterdam UMC, location VUmc
        • Contact:
      • Hoofddorp, Noord-Holland, Netherlands, 2134 TM
    • South Holland
      • Gouda, South Holland, Netherlands, 2803 HH
      • The Hague, South Holland, Netherlands, 2512 VA
    • Zuid-Holland
      • Leiden, Zuid-Holland, Netherlands, 2333 ZA
        • Recruiting
        • Leiden University Medical Center
        • Contact:
      • Rotterdam, Zuid-Holland, Netherlands, 3015 GD

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Description

Inclusion criteria:

In order to be eligible to participate in this study, a subject must meet all of the following criteria:

  • Patients with metastatic cancer (≥18 years);
  • Starting with slow release or transdermal opioids for pain;
  • Able to complete a Dutch questionnaire. Previous treatment with opioids is allowed, if discontinued more than 4 weeks ago.

Exclusion Criteria:

A potential subject who meets any of the following criteria will be excluded from participation in this study:

  • Patients with contra-indications for laxatives
  • Use of laxatives during the last four weeks
  • Severely impaired renal function (serum creatinine >180 umol/l)
  • Estimated life expectancy <3 months

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Prevention
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Macrogol/electrolytes

Macrogol/electrolytes is started at a dose of 1 sachet once a day orally, based on the current guideline 'Diagnosis and treatment of pain in patients with cancer' (www.pallialine.nl). The dose of macrogol/electrolytes may be increased to 2 sachets a day during the study period.

The effect of laxatives will be judged after 14 days.
Drug: Macrogol Only Product in Oral Dose Form
Information already included in arm/group description.
Other Names:
  • Macrogol/electrolytes
Active Comparator: Magnesium hydroxide
Magnesium hydroxide is started at a dose of 724 mg three times a day orally, based on the current guideline 'Diagnosis and treatment of pain in patients with cancer' (www.pallialine.nl). The dose of magnesium hydroxide may be increased to 1448 mg three times a day during the study period. The effect of laxatives will be judged after 14 days.
Drug: Magnesium hydroxide 724mg
Information already included in arm/group description.
Other Names:
  • Magnesiumoxide

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
The percentage of patients with a score of <30 of the Bowel Function Index
Time Frame: On day 14
A clinician-administered patient-reported questionnaire to assess clinically significant constipation, validated in patients receiving opioids for chronic non-malignant pain and for malignant pain (Abramovitz 2013, Rentz 2009 and 2011). It consists of three questions, assessing ease of defecation, feeling of incomplete bowel evacuation and personal judgement of the patient regarding constipation, each during the last 7 days and each rated on a scale of 0 (best possible outcome) to 100 (worst possible outcome). A total score ≥30 (mean of the three separate scores) indicates clinically significant constipation. A change of the total score of >12 is regarded as clinically meaningful. It has been used in a large observational study in cancer patients receiving opioids (Davies 2021) and in randomised trials of opioid antagonists for OIC (Ahmedzai 2012, Dupoiron 2017, Leng 2020, Poelaert 2015). It has been recommended as the assessment tool of choice for OIC (Argoff 2015, Farmer 2019).
On day 14

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
The EQ5D
Time Frame: On day 0 and day 14
A self-administered, generic assessment tool developed by the EuroQol Group, a network of international research teams, and consists of questions on five dimensions of health (i.e., mobility, self-care, pain/discomfort, usual activities, and anxiety/depression) (Pickard 2007). It has been used in cost-effectiveness studies on OIC (Dunlop 2012, Hjalte 2016, Lawson 2016).
On day 0 and day 14
Rome IV criteria for opioid-induced constipation
Time Frame: On day 0 and day 14

Rome IV criteria for opioid-induced constipation as judged by professional care givers (Davies 2021, Drossman 2016), including:

  • straining during >25% of defecations
  • lumpy or hard stools in >25% of defecations
  • sensation of incomplete evacuation in >25% of defecations
  • sensation of anorectal obstruction/blockage in >25% of defecations
  • manual manoeuvres to facilitate >25% of defecations
  • <3 spontaneous defecations per week At least two of these criteria have to be fulfilled in order to diagnose constipation, to be judged by the treating physician or clinical nurse specialists/nurse practitioners
On day 0 and day 14
Cancer pain score
Time Frame: On day 0 and day 14
Numeric Rating SDcale, ranging from 0 to 10
On day 0 and day 14
Patient satisfaction with laxative
Time Frame: On day 14
A single four-item question, ranging from unsatisfied to very satisfied.
On day 14
Side effects of laxatives
Time Frame: On day 14

All side-effects are scored on a four-point Likert scale (not at all, a bit, rather, very much):

  • Bad taste
  • Problems with swallowing
  • Abdominal cramps
  • Nausea
  • Flatulence
  • Diarrhea
  • Other (to be specified by the patient)
On day 14
Cost-effectiveness of macrogol/electrolytes compared to magnesium hydroxide
Time Frame: On day 14
We aim to perform a comparative cost-effectiveness of the laxatives. This requires data collection on healthcare procedures and QOL in responders, non-responders and patients with side-effects of laxatives for the follow-up period of the study. These healthcare procedures will be extracted from hospital databases and healthcare use outside the hospital will be collected with the iMCQ at 4 weeks. All individual health care procedures will be linked to their unit costs. Reimbursement prices issued by the Dutch Healthcare Authority and national reference prices will be used for this assessment as outlined in current Dutch pharmaco-economic guidance. The cost-effectiveness analysis will be performed using a decision tree including different branches for initial therapy and responders and non-responders. The costs and QOL of the patients in the trial will be used as input for this decision tree. Total costs and effects will be calculated by summing the costs and effects of each branch.
On day 14

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Amsterdam UMC, location VUmc

Collaborators

Radboud University Medical Center
University Medical Center Groningen
Erasmus Medical Center
Leiden University Medical Center
Rijnstate Hospital
Groene Hart Ziekenhuis
Flevoziekenhuis
Spaarne Gasthuis
Jeroen Bosch Ziekenhuis
Isala
Martini Hospital Groningen
Bernhoven Hospital
Universitiy Medical Centre Utrecht UMCU The Netherlands
Haaglanden Medical Centre
Antoni van Leeuwenhoekziekenhuis (AVL) Amsterdam

Investigators

  • Principal Investigator: Lia van Zuylen, Prof.dr., Amsterdam UMC, location VUmc

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Helpful Links

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

December 2, 2022

Primary Completion (Estimated)

December 1, 2025

Study Completion (Estimated)

December 1, 2025

Study Registration Dates

First Submitted

January 19, 2022

First Submitted That Met QC Criteria

January 19, 2022

First Posted (Actual)

January 31, 2022

Study Record Updates

Last Update Posted (Estimated)

November 22, 2024

Last Update Submitted That Met QC Criteria

November 19, 2024

Last Verified

November 1, 2024

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 08440012010002

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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