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Effect of opioids for breathlessness in heart failure
9
Systemic Review
Effect of opioids for breathlessness in heart failure: a systematic review and meta-analysis
About
first published in 6 march 2023
In Heart Journal(BMJ)
Table of contents
Rahma Younis
- Introduction
- Incentives
- Methods
- Results
- Discussion
- Recommendation
- Limitation
- Conclusion
Introduction
- Refractory breathlessness is defined as breathlessness that persists despite optimal treatment of its underlying cause.
- Complex neurophysiology that has not been determined.
Advanced heart failure (HF) is a chronic condition characterized by impaired myocardial function that can progress to a life-limiting state.
Symptoms include
- severe breathlessness (dyspnea).
- lightheadedness.
- reduced quality of life.
- fatigue during rest or exertion.
Typically, patients with advanced HF exhibit New York Heart Association (NYHA) functional class III symptoms (symptoms with slight exertion) or class IV symptoms (symptoms at rest or with any activity).
Most textbooks and recommendations advocate the use of opioids in HF, Opioids help manage breathlessness [proposed pathophysiology is connection to opiod receptor in the CNS] by improving comfort and reducing distress associated with shortness of breath.
Benefits also include:
- improving the quality of life.
- increased exercise capacity.
- better well-being.
- reduced anxiety, improved sleep.
- potential hospitalization reduction.
However, opioid use comes with many risks and side effects.
WHAT IS ALREADY KNOWN ON THIS TOPIC:
- Symptomatic treatment for breathlessness in patients with advanced heart failure (HF) often involves the use of opioids.
- However, there is currently a lack of data from meta-analyses to validate and support these treatment recommendations.
Incentives
Methods
Methods
Selection of studies
Data sources and search strategy
Data extraction and management
Methods
randomized controlled trials (RCTs) Published and unpublished conducted in English or German were considered for inclusion if they compared opioids with placebo or other treatments.
The participants had to be adults (≥18 years) with refractory breathlessness due to heart failure (HF) regardless of the underlying cause.
HF diagnosis was assumed based on author declaration, and refractory breathlessness was assumed if the study used opioids to relieve breathlessness or enhance exercise performance.
Two authors (JG and VV) collected data from the included studies, which were then verified by a third author (WS). Study characteristics and outcomes were summarized in data sheets.
The extracted information included:
- Methods : study design, intervention duration, study setting, and date.
- Participants : number, age, sex, inclusion/exclusion criteria, NYHA class.
- Intervention and control : specifics of intervention, dose, titration approach, administration method, concurrent medications.
- Outcomes : primary (breathlessness) and secondary outcomes (mortality, quality of life, adverse effects, physiological parameters), assessment scales used.
The authors conducted a search of medical databases (Pubmed and Embase) in July 2021 using search terms derived from previous Cochrane reviews.
The search included terms related to opioids , heart failure and arterial or pulmonary hypertension and so on . The search was limited to randomized controlled trials (RCTs).
Databases
identification of studies via databases
Nausea as secondary outcome
Vomiting as secondary outcome
RESULTS
Results
Constipation as secondary outcome
Discussion
Discussion
- The meta-analysis did not find any evidence of opioids being effective in relieving breathlessness among HF patients. Additionally, there was no superiority of opioid therapy over a placebo, with low heterogeneity and narrow confidence intervals.
- On the contrary, the use of opioids was associated with an increase in side effects such as nausea, vomiting, and constipation, leading to a higher likelihood of study withdrawal among patients receiving opioids.
- This withdrawal effect became more prominent with longer study interventions. For example , in a 12-week study, patients on morphine withdrew after a median of 12 days, compared to 48 days for those on placebo.
Recommendations for Practice and Future Researches
1. Reserve opioids for HF breathlessness as a last option if other interventions, non-pharmacological and pharmacological treatments have failed.
Swift discontinuation is essential if unresponsiveness or adverse events arise.
recent studies showing increased mortality in acute HF with opioid use.
2. Future studies mirroring our meta-analysis design are unlikely to alter results due to conclusive Prediction Intervals and the homogeneity of the included RCTs.
If conducted, these studies should involve titration steps and extended durations to reflect the real-world scenarios.
Recommendations for Practice and Future Researches
3. we cannot exclude the possibility that opioids may have
a beneficial effect in selected responders
The Prospective studies should include:
- more detailed breathlessness assessment.
- consider coexisting conditions like anxiety and depression.
- evaluate sex and ethnic differences.
- explore and report underlying HF causes.
Limitation
Limitations Of This Review
Limitations for this systematic review and meta-analysis :
1- Two independent reviewers conducted screening.
2- searches were limited to two primary databases.
3- no studies written in languages other than English or German were discovered during the entire selection process
Conclusion
Conclusion
This systematic review questions the benefits of opioids for the treatment of breathlessness in patients with HF. We suggest that opioids
may only be the very last option if all options have failed or in case of an emergency.
Thank You For Listening