Methylnaltrexone injection is used to treat constipation caused by opioid pain medications. Methylnaltrexone injection is in a class of medications called peripherally acting mu-opioid receptor antagonists. It works by protecting the bowel from the effects of opioid medications at receptor sites in the bowel. Methylnaltrexone injection comes as a solution to inject subcutaneously.
Ahmedzai, S.H., & Boland, J. (2010, April). Constipation in people prescribed opioids. Clinical Evidence, 2407.
To answer the following questions: What are the effects of oral laxatives, rectal preparations, and opioid antagonists for constipation in people prescribed opioids?
Databases searched were MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Library, NHS Centre for Reviews and Dissemination (CRD), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment, TRIP, and the National Institute for Health and Clinical Excellence (NICE) up to August 2009. Alerts from the U.S. Food and Drug Administration and the U.K. Medicines and Healthcare Products Regulatory Agency were included to identify any adverse effects.
Search keyword were constipation and opioids, Lactulose, macrogols, senna, bisacodyl, co-danthrusate/co-danthramer, docusate, ispaghula husk, liquid paraffin, magnesium salts, methylcellulose, arachis oil enema, glycerol suppository, phosphate enema, sodium citrate enema, and opioid antagonists.
Studies were included in the review if they
The GRADE System was used to evaluate study quality. Full information is available online with a subscription.
The final sample comprised 23 systematic reviews, RCTs, or observational studies. This was an update of a previous review that added 1 systematic review and 5 RCTs, with no change in overall recommendations provided.
Nurses should be aware of potential implications related to the use of opioid antagonists in controlling constipation for opioid interactions and changes in pain control. In addition, nurses should routinely assess for pain relief, as well as symptoms of constipation, in this patient population.
Becker, G., Galandi, D., & Blum, H.E. (2007). Peripherally acting opioid antagonists in the treatment of opiate-related constipation: A systematic review. Journal of Pain and Symptom Management, 34, 547-565.
To evaluate evidence on the effectiveness of the peripherally acting mu-receptor antagonists alvimopan and methylnaltrexone in the management of opioid-induced constipation.
Databases searched were Ovid MEDLINE, Biological Abstracts, BIOSIS Previews, CINAHL, Evidence-Based Medicine Reviews (EBMR) (Cochrane Database of Systematic Reviews, ACP [American College of Physicians] Journal Club, Database of Abstracts of Reviews of Effectiveness [DARE], and the Cochrane Central Register of Controlled Trials [1966-May 2005]), PubMed (1996-May 2005), CancerLit (1963-June 2005), and Embase (1980-May 2002). A hand search also was conducted on bibliographies of books about palliative care. From that hand search, reference citations concerning constipation were identified to find additional clinical trials to include in the review.
Search keywords were constipation, intestinal obstruction, opioid bowel dysfunction, opioid related constipation, opioid-related disorders, peripherally acting opioid antagonist, opioid antagonist, opioid mu receptors, narcotic antagonists/naltrexone, methylnaltrexone, and alvimopan.
Studies were included in the review if
Studies were excluded if they had a small sample size (fewer than 10 participants) or used the Rome Diagnostic Criteria to define constipation.
Ten studies were appropriate for this review. However, four of the 10 had two or three parts performed in different populations or using different dosing regimens. The differing parts were treated as different studies and assessed individually, yielding 15 studies (10 randomized controlled trials and five phase II studies addressing dose and toxicity).
This systematic review looked mainly at the efficacy of using the peripherally acting opioid antagonists methylnaltrexone (nine studies) and alvimopan (six studies) in managing opioid-induced constipation. Internal validity of the studies was high, indicating methylnaltrexone and alvimopan may be effective in relieving opioid-induced constipation. However, most study participants were healthy volunteers or members of methadone programs.
Brick, N. (2013). Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Clinical Journal of Oncology Nursing, 17(1), 91–92.
PHASE OF CARE: End of life care
APPLICATIONS: Palliative care
All of the studies investigated variables in laxative types, opioid doses, and frequency of stools. Outcome measures included change in frequency of bowel movements, ease of defection, relief of systemic and abdominal symptoms of constipation, change in quality of life, and the use of rescue laxatives. There were no significant cross-findings, except all participants required rescue laxatives despite the initiation of a constipation prevention regimen. In two studies of (288) participants using methylnaltrexone versus a placebo, a statistically significant difference favored the intervention of rescue-free laxation 4 hours and 24 hours after the first dose of methylnaltrexone. Thirty percent of those participants experienced adverse effects. One study of 33 participants with methylnaltrexone showed a statistical difference favoring higher doses. Adverse effects were similar.
There were no recommendations for optimal laxative management of constipation in palliative care patients.
There was little concrete evidence and too many variables across the studies. There was no information on how the search was conducted. It was very difficult to follow the evidence summary.
The effectiveness of laxatives and the optimum management of constipation in palliative care patients requires further investigation involving the measurement of standardized, clinically relevant outcomes in a clearly defined population.
Candy, B., Jones, L., Goodman, M.L., Drake, R., & Tookman, A. (2011). Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database of Systematic Reviews, 1, CD003448.
To update the information available on the effectiveness of laxatives and methylnaltrexone for constipation management in palliative care patients.
Databases searched were MEDLINE and the Cochrane Central Register of ControlLed Trials (Central).
Search keywords were laxatives, methylnaltrexone, and palliative care.
Studies were included in the review if
Studies were excluded if they reported on healthy volunteers, drug misuse–related constipation, or bowel obstruction.
A total of 186 references were retrieved. If citation screening did not identify whether a study was eligible, the full text was reviewed for acceptability. Two authors independently screened studies and discussed differences of opinion. Randomized controlled clinical trials were evaluated for inclusion.
Well-designed clinical trials are needed to help identify which laxatives are most effective for palliative care patients with constipation.
Very few clinical trials effectively evaluated the use of laxatives in this patient population.
Siemens, W., Gaertner, J., & Becker, G. (2015). Advances in pharmacotherapy for opioid-induced constipation–A systematic review. Expert Opinion on Pharmacotherapy, 16, 515–532.
STUDY PURPOSE: To evaluate the efficacy and safety of drugs reported in randomized controlled trial for the management of opioid-induced constipation
PHASE OF CARE: Active antitumor treatment
APPLICATIONS: Palliative care
Efficacy: Methylnaltrexone OOM were examined in seven studies. Averaged over all the studies, responder rated reached 30%. Median time to rescue-free bowel movement (RFBM) was shortest for doses 0.15 mg/kg and 0.3 mg/kg compared to placebo. Naloxone: Four studies' group differences were significant, but the mean difference of less than or equal to 0.5 and the one-week and four-week comparison was small. Noloxegel: Three studies with responder rates after 12 weeks of treatment were significantly higher for the 25 mg group, and there was no difference between noloxegel and the placebo group at 12.5 mg. Lubiprostone: Two RCTs showed results not consistent across studies. CB-5945: One study and statistical significant results for all BM frequency only in 0.25 mg bid versus placebo group. Pruclopride: One study with little statistical significance. Alvimopan: Three studies; after 12 weeks there were spontaneous bowel movement (SBM) in both intervention groups with statistical significance and improvement also.
Seven novel drugs for OIC were reviewed. Effectiveness was shown for all drugs, but BM frequency measures hindered comparison of the studies and the drugs.
The authors used different terms in their inclusion criteria for outcome analysis. Seven drugs were included in the review. Comparing seven drugs made comparisons difficult and conclusions limited.
Improvement in management of OIC could improve patient experience, reduce hospital stays, and decrease patient suffering. Nurses should ensure preventive and proactice measure for their patients on opioids.
Bull, J., Wellman, C.V., Israel, R., Barrett, A.C., Paterson, C., & Forbes, W.P. (2015). Fixed-dose subcutaneous methylnaltrexone in patients with advanced illness and opioid-induced constipation: Results of a randomized, placebo-controlled study and open-label extension. Journal of Palliative Medicine, 18, 593–600.
To determine safety and efficacy of fixed doses of methylnaltrexone (MNTX) in patients with advanced disease
After participation in a two-week placebo randomized controlled trial (RCT), patients were eligible to enroll in a 10-week open-label extension study to evaluate the use of MNTX at a fixed dose based on weight using as-needed dosing. Patients were dosed at 8 mg SC for weight of 38 kg to less than 62 kg or, if 62 kg or greater, at a dose of 12 mg. Doses were administered as needed but not more often than daily. Rescue doses of other bowel medications were permitted if the MNTX was not effective. Patients were taking stable laxative regimens and a stable dose of opioids.
MNTX was effective in the management of opioid-induced constipation in both the RCT and the open-label extension study. The results were based on rescue free bowel movements after doses of MNTX. For the MNTX arm in the RCT component, 62.9% of patients had bowel function compared with 9.6% of the placebo control group (p < 0.0001). Weight did not have an effect on outcome. Secondary end points were all in favor of MNTX, including time to bowel function after first dose. The most common side effects were abdominal pain and nausea.
A fixed dose of MNTX is safe and effective in the management of opioid-induced constipation in patients with advanced disease.
This study adds support to the data that MNTX is safe and effective for opioid-induced constipation.
Chamberlain, B.H., Cross, K., Winston, J.L., Thomas, J., Wang, W., Su, C., & Israel, R.J. (2009). Methylnaltrexone treatment of opioid-induced constipation in patients with advanced illness. Journal of Pain and Symptom Management, 38, 683-690.
To describe laxative response to subcutaneous methylnaltrexone in patients with advanced illness and opioid-induced constipation.
Patients were randomly assigned to receive either methylnaltrexone 0.15 mg/kg or placebo subcutaneously every other day for two weeks. Patients were permitted to continue their baseline laxatives. By day 8, the study drug dose (methylnaltrexone or placebo) could be doubled if patients had fewer than three rescue-free bowel movements (BMs).
The study has clinical applicability for the end-of-life and palliative phases of care.
This was a post-hoc analysis of a two-week double-blind, randomized, placebo-controlled study.
Methylnaltrexone 0.15 mg/kg administered subcutaneously every other day was effective in relieving opioid-induced constipation.
Sixteen percent of patients (10 of 62) in the methylnaltrexone group and 24% (17 of 71) in the placebo group did not complete the study.
Subcutaneous methylnaltrexone 0.15 mg/kg appears to be effective in relieving opioid-induced constipation in a timely and predictable manner without reducing pain control or producing symptoms of opioid withdrawal. If an individual does not respond to the first dose, they may still receive some benefit with additional doses. However, the response rate decreased to 25% for individuals receiving a third dose in this study. Reasons for constipation other than opioid use may need to be looked for in nonresponders.
Flerlage, J.E., & Baker, J.N. (2015). Methylnaltrexone for opioid-induced constipation in children and adolescents and young adults with progressive incurable cancer at the end of life. Journal of Palliative Medicine, 18, 631–633.
To describe the use of methylnaltrexone (MNTX) in pediatric patients with cancer in both inpatient and outpatient settings
A retrospective chart review was conducted on all children, adolescents, and young adults with incurable cancer treated at St. Jude Hospital from May 2008 to June 2013. Pharmacy data and chart data were reviewed for inclusion data. Patients had documented OIC and the administration of enteral preparations and/or suppositories to treat OIC. After standard therapy for OIC was not successful, MNTX was administered subcutaneously at 0.15 mg/kg per dose.
MNTX administration produced bowel function in seven (78%) of the patients in one hour and with five (71%) of the patients having a response to first dose. With repeated dosing, 71% had continued response. There were no side effects documented. Two patients responded to repeated doses. The drug was effective in four of five patients with intra-abdominal disease.
The study revealed that MNTX can be safe and effective in children, adolescents, and young adults with OIC and end-of-life disease.
OIC is a distressing side effect of opioid pain management. The use of MNTX in pediatric patients with cancer with progressive disease appears to be an effective and safe in this retrospective audit, but prospective randomized clinical trials are required.
Lipman, A.G., Karver, S., Cooney, G.A., Stambler, N., & Israel, R.J. (2011). Methylnaltrexone for opioid-induced constipation in patients with advanced illness: A 3-month open-label treatment extension study. Journal of Pain and Palliative Care Pharmacotherapy, 25, 136-145.
To provide access to methylnaltrexone for patients who participated in a prior study of the agent, and to continue to evaluate the safety and efficacy of methylnaltrexone in patients with opioid-induced constipation.
This open-label drug extension study recruited participants from both the control and active treatment groups of a prior methylnaltrexone study. All patients were at the end of life, were not pregnant, and were using birth control. Patient received methylnaltrexone 0.15 mg/kg subcutaneously as needed once per day. The dose was increased to 0.3 mg/kg if the agent was not effective in four hours. The dose was reduced to 0.075 mg/kg if the patient had adverse events.
This was a nonrandomized, single-arm, drug continuation study.
All patients (control group and active treatment group, as defined in the prior study) received a minimum of one drug dose. Patient laxation effect was similar between the active treatment (45.3%) and control (48.3%) groups. Most patients had an effect in less than one hour. Side effects included abdominal pain, nausea, and vomiting. Serious adverse events considered drug related were muscle spasms, abdominal pain, and pain exacerbation. The effect on patient pain levels was minimal. Opioid withdrawal symptoms ranged from none to mild.
Patients obtained benefit from methylnaltrexone for up to three months, and the agent was well tolerated.
Patients at the end of life who have an ongoing need for methylnaltrexone may continue to receive an effect from the drug for up to three months when it is used as needed.
Nalamachu, S.R., Pergolizzi, J., Taylor, R., Slatkin, N.E., Barrett, A.C., Yu, J., . . . Forbes, W.P. (2015). Efficacy and tolerability of subcutaneous methylnaltrexone in patients with advanced illness and opioid-induced constipation: A responder analysis of 2 randomized, placebo-controlled trials. Pain Practice, 15, 564–571.
To examine the influence of demographic and baseline characteristics on the efficacy and tolerability of methylnaltrexone (MNTX) in patients with advanced illness and opioid-induced constipation
Data were pooled from two multicenter, randomized, double-blinded, placebo-controlled, phase 3 clinical studies of subcutaneous MNTX (0.15 and 0.03 mg/kg). The primary outcome analyzed was the percentage of patients with rescue medication-free bowel movement (RFBM) within four hours of the first dose.
More than 50% of 165 patients treated with MNTX dose experienced a rescue-free bowel movement (RFBM) within four hours versus 14.6% of the placebo-treated patients. The largest difference was observed in patients taking the MNTX 0.3 mg/kg without cancer versus the placebo group.
Subcutaneous MNTX provides a rapid and robust and consistent RFBM response in patients with advance illness and OIC. MNTX 0.3 mg/kg may have a more favorable response in selected patient populations.
MNTX continues to show efficacy for opioid-induced constipation for various types of patients. Additional work is warranted to determine most effective doses.
Portenoy, R.K., Thomas, J., Moehl Boatwright, M.L., Tran, D., Galasso, F.L., Stambler, N., . . . Israel, R.J. (2008). Subcutaneous methylnaltrexone for the treatment of opioid-induced constipation in patients with advanced illness: A double-blind, randomized, parallel group, dose-ranging study. Journal of Pain and Symptom Management, 35, 458-468.
To assess the efficacy and safety of subcutaneous methylnaltrexone in patients with advanced illness and opioid-induced constipation (OIC), and to clarify whether a dose-response relationship could be identified.
Methylnaltrexone was administered in doses of 1 mg, 5 mg, or 12.5 mg subcutaneously; patients were randomized to those dose groups in a ratio of 1:1:1. After 22 patients, the dose range was extended to 20 mg; patients were randomized in a ratio of 1:1:3 to 1-mg, 12.5-mg, or 20-mg dose groups. Patients received study medication if they had no bowel movement for at least two days and had a score of 3 or higher on a 5-point scale assessing constipation-related distress. Patients receiving laxatives had to be on a stable regimen for at least four days and remain on regimen during the study.
During the first week of the study, subcutaneous injections were administered on days 1, 3, and 5. Following the first week of double-blind study, patients received the option for open-label study for a maximum of three weeks. The initial dose was 5 mg subcutaneously as often as every other day. The maximum dose was 15 mg in the first 22 patients and 20 mg for the remaining 11 patients. Dose could be increased or decreased by the investigator.
This randomized controlled, parallel-group, repeated-dose, dose-ranging trial included a double-blind phase for one week followed by an open-labeled phase for a maximum of three weeks.
Twenty-two patients completed the blinded phase, and 14 completed the open-label phase.
In the blinded phase, laxation occurred within four hours on day 1 for 1 of 10 patients (10%) in the 1-mg dose group, 3 of 7 patients (43%) in the 5-mg dose group, 6 of 10 patients (60%) in the 12.5-mg dose group, and 2 of 6 patients (33%) in the 20-mg dose group. On day 2, for all dose groups higher than 1 mg, 11 of 23 patients (48%) responded (p = 0.05). There was no dose-response relationship across the three highest doses compared to the 1-mg dose.
The median time to laxation was higher than 48 hours for the 1-mg dose group and 1.72, 0.48, and 6.75 hours in the 5-, 12.5-, and 20-mg dose groups, respectively. The median time to laxation was 1.26 hours for all patients dosed 5 mg or higher, and was statistically significant compared to the 1-mg group (p < 0.0003). The 1-mg dose group required laxative rescue approximately twice as often as other groups. There was no trend in worsening pain control over time.
In the open-label phase, the response rate was from 49% to 64% for patients in dose groups from 5 mg to 12.5 mg. Secondary outcomes were not evaluated because of the small sample size.
Methylnaltrexone doses of 5 mg or higher in patients with advanced illness relieved OIC without decreased analgesia or withdrawal symptoms.
Rodrigues, A., Wong, C., Mattiussi, A., Alexander, S., Lau, E., & Dupuis, L.L. (2013). Methylnaltrexone for opioid-induced constipation in pediatric oncology patients. Pediatric Blood & Cancer, 60(10), 1667–1670.
To determine if methylnaltrexone is an effective treatment for opioid-induced constipation in pediatric patients with cancer
Data were collected from pharmacy records and medical chart reviews. They included demographic data, history of constipation, history of vinca alkaloid use, history of abdominal surgery, history of laxative use and dose, duration of opioid use prior to methylnaltrexone administration, the dose and frequency of methylnaltrexone administration, and the patients' responses to the intervention. Opioid doses were converted to oral morphine equivalents. Bowel regimens were compared to pediatric practice guidelines to determine if the bowel regimen had been optimized prior to administration of methylnaltrexone. Patients were given methylnaltrexone in a single subcutaneous injection. The mean dose was 0.15 ± 0.02 mg/kg per dose (range = 3–12 mg per dose).
Retrospective chart review
Ten patients had a bowel movement within 30 minutes of receiving methylnaltrexone. Four patients had a bowel movement between 30 minutes and 4 hours of administration. Four patients were noted to have decreased abdominal girth and active bowel sounds after the intervention. No patients reported a decrease in pain control.
Methylnaltrexone is one effective intervention to treat opioid-induced constipation for pediatric patients after other interventions have failed. The use of methylnaltrexone to relieve constipation did not lead to an increase in pain for the patients in this study.
Methylnaltrexone should be considered for pediatric patients when other interventions have failed to relieve opioid-induced constipation.
Slatkin, N., Thomas, J., Lipman, A.G., Wilson, G., Boatwright, M., Wellman, C., . . . Israel, R. (2009). Methylnaltrexone for treatment of opioid-induced constipation in advanced illness patients. Journal of Supportive Oncology, 7, 39-46.
To determine the safety and efficacy of subcutaneous (SC) methylnaltrexone in opioid-induced constipation (OIC).
Patients were randomized to a single dose of study drug or placebo administered SC. Groups were 0.15 mg/kg, 0.3 mg/kg, or placebo. Patients were randomly assigned in a 1:1:1 ratio to each study group. Baseline laxative regimens could be continued. Rescue laxatives (laxatives administered on an as needed [PRN] basis) were allowed, except within four hours before or after dose administration.
This phase was 28 days with 1 dose per 24 hours PRN. The initial dose of 0.15 mg/kg could be decreased to 0.075 mg/kg or increased to 0.3 mg/kg, based on response.
Patients completing the open-label phase could enter a three-month extension. The initial dose was the same as in the open-label phase, with dosing adjusted to 0.075 mg/kg, 0.15 mg/kg, or 0.3 mg/kg by investigator discretion.
This was a double-blind, randomized, placebo-controlled, single-dose study, followed by an open-label phase, and then an open-label extension phase.
SC methylnaltrexone is effective in the treatment of OIC and generally is well tolerated. No relationship exists between dose and laxation response, suggesting the optimal dose is 0.15 mg/kg.
Thomas, J., Karver, S., Cooney, G.A., Chamberlain, B.H., Watt, C.K., Slatkin, N.E., . . . Israel, R.J. (2008). Methylnaltrexone for opioid-induced constipation in advanced illness. New England Journal of Medicine, 358, 2332-2343.
To examine the safety and efficacy of subcutaneous methylnaltrexone for treating opioid-induced constipation in patients with advanced illness.
Patients were randomly assigned to receive either methylnaltrexone 0.15 mg/kg or placebo subcutaneously every other day for two weeks. Patients were permitted to continue their baseline laxatives and could use rescue laxatives. By day 8, the study drug dose (methylnaltrexone or placebo) could be doubled if patients had fewer than three rescue-free bowel movements. Patients in both groups who completed the two-week study were eligible to enter an open-label extension phase. During the extension trial, methylnaltrexone 0.15 mg/kg was offered as needed every 24 hours for up to three months. Subsequent doses could be increased to 0.3 mg/kg if there was no defecation.
The study has clinical applicability for the end-of-life and palliative phases of care.
This was a two-week, double-blind, randomized, placebo-controlled phase III study with a subsequent three-month, open-label extension phase.
Efficacy Analysis: Double-Blind Phase
Pain Scores and Opioid Withdrawal
Methylnaltrexone as administered in this study was effective in inducing laxation in patients with advanced illness and opioid-induced constipation, without compromising analgesia or triggering withdrawal symptoms.
Calculations showed that a total of 130 patients (65 in each group) would allow detection of a difference of 30% to 35% in the proportion of patients having a laxation response. However, only 106 patients (52 in the methylnaltrexone group and 54 in the placebo group) completed the study.
Subcutaneous methylnaltrexone seems effective in treating constipation in patients with advanced illness and opioid-induced constipation without compromising analgesia or causing withdrawal symptoms. In this study, more than 50% of patients had a diagnosis of cancer; therefore, conclusions can likely be extended to patients with cancer. In addition, patients in this study were receiving a median opioid dose of approximately 100 mg of oral morphine equivalent. Many patients with cancer receive a larger dose; therefore, further study with increased doses of morphine equivalent is warranted.
Librach, S.L., Bouvette, M., De Angelis, C., Farley, J., Oneschuk, D., Pereira, J.L., . . . Canadian Consensus Development Group for Constipation in Patients With Advanced Progressive Illness. (2010). Consensus recommendations for the management of constipation in patients with advanced, progressive illness. Journal of Pain and Symptom Management, 40, 761-773.
To identify best practices for the management of constipation in patients with advanced progressive disease.
In this consensus-based guideline, the literature was reviewed and a multidisciplinary group met to develop the consensus statement. The guideline was revised and reviewed several times prior to publication.
Databases searched were PubMed and the Cochrane Library.
Search keywords were constipation, palliative care, advanced illness, laxatives, management, guidelines, and recommendations.
Inclusion and exclusion criteria were not provided.
This information was not provided. The consensus statement included only 20 references.
The consensus statement included information on the components of patient assessment, history, rectal and abdominal examination, management, goal development, and pharmacologic and nonpharmacologic interventions, as well as a best practice summary. Nonpharmacologic recommendations included maintaining adequate fluid and fiber intake, mobility, optimizing toileting with privacy, and positioning. Pharmacologic recommendations included selection of laxatives based on patient symptoms and preferences, as well as use of methylnaltrexone with opioid-induced constipation for patients who fail to respond to optimal laxative therapy. Osmotic laxatives, polyethylene glycol (PEG), and lactulose are supported by high-level evidence. Docusates and mineral oil should not be used.
The consensus statement included a summary in outline format that reviewed the information provided in the body of the article. The summary is the most useful section of the document as the information is concise but contains adequate detail. No new information is provided. In addition, a decision tree was included that may be useful. Regular assessment is needed for the management of patients with constipation.
National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v. 2.2011]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf
The guidelines recommend the following for management of opioid-induced constipation.
If Constipation Occurs:
Recommendations were identified as having low-level evidence and uniform consensus.
National Comprehensive Cancer Network. (2015). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Palliative care [v.1.2016]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf
RESOURCE TYPE: Consensus-based guideline
PROCESS OF DEVELOPMENT: Guidelines were developed by a panel
These guidelines did not provide a specific search strategy or information about literature search results.
These recommendations were made mainly by consensus, and the guidelines provided no information about literature search results and appeared to use only one database for searching. All suggestions were based on low-level evidence and uniform consensus.
These guidelines provided numerous suggestions for the management of various symptoms, but they were not truly evidence-based. In those aspects for which there was no research evidence, the guidelines provided expert opinion suggestions for management.