Opioids to be used as last option to control dyspnea in heart failure events

A new study published in Heart suggests that opioids may only be used as a very last resort in the event that all other methods have failed or in an emergency to treat dyspnea in heart failure (HF).

The majority of textbooks recommend the use of opioids to treat dyspnea caused by heart failure. Meta-analyses are sparse, nevertheless. So, this study was carried out by Jan Gaertner and colleagues to analyze the efficiency of opioids in treating dyspnea in heart failure patients as well as their negative effects.

Randomized controlled trials (RCTs) evaluating the effects of opioids on breathlessness (the primary outcome) in patients with HF were the subject of a systematic review. Quality of life (QoL), death, and adverse effects were significant secondary outcomes. In July 2021, searches were conducted on the Cochrane Central Registry of Controlled Trials, MEDLINE, and Embase. The Cochrane RoB 2 Tool and the Grading of Recommendations Assessment, Development and Evaluation criteria were used, respectively, to evaluate the risk of bias (RoB) and the certainty of the evidence. In all meta-analyses, the random-effects model served as the major analytical tool.

The key findings of this study were:

1180 records were checked after duplicates were removed. 

Eight RCTs with 271 randomly assigned patients were found. For the primary endpoint of breathlessness, seven RCTs with a standardized mean difference of 0.03 (95% CI 0.21 to 0.28), could be included in the meta-analysis. 

No investigation discovered significant variations between the treatments and placebo. The risk ratio for nausea was 3.13 (95% CI 0.70 to 14.07), the risk ratio for vomiting was 4.29 (95% CI 1.15 to 16.01), the risk ratio for constipation was 4.77 (95% CI 1.98 to 11.53), and the risk ratio for study withdrawal was 4.42 (95% CI 0.79 to 24.87). 

Little heterogeneity was found in all of the meta-analyses (I2 in all of these meta-analyses was 8%).

In conclusion, the authors advise that opioids should only be used as a last option or in urgent cases when all other therapies have failed.

Reference: 

 Gaertner, J., Fusi-Schmidhauser, T., Stock, S., Siemens, W., & Vennedey, V. (2023). Effect of opioids for breathlessness in heart failure: a systematic review and meta-analysis. Heart (British Cardiac Society). https://doi.org/10.1136/heartjnl-2022-322074