To the Editor:
Constipation is a frequent complication in patients with advanced cancer and is often underdiagnosed.
1
It may produce important symptoms such as pain, abdominal distention, anorexia, nausea and vomiting, overflow diarrhea, and urinary retention.2
Common causes of constipation in this group of patients include malnutrition, dehydration, inactivity, and drugs, especially opioid analgesics and drugs with anticholinergic effects.All the patients undergoing treatment with opioid analgesics must receive laxatives, and most of them receive two laxatives with different effects: a stool softener and another promoting bowel evacuation.
3
This combined laxative treatment is not universally effective, and 40 % of advanced patients require also enemas and/or rectal manipulation.4
Fresh baker's yeast (FBY) is a fungus (Saccharomyces cerevisiae), most commonly used in the kitchen for raising dough. In Argentina, it is a substance available in paste form that can be mixed with liquids and meals, and is used both as a food supplement to provide vitamins and as a bowel regulator.
We noted that some opioid-treated patients with advanced cancer were consuming FBY regularly and seemed to be less constipated. This prompted the present survey.
Methods
To study this possibility, we recorded the bowel habits of 17 consecutive cancer patients, who initiated opioid therapy and concurrently ingested FBY for 15 days. Fifteen of the patients were treated at home and two were inpatients. Initially, all received FBY as the only laxative. The FBY was administered daily in the morning, dissolved in water at room temperature, and with the option of mixing it with the patient's favorite food.
The initial daily dose of FBY was 6 g. The following doses were adjusted according to effects on bowel function. If defecation occurred, the dose was sustained. If defecation was not produced during the day, the dose was repeatedly doubled (i.e., 12, 25 and 50 g once per day, respectively). The maximum daily dose was 50 g.
When no results were attained in three days with the maximum dose, a stimulant laxative (sodium picosulfate or bisacodyl) was added to the treatment. When no results were achieved in another two days, an enema was ordered.
The results were assessed every day over the phone. Bowel function, fecal consistency and the presence of diarrhea, nausea/vomiting, and colic were recorded. The type of tumor, gender and age of the patients, performance status at the beginning of the treatment, previous bowel habits, the equivalent daily dose of oral morphine (EDDOM), and the use of other medication with constipatory effects also were registered. Statistical analysis was performed using descriptive statistics.
Results
The patients' data are shown in Table 1. One patient stopped taking FBY after few days because he did not like the taste and it generated nausea. Another patient stopped therapy because the treatment was totally ineffective. Of the patients that completed the 15 days of FBY ingestion, 8 had bowel movements once a day, 6 had bowel movements every other day, and 1 achieved defecation on the third day. Four required the use of stimulant laxatives in combination, 2 needed enemas, and 1 the use of a glycerine suppository. The fecal consistency was normal in 9 patients, soft in 4 and hard in the remaining 2. The opioid analgesics and other medications received by 15 patients who continued the study are shown in Table 2. Thirteen patients were previously constipated.
Table 1Patient characteristics (N = 17)
| Age | Sex (n) | ECOG (n) | Tumor (n) | |||
|---|---|---|---|---|---|---|
| 59 years | Male | 9 | One | 4 | Lung | 6 |
| (SD 13) | Female | 8 | Two | 6 | Breast | 3 |
| Three | 4 | Colon | 3 | |||
| Four | 3 | Laryngeal | 2 | |||
| Melanoma | 1 | |||||
| Penile | 1 | |||||
| Adrenal | 1 | |||||
| ECOG at the beginning of the study. | ||||||
Table 2Drugs Used During the Treatments
| Opioid analgesics (patients) | Other drugs (patients) | ||
|---|---|---|---|
| Methadone | 7 | Antidepressants | 3 |
| Morphine | 5 | Antacids | 1 |
| Propoxyphene | 2 | Antiemetics | 3 |
| Codeine | 1 | Neuroleptics | 2 |
| EDDOM 271 mg (SD 452) | Anxiolytics | 4 | |
| NSAIDS | 6 | ||
The approximate cost of the treatment per patient for the 15 days of FBY was $2.50.
Comment
FBY was effective in this group of patients, whose conditions varied and whose opioid consumption was relatively low (EDDOM 271 mg, ± SD 542). Seventy-three percent used FBY as the only laxative and 27% combined it with a stimulant and/or a rectal agent. The side effects were tolerated in all cases.
We do not know what triggers the laxative effects of the FBY, but we are under the impression that it starts a fermentation process in the intestine, and with an action similar to lactulose or sorbitol, retains water in the intestinal lumen.
5
The literature does not provide data on its laxative effects. There is mention of its use to improve the symptoms of patients with congenital sucrase-isomaltase deficiency.6
Some patients could not tolerate the taste of FBY, even when mixed with other foods. The need to maintain it refrigerated and the 30-day life span of the product are also inconvenient. These inconveniences probably could be avoided with the use of the more expensive lyophilized S.cereviciae, in more palatable preparations.
These results should be interpreted with caution because of the short follow-up (a period of 15 days), the uncontrolled nature of this study, and the lack of information concerning the mechanism, and possible side effects of FBY. The long-term efficacy and side effects of this product have not been established.
These preliminary findings should be confirmed in randomized, controlled trials comparing FBY with standard cathartics, such as lactulose or senna. These preliminary results and the extremely low cost of this preparation suggest that these studies are justified. It is possible that this preparation could be added to the list of laxatives effective in patients who receive opioids. This is certainly true in countries such as ours, where a 15-day treatment with lactulose costs $40–60.00.
Acknowledgements
The authors thank Gino Lucco for his translation from the Spanish.
References
- The assessment of constipation in terminal cancer patients admitted to a palliative care unit.J Pain Symptom Manage. 1994; 8: 515-519
- Constipation in the cancer patient.Med Clin North Am. 1987; 71: 303-311
- Constipation and diarrhoea.in: Doyle D. Hanks G. MacDonald N. Oxford textbook of palliative medicine. Oxford University Press, Oxford1993: 299-310
- Control of alimentary symptoms in far advanced cancer. Churchill Livingstone, London1986: 166-207
Brunton LL, Laxante S. In: Hardman JG, Limbird LE, Goodman GA, eds. Las bases farmacologicas de la terapéutica. McGraw-Hill Interamericana Editores SA, 1996:986–987.
- Enzyme-substitution therapy with the yeast Saccharomyces cerevisiae in congenital sucrase-isomaltase deficiency.N Engl J Med. 1987; 316: 1306-1309
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© 2000 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc.
