Clinical utilization patterns of alvimopan in a contemporary cohort of patients undergoing radical cystectomy

Objective: To evaluate the clinical utilization patterns and outcomes of alvimopan, a peripherally-acting µ-opioid receptor antagonist, after radical cystectomy (RC) and urinary diversion at a high-volume cancer center. Patients and Methods: We retrospectively identified 130 consecutive patients who underwent RC and urinary diversion for bladder cancer at our institution from October 2013 to September 2014.  Demographic, clinical, and postoperative outcomes were compared between patients who did and did not receive alvimopan using the Kruskal-Wallis test for medians and the chi-square test for proportions.  Predictors of 30-day complications and prolonged length of stay (LOS) were analyzed using multivariate logistic regression analysis.    Results: Perioperative alvimopan was given to 81 patients (62.3%) during the study period although in 17 patients (13.1%) it was indicated but not given.  The most common absolute or relative contraindication for alvimopan usage was prior consumption of opioids for more than 7 consecutive days (n=18; 13.8%).  Patients who received alvimopan had a better performance status (p=0.06), less comorbidities (p=0.08), and were more likely to have minimally-invasive surgery (p=0.07) although these differences did not reach statistical significance.  Alvimopan usage was independently associated with less postoperative 30-day complications (odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.15 – 0.82; p=0.015), less high-grade complications (OR: 0.12, 95% CI: 0.044 – 0.34; p 10 days (OR: 0.28, 95% CI: 0.11 – 0.72; p=0.008).  Conclusions: Despite its clinical benefits, alvimopan was under-utilized in RC patients, especially in those with worse baseline health.  We recommend its incorporation into standardized protocols to optimize perioperative care.