This manuscript is a well-designed, nonrandomized study investigating naloxegol vs alvimopan in patients undergoing radical cystectomy following an identical enhanced recovery after surgery process. The authors have pointed out the potential biases of the study, in particular the small sample size and lack of randomization. Importantly, naloxegol is not contraindicated in current narcotic users and may impact more than just the cost, but the scope of using this as an alternative to alvimopan. The authors did discuss that this is technically an off-label use of naloxegol as it is indicated for the treatment of opioid-induced constipation in adult patients with chronic noncancer pain. It does not have an approved indication to accelerate bowel function recover after surgery, as does alvimopan. This manuscript provides an encouraging, real-world look at the potential differences between these 2 medications. Additional, well-designed and appropriately powered studies are needed to assess the utility, safety, scope and cost of naloxegol for this indication. Reimbursement for this off-label use of this drug was not commented on, and when considering budgetary impact both the cost and reimbursement must be considered.
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