Acute morphine intoxication during high-dose recombinant interleukin-2 treatment for metastatic renal cell cancer

Clinically significant drug-drug interactions involving opioid analgesics used for pain treatment in patients with cancer: a systematic review

BACKGROUND

Opioids are the most frequently used drugs to treat pain in cancer patients. In some patients, however, opioids can cause adverse effects and drug-drug interactions. No advice concerning the combination of opioids and other drugs is given in the current European guidelines.

OBJECTIVE

To identify studies that report clinically significant drug-drug interactions involving opioids used for pain treatment in adult cancer patients.

DESIGN AND DATA SOURCES

Systematic review with searches in Embase, MEDLINE, and Cochrane Central Register of Controlled Trials from the start of the databases (Embase from 1980) through January 2014. In addition, reference lists of relevant full-text papers were hand-searched.

RESULTS

Of 901 retrieved papers, 112 were considered as potentially eligible. After full-text reading, 17 were included in the final analysis, together with 15 papers identified through hand-searching of reference lists. All of the 32 included publications were case reports or case series. Clinical manifestations of drug-drug interactions involving opioids were grouped as follows: 1) sedation and respiratory depression, 2) other central nervous system symptoms, 3) impairment of pain control and/or opioid withdrawal, and 4) other symptoms. The most common mechanisms eliciting drug-drug interactions were alteration of opioid metabolism by inhibiting the activity of cytochrome P450 3A4 and pharmacodynamic interactions due to the combined effect on opioid, dopaminergic, cholinergic, and serotonergic activity in the central nervous system.

CONCLUSION

Evidence for drug-drug interactions associated with opioids used for pain treatment in cancer patients is very limited. Still, the cases identified in this systematic review give some important suggestions for clinical practice. Physicians prescribing opioids should recognize the risk of drug-drug interactions and if possible avoid polypharmacy.

High-dose, continuous infusion Interleukin-2 in the treatment of metastatic renal cell carcinoma: Experience of the C.R.O., Aviano

Interleukin-2 (IL-2, Proleukin, Chiron Therapeutics Inc., Emeryville, CA) has been approved in Italy for the therapy of patients affected by metastatic renal cell carcinoma (RCC) with a good performance status. The basis for approval in the USA and Europe was a series of clinical trials demonstrating that high-dose IL-2, although significantly toxic, can obtain approximately 20% objective responses and improve survival. Between July 1988 and September 1993, 50 patients were treated with high-dose IL-2 in continuous infusion (according to the West protocol), first as part of a European multicentric study, and subsequently as standard treatment. Responses were seen in 9 of the 45 evaluable patients, and, at the last control (December 1995), an improvement in the survival of responding or unchanged patients was clear. This statement may seem excessive but is based on clinical evidence showing a change in the natural history of some of our patients, which is unusual in patients with solid tumors, and in particular RCC patients.