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Fink PB, Wheeler AR, Smith WR, Brant-Zawadzki G, Lieberman JR, McIntosh SE, Van Tilburg C, Wedmore IS, Windsor JS, Hofmeyr R, Weber D. Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update. Wilderness Environ Med 2024; 35:198-218. [PMID: 38651342 DOI: 10.1177/10806032241248422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.
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Affiliation(s)
- Patrick B Fink
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Albert R Wheeler
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | - William R Smith
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | | | | | - Scott E McIntosh
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | - Ian S Wedmore
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Ross Hofmeyr
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - David Weber
- Mountain Rescue Collective, LLC, Park City, UT
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Peters M, Kutzko DJ, Stilos K. Continuous Ambulatory Delivery Device Use for Patients Managed by an Inpatient Palliative Care Team. Pain Manag Nurs 2024:S1524-9042(24)00023-7. [PMID: 38616457 DOI: 10.1016/j.pmn.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/25/2024] [Accepted: 02/19/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The use of Patient Controlled Analgesia (PCA) via a Continuous Ambulatory Delivery Device (CADD) is a common and effective means of pain and symptom management for hospitalized patients with a malignancy. Studies exploring the indications for starting such a device for hospitalized inpatients referred to inpatient palliative care teams are limited. AIM This retrospective chart review aims to explore indications, timing of initiation, and barriers to the use of a CADD. METHODS Over a six month period, during daily inpatient palliative care consult team rounds, patients who required a CADD were enrolled in this study. Sixty-one adult patients were identified who required a pump for symptom control. The team's database sheets were used to capture patient demographics. RESULTS The main reasons for initiating a Continuous Ambulatory Delivery Device in the above setting included: lack of efficacy of oral opioids and to increase patient autonomy of their pain management. Approximately 20% of patients required transfer to another unit that could accommodate the CADD. The median length of stay for these patients was 13 days, with a median length of half a day for a pump to be started. CONCLUSIONS This initial study provides the Palliative Care Consult Team with information on the indications for the use of a CADD. The lack of universal access to a CADD in various areas of our hospital due to differences in departmental protocols may compromise good symptom management and patient safety. These results strengthen the argument that the existing hospital policy requires revamping to improve CADD access. A CADD has been shown to provide hospitalized patients, with a malignancy, with timely access to effective symptom management, and in turn, reducing their length of stay in hospital. These findings will help inform this organization's CADD policy and support the need to broaden access to this device.
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Affiliation(s)
- Madison Peters
- Advanced Practice Nurse, Division of Palliative Care Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dr Justin Kutzko
- Palliative Care Physician, Division of Supportive and Palliative Care, Brampton Civic Hospital, William Osler Health System, Brampton, Ontario, Canada; Senior Lecturer, University of Queensland, Brisbane, Australia
| | - Kalli Stilos
- Advanced Practice Nurse, Division of Palliative Care Sunnybrook Health Sciences Centre, Adjunct Clinical Faculty for Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
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3
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Cuomo A. Fentanyl in cancer pain management: avoiding hasty judgments and discerning its potential benefits. Drugs Context 2023; 12:2023-10-2. [PMID: 38148830 PMCID: PMC10751104 DOI: 10.7573/dic.2023-10-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/14/2023] [Indexed: 12/28/2023] Open
Abstract
Cancer pain is an important challenge in treatment and requires a rapid onset of action for its control. In particular, breakthrough cancer pain (BTcP) should be adequately controlled with a stable dose of a short-acting oral opioid. Fentanyl is a synthetic, highly selective opioid with many advantageous chemical properties, including high lipophilicity and distinct pharmacokinetic properties. It is recommended for pain management in a variety of settings, including acute pain, chronic pain and BTcP. To date, its variously designed formulations allow non-invasive administration; amongst others, sublingual fentanyl has proven useful in the management of BTcP and in improving the quality of life of patients with cancer. This review provides an update on the management of BTcP with fentanyl, with consideration of safety, as it remains an important tool in the treatment of cancer pain.
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Affiliation(s)
- Arturo Cuomo
- Istituto Nazionale dei Tumori, IRCCS Fondazione G. Pascale, Naples,
Italy
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Yu Y, Zhang P, Chen D, Jiang SF. Knowledge and practice of the management of breakthrough cancer pain among general practitioners providing palliative care in Shanghai, China: a cross-sectional survey. BMJ Open 2023; 13:e073670. [PMID: 37770268 PMCID: PMC10546098 DOI: 10.1136/bmjopen-2023-073670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/01/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE This study examined knowledge and practice of breakthrough cancer pain (BTcP) management among general practitioners (GPs) providing palliative care in Shanghai. DESIGN Cross-sectional study using a self-administered questionnaire. SETTING AND PARTICIPANTS A total of 393 GPs providing palliative care in 32 community health service centres in Shanghai were recruited by stratified cluster random sampling between 1 May and 30 June 2022. OUTCOME MEASURES Knowledge and practice concerning BTcP management. RESULTS A total of 375 questionnaires were collected and declared valid. The median knowledge score was 11 out of 21 points. Only 36.3% (n=136) of the participating GPs scored 11 points or more, which was categorised as good knowledge. Only 24.8% (n=93) of the GPs used Davies' adapted diagnostic algorithm as the gold standard for diagnosis. All of the GPs assessed the intensity of BTcP; however, less than a quarter of the GPs evaluated the relationship between background pain and BTcP (22.1%, n=83), the impact of BTcP on activities of daily living (24.0%, n=90), the impact of BTcP on social relationships (14.4%, n=54) and the impact of BTcP on mood (10.1%, n=38). 56.5% (n=212) of the GPs reported that they used pain tools in the assessment of BTcP. All of the GPs prescribed immediate-release morphine as rescue medication for relieving BTcP; however, 60.5% (n=227) prescribed the dose based on their personal experiences, irrespective of the basal opioid dose, and 57.3% (n=215) did not conduct dose titration after providing the initial dose. No GPs reported that they ever administered interventional treatment to their patients. CONCLUSIONS Insufficient knowledge and inappropriate behaviours in BTcP diagnosis, assessment and treatment were identified. There is an urgent need to improve BTcP management among GPs providing palliative care in Shanghai.
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Affiliation(s)
- Ying Yu
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
| | - Panpan Zhang
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
| | - Danxia Chen
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
| | - Sun Fang Jiang
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
- Department of Health Management Center, Zhongshan Hospital Fudan University, Shanghai, China
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Sharifi N, Mortazavi SA, Rabbani S, Torshabi M, Talimi R, Haeri A. Fast dissolving nanofibrous mats for diclofenac sodium delivery: Effects of electrospinning polymer and addition of super-disintegrant. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bossi P, Escobar Y, Pea F. Rapid-Onset Opioids for Management of Breakthrough Cancer Pain: Considerations for Daily Practice. FRONTIERS IN PAIN RESEARCH 2022; 3:893530. [PMID: 35721659 PMCID: PMC9204512 DOI: 10.3389/fpain.2022.893530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background and Objective Rapid-onset opioids (ROOs) are effective treatments for breakthrough cancer pain (BTcP) given their rapid onset of action and relatively short duration of analgesia. The aim of this article is to describe specific considerations for the use of ROOs in daily practice, focusing on dose titration and treatment of specific populations. Type of Review We conducted a narrative review on the use of ROOs for BTcP. We selected papers according to the following search terms: “breakthrough cancer pain” and “rapid onset opioids”. Results ROOs may be considered as the most suitable drugs to treat BTcP and can be used “on-demand”. Several fentanyl formulations are available and have been associated with control of BTcP and with improvement in quality of life. Various titration schemes have been used to optimize ROO dosing; however, a dose-proportional scheme could be considered safe and effective in most patients. Specific formulations may be more suitable for specific patient subgroups; for example, patients with oral mucositis may prefer intranasal to oral formulations. Moreover, elderly patients or those without caregivers should be clearly educated on the use of these formulations. A key element in achieving successful treatment of BTcP is awareness of the barriers to pain management, including poor overall assessment, patient reluctance to take opioids or report pain, and physician reluctance to prescribe opioids. Conclusion A personalized approach is fundamental when prescribing a medication for BTcP, and careful attention should be given to drug choice and route of administration, and to the need for alternative therapeutic options.
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Affiliation(s)
- Paolo Bossi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health - Medical Oncology, ASST-Spedali Civili, University of Brescia, Brescia, Italy
- *Correspondence: Paolo Bossi
| | - Yolanda Escobar
- Medical Oncology, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero Universitaria Sant'Orsola, Bologna, Italy
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7
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Banala SR, Khattab OK, Page VD, Warneke CL, Todd KH, Yeung SCJ. Intranasal fentanyl spray versus intravenous opioids for the treatment of severe pain in patients with cancer in the emergency department setting: A randomized controlled trial. PLoS One 2020; 15:e0235461. [PMID: 32649717 PMCID: PMC7351205 DOI: 10.1371/journal.pone.0235461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 06/15/2020] [Indexed: 11/17/2022] Open
Abstract
Objective Intranasal fentanyl (INF) quickly and noninvasively relieves severe pain, whereas intravenous hydromorphone (IVH) reliably treats severe cancer pain but requires vascular access. The trial evaluated the efficacy of INF relative to IVH for treating cancer patients with severe pain in an emergency department (ED) setting. Methods We randomized 82 patients from a comprehensive cancer center ED to receive INF (n = 42) or IVH (n = 40). Eligible patients reported severe pain at randomization (≥7, scale: 0 “none” to 10 “worst pain”). We conducted non-inferiority comparisons (non-inferiority margin = 0.9) of pain change from treatment initiation (T0) to one hour later (T60). T0 pain ratings were unavailable; therefore, we estimated T0 pain by comparing 1) T60 ratings, assuming similar group T0 ratings; 2) pain change, estimating T0 pain = randomization ratings, and 3) pain change, with T0 pain = 10 (IVH group) or T0 pain = randomization rating (INF group). Results At T60, the upper 90% confidence limit (CL) of the mean log-transformed pain ratings for the INF group exceeded the mean IVH group rating by 0.16 points (>pain). Substituting randomization ratings for T0 pain, the lower 90% CL of mean pain change in the INF group extended 0.32 points below (<pain relief) mean change in the IVH group. Finally, assuming all subjects in the IVH group had maximum pain at T0 and that T0 pain for the INF group remained unchanged from randomization, the lower bound of the 90% CL for mean pain decrease in the INF group extended 1.37 points below (<pain relief) mean decrease in the IVH group. Time (minutes) from randomization until T0 was longer for the IVH (Median 23, IQR 12) versus INF (Median 15, IQR 11) group (P<0.001). Conclusions Two of three analyses supported non-inferiority of INF versus IVH, while one analysis was inconclusive. Compared to IVH, INF had the advantage of shorter time to administration. Trial registration ClinicalTrials.gov Identifier: NCT02459964
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Affiliation(s)
- Srinivas R Banala
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America.,Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Osama K Khattab
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Valda D Page
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Carla L Warneke
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Knox H Todd
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
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Thota RS, Ramanjulu R, Ahmed A, Jain P, Salins N, Bhatnagar S, Chatterjee A, Bhattacharya D. Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Pharmacological Management of Cancer Pain (Part II). Indian J Palliat Care 2020; 26:180-190. [PMID: 32874031 PMCID: PMC7444569 DOI: 10.4103/0973-1075.285693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group (SIG) guidelines on pharmacological management of cancer pain in adults provide a structured, stepwise approach, which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire, based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking, was made available on the ISSP website and circulated by e-mail to all the ISSP and Indian Association of Palliative Care members. We recommend that analgesics for cancer pain management should follow the World Health Organization 3-step analgesic ladder appropriate for the severity of pain. The use of paracetamol and nonsteroidal anti-inflammatory drugs alone or in combination with opioids for mild-to-moderate pain should be used. For mild-to-moderate pain, weak opioids such as tramadol, tapentadol, and codeine can be given in combination with nonopioid analgesics. We recommend morphine as the opioid of the first choice for moderate-to-severe cancer pain. Sustained-release formulations can be started 12 hourly, once the effective 24 h dose with immediate-release morphine is established. Opioid switch or rotation should be considered if there is inadequate analgesia or intolerable side effects. For opioid-induced respiratory depression, μ receptor antagonists (e.g. naloxone) must be used promptly. Antidepressants and/or anticonvulsants should be used to treat neuropathic cancer pain, and the dose should be titrated according to the clinical response and side effects. External beam radiotherapy should be offered to all patients with painful metastatic bone pain. There is evidence on use of ketamine in cancer neuropathic pain, but with no beneficial effect, thus, it is not recommended.
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Affiliation(s)
- Raghu S Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Raghavendra Ramanjulu
- Department of Pain and Palliative Care, Cytecare Hospital, Bengaluru, Karnataka, India
| | - Arif Ahmed
- Department of Anaesthesia, Critical Care and Pain Management, CK Birla Hospital for Women, Gurugram, Haryana, India
| | - Parmanand Jain
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. B. R. A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Chatterjee
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dipasri Bhattacharya
- Department of Anaesthesiology, Critical Care and Pain, R. G. Kar Medical College, Kolkata, West Bengal, India
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Manirakiza A, Irakoze L, Manirakiza S, Bizimana P. Efficacy and Safety of Fentanyl Compared With Morphine among Adult Patients with Cancer: A Meta-Analysis. East Afr Health Res J 2020; 4:8-16. [PMID: 34308214 PMCID: PMC8279272 DOI: 10.24248/eahrj.v4i1.617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 04/29/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Cancer pain is experienced by numerous patients; thus, the main pain-relieving opioid analgesics, fentanyl and morphine, are of great importance. However, their analgesic efficacy and safety are different among individuals and are still controversial. The aim of this study was to compare the safety and efficacy of fentanyl and morphine among patients with cancer. Methods: We performed a meta-analysis by searching PubMed and the Cochrane Library up to 01 April 2019. The search terms were fentanyl, morphine, opioids and cancer pain. All randomised controlled trials comparing fentanyl and morphine were included in the analysis. Results: Overall, the initial search identified 2970 published studies; among them, 9 studies were included in the efficacy analysis and 8 studies were included in the safety analysis. The oral morphine versus oral transmucosal fentanyl subgroup analysis showed a mean difference(MD)=0.47[Confidence interval(CI):0.35-0.58] with an overall effect, Z=8.10, P<.00001. The outcome of the oral morphine versus nasal/transdermal fentanyl subgroup indicated a MD=0.20[CI:0.3-0.37] with an overall effect, Z=2.24 and P=.02. For the oral morphine versus buccal/sublingual fentanyl subgroup, the analysis revealed a MD=1.80[CI:1.35-2.25] with an overall effect, Z=7.87 and P<.00001. The oral morphine versus other forms of fentanyl subgroup showed a MD=0.70[95%CI:0.34-1.06] with the test for the overall effect, Z=3.81 and P=.0001. Constipation, drowsiness, confusion and dry mouth were more common in the morphine group than in the fentanyl group, with a risk ratio=0.60[CI:0.37-0.97]; 0.93[CI:0.69-1.25]; 0.85[CI:0.23-3.13] and 0.54[CI:0.05-6.43], respectively. Conclusions: Compared with oral morphine, fentanyl is safer and more effective. Moreover, fentanyl presents fewer side effects than morphine, especially constipation, drowsiness, confusion and dry mouth.
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Effects of age and gender in patients receiving doses of opioids for breakthrough pain proportional to background opioid doses. Support Care Cancer 2019; 28:3813-3818. [PMID: 31832823 DOI: 10.1007/s00520-019-05227-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
AIM To identify the role of age and gender in analgesic and adverse effects after administering fentanyl products for breakthrough pain (BT), given in doses proportional to opioid doses given for background pain. METHODS Data from nine studies, in which patients with BP were given fentanyl products in doses proportional to their basal opioid regimen, were analyzed. RESULTS A total 462 patients presenting 1905 episodes of BP were included in this analysis. In older patients, the decrease in pain intensity was more pronounced 15 min after administration of a BP medication. No gender differences were found. No significant differences in frequency and intensity of adverse effects for age and gender were found. CONCLUSION Fentanyl products given for BP in doses proportional to background opioid regimen were more effective in older patients without adding risks of adverse effects. Gender did not influence analgesia and adverse effects of fentanyl products.
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Tung S, Coburn NG, Davis LE, Mahar AL, Myrehaug S, Zhao H, Earle CC, Nathens A, Hallet J. Population-based study of the prevalence and management of self-reported high pain scores in patients with non-resected pancreatic adenocarcinoma. Br J Surg 2019; 106:1666-1675. [PMID: 31639208 DOI: 10.1002/bjs.11330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/09/2019] [Accepted: 07/09/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pain is a common debilitating symptom in pancreatic adenocarcinoma. This cohort study examined the use of, and factors associated with, pain-directed interventions for a high pain score in patients with non-curable pancreatic adenocarcinoma. METHODS Administrative databases were linked and patients with non-resected pancreatic adenocarcinoma diagnosed between 2010 and 2016, who reported one or more Edmonton Symptom Assessment System (ESAS) score, were identified. A high pain score was defined as an ESAS score of at least 4. Outcomes were pain-directed interventions: opiates (in patients aged 65 years or more with universal drug coverage), nerve block and radiation therapy for a high pain score. Reduction in pain score of at least 1 point after pain-directed intervention was also evaluated. Modified Poisson regression was used to examine factors associated with pain-directed intervention. RESULTS Among 2623 patients with a median age of 67 years, 1223 (46·6 per cent) were women, and 1621 (61·8 per cent) reported a high pain score at a median of 38 days after diagnosis. Of those with a high pain score, 75·6 per cent (688 of 910) received opiates, 13·5 per cent (219 of 1621) radiation and 1·2 per cent (19 of 1621) nerve block. The pain score decreased in 62·1 per cent of patients after administration of opiates, 73·4 per cent after radiation and all patients after nerve block. In multivariable analysis, no patient factor (age, sex, co-morbidity burden, rurality, income quintile) was associated with receipt of non-opiate pain-directed intervention for a high pain score. In patients aged at least 65 years, advanced age was associated with lower odds of opiate use. CONCLUSION Opiates are the most common pain-directed intervention for non-curable pancreatic adenocarcinoma, whereas radiation therapy and nerve blocks are seldom used. The lack of association between pain-directed interventions and patient factors points toward practice-driven patterns.
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Affiliation(s)
- S Tung
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Divisions of General Surgery, Odette Cancer Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - L E Davis
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - A L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S Myrehaug
- Divisions of Radiation Oncology, Odette Cancer Centre, Toronto, Canada
| | - H Zhao
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - C C Earle
- Divisions of Medical Oncology, Odette Cancer Centre, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - A Nathens
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Divisions of General Surgery, Odette Cancer Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - J Hallet
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Divisions of General Surgery, Odette Cancer Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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12
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Yan XB. Breakthrough Cancer Pain. FROM CONVENTIONAL TO INNOVATIVE APPROACHES FOR PAIN TREATMENT 2019. [DOI: 10.5772/intechopen.84581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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13
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Swarm RA, Paice JA, Anghelescu DL, Are M, Bruce JY, Buga S, Chwistek M, Cleeland C, Craig D, Gafford E, Greenlee H, Hansen E, Kamal AH, Kamdar MM, LeGrand S, Mackey S, McDowell MR, Moryl N, Nabell LM, Nesbit S, O'Connor N, Rabow MW, Rickerson E, Shatsky R, Sindt J, Urba SG, Youngwerth JM, Hammond LJ, Gurski LA. Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 17:977-1007. [PMID: 31390582 DOI: 10.6004/jnccn.2019.0038] [Citation(s) in RCA: 258] [Impact Index Per Article: 51.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.
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Affiliation(s)
- Robert A Swarm
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Judith A Paice
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | - Doralina L Anghelescu
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | | | - Ellin Gafford
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Heather Greenlee
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | - Susan LeGrand
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Nina O'Connor
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | - Jill Sindt
- Huntsman Cancer Institute at the University of Utah
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Alarcón MDL, Estévez FV, Cabezón-Gutiérrez L, Padrós MC, Martín-Arroyo JMT, Rebollo MA, Jiménez-López AJ, Sanz-Yagüe A. Expert consensus on the management of breakthrough cancer pain in older patients. A Delphi study. J Geriatr Oncol 2019; 10:643-652. [PMID: 31036463 DOI: 10.1016/j.jgo.2019.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/31/2019] [Accepted: 03/19/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES We aimed to generate expert-based recommendations on the management of breakthrough cancer pain (BTcP) in older patients with cancer. MATERIAL AND METHODS A two-round multidisciplinary Delphi study. Specialists rated their agreement with a set of statements using a nine-point Likert scale (one = totally disagree and nine = totally agree). Statements were classified as appropriate (median ranged from seven to nine), irrelevant (median ranged from four to six) or inappropriate (median ranged from one to three). Consensus was established when at least two thirds of the panel scored within any of the ranges. RESULTS A total of 64 specialists from pain units (44.4%), palliative care units (25.4%), medical oncology (19.1%), geriatric medicine (7.9%) and others (3.2%), participated in two consultation rounds. Specialists agreed that effective coordination between the different specialties and levels of care is essential for proper management of BTcP. Most participants (81.3%) supported the assessment of frailty and resolved (96.8%) that frailty status is a better indicator of patient needs than biological age. Participants agreed (75.8%) in the application of the Davies algorithm for diagnosis of BTcP in older patients. A strong consensus was achieved regarding which pharmacological treatment (transmucosal fentanyl) and dosing method (start low and go slow) are the most suitable for the older population. No agreement was reached on how interventionist techniques should be integrated into the therapeutic strategy for BTcP. CONCLUSIONS The present Delphi has generated a set of recommendations that will help healthcare professionals in the management of BTcP in older patients.
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Affiliation(s)
| | | | - Luis Cabezón-Gutiérrez
- Hospital Universitario de Torrejón, Calle Mateo Inurria, s/n, 28850 Torrejón de Ardoz, Madrid, Spain.
| | - Manuel Castillo Padrós
- Complejo Hospitalario Universitario Nuestra Señora de Candelaria, Ctra. Gral. del Rosario, 145, 38010 Santa Cruz de Tenerife, Spain
| | | | - Maite Antonio Rebollo
- Hospital Duran i Reynals, Institut Català d' Oncología (ICO), Avinguda de la Gran via, 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain.
| | | | - Almudena Sanz-Yagüe
- Kyowa Kirin Farmacéutica, S.L.U, Edificio Triada, Av. de Burgos, 17, 28036, Madrid, Spain.
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15
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Current management of breakthrough cancer pain according to physicians from pain units in Spain. Clin Transl Oncol 2019; 21:1168-1176. [PMID: 30783918 DOI: 10.1007/s12094-019-02044-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Current evidence suggests the need to improve the management of breakthrough cancer pain (BTcP). For this reason, we aimed to assess the opinion of a panel of experts composed exclusively of physicians from pain units, who play a major role in BTcP diagnosis and treatment, regarding the key aspects of BTcP management. METHODS An ad hoc questionnaire was developed to collect real-world data on the management of BTcP. The questionnaire had 5 parts: (a) organizational aspects of pain units (n = 12), (b) definition and diagnosis (n = 3), (c) screening (n = 3), (d) treatment (n = 8), and (e) follow-up (n = 7). RESULTS A total of 89 pain-unit physicians from 13 different Spanish regions were polled. Most of them agreed on the traditional definition of BTcP (78.9%) and the key features of BTcP (92.1%). However, only 30.3% of participants used the Davies' algorithm for BTcP diagnosis. Respondents preferred to prescribe rapid-onset opioids [mean 77.0% (SD 26.7%)], and most recommended transmucosal fentanyl formulations as the first option for BTcP. There was also considerable agreement (77.5%) on the need for early follow-up (48-72 h) after treatment initiation. Finally, 65.2% of participants believed that more than 10% of their patients underused rapid-onset opioids. CONCLUSIONS There was broad agreement among pain experts on many important areas of BTcP management, except for the diagnostic method. Pain-unit physicians suggest that rapid-onset opioids may be underused by BTcP patients in Spain, an important issue that need to be evaluated in future studies.
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16
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Azhar A, Kim YJ, Haider A, Hui D, Balankari VR, Epner MC, Park M, Liu DD, Williams J, Frisbee-Hume SE, Allo JA, Bruera E. Response to Oral Immediate-Release Opioids for Breakthrough Pain in Patients with Advanced Cancer with Adequately Controlled Background Pain. Oncologist 2019; 24:125-131. [PMID: 30254187 PMCID: PMC6324637 DOI: 10.1634/theoncologist.2017-0583] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 05/31/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is limited evidence about the response of breakthrough pain (BTP) to the most commonly used oral immediate-release (IR) opioids. Our aim was to determine response rate to oral IR opioids for BTP control in patients with advanced cancer. MATERIALS AND METHODS In this prospective study, palliative care outpatients, with advanced cancer and adequately managed background pain, were asked to complete a self-administered survey. We assessed patients' baseline demographics, pain characteristics, alcoholism (CAGE questionnaire), tobacco and substance abuse, and Edmonton Symptom Assessment Scores (ESAS). We determined the effectiveness of oral IR BTP opioids by using a 7-point Likert scale ranging from "very ineffective" to "very effective." "Effective" and "very effective" were defined a priori as a good response to IR opioids for BTP. RESULTS Of 592 evaluable patients, 192 (32%) had background pain of ≤3 (ESAS pain scale 0-10). Among these 192 patients, 152 (79%) reported BTP, 143/152 (94%) took oral IR opioids for BTP, and 127/143 (89%) responded to a median dose of 10% of the total morphine equivalent daily dose. In univariate logistic regression analysis, younger age (odds ratio [OR], 0.94 per year; p = .008), higher ESAS scores for pain (OR, 1.32; p = .012), anxiety (OR, 1.24; p = .017), and dyspnea (OR, 1.31; p = .007) had statistically significant association with poor response to IR opioids for BTP. In multicovariate logistic regression, adjusted for age, a higher ESAS dyspnea score was significantly associated with poor response to oral IR opioids (OR, 1.44; p = .002). CONCLUSION The vast majority of patients with advanced cancer with adequately controlled background pain reported a good response to oral IR opioids for BTP, supporting their use in clinical practice. IMPLICATIONS FOR PRACTICE Oral immediate-release opioids are standard treatment for cancer breakthrough pain. However, information regarding treatment response to these commonly used opioids is limited. This study provides information that the vast majority of patients with advanced cancer, with adequately controlled background pain, reported good response to oral immediate release opioids for managing their breakthrough pain episodes. Results of this study support the use of conventional oral immediate release opioids that are relatively inexpensive and readily available for management of breakthrough pain in patients with advanced cancer.
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Affiliation(s)
- Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vishidha R Balankari
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Margeaux Chiou Epner
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janet Williams
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan E Frisbee-Hume
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julio A Allo
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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17
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Mercadante S, Adile C, Masedu F, Marchetti P, Costanzi A, Aielli F. Factors influencing the use of opioids for breakthrough cancer pain: A secondary analysis of the IOPS-MS study. Eur J Pain 2018; 23:719-726. [PMID: 30421474 DOI: 10.1002/ejp.1339] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/19/2018] [Accepted: 11/07/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Controversies exist about the choice and the doses of opioid medication in breakthrough cancer pain (BTcP). METHODS The aim was to assess factors influencing the use and the doses of opioids prescribed for BTcP. There was performed a secondary analysis of a national, multicentre study that involving 32 centres performed in patients having BTcP. Diagnosis of BTcP was based on a definite algorithm. Patients using opioids for background pain and for BTcP were selected. Average pain intensity and opioids used for background pain and BTcP, and adverse effects were assessed, as well as patient's satisfaction and the grade of mucositis. RESULTS The analysis was performed in 2,771 patients. Opioid doses given for BTcP were significantly associated with those given for background pain. No relationship between adverse effects and the use and the doses of opioids used for BTcP was found. Drugs and doses were not correlated to the grade of oral mucositis. Nasal fentanyl preparations provided the fastest meaningful pain relief in comparison with other fentanyl transmucosal preparations or morphine preparations (P = 0.000). The majority of patients were satisfied with opioid medications given for BTcP. Only 2.8% of patients reported adverse effects related to opioid medication used for BTcP. Age and gender were independently associated with dosages of some fentanyl products. CONCLUSIONS Opioids for BTcP were effective and safe in a large sample of cancer patients with different stages of disease. Doses of opioids proportional to doses used for background pain seem to guarantee both efficacy and safety. SIGNIFICANCE The use of opioids for breakthough cancer pain was effective and safe in a large sample of advanced cancer patients recruited in different stages of disease and settings. Doses of opioids proportional to opioid doses used for background analgesia, seem to guarantee both effectiveness and safety.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy.,Department of Supportive/Palliative Care, MD Anderson, Houston, Texas
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Paolo Marchetti
- Medical Oncology, Sapienza University of Rome and IDI-IRCCS Rome, Rome, Italy
| | - Andrea Costanzi
- Medical Oncology, Sapienza University of Rome and IDI-IRCCS Rome, Rome, Italy
| | - Federica Aielli
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
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18
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Kuip EJM, Oldenmenger WH, Oomen-de Hoop E, Verduijn GM, Thijs-Visser MF, de Bruijn P, van Meerten E, Koolen SLW, Mathijssen RHJ, van der Rijt CCD. Pharmacokinetics of Sublingually Delivered Fentanyl in Head and Neck Cancer Patients Treated with Curatively Aimed Chemo or Bioradiotherapy. Cancers (Basel) 2018; 10:cancers10110445. [PMID: 30445772 PMCID: PMC6266947 DOI: 10.3390/cancers10110445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 02/05/2023] Open
Abstract
Over 90% of patients treated for head and neck cancer with curatively aimed chemo or bioradiotherapy will develop painful mucositis and xerostomia. Sublingually delivered fentanyl (SDL) is a rapid acting opioid to treat breakthrough pain. It is unclear how SDL is absorbed by the mucosa of these patients. Therefore, the aim of this study was to investigate the effects of mucositis and xerostomia on the absorption of SDL. Thirteen patients who received chemo or bioradiotherapy (RT), were given a single dose of fentanyl: Before start of RT, 3 and 6 weeks after start of RT, and 6 weeks after finishing RT. Pharmacokinetic samples were taken. The primary endpoint was the relative difference (RD) between systemic exposure to fentanyl (area under the curve; AUC) at baseline (AUCbaseline) and fentanyl AUC in the presence of mucositis grade ≥2. The secondary endpoint was the RD between AUCbaseline and fentanyl AUC in the presence of xerostomia, which were analyzed by means of a paired t-test on log-transformed data. Mucositis resulted in a 12.7% higher AUC (n = 13; 95% CI: −10.7% to +42.2%, p = 0.29) compared to baseline levels and xerostomia resulted in a 22.4% lower AUC (n = 8; 95% CI: −51.9% to +25.3%, p = 0.25) compared to baseline levels. Mucositis grade ≥2 or xerostomia caused by chemo or bioradiotherapy does not significantly alter the systemic exposure to SDL. Patients with pain during and after chemo or bioradiotherapy may be safely treated with SDL.
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Affiliation(s)
- Evelien J M Kuip
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
- Department of Medical Oncology, Radboud University Medical Center, Geert Grooteplein Zuid 8, 6500 HB Nijmegen, The Netherlands.
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6500 HB Nijmegen, The Netherlands.
| | - Wendy H Oldenmenger
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Gerda M Verduijn
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Martine F Thijs-Visser
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Peter de Bruijn
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Esther van Meerten
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Stijn L W Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
- Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, 3511 DT Utrecht, The Netherlands.
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19
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Magnani C, Giannarelli D, Calvieri A, Dardeli A, Eusepi G, Restuccia MR, Mastroianni C, Casale G. Breakthrough cancer pain tailored treatment: which factors influence the medication choice? An observational, prospective and cross-sectional study in patients with terminal cancer. Postgrad Med J 2018; 94:566-570. [DOI: 10.1136/postgradmedj-2018-135659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 09/07/2018] [Accepted: 09/15/2018] [Indexed: 11/04/2022]
Abstract
BackgroundVarious options for the pharmacological treatment of breakthrough cancer pain (BTcP) are available. International guidelines on BTcP treatment are not univocal. A tailored treatment should be based on the assessment of different variables such as BTcP characteristics, oral mucositis, chronic rhinitis and a patient’s ability to take medication.ObjectiveThe goal of this study is to assess the relationship between these variables and the medication treatment for BTcP in a sample of patients with terminal cancer.MethodsA prospective, cross-sectional study was carried out among 1180 patients who were receiving palliative care programmes. Patients were recruited if they had a diagnosis of BTcP and had been prescribed rescue opioids. Variables that might influence the BTcP treatment were assessed.ResultsOne hundred and forty-nine eligible patients were enrolled; 59.1% of patients received short-acting oral morphine (OM), 27.5% transmucosal immediate-release fentanyl (TIRF) and 13.4% parenteral morphine for BTcP treatment. Short-acting OM prescription was related to background pain treatment with OM <60 mg daily (p<0.0001) and to home-care setting of assistance (p=0.004). Continuous intravenous morphine infusion and the presence of a vascular access were the main factors related to intravenous morphine prescription for BTcP. TIRF use was mainly related to background opioid dosage and the patient’s self-sufficiency in taking medication.ConclusionIn clinical practice, the factors that most influenced the pharmacological treatment for BTcP were baseline opioid dosage, setting of assistance and self-ability to take medication. Further research is needed to improve the knowledge on tailored BTcP treatment.
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20
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The efficacy of oral piroxicam fast-dissolving tablets versus sublingual fentanyl in incident breakthrough pain due to bone metastases: a double-blinded randomized study. Support Care Cancer 2018; 27:2171-2177. [PMID: 30306325 DOI: 10.1007/s00520-018-4469-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Breakthrough pain (BTP) is a transient exacerbation of pain occurring in a patient with chronic, persistent pain. The most common type is incident pain that is mostly related to bone metastases. The oral mucosa is an attractive route for drug delivery. Sublingual fentanyl preparations are a very attractive agent in controlling attacks of BTP due to its rapid absorption through the oral mucosa. Non-steroidal anti-inflammatory drugs (NSAIDs) play a key role as a first step in treatment of cancer pain; piroxicam sublingual formulations could be a useful alternative in controlling incident pain. Our study hypothesis is to evaluate the efficacy of sublingual fentanyl versus oral piroxicam fast-dissolving tablets in patients with incident pain and its impact on functional status. PATIENTS AND METHODS A cohort of 100 adults of both genders suffering from bone metastases. Patients were assigned to receive either sublingual fentanyl tablet (group 1) or oral piroxicam fast-dissolving tablets (group 2). The pain intensity reduction on a 0-10 visual analog scale (VAS), frequency of BTP attacks, and onset of pain relief. Secondary end points included the functional interference items of the Brief Pain Inventory (BPI). RESULTS There is no significant difference between the two groups regarding the patients' demographics. Significant decline of the VAS in each group in comparison to the pretreatment values (p = 0.001). Non-significant changes of the VAS, duration of pain attacks, and number of rescue doses in comparing both groups were measured. There was significant reduction in group 2 BPI regarding the relation with others, sleep pattern and enjoyment of life parameters at 2 and 4 weeks (p = 0.001). CONCLUSION Our study demonstrated that oral piroxicam fast-dissolving tablet is an analgesic alternative to sublingual fentanyl in patients with bone metastasis to control incidental BTP attacks with more favorable cost-benefit values.
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21
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Guitart J, Vargas MI, De Sanctis V, Folch J, Salazar R, Fuentes J, Coma J, Ferreras J, Moya J, Tomás A, Estivill P, Rodelas F, Jiménez AJ, Sanz A. Efficacy and Safety of Sublingual Fentanyl Tablets in Breakthrough Cancer Pain Management According to Cancer Stage and Background Opioid Medication. Drugs R D 2018; 18:119-128. [PMID: 29572732 PMCID: PMC5995789 DOI: 10.1007/s40268-018-0231-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective Our objective was to assess the effect of sublingual fentanyl tablets (SFTs) on pain relief, quality of life, and adverse effects in patients with cancer pain, according to cancer stage and background opioid regimen. Methods Subgroup analyses from a recently completed study were performed according to cancer stage (locally advanced cancer [LAC] vs. metastatic cancer) and most frequent background opioid medication (fentanyl vs. oxycodone/naloxone). The efficacy and safety of SFTs were evaluated, recording pain intensity (PI), onset of pain relief, and adverse events (AEs). Health status was assessed with the Short Form 12, version 2 (SF-12v2) questionnaire and the Hospital Anxiety and Depression Scale (anxiety subscale [HADS-A] and depression subscale [HADS-D]). Results In total, 54 (67.5%) patients had LAC and 26 (32.5%) had metastatic cancer. The oxycodone/naloxone group included 39 patients (48.1%) and the fentanyl group 29 (35.8%). In all subgroups, pain relief was achieved within 5 min in an increasing number of individuals over time; at the end of the study, PI values decreased (PI-end: 44.4% for LAC vs. 57.9% for metastatic cancer; 44.4% for fentanyl vs. 38.6% for oxycodone/naloxone). HADS and mental component summary (MCS) SF-12v2 scores significantly improved in the LAC group (HADS-A 9.44–8.04; HADS-D 10.46–8.15; MCS 44.69–45.94) and in the fentanyl group (HADS-A 10.05–8.33; HADS-D 11.95–8.76; MCS 44.38–47.19). AEs were reported in few patients and were mostly mild. Conclusions Exploratory subgroup analyses show the efficacy and safety of SFTs for the treatment of breakthrough pain in patients with cancer, regardless of their cancer stage and background opioid medication.
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Affiliation(s)
- Jordi Guitart
- Department of Anesthesiology, Hospital Plató, C/Plató 21, 08006, Barcelona, Spain.
| | - María Isabel Vargas
- Department of Anesthesiology, Parc Sanitari Sant Joan de Deu, Barcelona, Spain
| | - Vicente De Sanctis
- Pain Unit, Department of Anesthesiology, Hospital Universitari Sagrat Cor, Barcelona, Spain
| | - Jordi Folch
- Department of Anesthesiology, Hospital Plató, C/Plató 21, 08006, Barcelona, Spain
| | - Rafael Salazar
- Department of Anesthesiology, Hospital Comarcal d'Inca, Palma de Mallorca, Spain
| | - José Fuentes
- Department of Anesthesiology, Pius Hospital de Valls, Tarragona, Spain
| | - Joan Coma
- Department of Anesthesiology, Hospital General de l'Hospitalet, Barcelona, Spain
| | - Julia Ferreras
- Pain Unit, Department of Anesthesiology, Hospital Residència Sant Camil, Barcelona, Spain
| | - Jordi Moya
- Pain Unit, Department of Anesthesiology, Hospital Mateu Orfila, Menorca, Spain
| | - Albert Tomás
- Pain Unit, Department of Anesthesiology, Fundació Hospital Sant Bernabé, Barcelona, Spain
| | - Pere Estivill
- Department of Anesthesiology, Parc Sanitari Sant Joan de Deu, Barcelona, Spain
| | - Francisco Rodelas
- Department of Anesthesiology, Hospital Comarcal d'Inca, Palma de Mallorca, Spain
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Fallon M, Giusti R, Aielli F, Hoskin P, Rolke R, Sharma M, Ripamonti CI. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv166-iv191. [PMID: 30052758 DOI: 10.1093/annonc/mdy152] [Citation(s) in RCA: 370] [Impact Index Per Article: 61.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Fallon
- Edinburgh Cancer Research Centre, IGMM, University of Edinburgh, Edinburgh, UK
| | - R Giusti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome
| | - F Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, Hertfordshire, UK
| | - R Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - M Sharma
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - C I Ripamonti
- Department of Onco-Haematology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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23
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Kwon MY, Cho HN, Koo DH, Lee YG, Oh S, Lee SS. Initial titration with 200 μg fentanyl buccal tablets: a retrospective safety analysis in Korean cancer patients. Korean J Intern Med 2018; 33:577-584. [PMID: 28111431 PMCID: PMC5943645 DOI: 10.3904/kjim.2016.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/AIMS Managing breakthrough pain (BTP) is important for many cancer patients because of the rapid onset and unpredictable nature of the pain episodes. Fentanyl buccal tablets (FBTs) are a rapid-onset opioid indicated for BTP management. However, FBT titration is needed to optimize BTP management. In this study, we aimed to evaluate the safety and efficacy of initiating 200 μg FBTs in Korean cancer patients. METHODS A retrospective analysis of medical records was performed on all advanced cancer patients treated with FBTs for BTP between October 2014 and July 2015. Patients who received initial doses of 200 μg FBTs for at least 3 days and cases in which FBT was available at doses of 200, 400, and 800 μg were included. RESULTS A total of 56 patients with a median age of 62 years (range, 32 to 80) were analyzed, 61% of whom were male. The median and mean values of morphine equivalent daily doses were 60 mg/day (range, 15 to 540) and 114.8 ± 124.8 mg/day, respectively. The most frequent effective doses of FBT were 200 μg (41 patients, 74%) and 400 μg (12 patients, 21%). Three patients (5%) could not tolerate 200 μg of FBT and discontinued treatment. Nausea, vomiting, somnolence, and dizziness were the most frequent treatment-related adverse events (AEs), and all AEs were grade 1 (mild) or 2 (moderate). CONCLUSIONS FBT at the initial 200 μg dosage was well-tolerated and effective as a BTP management strategy in Korean cancer patients. Further prospective studies are needed to determine appropriate initiating doses of FBT in Korean patients with opioid tolerance.
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Affiliation(s)
- Mi-Young Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Ha-Na Cho
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Dong-Hoe Koo
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence to Dong-Hoe Koo, M.D. Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Korea Tel: +82-2-2001-8330 Fax: +82-2-2001-8360 E-mail:
| | - Yun-Gyoo Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sukjoong Oh
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Sei Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Brant JM, Rodgers BB, Gallagher E, Sundaramurthi T. Breakthrough Cancer Pain: A Systematic Review of Pharmacologic Management
. Clin J Oncol Nurs 2018; 21:71-80. [PMID: 28524907 DOI: 10.1188/17.cjon.s3.71-80] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Breakthrough cancer pain (BtCP), defined as a transient exacerbation of pain that occurs in conjunction with well-controlled background pain, is a common and burdensome problem in patients with cancer.
. OBJECTIVES The aim of this systematic review is to identify evidence-based pharmacologic modalities for adequate management of BtCP.
. METHODS PubMed and CINAHL® databases were searched to identify literature regarding pharmacologic strategies for BtCP published from January 2006 to June 2016. These studies were then synthesized by the Oncology Nursing Society Putting Evidence Into Practice pain team.
. FINDINGS Forty-four studies provide evidence for the use of opioids for the management of BtCP. Transmucosal immediate-release fentanyl (TIRF) was found to have the most evidence for BtCP. Five studies and guidelines also suggest that oral opioids (not including TIRF products) be dosed proportionally to baseline opioids at 10%-20% of the 24-hour, around-the-clock dose.
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Satheeshkumar PS, Mohan MP. Prevention and treatment of oral mucositis pain following cancer therapy. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0486-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care &Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
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Mercadante S. Non pharmacological interventions and non-fentanyl pharmacological treatments for breakthrough cancer pain: A systematic and critical review. Crit Rev Oncol Hematol 2017; 122:60-63. [PMID: 29458790 DOI: 10.1016/j.critrevonc.2017.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/21/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oral opioids or other pharmacological or non-pharmacological interventions are often suggested in the management of breakthrough cancer pain (BTcP). The aim of this systematic and critical review was to analyse and critically comment the evidence of any non-fentanyl therapies proposed for BTcP. METHODS A systematic literature search was carried out to find studies providing clinical data on any treatment excluding fentanyl products. RESULTS No data exist about the use of oral opioids. Some information is available on parenteral morphine in a large sample of patients and episodes of BTcP. For other treatments, including methadone, nitrous oxide, anti-inflammatory drugs, samarium, and gabapentin the existing data, observational and obtained in a small number of patients do not provide useful information to be generalized. Only ketamine, a drug difficult to use for many physicians, particularly in determined setting, provided some evidence according a randomized controlled double-blind study. CONCLUSIONS Recommendations suggesting the use of oral opioids or other pharmacological and non-pharmacologic interventions for BTcP, are not based on any, even minimal evidence. These treatments are worthwhile of further investigation, particularly in determined conditions that should fit the pharmacokinetics of oral opioids.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia & Intensive Care and Pain relief & Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90145, Italy; SAMO, Palermo, Italy; University of Texas, USA; University of Palermo, Italy.
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Oncologist’s knowledge and implementation of guidelines for breakthrough cancer pain in Spain: CONOCE study. Clin Transl Oncol 2017; 20:613-618. [DOI: 10.1007/s12094-017-1756-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/19/2017] [Indexed: 12/20/2022]
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The use of rapid onset fentanyl in children and young people for breakthrough cancer pain. Scand J Pain 2017; 17:256-259. [DOI: 10.1016/j.sjpain.2017.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/19/2017] [Accepted: 07/05/2017] [Indexed: 11/20/2022]
Abstract
Abstract
Background and aims
No published studies have looked at the dosing and use of rapid onset fentanyl preparations in children. The primary aim of this study was to assess whether there is a correlation between effective dose of rapid onset fentanyl and background oral morphine equivalent analgesia in children less than 18 years old. Secondary objectives included establishing whether there is a correlation between effective dose of rapid onset fentanyl and age and weight. Reported side effects were also reviewed.
Methods
This study is a retrospective case note review of all children less than 18 years old who received rapid onset fentanyl products in a tertiary paediatric oncology centre in England between 2010 and 2015. Correlations were analysed using Spearman’s correlation coefficient as data was non-parametric.
Results
Data on 26 children (5-17 yrs; 13-100 kg) was analysed. The most common diagnosis in children being given rapid onset fentanyl products was a solid tumour (84.6%). Eleven children used sublingual tablets, 17 used lozenges and one used a fentanyl nasal spray (three patients used two different preparations). The only significant correlation found was between dose of fentanyl lozenge and weight (r
s
= 0.81, p < 0.001). Very few side effects were reported with the most frequent being nausea (8%) and sleepiness (8%).
Conclusions
Fentanyl lozenges seem to be safe and well tolerated in children as young as five years old, weighing as little as 13 kg. Results suggest that children should always be started on the lowest available dose of chosen preparation and that this dose should be titrated according to response.
This study demonstrates that there is no correlation between background opioid dose and effective dose of rapid onset fentanyl in children. This mirrors findings of similar studies in adults. There was a strong correlation between effective dose of fentanyl lozenge and weight. This may be in part due to clinicians being more inclined to increase fentanyl lozenge doses as the child is in control of when they have had enough medication. In contrast, buccal tablets are absorbed quickly and the child always receives the full dose, making clinicians more reluctant to titrate the dose.
Implications
This article presents initial evidence for feasibility and tolerability of fentanyl lozenges in children as young as five years old, who are on relatively low doses of background opioids. This could be of interest to clinicians who are looking for alternatives to oral opioids to manage breakthrough pain in children with cancer.
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Harrop E, Jamieson L, Choy TH, Ho WHP, Wong ICK. Barriers to the use of buccal and intranasal fentanyl for breakthrough pain in paediatric palliative care: an exploratory survey. BMJ Support Palliat Care 2017; 8:355-356. [PMID: 28801316 DOI: 10.1136/bmjspcare-2017-001413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/02/2017] [Indexed: 11/03/2022]
Affiliation(s)
| | - Liz Jamieson
- University College London School of Pharmacy, London, UK
| | - Tsun Ho Choy
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | - Wing Hei Phoebe Ho
- Li Ka Shing Faculty of Medicine, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | - Ian C K Wong
- University College London School of Pharmacy, London, UK
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Malotte KL, Groninger H. Comparison of Fentanyl Oral and Nasal Formulations #331. J Palliat Med 2017; 20:784-786. [DOI: 10.1089/jpm.2017.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Mercadante S. New drugs for pain management in advanced cancer patients. Expert Opin Pharmacother 2017; 18:497-502. [DOI: 10.1080/14656566.2017.1299711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Janknegt R, van den Beuken M, Schiere S, Überall M, Knaggs R, Hanley J, Thronaes M. Rapid acting fentanyl formulations in breakthrough pain in cancer. Drug selection by means of the System of Objectified Judgement Analysis. Eur J Hosp Pharm 2017; 25:e2. [PMID: 29732145 PMCID: PMC5931243 DOI: 10.1136/ejhpharm-2016-001127] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/17/2016] [Accepted: 11/28/2016] [Indexed: 11/20/2022] Open
Abstract
Drug selection of rapid acting fentanyl formulations in the treatment of breakthrough pain in patients with cancer is performed by the System of Objectified Judgement Analysis method. All seven available formulations were included in the analysis. The following selection criteria were used: number of available strengths, variability in the rate of absorption, interactions, clinical efficacy, side effects, ease of administration and documentation. No direct double-blind comparative studies between two or more formulations were identified and the clinical documentation of all formulations is limited. The most distinguishing criterion was ease of use. This led to slightly higher scores for Abstral, Instanyl and PecFent than for the other formulations. The pros and cons of each formulation should be discussed with the patient, and the most suitable formulation selected for each individual patient.
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Affiliation(s)
- Robert Janknegt
- Department of Clinical Pharmacy and Toxicology, Zuyderland Medical Centre, Sittard, The Netherlands
| | | | | | - Michael Überall
- IFNAP Institute for Neurosciences, Algesiology and Paediatrics, Nürnberg, Germany
| | - Roger Knaggs
- University of Nottingham, Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Morten Thronaes
- Faculty of Medicine, Department of Cancer Research and Molecular Medicine, European Palliative Care Research Centre (PRC), Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Liu Q, Wang Y, Luo XJ, Wang NJ, Chen P, Jin X, Mu GX, Chai XM, Zhang YJ, Li YX, Yu JQ. A fixed inhaled nitrous oxide/oxygen mixture as an analgesic for adult cancer patients with breakthrough pain: study protocol for a randomized controlled trial. Trials 2017; 18:13. [PMID: 28077162 PMCID: PMC5225628 DOI: 10.1186/s13063-016-1739-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 12/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The management of breakthrough pain in cancer patients is always a challenge for medical professions. Occurring in 80% of cancer patients with advanced disease, breakthrough pain significantly decreases both patient's and caregiver's quality of life. The aim of this study is to assess the analgesic efficacy of a fixed inhaled nitrous oxide/oxygen mixture for adult cancer patients with breakthrough pain. METHODS/DESIGN This is a randomized, placebo-controlled, double-blind study; it will be conducted in the General Hospital of Ningxia Medical University. The target study subjects are at least 18 years old, and are hospitalized cancer patients who are receiving routine opioids to control cancer-related pain but still experience breakthrough pain. A total of 240 patients will be recruited and randomly allocated between three treatment groups (A, B, C) and a control group (group D) in a ratio of 3:1. All treatment groups (A, B, C) will receive standard pain treatment (oral immediate-release morphine) plus a pre-prepared nitrous oxide/oxygen mixture, and the control group (D) will receive the standard pain treatment plus oxygen. Patients, doctors, nurses, and data collectors are all blind to the experiment. Assessments will be taken before treatment (T0), at 5 min (T1) and 15 min (T2) during treatment, and at 5 min after treatment (T3). The primary endpoint measures will be the percentage of patients whose pain is relieved at T1, T2, and T3. Secondary outcome measures will include the safety of treatment, adverse events, and satisfaction from both health professionals and patients. DISCUSSION This study aims to provide an effective and practical intervention for a fast breakthrough pain relief and to improve cancer patients' quality of life significantly. The Evidence-Based Medicine Working Group claim that a randomized, double-blind, placebo-controlled experimental intervention is the most appropriate design to demonstrate its efficacy, so this study could give a new approach to controlling breakthrough pain episodes. TRIAL REGISTRATION ChiCTR-INC-16008075 . Registered on 8 March 2016.
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Affiliation(s)
- Qiang Liu
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
- Yinchuan Guolong Hospital, 536 Chang Cheng Road, Xing Qing Area, Yinchuan, 750004 China
| | - Yu Wang
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
| | - Xiang-Jiang Luo
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Ning-Ju Wang
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Ping Chen
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Xin Jin
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
- Department of Nursing, Ningxia People’s Hospital, 301 Zheng Yuan Street, Yinchuan, 750004 China
| | - Guo-Xia Mu
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
| | - Xiao-Min Chai
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
| | - Yue-Juan Zhang
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Yu-Xiang Li
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
| | - Jian-Qiang Yu
- Department of Pharmacology, Pharmaceutical Institute of Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
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Mercadante S, Aielli F, Adile C, Costanzi A, Casuccio A. Fentanyl Pectin Nasal Spray Versus Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Comparative Study. J Pain Symptom Manage 2016; 52:27-34. [PMID: 27208863 DOI: 10.1016/j.jpainsymman.2016.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/14/2016] [Accepted: 02/13/2016] [Indexed: 11/21/2022]
Abstract
CONTEXT Fentanyl products have shown superiority over oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use an appropriate patient selection, and drugs have been compared using a different rationale. OBJECTIVES The aim of this randomized, crossover, controlled study was to compare the efficacy and safety of fentanyl pectin nasal spray (FPNS) and oral morphine (OM), given in doses proportional to opioid daily doses. METHODS Cancer patients with pain receiving ≥60 mg of OM equivalents/day and presenting with ≤3 episodes of BTcP/day were included. Patients received, in a randomized, crossover manner, FPNS or OM at doses proportional to the daily opioid regimen in four consecutive episodes of BTcP. Pain intensity was measured before (T0), 15 (T15), and 30 minutes (T30) after study drugs. RESULTS A total of 167 episodes were treated, 82 with FNPS and 85 with OM. A statistical difference in pain intensity between the two groups was observed at T15, but not at T30 (P = 0.018 and P = 0.204, respectively). In a greater number of episodes treated with FPNS, there was a pain decrease of ≥33% in comparison with OM after 15 and 30 minutes (76.5% vs. 32.8%, and 89% vs. 54.9%, respectively). Similar differences were found in the decrease in pain intensity of ≥50% after 15 and 30 minutes (52.3% vs. 11.4%, and 75% vs. 45.8%, respectively). The difference was highly significant at T15 (P < 0.0005). The mean (SD) pain difference at T15 of FPNS and OM were 3.24 (1.7) and 2.70 (1.2), respectively, whereas the mean (SD) SPIDs30 of FPNS and OM were 4.87 (1.7) and 4.54 (1.5), respectively. The difference was highly significant at T15 (P = 0.019). No severe adverse effects after study drug administration were observed. CONCLUSION When used in doses proportional to the basal opioid regimen, FPNS showed a superior analgesic effect over OM for the management of BTcP. Only minor adverse effects were found with both medications.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Andrea Costanzi
- Department of Oncology, Hospital Sant'Andrea, University of Rome, Rome, Italy
| | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
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Breakthrough pain in cancer patients: prevalence, mechanisms and treatment options. Curr Opin Anaesthesiol 2016; 28:559-64. [PMID: 26263120 DOI: 10.1097/aco.0000000000000224] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The aim of this article was to examine the definition, the characteristics, and the management of breakthrough cancer pain (BTP) in cancer patients by a critical review of recent literature. RECENT FINDINGS BTP should be more correctly defined as an episode of severe intensity in patients receiving an adequate treatment with opioids able to provide at least mild analgesia. BTP is a heterogeneous condition as episodes vary between individuals. BTP can be classified into two big distinct pictures: spontaneous-type and incident-type pain. The principal pharmacological treatment of BTP is represented by the administration of opioids as needed. Recent reviews revealed that transmucosal preparation of fentanyl provided superior and more rapid pain relief as compared with placebo in the first 30 min after dosing. Few comparison studies among fentanyl products have been performed.Finally, although dose titration was recommended for years, a meaningful dosing according to the level of opioid tolerance may enhance the advantages of such products. SUMMARY BTP represents a serious problem reported by many cancer patients despite receiving regular use of opioids. Subgroups of breakthrough pain have been identified. Different modalities of pharmacological interventions are available. Further studies are warranted to assess the net benefit of these drugs to assist decision-making by patients, clinicians, and payers according to individual clinical conditions.
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Daeninck P, Gagnon B, Gallagher R, Henderson J, Shir Y, Zimmermann C, Lapointe B. Canadian recommendations for the management of breakthrough cancer pain. Curr Oncol 2016; 23:96-108. [PMID: 27122974 PMCID: PMC4835001 DOI: 10.3747/co.23.2865] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Breakthrough cancer pain (btcp) represents an important element in the spectrum of cancer pain management. Because most btcp episodes peak in intensity within a few minutes, speed of medication onset is crucial for proper control. In Canada, several current provincial guidelines for the management of cancer pain include a brief discussion about the treatment of btcp; however, there are no uniform national recommendations for the management of btcp. That lack, accompanied by unequal access to pain medication across the country, contributes to both regional and provincial variability in the management of btcp. Currently, immediate-release oral opioids are the treatment of choice for btcp. This approach might not always offer optimal speed for onset of action and duration to match the rapid nature of an episode of btcp. Novel transmucosal fentanyl formulations might be more appropriate for some types of btcp, but limited access to such drugs hinders their use. In addition, the recognition of btcp and its proper assessment, which are crucial steps toward appropriate treatment selection, remain challenging for many health care professionals. To facilitate appropriate management of btcp, a group of prominent Canadian specialists in palliative care, oncology, and anesthesiology convened to develop a set of recommendations and suggestions to assist Canadian health care providers in the treatment of btcp and the alleviation of the suffering and discomfort experienced by adult cancer patients.
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Affiliation(s)
| | - B. Gagnon
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, QC
| | - R. Gallagher
- University of British Columbia, Vancouver, BC, and Division of Palliative Care, Providence Health Care, Toronto, ON
| | - J.D. Henderson
- Colchester East Hants Palliative Care Program, Truro, and Atlantic Palliative Medicine Group and Dalhousie University, Halifax, NS
| | - Y. Shir
- Alan Edwards Pain Management Unit, McGill University, Montreal, QC
| | - C. Zimmermann
- Palliative Services, University Health Network, University of Toronto, Toronto, ON
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Mercadante S, Adile C, Cuomo A, Aielli F, Cortegiani A, Casuccio A, Porzio G. Fentanyl Buccal Tablet vs. Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Randomized, Crossover, Comparison Study. J Pain Symptom Manage 2015; 50:579-86. [PMID: 26303188 DOI: 10.1016/j.jpainsymman.2015.05.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/28/2015] [Accepted: 05/31/2015] [Indexed: 11/16/2022]
Abstract
CONTEXT Fentanyl products have shown superiority to oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use appropriate patient selection, and drugs have been compared by using different rationales. OBJECTIVES The aim of this randomized, crossover, controlled study was to compare efficacy and safety of fentanyl buccal tablets (FBTs) and oral morphine (OM), given in doses proportional to opioid daily doses. METHODS Cancer patients with pain receiving ≥60 mg or more of oral morphine equivalents per day and presenting with ≤3 episodes of BTcP per day were included. In a randomized, crossover manner, patients received FBT or OM at doses proportional to the daily opioid regimen in four consecutive episodes of BTcP. Pain intensity was measured before (T0) and 15 (T15) and 30 minutes (T30), after study drugs. RESULTS In total, 263 episodes of BTcP were treated. A statistical difference in changes in pain intensity-decrease of ≥33% and ≥50%-between the two groups was observed at T15 and T30 (P < 0.0005). No severe adverse effects after study drug administration were observed. CONCLUSION When used in doses proportional to the basal opioid regimen, FBT showed a clear superiority and was well tolerated when compared with OM during the first 30 minutes, which is the approximate target for a timely intervention required for a BTcP medication.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Arturo Cuomo
- Anesthesia and Pain Therapy, National Cancer Institute Pascale, Naples, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Andrea Cortegiani
- Section of Anesthesia, Analgesia, Intensive Care and Emergency, Department of Biopathology, Medical and Forensic Biotechnologies, Policlinico P. Giaccone, University of Palermo, Palermo, Italy
| | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
| | - Giampiero Porzio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Breakthrough pain and its treatment: critical review and recommendations of IOPS (Italian Oncologic Pain Survey) expert group. Support Care Cancer 2015; 24:961-968. [PMID: 26438145 DOI: 10.1007/s00520-015-2951-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/14/2015] [Indexed: 10/23/2022]
Abstract
Controversies exist about the definition and epidemiology of breakthrough cancer pain (BTcP), the pharmacological treatment options, drug dosing, and how to select the medications for BTcP among the new fentanyl products. Existing data were critically evaluated to provide recommendations by an expert group. An algorithm to diagnose BTcP should be used followed by a careful assessment. Fentanyl products provide efficacy and rapidity of action to counteract the temporal pattern of BTcP. The doses of opioids used for background pain should guide the choice of the doses of fentanyl products. The choice of fentanyl products should be based on individual clinical conditions.
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Chang A, Roeland EJ, Atayee RS, Revta C, Ma JD. Transmucosal Immediate-Release Fentanyl for Breakthrough Cancer Pain: Opportunities and Challenges for Use in Palliative Care. J Pain Palliat Care Pharmacother 2015; 29:247-60. [PMID: 26368648 DOI: 10.3109/15360288.2015.1063560] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Opioids are used to treat breakthrough cancer pain (BTCP) and can be classified by relative duration and onset of action. Regulatory approvals of numerous transmucosal immediate-release fentanyl (TIRF) formulations provide alternative options to palliative care-trained providers in the management of BTCP. TIRFs have been formulated as a sublingual tablet, sublingual spray, intranasal spray, pectin-based nasal spray, buccal tablet, and buccal soluble film. Differences exist between TIRFs regarding formulation design and dosing to treat BTCP. Opportunities for use include palliation of BTCP in head and neck cancer and/or radiation-induced mucositis. The purpose of this review is to discuss TIRF formulation and dosing, pharmacokinetics, clinical efficacy, patient acceptability, and safety/tolerability. In addition, barriers to TIRF utilization will be discussed.
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Yaksh TL, Woller SA, Ramachandran R, Sorkin LS. The search for novel analgesics: targets and mechanisms. F1000PRIME REPORTS 2015; 7:56. [PMID: 26097729 PMCID: PMC4447049 DOI: 10.12703/p7-56] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The management of the pain state is of great therapeutic relevance to virtually every medical specialty. Failure to manage its expression has deleterious consequence to the well-being of the organism. An understanding of the complex biology of the mechanisms underlying the processing of nociceptive information provides an important pathway towards development of novel and robust therapeutics. Importantly, preclinical models have been of considerable use in determining the linkage between mechanism and the associated behaviorally defined pain state. This review seeks to provide an overview of current thinking targeting pain biology, the use of preclinical models and the development of novel pain therapeutics. Issues pertinent to the strengths and weaknesses of current development strategies for analgesics are considered.
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Abstract
Cancer pain management is a major element of successful cancer survivorship. Regardless of where someone is along the cancer experience, from a newly diagnosed patient to long-term survivor, pain is a potential treatment-related effect that can have a significant impact on a survivor's life. Quality pain management for cancer survivors is complicated by the fact that cancer-related pain can be due to the tumor, surgery, radiation, and/or chemotherapy. Additionally, the pain experience is related to many psychosocial/spiritual factors. Despite almost 40 years of attention devoted to improving cancer pain management, many cancer survivors are less than optimally treated, often owing to survivor and healthcare provider knowledge barriers. This article reviews some of the latest research related to cancer pain management treatment options, measurement/assessment, and interventions. Progress has been made in understanding new aspects of the pain experience, but more work is yet to be done.
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Affiliation(s)
- Judith A Schreiber
- University of Louisville, School of Nursing, 555 S. Floyd St., Room 4057, Louisville, KY, 40592, USA,
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Pautex S, Vogt-Ferrier N, Zulian GB. Breakthrough pain in elderly patients with cancer: treatment options. Drugs Aging 2015; 31:405-11. [PMID: 24817569 DOI: 10.1007/s40266-014-0181-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The prevalence of pain is high in the elderly and increases with the occurrence of cancer. Pain treatment is challenging because of age-related factors such as co-morbidities, and over half of the patients with cancer pain experience transient exacerbation of pain that is known as breakthrough pain (BTP). As with background pain, BTP should be properly assessed before being treated. The first step to be taken is optimizing around-the-clock analgesia with expert titration of the painkiller. Rescue medication should then be provided as per the requested need, while at the same time preventing identified potential precipitating factors. In the elderly, starting treatment with a lower dose of analgesics may be justified because of age-related physiological changes such as decreased hepatic and renal function. Whenever possible, oral medication should be provided prior to a painful maneuver. In the case of unpredictable BTP, immediate rescue medication is mandatory and the subcutaneous route is preferred unless patient-controlled analgesia via continuous drug infusion is available. Recently, transmucosal preparations have appeared in the medical armamentarium but it is not yet known whether they represent a truly efficient alternative, although their rapid onset of activity is already well recognized. Adjuvant analgesics, topical analgesics, anesthetic techniques and interventional techniques are all valid methods to help in the difficult management of pain and BTP in elderly patients with cancer. However, none has reached a satisfying scientific level of evidence as to nowadays make the development of undisputed best practice guidelines possible. Further research is therefore on the agenda.
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Affiliation(s)
- Sophie Pautex
- Community Palliative Care Unit, Division of Primary Care, Department of Community Medicine and Primary Care, Geneva University Hospitals, Geneva, Switzerland
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Abstract
INTRODUCTION Cancer pain is one of the most important symptoms of malignant disease, which has a major impact on the quality of life of cancer patients. Therefore, it needs to be treated appropriately after a careful assessment of the types and causes of pain. AREAS COVERED The mainstay of cancer pain management is systemic pharmacotherapy. This is, in principle, still based on the WHO guidelines initially published in 1986. Although these have been validated, they are not evidence-based. The principles are a stepladder approach using non-opioids, weak and then strong opioids. In addition, adjuvants can be added at any step to address specific situations such as bone or neuropathic pain. Patients, even if they are on long-acting opioids, need to be provided with immediate-release opioids for breakthrough pain. In case of inefficacy or severe adverse effects of one opioid, rotation to another opioid is recommended. EXPERT OPINION There is a major need for more and better randomized controlled trials in the setting of cancer pain as the lack of evidence is hampering the improvement of current treatment guidelines.
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Affiliation(s)
- Stephan A Schug
- Professor, Chair of Anaesthesiology, The University of Western Australia, School of Medicine and Pharmacology, Pharmacology, Pharmacy and Anaesthesiology Unit , Perth , Australia
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Chen C, Gupta A. Clinical and pharmacokinetic considerations of novel formulations of fentanyl for breakthrough cancer pain. Pain Manag 2014; 4:339-50. [DOI: 10.2217/pmt.14.32] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
SUMMARY This review will provide an overview of pharmacokinetics and clinical practice considerations of the novel formulations of fentanyl for the treatment of breakthrough cancer pain. First, we provide a brief description of the physicochemical properties of fentanyl. Second, we describe the basic pharmacokinetics of fentanyl, the specifics of various formulations and how they affect pharmacokinetics of fentanyl. Finally, we offer the perspectives on clinical practices in the proper uses of these products. Advancements in the formulations and delivery of fentanyl have provided a safer and more effective treatment for breakthrough cancer pain. These dosage forms offer overlapping yet distinct pharmacokinetic advantages to allow more choices for physicians and patients in the management of breakthrough cancer pain.
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Affiliation(s)
- Cuiping Chen
- Pharmacokinetics & Clinical Pharmacology, Depomed Inc., Newark, CA, USA
| | - Anita Gupta
- Division of Pain Medicine & Regional Anesthesiology, Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
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Hastie BA, Gilson AM, Maurer MA, Cleary JF. An Examination of Global and Regional Opioid Consumption Trends 1980–2011. J Pain Palliat Care Pharmacother 2014; 28:259-75. [DOI: 10.3109/15360288.2014.941132] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Bossi P, Locati L, Bergamini C, Mirabile A, Granata R, Imbimbo M, Resteghini C, Licitra L. Fentanyl pectin nasal spray as treatment for incident predictable breakthrough pain (BTP) in oral mucositis induced by chemoradiotherapy in head and neck cancer. Oral Oncol 2014; 50:884-7. [PMID: 25001894 DOI: 10.1016/j.oraloncology.2014.06.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 05/26/2014] [Accepted: 06/12/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Painful mucositis is one of the most distressing toxicities of chemoradiotherapy (CRT) for head and neck cancer (HNC), with the characteristics of incidental predictable breakthrough pain (BTP) during swallowing. Fentanyl pectin nasal spray (FPNS) could be a good therapeutic option. METHODS Patients were prospectively considered if receiving basal analgesic therapy with opiates for painful mucositis of grade ⩾4 on a numerical rating scale from 0 to 10. They were offered FPNS 100mcg before oral intake. When patients reached the effective dose, they evaluated the basal pain intensity before FPNS use and after 10, 20, 30 and 40min. RESULTS Seventeen HNC patients were offered FPNS before oral intake, with 15 patients completing treatment. Mean reduction of incidental BTP intensity after FPNS was 3.1 points (range 1.2-5.8). Mean time elapsed since FPNS use and highest pain reduction was 26min. CONCLUSIONS FPNS demonstrated activity against BTP when swallowing in HNC patients. These data should be considered as hypothesis-generating.
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Affiliation(s)
- Paolo Bossi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Laura Locati
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Aurora Mirabile
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Roberta Granata
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Martina Imbimbo
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Lisa Licitra
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Davis MP. Efficacy of rapid-onset oral fentanyl: what does it mean? J Pain Symptom Manage 2014; 48:e2-3. [PMID: 24704798 DOI: 10.1016/j.jpainsymman.2014.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Mellar P Davis
- Department of Hospice and Palliative Medicine, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Affiliation(s)
| | - Karen Neoh
- St Gemma's Academic Unit of Palliative Care
| | - Adam Hurlow
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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