Methadone rotation and initiation in outpatient cancer pain

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Background: Methadone is an effective mu opioid agonist. Delta receptor affinity, monoamine reuptake inhibition an antagonism in N-methyl-D-aspartate receptor have been described. Because of itst long half-life and lack of standart conversion ratio outpatient use is chalinging. Methods: Retrospective review of consecutive medical reports were performed from 2002 to 2007. Patients with methadone as exclusive drug for the first two months were selected. A total of 143 patients were analyzed. Symptoms, toxicities, clinical caraceristics rotation e neuropatic pain were acessed. Results: 89 (62.2%) were female, 54 (37.7%) were male, all patients had solid tumors and were under palliative care only. 52 (36.6%) had neuropathic pain. Median age was 67 years. Median pain score at baseline was 7. After four follow-up with intervals of four days in average, 78% patients had score zero. At the end of two months we found a median (range) of 18 follow-ups performed. 127 (88.8%) patients had score zero. The remaining patients were rotated to other opioid. Neuropathic pain was improved in 36 (73%) of patients only with methadone. 16 (17%) had to use adjuvant drugs. Mean methadone dose was 10mg/day at baseline and 20mg/day at the end of two months.Sedation, obstipation and neurologic symptoms were mild and no major complication was observed. Conclusions: Methadone as initial opioid opyion showed excelent and safe response rates. Its capacity of blocking NMDA receptors may explain the high rate control for neuropathic pain. This finding was not observed in others studies. The low cost, lack of active metabolites, good tolerance in older patents and the finding in neuropathic pain should be better explored in well prospective randomized future clinical trials.

No significant financial relationships to disclose.

Gemcitabine and cisplatin in metastatic breast cancer

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Background: Gemcitabine plus cisplatin have synergistic activity and have been tested in several schedules and doses in metastatic breast cancer. Our objectives were to assesss the efficacy and toxicity of gemcitabine and cisplatin in pretreated patients. Methods: Measurable disease and at least two prior anthracycline and /or taxane-containing regimen in either metastatic or adjuvant setting was required. Treatment consisted of gemcitabine 700mg/m(2) IV infusion over 30 min plus cisplatin 30mg(2) given on day1 and 8 every 3 weeks. Results: Seventy four patients with median age of 48 years (range 26- 73) were recruited. A median of six cycles of the study treatment was delivered. The overal response rate was 30% (95% confidence interval, 12–53%). Median time to progreesion was 30.6 weeks (95%CI, 12.6–44 weeks). Median survival was 73.2 weeks (95% CI, 47.1–93.2 weeks). Toxicities included grade 3 and 4 leukopenia in 27(36.4%), anemia in 19 (25.6%) and oral mucositis in 4 (5.4%). No grade 3 or 4 peripheral neurophaty, hepatic or renal dysfunction was observed. No treatment-related death ocurred. Conclusions: Gemcitabine plus cisplatin is a well tollerated and active treatment in heavily pretreated patients with metastatic breast cancer.

No significant financial relationships to disclose.

Effectiveness,safety and tolerability of codeine in cancer patients

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Background: In 1984 WHO guidelines for cancer pain was proposed. Codeine was selected among several others drugs when pain ladder step II was required. Since then very few comparative studies have been performed. Codein is a weak opioid and its analgesic action is not completely understood. A possible conversion into morphine is postulated. To determine efficacy, safety and tolerability of codein in advanced cancer patient we designed a prospective cohort study. Methods 150 metastatic cancer patients were studied during six months. A standard zero to then table scale for pain rating was used. The malignacies were: prostate 15 (10%), breast 42 (28%), lung 33 (22%), colon 37 (24.6%), other cancer 23 (15.3%). 62 patients were under treatment (41.3%). Results: There were: 83 M (55.3%) 67 F(44,7%) and the mean age was 62 years. Mean initial and final pain score were 7.1 and 1.3 respectively. Codein dose range from 30 mg/day to 270 mg/day (mean dose 180 mg/day). The average time of use was 13,7 months. Severe toxicity was 0% and the most often side effect was constipation (38.7%). Adjuvant drugs were used in 97 patients (64.7%) of patients. Uncontrolled pain ocurred in 17 patients (11.3%). Conclusions: During the last decade a great increase in the range of opioid agents and formulations available have emerged. Codein still represents an excellent drug for patients with long life expectancy. Side effects are manageable and are mainly constipation. Pain control was achieved in the majority of patients. Codein showed a low toxicity profile with a high compliance rate. Economic reasons must be strongly consider in poor countries and codein represents a good alternative option. Future comparative studies addressing also quality of life should be performed.

No significant financial relationships to disclose.

Quality of life (QoL) improvements in 1,464 patients (pts) with metastatic breast cancer (MBC) receiving capecitabine (X) in Brazil: Updated results from a large pt cohort, including analysis as a function of pts’ ECOG PS

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Background: The oral fluoropyrimidine capecitabine is highly active and well tolerated as single-agent therapy and extends survival when added to docetaxel in pretreated MBC. QoL data would enhance understanding of X’s pt benefits. Methods: QoL was evaluated in women with anthracycline ± taxane-pretreated MBC while receiving X (baseline, before cycle 1, at weeks 7 and 13, and at treatment end) using EORTC QLQ C-30 (v3.0) and BR-23 questionnaires. We used linear models with repeated measures (generalized estimating questions technique) and SAS (v8.2) to determine improvement, stabilization or worsening of QoL scores from week 7 onwards. Each questionnaire item was analyzed as a function of pts’ ECOG status before first cycle and the evaluation periods. Results: Baseline characteristics of the 1,464 evaluable pts were: median age 54 years (range 22–92); 42% had ECOG 0. As expected, pts with worse initial PS (ECOG ≥2) had lower mean scores during treatment. Regardless of baseline ECOG score, X therapy was associated with significant (p<0.0001 unless stated) improvements in pts’ perception of: role functioning (p=0.001), pain, nausea/vomiting, fatigue, constipation, emotional functioning, and global health status. Capecitabine was also associated with significant improvements in pts’ perception of systemic therapy side effects (p<0.0001), breast symptoms (p<0.0001), arm symptoms (p=0.0047), hair loss (p<0.0001), and future perspective (p<0.0001). Conclusions: Pts receiving X had substantial improvements in almost all functional and symptomatic QoL domains. These findings highlight the importance of considering QoL and other measurable benefits of oral treatments alongside well-established measures of clinical evaluation in pts with metastatic disease. The QoL benefits, together with other proven clinical outcomes, suggest that early use of X in MBC would be of benefit to pts.

No significant financial relationships to disclose.

Whole-blood platelet aggregation predicts in vitro and in vivo primary hemostatic function in the elderly

Increased platelet aggregation is associated with higher coronary artery disease mortality. Enhanced platelet aggregation in platelet-rich plasma has also been described in the elderly. To define age-related changes in primary hemostasis, we studied 37 elderly and 31 young blood donors. There were no significant age-related differences in whole-blood platelet aggregation, platelet adherence and thrombus formation on human umbilical artery segments, or bleeding time. Plasma fibrinogen was significantly higher in elderly men and women, whereas activated factor VII was elevated only in elderly women. Collagen-induced platelet aggregation was significantly correlated with platelet adherence to the subendothelium in elderly (r = .488, P = .002) but not in young donors. Accordingly, collagen-induced platelet aggregation showed a significant inverse correlation with bleeding time only in the elderly (r = -.401, P = .014). Arachidonic acid-induced platelet aggregation was significantly associated with platelet adherence to the subendothelium (r = .658, P = .003) and bleeding time (r = -.540, P = .021) only in elderly men. In young donors, ADP-induced platelet aggregation was significantly correlated with platelet adherence to the thrombogenic adventitial surface (r = .395, P = .031); in the elderly this association only approached significance (r = .315, P = .058). Whole-blood platelet aggregation in response to collagen and arachidonic acid may be more useful in predicting primary hemostatic function in the elderly than in the young. Furthermore, in the elderly, the correlation between platelet aggregation in whole blood and platelet-arterial wall interactions in vitro and in vivo may contribute to the ability of this test to predict coronary risk.

Sex differences in platelet adherence to subendothelium: relationship to platelet function tests and hematologic variables

Men have significantly more atherosclerotic disease than women. Platelet-mediated thrombosis plays a role in the initiation of myocardial infarction and stroke. Citrated whole blood from male and female donors was perfused through an annular system over everted human umbilical artery segments. Comparisons were made between platelet adherence and thrombus formation on subendothelium, platelet aggregation in citrated whole blood, hematologic variables, and the bleeding time. Platelet spreading and adherence were approximately 22% greater with male blood (P < 0.001), whereas thrombus formation on subendothelium and collagen- and arachidonic acid-induced platelet aggregation did not show sex-related differences. Platelet aggregation with adenosine diphosphate was greater in women, related to their lower hematocrit values. By contrast, in women hematocrit values showed a slight but significant positive correlation with platelet adherence on subendothelium. Fibrinogen was significantly correlated with collagen- and adenosine-diphosphate-induced platelet aggregation and with platelet adherence, spreading, and thrombus formation on subendothelium. The mean bleeding time was slightly longer in women than in men (P = 0.118). Platelet aggregation was not associated with the bleeding time except for collagen-induced platelet aggregation in males; the latter was significantly correlated with platelet adherence and spreading in both sexes, while arachidonic acid-induced platelet aggregation predicted platelet adherence and spreading in males. Male blood shows enhanced primary hemostatic activity; this may predispose men to atherosclerosis.