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SEOM clinical guideline for treatment of cancer pain (2017). Clin Transl Oncol 2017; 20:97-107. [PMID: 29127593 PMCID: PMC5785609 DOI: 10.1007/s12094-017-1791-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 10/26/2017] [Indexed: 11/23/2022]
Abstract
Pain is a highly prevalent symptom in patients with cancer. Despite therapeutic advances and well-accepted treatment guidelines, a percentage of patients with pain are under-treated.
Currently, it has been recognized that several barriers in pain management still exist and, in addition, there are new challenges surrounding complex subtypes of pain, such as breakthrough and neuropathic pain, requiring further reviews and recommendations. This is an update of the guide our society previously published and represents the continued commitment of SEOM to move forward and improve supportive care of cancer patients.
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Abstract
Opioid analgesia continues to be the primary pharmacologic intervention for managing acute pain and malignant pain in both hospitalized and ambulatory patients. The increasing use of opioids in chronic nonmalignant pain is more problematic. Opioid treatment is complicated with the risks raised by adverse effects, especially cognitive disturbance, respiratory depression but also the risk of tolerance, opioid abuse and drug-disease interactions. Despite the growing number of available opioids within the last years, adequate trials of opioid rotation are lacking and most of the information is anecdotal. This article reviews the clinical evidence surrounding the switch from transdermal buprenorphine to tapentadol in malignant and non-malignant pain. Tapentadol acts on both the μ-opioid receptors (MOR) and on the neuronal reuptake of noradrenaline with a limited usefulness in acute pain management while buprenorphine is a mixed agonist-antagonist, and both present some advantages over other opioids. Both drugs show particular pharmacodynamic and pharmacokinetic properties which reduce the risks of development of tolerance, opioid abuse, diversion and determine fewer hormone changes than the "classical opioids" making these opioids more attractive than other opioids in long term opioid treatment. However, in the absence of powered clinical trials, the evidence to support the method used for transdermal buprenorphine rotation to tapentadol is weak.
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Affiliation(s)
- Adriana Miclescu
- Department of Anaesthesia and Intensive Care, Uppsala University Hospital, Sweden
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Tolerance and cross-tolerance to the antinociceptive effects of oxycodone and the imidazoline I 2 receptor agonist phenyzoline in adult male rats. Psychopharmacology (Berl) 2017; 234:1871-1880. [PMID: 28314949 PMCID: PMC5451304 DOI: 10.1007/s00213-017-4599-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 03/08/2017] [Indexed: 10/19/2022]
Abstract
RATIONALE Emerging evidence suggests the potential utility of combining opioids with imidazoline I2 receptor agonists for chronic pain. However, chronic pain management requires prolonged pharmacotherapy, and the consequence of such combination therapy remains unclear. OBJECTIVE This study examined the anti-hyperalgesic effect of the opioid oxycodone, the selective I2 receptor agonist phenyzoline, alone and in combination, during prolonged treatment. METHODS Von Frey filament test was used to examine the anti-hyperalgesic effect of drugs in complete Freund's adjuvant (CFA)-induced inflammatory pain or chronic constriction injury (CCI)-induced neuropathic pain in rats. Twice-daily treatment with oxycodone and phenyzoline, alone or in combination, was continued until the development of significant tolerance (oxycodone) or as long as 19 days passed (phenyzoline). RESULTS In rats receiving CFA or CCI manipulation, mechanical hyperalgesia was dose-dependently reversed by oxycodone and phenyzoline. Twice-daily treatment with 2 × ED50 dose of oxycodone for 7 days led to significant antinociceptive tolerance to oxycodone but not cross-tolerance to phenyzoline. Similarly, twice-daily treatment with 2 × ED50 dose of phenyzoline for 19 days led to significant antinociceptive tolerance to phenyzoline but not cross-tolerance to oxycodone. Twice-daily treatment with the combined oxycodone and phenyzoline using different ratios (1:3, 1:1 and 3: 1) at the doses that were functionally equivalent to the treatment doses of oxycodone and phenyzoline for 13-19 days generally led to delayed antinociceptive tolerance. CONCLUSIONS Combination therapy with oxycodone and I2 receptor agonists maintains prolonged antinociceptive effectiveness with reduced propensity to develop tolerance.
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Koblish M, Carr R, Siuda ER, Rominger DH, Gowen-MacDonald W, Cowan CL, Crombie AL, Violin JD, Lark MW. TRV0109101, a G Protein-Biased Agonist of the µ-Opioid Receptor, Does Not Promote Opioid-Induced Mechanical Allodynia following Chronic Administration. J Pharmacol Exp Ther 2017; 362:254-262. [PMID: 28533287 DOI: 10.1124/jpet.117.241117] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/19/2017] [Indexed: 02/05/2023] Open
Abstract
Prescription opioids are a mainstay in the treatment of acute moderate to severe pain. However, chronic use leads to a host of adverse consequences including tolerance and opioid-induced hyperalgesia (OIH), leading to more complex treatment regimens and diminished patient compliance. Patients with OIH paradoxically experience exaggerated nociceptive responses instead of pain reduction after chronic opioid usage. The development of OIH and tolerance tend to occur simultaneously and, thus, present a challenge when studying the molecular mechanisms driving each phenomenon. We tested the hypothesis that a G protein-biased µ-opioid peptide receptor (MOPR) agonist would not induce symptoms of OIH, such as mechanical allodynia, following chronic administration. We observed that the development of opioid-induced mechanical allodynia (OIMA), a model of OIH, was absent in β-arrestin1-/- and β-arrestin2-/- mice in response to chronic administration of conventional opioids such as morphine, oxycodone and fentanyl, whereas tolerance developed independent of OIMA. In agreement with the β-arrestin knockout mouse studies, chronic administration of TRV0109101, a G protein-biased MOPR ligand and structural analog of oliceridine, did not promote the development of OIMA but did result in drug tolerance. Interestingly, following induction of OIMA by morphine or fentanyl, TRV0109101 was able to rapidly reverse allodynia. These observations establish a role for β-arrestins in the development of OIH, independent of tolerance, and suggest that the use of G protein-biased MOPR ligands, such as oliceridine and TRV0109101, may be an effective therapeutic avenue for managing chronic pain with reduced propensity for opioid-induced hyperalgesia.
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Horst J, Kharasch ED. Reply to comment on: Pharmacokinetics and analgesic effects of methadone in children and adults with sickle cell disease. Pediatr Blood Cancer 2017; 64. [PMID: 27860157 DOI: 10.1002/pbc.26343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Jennifer Horst
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Evan D Kharasch
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri.,Department of Biochemistry and Biophysics, Washington University in St. Louis, St. Louis, Missouri.,The Center for Clinical Pharmacology, St. Louis College of Pharmacy and Washington University School of Medicine, St. Louis, Missouri
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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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Dima D, Tomuleasa C, Frinc I, Pasca S, Magdo L, Berindan-Neagoe I, Muresan M, Lisencu C, Irimie A, Zdrenghea M. The use of rotation to fentanyl in cancer-related pain. J Pain Res 2017; 10:341-348. [PMID: 28223843 PMCID: PMC5310636 DOI: 10.2147/jpr.s121920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pain is commonly diagnosed with respect to cancer and heart diseases, being a major symptom in most neoplastic diseases. Uncontrolled pain leads to a decrease in the quality of life and an increase in the morbidity of the patient. Opioids represent the best analgetic supportive therapy and are frequently used in patients suffering from cancer and experiencing a high level of pain. Opioid treatment starts with a gradual titration of the dose until the minimum effective dose and the maximum tolerated dose are determined. Opioid rotation refers to the switch from one opioid to another in order to get a better response to analgetic therapy and reduce side effects. Fentanyl therapy is recommended to be continued during chemotherapy, radiotherapy, or in the case of surgical intervention. Rotation to fentanyl patches is an efficient and elegant solution for cancer patients, with reduced side effects. Opioid rotation, especially to fentanyl, was shown to increase the quality of life in patients with malignant disease. Finally, rotation to fentanyl is also advantageous from an economic point of view.
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Affiliation(s)
- Delia Dima
- Department of Hematology, Ion Chiricuta Oncology Institute
| | | | - Ioana Frinc
- Department of Hematology, Ion Chiricuta Oncology Institute
| | - Sergiu Pasca
- Faculty of Medicine, Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Iuliu Hatieganu
| | - Lorand Magdo
- Faculty of Medicine, Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Iuliu Hatieganu
| | - Ioana Berindan-Neagoe
- Faculty of Medicine, Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Iuliu Hatieganu; Department of Functional Genomics, The Oncology Institute Ion Chiricuta; Medfuture Research Center for Advanced Medicine, University of Medicine and Pharmacy, Iuliu Hatieganu
| | - Mihai Muresan
- Department of Surgery, Ion Chiricuta Oncology Institute
| | | | - Alexandru Irimie
- Department of Surgery, Ion Chiricuta Oncology Institute; Department of Oncology, University of Medicine and Pharmacy, Iuliu Hatieganu
| | - Mihnea Zdrenghea
- Department of Hematology, Ion Chiricuta Oncology Institute; Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
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Sathornviriyapong A, Nagaviroj K, Anothaisintawee T. The association between different opioid doses and the survival of advanced cancer patients receiving palliative care. BMC Palliat Care 2016; 15:95. [PMID: 27871265 PMCID: PMC5117570 DOI: 10.1186/s12904-016-0169-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 11/15/2016] [Indexed: 11/16/2022] Open
Abstract
Background Concerns that opioids may hasten death can be a cause of the physicians’ reluctance to prescribe opioids, leading to inadequate symptom palliation. Our aim was to find if there was an association between different opioid doses and the survival of the cancer patients that participated in our palliative care program. Methods A retrospective study was conducted at Ramathibodi Hospital, Bangkok between January 2013 and December 2015. All of the cancer patients that were referred to palliative care teams by their primary physicians were included in the study. The study data included the patients’ demographics, disease status, comorbidities, functional status, type of services, cancer treatments, date of consultation, and the date of the patient’s death or last follow-up. The information concerning opioid use was collected by reviewing the medical records and this was converted to an oral morphine equivalent (OME), following a standard ratio. The time-varying covariate in the Cox regression analysis was applied in order to determine the association between different doses of opioids and patient survival. Results A total of 317 cancer patients were included in the study. The median (IQR) of the OME among our patients was 6.43 mg/day (0.53, 27.36). The univariate Cox regression analysis did not show any association between different opioid doses (OME ≤ 30 mg/day and > 30 mg/day) and the patients’ survival (p = 0.52). The PPS levels (p < 0.01), palliative care clinic visits (HR 0.32, 95%CI 0.24–0.43), home visits (HR 0.75, 95%CI 0.57–0.99), chemotherapy (HR 0.32, 95%CI 0.22–0.46), and radiotherapy (HR 0.53, 95%CI 0.36–0.78) were identified as factors that increased the probability of survival. Conclusions Our study has demonstrated that different opioid doses in advanced cancer patients are not associated with shortened survival period.
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Affiliation(s)
- Anon Sathornviriyapong
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Street, Rajthevi, Bangkok, 10400, Thailand
| | - Kittiphon Nagaviroj
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Street, Rajthevi, Bangkok, 10400, Thailand.
| | - Thunyarat Anothaisintawee
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Street, Rajthevi, Bangkok, 10400, Thailand
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Roeckel LA, Le Coz GM, Gavériaux-Ruff C, Simonin F. Opioid-induced hyperalgesia: Cellular and molecular mechanisms. Neuroscience 2016; 338:160-182. [PMID: 27346146 DOI: 10.1016/j.neuroscience.2016.06.029] [Citation(s) in RCA: 261] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/10/2016] [Accepted: 06/16/2016] [Indexed: 12/18/2022]
Abstract
Opioids produce strong analgesia but their use is limited by a paradoxical hypersensitivity named opioid-induced hyperalgesia (OIH) that may be associated to analgesic tolerance. In the last decades, a significant number of preclinical studies have investigated the factors that modulate OIH development as well as the cellular and molecular mechanisms underlying OIH. Several factors have been shown to influence OIH including the genetic background and sex differences of experimental animals as well as the opioid regimen. Mu opioid receptor (MOR) variants and interactions of MOR with different proteins were shown important. Furthermore, at the cellular level, both neurons and glia play a major role in OIH development. Several neuronal processes contribute to OIH, like activation of neuroexcitatory mechanisms, long-term potentiation (LTP) and descending pain facilitation. Increased nociception is also mediated by neuroinflammation induced by the activation of microglia and astrocytes. Neurons and glial cells exert synergistic effects, which contribute to OIH. The molecular actors identified include the Toll-like receptor 4 and the anti-opioid systems as well as some other excitatory molecules, receptors, channels, chemokines, pro-inflammatory cytokines or lipids. This review summarizes the intracellular and intercellular pathways involved in OIH and highlights some mechanisms that may be challenged to limit OIH in the future.
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Affiliation(s)
- Laurie-Anne Roeckel
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France; Université de Strasbourg, Illkirch, France; Centre National de la Recherche Scientifique, UMR7104, Illkirch, France; Institut National de la Santé et de la Recherche Médicale, U964, Illkirch, France
| | - Glenn-Marie Le Coz
- Biotechnologie et Signalisation Cellulaire, UMR 7242 CNRS, Université de Strasbourg, Illkirch, France
| | - Claire Gavériaux-Ruff
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France; Université de Strasbourg, Illkirch, France; Centre National de la Recherche Scientifique, UMR7104, Illkirch, France; Institut National de la Santé et de la Recherche Médicale, U964, Illkirch, France; Ecole Supérieure de Biotechnologie de Strasbourg, Université de Strasbourg, France
| | - Frédéric Simonin
- Biotechnologie et Signalisation Cellulaire, UMR 7242 CNRS, Université de Strasbourg, Illkirch, France.
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