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Benedetti F, Zoletto S, Salerno A, Avagnina I, Benini F. Old Drug, New Pain. Roles and Challenges of Methadone Therapy in Pediatric Palliative Care: A Systematic Review. Front Pediatr 2022; 10:874529. [PMID: 35712616 PMCID: PMC9196103 DOI: 10.3389/fped.2022.874529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pediatric palliative care (PPC) is defined as the prevention and relief from suffering of families and children with life-limiting (LLDs) or life-threatening diseases (LTDs). These patients often experience pain, with morphine being the most widely used drug to treat it. Few studies investigated the role of methadone in PPC patients, although it is considered among the most effective and underutilized drugs in PPC. OBJECTIVES Our aim was to evaluate the efficacy, safety, and dosage of methadone in PPC. METHODS Between August and October 2021 PubMed, Scopus and the Cochrane Library were searched for studies on the use of methadone in children with LLDs and LTDs. Articles were included if they met the following criteria: published in the last 10 years, English language, patients aged 0-23 years; children enrolled in a PPC center or receiving declared support from a PPC service; reporting of specific data on methadone in interventional trials, observational studies, or case series on >10 patients. The reporting of the article was guided by the PRISMA guidelines, and a critical appraisal of the included studies was performed using the JBI-tool. RESULTS After duplicates removal and full-text assessment, four studies were included and another one was added after checking the references of the retrieved papers. All were retrospective, and the literature is concordant in documenting the lack of evidence. A total of 116 children received methadone in PPC. From our review emerges the poor quality of data collection: in only one study pain was assessed with standardized scales. All studies documented the effectiveness of methadone in treating complex pain, either nociceptive or neuropathic. No serious adverse events were reported, with no cases of cardiac arrhythmias. CONCLUSION Our results suggest that methadone could represent a suitable strategy for treating pain in PPC. However, the evidence base is insufficient, and further research is warranted.
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Affiliation(s)
| | - Silvia Zoletto
- Pediatric Residency Program, University of Padova, Padova, Italy
| | - Annalisa Salerno
- Pediatric Residency Program, University of Padova, Padova, Italy
| | - Irene Avagnina
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Franca Benini
- Pediatric Pain and Palliative Care Service, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
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Li GZ, Hu YH, Li DY, Zhang Y, Guo HL, Li YM, Chen F, Xu J. Vincristine-induced peripheral neuropathy: A mini-review. Neurotoxicology 2020; 81:161-171. [DOI: 10.1016/j.neuro.2020.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/29/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022]
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Fenton C, Lyseng-Williamson KA. Methadone is an option to treat cancer pain in carefully selected patients. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00772-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hall EA, Sauer HE, Habashy C, Anghelescu DL. Methadone for Cancer Pain in Pediatric End-of-Life Care. Am J Hosp Palliat Care 2020; 38:914-919. [PMID: 33000633 DOI: 10.1177/1049909120963641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The goal of adequate pain control becomes increasingly salient for children with cancer and their families as the patients approach the end of life. Methadone is one option that is particularly desirable in end-of-life care given its long duration of action and NMDA antagonism that may help in controlling pain refractory to conventional opioids. The purpose of this study was to describe a single institution's experience with methadone for the treatment of cancer pain in pediatric end-of-life care. METHODS This retrospective, observational, single-center study included all patients during a 9-year period who died in the inpatient setting and were receiving methadone in their last 30 days of life. RESULTS Twenty patients were identified, 18 (90%) of whom received methadone for nociceptive pain. The median duration of methadone use was 32 days (range 2-323 days). Methadone doses ranged from 0.09 to 7.76 mg/kg per day. There were no instances of discontinuing methadone due to an increased QTc interval. No episodes of torsades de pointes were observed. CONCLUSION In patients with pediatric cancer who are nearing the end of life, methadone is a valuable adjunctive therapy to treat nociceptive and neuropathic pain and to prevent opioid-induced hyperalgesia and opioid tolerance. An individualized approach to dosage and route should be considered based on specific clinical circumstances.
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Affiliation(s)
- Elizabeth A Hall
- Department of Pharmaceutical Services, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Hannah E Sauer
- Department of Pharmaceutical Services, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Catherine Habashy
- Division of Quality Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Doralina L Anghelescu
- Anesthesiology Division, Pediatric Medicine Department, St. Jude Children's Research Hospital, Memphis, TN, USA
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Madden K, Jo E, Williams JL, Liu D, Bruera E. Corrected QT Interval Prolongation in Pediatric and Young Adult Patients on Methadone for Cancer-Related Pain. J Pain Symptom Manage 2019; 58:678-684. [PMID: 31195079 DOI: 10.1016/j.jpainsymman.2019.05.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Methadone has been reported to prolong the corrected QT (QTc) interval and increase the risk of torsades de pointes. OBJECTIVES Our study examined the frequency of QTc prolongation among pediatric and young adult patients starting methadone for cancer pain. METHODS All patients followed a standardized protocol. Electrocardiograms (ECGs) were obtained at baseline (methadone starting day to 14 days prior), 1-2 weeks, and 4-6 weeks later. QTc values were manually calculated using the Bazett formula. QTc prolongation was defined as ≥460 milliseconds (ms) for prepubertal children, ≥470 ms for pubertal males, and ≥480 ms for pubertal females. RESULTS Baseline ECGs were completed in 42 patients. Follow-up ECGs were completed in 38 of 42 (91%) and 31 of 42 (74%) patients at 1-2 weeks and 4-6 weeks, respectively. No patients had prolongation of the QTc at baseline, and 1 of 38 (3%) patients had a prolonged QTc at weeks 1-2. This patient had a history of prolonged QTc that the family did not initially report. No patients had prolongation of the QTc at weeks 4-6. No patients had torsades de pointes or ventricular fibrillation, and none died suddenly. Median (interquartile range [IQR]) baseline QTc was 391 (377-400) ms; median (IQR) 1-2 week follow-up QTc was 399 (374-411) ms (P = .05), and median (IQR) 4-6 week follow-up QTc was 393 (379-423) ms (P = .01). CONCLUSION Clinically significant prolongation of the QTc interval occurred only in one patient who had a history of prolonged QTc. Prolonged QTc is rare in this population.
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Affiliation(s)
- Kevin Madden
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA.
| | - Eunji Jo
- Department of Biostatistics, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Janet L Williams
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
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Windsor RB, Tham SW, Adams TL, Anderson A. The Use of Opioids for Treatment of Pediatric Neuropathic Pain: A Literature Review. Clin J Pain 2019; 35:509-514. [PMID: 30985402 DOI: 10.1097/ajp.0000000000000712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pediatric neuropathic pain is caused by a spectrum of disorders that are generally challenging to treat. Many of the underlying altered neurological processes are being elucidated through mechanistic studies. Few randomized control trials have evaluated the use of opioids for the treatment of adult neuropathic pain conditions, and there have been none in pediatric populations. With sparse data to provide guidance and an incomplete understanding of the underlying mechanisms, the use of opioids remains unclear. Our clinical experience and typical risk versus benefit considerations suggest a limited, if any, role for using opioids to treat pediatric neuropathic pain. In this literature review, we review the available adult and pediatric data and provide general guidance on this subject matter.
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Affiliation(s)
- Robert B Windsor
- Departments of Pediatrics and Anesthesiology, University of South Carolina School of Medicine Greenville
- Department of Pediatrics, Children's Hospital of Prisma Health-Upstate, Greenville, SC
| | - See Wan Tham
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA
| | - Trevor L Adams
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA
| | - Annette Anderson
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA
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Abstract
Neuropathic pain in pediatric oncology can be caused by distinct lesions or disease processes affecting the somatosensory system, including chemotherapy-related neuronal injury, solid tumor-related involvement of neural structures, post-surgical neuropathic pain-including phantom limb pain and pain after limb-sparing surgery-and the complex circumstances of neuropathic pain at the end of life. Treatment algorithms reflect the general treatment principles applied for adult neuropathic pain, but the dose regimens applied in children are modest and rarely escalated to the maximum doses to optimize analgesic efficacy. Pharmacological management of neuropathic pain should be based on a stepwise intervention strategy, as combinations of medications are the most effective approach. Gabapentinoids and tricyclic antidepressants are recommended as first-line therapy. Methadone, ketamine, and lidocaine may be useful adjuvants in selected patients. Prospective studies extended over a substantial length of time are recommended because of the nature of neuropathic pain as persistent, chronic pain and based on the need for sufficient time to escalate medication dose regimens to full analgesic efficacy.
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Affiliation(s)
- Doralina L. Anghelescu
- Division of Anesthesia, Department of Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN 38105,Correspondence: doralina.anghelescu@stjude; Tel: 901-595-4035
| | - Jessica Michala Tesney
- Division of Anesthesia, Department of Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN 38105
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Madden K, Liu D, Bruera E. Attitudes, Beliefs, and Practices of Pediatric Palliative Care Physicians Regarding the Use of Methadone in Children With Advanced Cancer. J Pain Symptom Manage 2019; 57:260-265. [PMID: 30447383 DOI: 10.1016/j.jpainsymman.2018.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 11/20/2022]
Abstract
CONTEXT Methadone is a long-acting opioid known for its unique pharmacokinetic and pharmacodynamic properties. Most research on methadone in children is limited to its effect on the prolongation of the corrected QT (QTc) interval. OBJECTIVES To better understand the attitudes, beliefs, and practices of pediatric palliative care physicians regarding the use of methadone in children with advanced cancer. METHODS A survey was sent to the American Academy of Pediatrics Section of Hospice and Palliative Medicine LISTSERV. Information on demographics, dosing of methadone, and the use of electrocardiograms (ECGs) was collected. RESULTS One-hundred and five respondents (91%) provide palliative care to children ≥ 50% of the time, and a majority (81, 77%) prescribe methadone. Most (62, 77%) physicians were board certified in Hospice and Palliative Medicine, and most (39, 63%) certified via the direct pathway ("grandfathering"). Most physicians (57, 70%) do not use loading doses of methadone. Board-certified physicians trended toward decreasing methadone dose more (40% ± 19%) than non-board-certified physicians (28%, ±20%) when changing from the oral to intravenous route (P = 0.07). Respondents defined a QTc interval as "prolonged" (mean ± SD) at 444 milliseconds (±68 milliseconds). The percentage of patients receiving a baseline ECG was 65% (±33%). The most common reason for not performing a baseline ECG was that the patient was on hospice (13, 36%). CONCLUSIONS There are consistent practices, attitudes, and beliefs of pediatric palliative care providers with regard to methadone. More education is needed on the accurate value of a prolonged QTc interval.
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Affiliation(s)
- Kevin Madden
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA.
| | - Diane Liu
- Department of Biostatistics, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA
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Abstract
Methadone is a synthetic opioid with unique pharmacodynamic and pharmacokinetic properties. It is effective in treating both nociceptive and neuropathic pain, which commonly co-exist in children with cancer. Upon reviewing the literature describing the use of methadone in pediatric oncology patients, publications are limited in number and low in quality of evidence; nevertheless, there is support for the safety and efficacy of methadone in treating pain in children with cancer, particularly when pain is refractory to conventional treatment. Although the risk of life-threatening arrhythmia is commonly cited as an argument against the use of methadone, our review of the literature did not support this finding in children. Further evaluation with prospective studies is warranted to develop evidence-based recommendations for the use of methadone in pediatric oncology.
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Mott C, Sarpal A, Moss K, Herbert A. Methadone for Analgesia in Children with Life-Limiting Illness: Experience from a Tertiary Children's Health Service. CHILDREN-BASEL 2018; 5:children5070086. [PMID: 29954057 PMCID: PMC6068960 DOI: 10.3390/children5070086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/20/2018] [Accepted: 06/20/2018] [Indexed: 01/08/2023]
Abstract
Methadone has the potential to assist in the management of pain in children with life-limiting illness, but its use is limited by its complex pharmacokinetic profile and limited research on its use in children. This is a retrospective review of the use of methadone as an analgesic in 16 children with life-limiting illness. Efficacy, dosing and side effect profile were analysed. Fifteen (94%) patients had improvements in their analgesia with minimal observed adverse effects. Patients were either rapidly converted from a prior opioid in one change or received methadone as an adjunct medication. Conversions were calculated using ratios frequently in the range of 10:1 to 20:1 from the oral morphine equivalent total daily dose (MEDD). Adjunct initial dosing was a low dose trial, often beginning with 1 mg at night. Only two patients required a dose adjustment due to side effects attributed to methadone. This was despite the cohort having significant underlying illnesses, extensive concurrent medications, and high methadone dosing where needed. Analysis of dosing and ratios indicates that an individualised approach is required. Based on this and on the infrequency of methadone use in this population, specialist assistance with dosing is recommended. Further research, including prospective and pharmacokinetic studies, is recommended.
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Affiliation(s)
- Christine Mott
- Lady Cilento Children's Hospital, Brisbane 4069, Australia.
| | - Amrita Sarpal
- Children's Hospital London Health Sciences Centre, London, ON N6A 5W9, Canada.
| | - Krista Moss
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK.
| | - Anthony Herbert
- Lady Cilento Children's Hospital, Brisbane 4069, Australia.
- Centre for Children's Health Research at Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane 4069, Australia.
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Madden K, Park M, Liu D, Bruera E. Practices, Attitudes, and Beliefs of Palliative Care Physicians Regarding the Use of Methadone and Other Long-Acting Opioids in Children with Advanced Cancer. J Palliat Med 2018; 21:1408-1413. [PMID: 29893627 DOI: 10.1089/jpm.2017.0670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
BACKGROUND Palliative care physicians often assist with pain management in children with cancer, but little is known about how they use long-acting opioids for chronic pain with these patients. OBJECTIVE To determine the practices, attitudes, and beliefs of palliative care physicians toward the use of long-acting opioids in children with advanced cancer. DESIGN An electronic survey was sent to all members of The American Academy of Pediatrics (AAP) Section of Hospice and Palliative Medicine (SOHPM) and those identified as physicians who provide palliative care to children on the AAP SOHPM LISTSERV®. RESULTS The response rate to the survey was 62% (116/188). A majority (66% [77/116]) of physicians are board certified in both pediatrics and hospice and palliative medicine. This represents 28% of all board-certified pediatric palliative care physicians. Most palliative care physicians report comfort in using long-acting opioids in children (84-94%), with the exception of long-acting hydromorphone (37%). Physicians perceived methadone as least costly (3%) but associated it with a higher perceived family resistance (51%). As compared with pediatric palliative care fellowship-trained physicians, nonpediatric fellowship-trained physicians perceived titration of oxycodone ER and morphine ER to be easier (p = 0.06, p = 0.07) and less likely to agree that the main reason for starting methadone is that the existing formulations of other long-acting opioids are unsuitable for children (p = 0.05). CONCLUSIONS Most physicians who provide palliative care to children are comfortable using opioids but there is significant variation in the level of comfort with different opioids. This information will be helpful in developing targeted education for palliative care providers.
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Affiliation(s)
- Kevin Madden
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas , M.D. Anderson Cancer Center, Houston, Texas
| | - Minjeong Park
- 2 Department of Biostatistics, University of Texas , M.D. Anderson Cancer Center, Houston, Texas
| | - Diane Liu
- 2 Department of Biostatistics, University of Texas , M.D. Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas , M.D. Anderson Cancer Center, Houston, Texas
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Madden K, Mills S, Dibaj S, Williams JL, Liu D, Bruera E. Methadone as the Initial Long-Acting Opioid in Children with Advanced Cancer. J Palliat Med 2018; 21:1317-1321. [PMID: 29664690 DOI: 10.1089/jpm.2017.0712] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Methadone is an attractive medication for treating children with advanced cancer with pain as it is the only long-acting opioid available as a liquid. However, it is not frequently used due to concerns about potential toxicities and side effects. OBJECTIVE Evaluate the efficacy and safety of methadone as the first long-acting opioid in children with advanced cancer. DESIGN Retrospective chart review of 52 consecutive patients referred to Pediatric Supportive Care for pain management started on methadone as their first long-acting opioid. Data collected at baseline, follow-up visits #1 (F1) and #2 (F2) included child and parent-reported outcomes for various physical and psychological symptoms, opioid side effects and other clinical data. Symptoms were rated on a 0 (not at all) to 4 (a lot) scale. RESULTS Pain (mean ± standard deviation [SD]) scored by the child was 3.6 (±0.6)/4 at baseline and 1.8 (±1.1)/4 at F1 (p < 0.0001). Compared to baseline, pain scored by the child at F2 was 1.2 (±1.3)/4 (p < 0.0001). Pain scored by the parent was 3.5 (±0.7)/4 at baseline and 1.4 (±1.3)/4 at F1 (p < 0.0001). Compared to baseline, pain scored by the parent at F2 was 1.0 (±1.2)/4 (p < 0.0001). Thirty-three (70%) patients at F1 and 23 (79%) patients at F2 did not need a change in dose of methadone. No cardiac arrhythmias or opioid neurotoxicity was observed. CONCLUSIONS Initiation of methadone was effective and safe as the first long-acting opioid in children with pain.
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Affiliation(s)
- Kevin Madden
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Sarah Mills
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas.,2 Department of Palliative Care, Dell Seton Medical Center, The University of Texas , Austin, Texas
| | - Seyedeh Dibaj
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas.,3 Department of Biostatistics, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Janet L Williams
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Diane Liu
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas.,3 Department of Biostatistics, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Eduardo Bruera
- 1 Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas
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Heath TS, Greenberg RG, Hupp SR, Turner DA, Hornik CP, Zimmerman KO. Effects of Methadone on Corrected Q-T Interval Prolongation in Critically Ill Children. J Pediatr Pharmacol Ther 2018; 23:119-124. [PMID: 29720913 DOI: 10.5863/1551-6776-23.2.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aimed to determine the association between methadone use and corrected Q-T interval (QTc) prolongation in critically ill children. METHODS A retrospective cohort study of critically ill children receiving methadone at a tertiary care pediatric hospital was conducted. Patients younger than 19 years who had been admitted to the intensive care unit between January 1, 2009, and June 21, 2013, who had received methadone while inpatients, and who had had electrocardiograms (ECGs) performed within 30 days before and after methadone initiation were included. The primary outcome was the net change in QTc interval between baseline and postmethadone ECGs. Secondary outcomes included percent change in QTc interval and the proportion of patients whose QTc intervals changed from normal to prolonged following methadone initiation. We also evaluated potential predictors of QTc interval prolongation, including age, sex, admission diagnosis category, exposure to other QTc-prolonging medications, presence of congenital heart disease or known arrhythmias, and methadone daily dose and route of administration. RESULTS Sixty-four patients met the inclusion criteria. The median (25th, 75th percentiles) change in QTc interval following methadone initiation was -8 msec (-34, 13.5 msec; p = 0.19). Five patients (8%) had a baseline normal QTc interval that became prolonged after methadone initiation. We identified no statistically significant predictors of QTc prolongation after methadone initiation. CONCLUSIONS In this dedicated pediatric safety study, methadone initiation did not result in prolongation of the QTc interval. Although these findings suggest methadone initiation may not have a substantial effect of QTc prolongation in critically ill children, a controlled, prospective evaluation in this population remains warranted.
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Madden K, Park M, Liu D, Bruera E. The frequency of QTc prolongation among pediatric and young adult patients receiving methadone for cancer pain. Pediatr Blood Cancer 2017; 64. [PMID: 28449209 DOI: 10.1002/pbc.26614] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 03/08/2017] [Accepted: 03/27/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION A prolonged corrected QT (QTc) interval in pediatric patients is defined as ≥470 msec. Methadone can cause a prolonged QTc interval that can lead to ventricular arrhythmias. The risk of methadone-induced prolongation of the QTc interval in children and young adults is unknown. The purpose of the study was to determine the frequency of QTc prolongation among pediatric and young adult patients with cancer pain on methadone treatment. METHODS We retrospectively reviewed data for all patients on methadone during the study period. Qualifying patient data were reviewed to determine whether these patients had an electrocardiogram (ECG) while on methadone. The QTc values for analysis were manually calculated using the standard formula described by Bazett. RESULTS Twenty-five patients were identified that met eligibility criteria. The median QTc decreased from baseline after initiation of methadone. QTc prolongation occurred in four of 25 (16%) patients and only one patient had a QTc greater than 500 msec. This patient had 17 normal QTc intervals on methadone prior to the prolongation. After resolution of electrolyte abnormalities, six subsequent ECGs on methadone had a normal QTc interval. CONCLUSIONS Prolongation of the QTc interval is infrequent. The only observed case was transient during multiple comorbid conditions. A prospective study is justified to better understand what role methadone plays as one of many risk factors for prolongation of the QTc interval in children and young adults.
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Affiliation(s)
- Kevin Madden
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Minjeong Park
- Department of Biostatistics, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Diane Liu
- Department of Biostatistics, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas
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