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Chary S, Abdul-Razzak A, Galloway L. Ultralow-Dose Adjunctive Methadone with Slow Titration, Considering Long Half-Life, for Outpatients with Cancer-Related Pain. Palliat Med Rep 2021; 1:119-123. [PMID: 34223466 PMCID: PMC8241322 DOI: 10.1089/pmr.2020.0034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The unique properties of methadone make it attractive for use in cancer pain. The use of very low initial doses of adjunctive methadone is a promising strategy given its simplicity and potentially reduced risk profile. Objective: To understand if an ultralow-dose (ULD) methadone protocol (1 mg by mouth daily initial dose with gradual titration) can improve pain control in outpatients with cancer-related pain not responsive to previous opioids and/or nonopioid analgesics. We also sought to assess if the use of ULD methadone resulted in improvement in mood and sleep among other outcomes. Design and Setting/Subjects: This study is a retrospective chart review of outpatients at the cancer pain clinic at the Tom Baker Cancer Centre in Calgary, Alberta, Canada. Measurements: The mean ratings in maximum and average pain before methadone initiation, and at the final follow-up point are reported. Paired sample t tests evaluate for statistically significant differences in pain ratings before methadone initiation and at final follow-up. We also report the proportion of participants with a subjective improvement in pain, sleep, and mood (dichotomous “yes/no”), and the mean number of weeks to initial documented pain improvement. Results: 68.6% of patients (24/34) reported a subjective improvement in pain. Most patients reported improved sleep and mood (78.8% and 64.7%, respectively). Conclusions: More than two-thirds of patients reported an improvement in pain with a protocol using very low initial doses of adjunctive methadone. Our report is a preliminary retrospective chart review and larger prospective trials are warranted.
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Affiliation(s)
- Srini Chary
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Amane Abdul-Razzak
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Lyle Galloway
- Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada
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Lombardi N, Crescioli G, Maggini V, Ippoliti I, Menniti-Ippolito F, Gallo E, Brilli V, Lanzi C, Mannaioni G, Firenzuoli F, Vannacci A. Acute liver injury following turmeric use in Tuscany: An analysis of the Italian Phytovigilance database and systematic review of case reports. Br J Clin Pharmacol 2020; 87:741-753. [PMID: 32656820 DOI: 10.1111/bcp.14460] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Several cases of acute non-infectious cholestatic hepatitis recently appeared in Italy following consumption of Curcuma longa-containing dietary supplements. The aim of this research was to describe the Tuscan (Italy) cases of acute hepatitis and to compare them with similar cases of hepatotoxicity published in the literature by performing a systematic review. METHODS Records of Tuscan cases of acute hepatitis were obtained from the Italian Phytovigilance system. Each spontaneous report was analysed in order to collect all relevant clinical information of patients and information concerning the Curcuma longa-containing dietary supplement. Moreover, both the RUCAM and WHO-UMC systems were used to evaluate the causal relationship between the use of dietary supplement and acute hepatitis. A systematic literature review was performed in MEDLINE and Embase and all case-reports and case-series published in English were included. RESULTS Seven cases of acute hepatitis occurring in Tuscany up to September 2019 are described. In all cases, hepatotoxicity was associated with Curcuma longa formulations with high bioavailability and high dosage of curcumin/curcuminoids. The causal relationship was also supported by the positive dechallenge observed in most cases. In the 23 cases identified through the systematic review, the majority of patients were concomitantly exposed to at least one other medication and 16 of them experienced a positive dechallenge. CONCLUSIONS Within the frame of poorly controlled and regulated products, such as dietary supplements, the evaluation of Italian cases of Curcuma longa-induced acute hepatitis and the systematic review of literature confirmed the association between Curcuma longa and liver injury.
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Affiliation(s)
- Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Valentina Maggini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,CERFIT, Research and Innovation Center in Phytotherapy and Integrated Medicine, Referring Center for Phytotherapy, Tuscany Region, Careggi University Hospital, Florence, Italy
| | - Ilaria Ippoliti
- National Centre for Drug Research and Evaluation, National Institute of Health, Rome, Italy
| | | | - Eugenia Gallo
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,CERFIT, Research and Innovation Center in Phytotherapy and Integrated Medicine, Referring Center for Phytotherapy, Tuscany Region, Careggi University Hospital, Florence, Italy
| | - Valentina Brilli
- Toxicology Unit and Poison Centre, Careggi University Hospital, Florence, Italy
| | - Cecilia Lanzi
- Toxicology Unit and Poison Centre, Careggi University Hospital, Florence, Italy
| | - Guido Mannaioni
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy.,Toxicology Unit and Poison Centre, Careggi University Hospital, Florence, Italy
| | - Fabio Firenzuoli
- CERFIT, Research and Innovation Center in Phytotherapy and Integrated Medicine, Referring Center for Phytotherapy, Tuscany Region, Careggi University Hospital, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
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Smith MA, Quirk KC, Saul DC, Rodgers PE, Silveira MJ. Comparing Methadone Rotation to Consensus Opinion. J Pain Symptom Manage 2020; 59:116-120. [PMID: 31560968 DOI: 10.1016/j.jpainsymman.2019.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Methadone is a complex but useful medication for pain management in palliative care. Recent expert opinions have been published on the safe and effective use of methadone. OBJECTIVES To determine the success of methadone rotations and evaluate concordance with consensus recommendations by a palliative care consult service. METHODS A retrospective study of methadone rotation practice by a palliative care consult service and outcomes for patients hospitalized between January 1, 2012 and December 31, 2018 at a single academic medical center. A successful rotation was defined as a 30% reduction in pain or as-needed medication use sustained for at least three consecutive days. Patient outcomes were compared with expert consensus recommendations. RESULTS About 59 patients met the inclusion criteria. The study population was mostly Caucasian men and women of equal proportions who were started on methadone for inadequate pain control. Sixty-eight percent of patients were successfully rotated. Subjects who were rotated using a standardized protocol were six times more likely to have a successful rotation (odds ratio 6.28 [1.25-30.92]; P = 0.0238). CONCLUSION The utilization of a standardized protocol was associated with better patient outcomes.
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Affiliation(s)
- Michael A Smith
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA; University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA.
| | - Kyle C Quirk
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA; University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - D'Anna C Saul
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA; Department of Pediatrics, Ann Arbor, Michigan, USA
| | - Phillip E Rodgers
- Department of Family Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Maria J Silveira
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
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4
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Schuster M, Bayer O, Heid F, Laufenberg-Feldmann R. Opioid Rotation in Cancer Pain Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:135-142. [PMID: 29563006 PMCID: PMC5876542 DOI: 10.3238/arztebl.2018.0135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 07/11/2016] [Accepted: 11/14/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Rotating several different WHO level III opioid drugs is a therapeutic option for patients with chronic cancer-related pain who suffer from inadequate analgesia and/or intolerable side effects. The evidence favoring opioid rotation is controversial, and the current guidelines in Germany and other countries contain only weak recommendations for it. METHODS This review is based on pertinent publications retrieved by a systematic review of the literature on opioid rotation for adult patients with chronic cancerrelated pain who are regularly taking WHO level III opioids by the oral or trans - dermal route. RESULTS 9 individual studies involving a total of 725 patients were included in the analysis, and 3 previous systematic reviews of studies involving a total of 2296 patients were also analyzed. Morphine, oxycodone, fentanyl, hydromorphone, and buprenorphine were used as first-line opioid drugs, and hydromorphone, bupre - norphine, tapentadol, fentanyl, morphine, oxymorphone, and methadone were used as second-line opioid drugs. In all of the studies, pain control was achieved for 14 days after each rotation. In most of them, the dose of the new drug introduced in each rotation needed to be increased above the dose initially calculated from a rotation ratio, with the exception of rotations to methadone. The frequency of side effects was only rarely lessened, but patients largely considered the result of opioid rotation to be positive. No particular opioid drug was found to be best. CONCLUSION Opioid rotation can improve analgesia and patient satisfaction. The success of opioid rotation appears to depend on the magnitude of the initial dose, among other factors. Tables of equianalgesic doses should be considered no more than a rough guide for determining the dose of the new drug. Rotations to methadone should be carried out under clinical supervision in experienced hands.
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Affiliation(s)
| | - Oliver Bayer
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Hospital Mainz
| | - Florian Heid
- Department of Anesthesiology, University Hospital Mainz
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5
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Carvalho AC, Sebold FJG, Calegari PMG, Oliveira BHD, Schuelter-Trevisol F. [Comparison of postoperative analgesia with methadone versus morphine in cardiac surgery]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2018; 68:122-127. [PMID: 29096877 PMCID: PMC9391719 DOI: 10.1016/j.bjane.2017.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 06/22/2017] [Accepted: 09/26/2017] [Indexed: 08/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Pain is an aggravating factor of postoperative morbidity and mortality. The aim of this study was to compare the effects of methadone versus morphine using the numerical rating scale of pain and postoperative on-demand analgesia in patients undergoing myocardial revascularization. METHOD A randomized, double-blind, parallel clinical trial was performed with patients undergoing coronary artery bypass grafting. The subjects were randomly divided into two groups: morphine group and methadone group. At the end of cardiac surgery, 0.1 mg.kg−1 adjusted body weight of methadone or morphine was administered intravenously. Patients were referred to the ICU, where the following was assessed: extubation time, time to first analgesic request, number of analgesic and antiemetic drug doses within 36 h, numerical pain scale at 12, 24, and 36 h postoperatively, and occurrence of adverse effects. RESULTS Each group comprised 50 patients. Methadone showed 22% higher efficacy than morphine as it yielded a number-needed-to-treat score of 6 and number-needed-to-harm score of 16. The methadone group showed a mean score of 1.9 ± 2.2 according to the numerical pain scale at 24 h after surgery, whereas as the morphine group showed a mean score of 2.9 ± 2.6 (p = 0.029). The methadone group required less morphine (29%) than the morphine group (43%) (p = 0.002). However, the time to first analgesic request in the postoperative period was 145.9 ± 178.5 min in the methadone group, and 269.4 ± 252.9 in the morphine group (p = 0.005). CONCLUSIONS Methadone was effective for analgesia in patients undergoing coronary artery bypass grafting without extracorporeal circulation.
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Affiliation(s)
- Ana Carolina Carvalho
- Universidade do Sul de Santa Catarina (Unisul), Curso de Medicina, Campus Tubarão, Tubarão, SC, Brasil
| | | | | | | | - Fabiana Schuelter-Trevisol
- Universidade do Sul de Santa Catarina (Unisul), Programa de Pós-Graduação em Ciências da Saúde, Tubarão, SC, Brasil; Hospital Nossa Senhora da Conceição (HNSC), Centro de Pesquisas Clínicas, Tubarão, SC, Brasil.
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Comparação da analgesia pós‐operatória com uso de metadona versus morfina em cirurgia cardíaca. Braz J Anesthesiol 2018; 68:122-127. [DOI: 10.1016/j.bjan.2017.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 06/22/2017] [Accepted: 09/26/2017] [Indexed: 11/20/2022] Open
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Sunilkumar MM, Lockman K. Practical Pharmacology of Methadone: A Long-acting Opioid. Indian J Palliat Care 2018; 24:S10-S14. [PMID: 29497249 PMCID: PMC5806300 DOI: 10.4103/ijpc.ijpc_180_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Methadone is a naturally long-acting analgesic with unique pharmacodynamic and pharmacokinetic properties compared to other opioids, available now in India, to treat severe pain. It has the potential to dramatically relieve suffering among patients with serious illness who are living with persistent physical pain. However, clinicians must appreciate its unique pharmacologic properties and its use in clinical practice safely and effectively. The available formulation in India is a racemic mixture of the S- and R-enantiomers, and as such, it will have a propensity for drug-drug and drug-genetic interactions that can increase the risk of Torsades de Point and respiratory depression. Appropriate patient selection, careful dosing and thorough monitoring of methadone will mitigate these risks.
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Affiliation(s)
- M M Sunilkumar
- Department of Pain and Palliative Medicine, Trivandrum Institute of Palliative Sciences, WHO Collaborating Centre for Training and Policy on Access to Pain Relief, Thiruvananthapuram, Kerala, India
| | - Kashelle Lockman
- Department of Pharmacy Practice and Science, University of Iowa, College of Pharmacy, Iowa City, IA 52242, USA
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Peirano GP, Mammana GP, Bertolino MS, Pastrana T, Vega GF, Russo J, Varela G, Vignaroli E, Ruggiero R, Armesto A, Camerano G, Dran G. Methadone as first-line opioid treatment for cancer pain in a developing country palliative care unit. Support Care Cancer 2016; 24:3551-6. [PMID: 27022964 DOI: 10.1007/s00520-016-3191-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/21/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The use of methadone for cancer pain is limited by the need of expertise and close titration due to variable half-life. Yet, it is a helpful palliative strategy in low-resources countries given its long-acting effect at low cost and worth additional study. Our aim was to describe the prescription and outcomes of methadone as a first-line treatment for cancer pain in a tertiary palliative care unit (PCU) in Argentina. METHODS Retrospective review of medical records of patients with moderate to severe cancer pain seen at the PCU in 1-year period, who initiated strong opioids at the first consultation. Data collected during the first month of treatment included disease and pain characteristics, initial and final opioid type and dose and need for opioid rotation. RESULTS Methadone was the most frequent opioid both at the initial and last assessment (71 and 66 % of the prescriptions). In all, treatment with strong opioids provided considerable decrease in pain intensity (p < 0.001) with low and stable opioid dose. Median and interquartile range (IR) of oral morphine equivalent daily dose (OMEDD) was 26 (16-32) and 39 (32-55) mg for initial and final assessments, respectively (p = 0.3). In patients initiated with methadone, the median (IR) daily methadone dose was 5 (4-6) mg at first and 7.5 (6-10) mg at final assessment, and the median (IR) index of opioid escalation was 0 (0-4) mg; (p < 0.05). Patients on methadone underwent less percentage of opioid rotation (15 versus 50 %; p < 0.001) and longer time to rotation (20.6 ± 4.4 versus 9.0 ± 2.7 days; p < 0.001) than patients on other opioids. CONCLUSIONS Results indicate the preference of methadone as first-line strong opioid treatment in a PCU, providing good pain relief at low doses with low need for rotation. Several considerations about the costs of strong opioids in the region are given.
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Affiliation(s)
- Gabriela P Peirano
- Unidad de Cuidados Paliativos- Fundación Femeba, Hospital General de Agudos Dr. Enrique Tornú, Combatientes de Malvinas 3002, 1427, Buenos Aires, Argentina
| | - Guillermo P Mammana
- Unidad de Cuidados Paliativos- Fundación Femeba, Hospital General de Agudos Dr. Enrique Tornú, Combatientes de Malvinas 3002, 1427, Buenos Aires, Argentina
| | - Mariela S Bertolino
- Unidad de Cuidados Paliativos- Fundación Femeba, Hospital General de Agudos Dr. Enrique Tornú, Combatientes de Malvinas 3002, 1427, Buenos Aires, Argentina
| | - Tania Pastrana
- Palliative Medicine, University of Aachen, Aachen, Germany
| | - Gloria F Vega
- Unidad de Cuidados Paliativos- Fundación Femeba, Hospital General de Agudos Dr. Enrique Tornú, Combatientes de Malvinas 3002, 1427, Buenos Aires, Argentina
| | - Jorgelina Russo
- Unidad de Cuidados Paliativos- Fundación Femeba, Hospital General de Agudos Dr. Enrique Tornú, Combatientes de Malvinas 3002, 1427, Buenos Aires, Argentina
| | - Gabriela Varela
- Unidad de Cuidados Paliativos- Fundación Femeba, Hospital General de Agudos Dr. Enrique Tornú, Combatientes de Malvinas 3002, 1427, Buenos Aires, Argentina
| | - Ernesto Vignaroli
- Unidad de Cuidados Paliativos- Fundación Femeba, Hospital General de Agudos Dr. Enrique Tornú, Combatientes de Malvinas 3002, 1427, Buenos Aires, Argentina
| | - Raúl Ruggiero
- Laboratorio de Oncología Experimental, Instituto de Medicina Experimental IMEX-CONICET-Academia Nacional De Medicina, José Andrés Pacheco de Melo 3081. C1425AUM, Ciudad Autónoma de Buenos Aires, Argentina
| | - Arnaldo Armesto
- Department of Pharmacology, School of Medicine-University of Buenos Aires, Paraguay 2155, Ciudad Autónoma de Buenos Aires, C1121ABG, Buenos Aires, Argentina
| | - Gabriela Camerano
- Laboratorio de Oncología Experimental, Instituto de Medicina Experimental IMEX-CONICET-Academia Nacional De Medicina, José Andrés Pacheco de Melo 3081. C1425AUM, Ciudad Autónoma de Buenos Aires, Argentina
| | - Graciela Dran
- Laboratorio de Oncología Experimental, Instituto de Medicina Experimental IMEX-CONICET-Academia Nacional De Medicina, José Andrés Pacheco de Melo 3081. C1425AUM, Ciudad Autónoma de Buenos Aires, Argentina.
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McLean S, Twomey F. Methods of Rotation From Another Strong Opioid to Methadone for the Management of Cancer Pain: A Systematic Review of the Available Evidence. J Pain Symptom Manage 2015; 50:248-59.e1. [PMID: 25896106 DOI: 10.1016/j.jpainsymman.2015.02.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 02/10/2015] [Accepted: 02/18/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Up to 44% of patients with cancer-related pain require opioid rotation (OR) because of inadequate analgesia or side effects. No consensus exists regarding the most efficacious method for rotation to methadone. OBJECTIVES To define the available evidence regarding methods of rotation to methadone and to determine if sufficient evidence exists regarding the superiority of one method. METHODS A predefined search strategy, using Medical Subject Headings (MeSH) search terms and keywords combined using Boolean operators, was performed. Study selection was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. Data were extracted, quality of studies assessed, and narrative synthesis undertaken. RESULTS A total of 3214 potentially relevant studies were identified. Twenty-five studies were included: 15 retrospective and 10 prospective (n = 1229). One trial compared three-day switch (3DS) and rapid conversion (RC) methods; two, 3DS; 10, RC; nine, ad libitum (AL). Success rates were as follows: 3DS-93%, RC-71.7%, and AL-92.8%. The single clinical trial and retrospective studies demonstrated poorer analgesia and an excess of adverse events (AEs) in the RC group (five dropouts because of AEs) compared with the 3DS group (no severe AEs). Time to stable analgesia was as follows: RC <4.3 days and AL <6 days. CONCLUSION Evidence identified was mainly from uncontrolled observational studies, making causality difficult to establish. Studies were heterogeneous in methodology and outcome measures. There was a trend toward excess AEs using the RC method, in comparison to the AL and 3DS methods. The methodological quality of the AL studies was low. A direct comparison of AL and 3DS methods would be informative.
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Affiliation(s)
- Sarah McLean
- Our Lady's Hospice and Care Services, Blackrock Hospice, Dublin, Ireland.
| | - Feargal Twomey
- Milford Hospice and University Hospital Limerick, Limerick, Ireland
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10
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Pharmacological options for the management of refractory cancer pain—what is the evidence? Support Care Cancer 2015; 23:1473-81. [DOI: 10.1007/s00520-015-2678-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 02/22/2015] [Indexed: 01/30/2023]
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Riley J, Branford R, Droney J, Gretton S, Sato H, Kennett A, Oyebode C, Thick M, Wells A, Williams J, Welsh K, Ross J. Morphine or oxycodone for cancer-related pain? A randomized, open-label, controlled trial. J Pain Symptom Manage 2015; 49:161-72. [PMID: 24975432 DOI: 10.1016/j.jpainsymman.2014.05.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 05/19/2014] [Accepted: 05/28/2014] [Indexed: 11/28/2022]
Abstract
CONTEXT There is wide interindividual variation in response to morphine for cancer-related pain; 30% of patients do not have a good therapeutic outcome. Alternative opioids such as oxycodone are increasingly being used, and opioid switching has become common clinical practice. OBJECTIVES To compare clinical response to oral morphine vs. oral oxycodone when used as first-line or second-line (after switching) treatment in patients with cancer-related pain. METHODS In this prospective, open-label, randomized, controlled trial (ISRCTN65155201) with a selected crossover phase, patients with cancer-related pain were randomized to receive either oral morphine or oxycodone as first-line treatment. Dose was individually titrated until the patient reported adequate pain control. Patients who did not respond to the first-line opioid (either because of inadequate analgesia or unacceptable adverse effects) were switched to the alternative opioid. RESULTS Two hundred patients were recruited. On intention-to-treat analysis (n = 198, morphine 98, oxycodone 100), there was no significant difference between the numbers of patients responding to morphine (61/98 = 62%) or oxycodone (67/100 = 67%) when used as a first-line opioid. Similarly, there was no significant difference in subsequent response when patients were switched to either morphine (8/12 = 67%) or oxycodone (11/21 = 52%). Per-protocol analysis demonstrated a 95% response rate when both opioids were available. There was no difference in adverse reaction scores between morphine and oxycodone either in first-line responders or nonresponders. CONCLUSION In this population, there was no difference between analgesic response or adverse reactions to oral morphine and oxycodone when used as a first- or second-line opioid. These data provide evidence to support opioid switching to improve outcomes.
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Affiliation(s)
- Julia Riley
- Royal Marsden NHS Foundation Trust, London, United Kingdom; National Heart & Lung Institute, Imperial College London, London, United Kingdom.
| | - Ruth Branford
- Royal Marsden NHS Foundation Trust, London, United Kingdom; National Heart & Lung Institute, Imperial College London, London, United Kingdom; St. Joseph's Hospice, London, United Kingdom
| | - Joanne Droney
- Royal Marsden NHS Foundation Trust, London, United Kingdom; National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Sophy Gretton
- Royal Marsden NHS Foundation Trust, London, United Kingdom; National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Hiroe Sato
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Alison Kennett
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Michael Thick
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Athol Wells
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - John Williams
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Ken Welsh
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Joy Ross
- Royal Marsden NHS Foundation Trust, London, United Kingdom; National Heart & Lung Institute, Imperial College London, London, United Kingdom
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Poulain P, Michenot N, Delorme T, Filbet M, Hubault P, Jovenin N, Rostaing S, Colin E, Chvetsoff G, Ammar D, Delorme C, Diquet B, Krakowski I, Magnet M, Minello C, Morere JF, Serrie A. Mise au point sur l’utilisation pratique de la méthadone dans le cadre des douleurs en oncologie. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.douler.2014.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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13
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Taberna M, Villavicencio-Chávez C, González-Barboteo J. [Use of methadone in the elderly with cancer pain: a systematic review]. Rev Esp Geriatr Gerontol 2014; 49:129-136. [PMID: 24457178 DOI: 10.1016/j.regg.2013.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/07/2013] [Accepted: 08/30/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To identify the clinical use of methadone as an analgesic in the management of cancer pain in elderly patients. MATERIAL AND METHODS We performed a systemic review of the literature on the specific use of methadone in elderly with cancer pain in MEDLINE, COCHRANE DATABASE and SCOPUS. A second search was conducted in MEDLINE to look for clinical trials and systematic review of the use of methadone in cancer pain, selecting only those in which the mean age of patients was ≥ 65 years old. RESULTS Four articles were obtained in the first search, and from the second 7 clinical trials, none of them specific to methadone use in elderly patients with cancer. CONCLUSIONS There are insufficient data on the use of methadone as an analgesic in the elderly with cancer. Given its pharmacological characteristics it must be used by trained personnel. Several recommendations are proposed for its use as an analgesic in the treatment of cancer pain in the elderly.
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Affiliation(s)
- Miren Taberna
- Servicio de Oncología Médica, Institut Català d́Oncologia, Hospital Duràn i Reynals, L'Hospitalet de Llobregat, Barcelona, España
| | - Christian Villavicencio-Chávez
- Servicio de Cuidados Paliativos, Institut Català d́Oncologia, Hospital Duràn i Reynals, L'Hospitalet de Llobregat, Barcelona, España; Grup de Cures Pal·liatives, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España; Facultat de Medicina, Universitat Internacional de Catalunya, Barcelona, España
| | - Jesús González-Barboteo
- Servicio de Cuidados Paliativos, Institut Català d́Oncologia, Hospital Duràn i Reynals, L'Hospitalet de Llobregat, Barcelona, España; Grup de Cures Pal·liatives, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España; Càtedra de Cures Pal·liatives-Centre d'Estudis Sanitaris i Socials, Universitat de Vic, Vic, España; Comisión de Oncogeriatría, Institut Català d́Oncologia, Hospital Duràn i Reynals, L'Hospitalet de Llobregat, Barcelona, España.
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Drewes AM, Jensen RD, Nielsen LM, Droney J, Christrup LL, Arendt-Nielsen L, Riley J, Dahan A. Differences between opioids: pharmacological, experimental, clinical and economical perspectives. Br J Clin Pharmacol 2013; 75:60-78. [PMID: 22554450 DOI: 10.1111/j.1365-2125.2012.04317.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Clinical studies comparing the response and side effects of various opioids have not been able to show robust differences between drugs. Hence, recommendations of the regulatory authorities have been driven by costs with a general tendency in many countries to restrict physician's use of opioids to morphine. Although this approach is recognized as cost-effective in most cases there is solid evidence that, on an individual patient basis, opioids are not all equal. Therefore it is important to have an armamentarium of strong analgesics in clinical practice to ensure a personalized approach in patients who do not respond to standard treatment. In this review we highlight differences between opioids in human studies from a pharmacological, experimental, clinical and health economics point of view. We provide evidence that individuals respond differently to opioids, and that general differences between classes of opioids exist. We recommend that this recognition is used to individualize treatment in difficult cases allowing physicians to have a wide range of treatment options. In the end this will reduce pain and side effects, leading to improved quality of life for the patient and reduce the exploding pain related costs.
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Affiliation(s)
- Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
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15
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Recent Literature Feature Editor: Paul C. Rousseau. J Palliat Med 2012. [DOI: 10.1089/jpm.2012.9575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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