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Mercadante S. Methadone for Cancer Pain Management in Children: A Review of Literature. Drugs 2024; 84:203-208. [PMID: 38324240 DOI: 10.1007/s40265-024-02001-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
Pain associated with cancer is a common feature among children and adolescents. Among opioids, methadone is a unique drug for its multiple mechanisms of action. Methadone is currently underutilized in children. The use of methadone for cancer pain management in children was assessed in a systematic review. Altogether, 141 children receiving methadone were examined, and another 126 children were assessed for QT prolongation. In the clinical studies, modalities of use, dosing, and duration of assessment were highly variable. In general, methadone was effective and well tolerated with a limited tendency for dose increases. QT prolongation was reported in a percentage of patients independently of the dosages or other variables. The majority of studies considered the use of methadone to be safe and effective in children. Despite methadone possessing interesting properties that make this drug unique in a pediatric context, data is limited, and the literature available is based on retrospective studies. Methadone could be an effective, inexpensive, and versatile medication in children with cancer who have pain. This drug deserves more interest and should prompt studies of better quality with a larger number of patients.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
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2
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Einhorn LM, Hudon J, Ingelmo P. The Pharmacological Treatment of Neuropathic Pain in Children. Curr Neuropharmacol 2024; 22:38-52. [PMID: 37539933 DOI: 10.2174/1570159x21666230804110858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/22/2023] [Accepted: 03/12/2023] [Indexed: 08/05/2023] Open
Abstract
The International Association for the Study of Pain (IASP) defines neuropathic pain as pain caused by a lesion or disease of the somatosensory nervous system. It is characterized as a clinical condition in which diagnostic studies reveal an underlying cause of an abnormality in the peripheral or central nervous system. Many common causes of neuropathic pain in adults are rare in children. The purpose of this focused narrative review is, to 1) provide an overview of neuropathic pain in children, 2) highlight unique considerations related to the diagnosis and mechanisms of neuropathic pain in children, and 3) perform a comprehensive analysis of the pharmacological treatments available. We emphasize that data for routine use of pharmacological agents in children with neuropathic pain are largely inferred from adult literature with little research performed on pediatric populations, yet have clear evidence of harms to pediatric patients. Based on these findings, we propose risk mitigation strategies such as utilizing topical treatments whenever possible, assessing pain phenotyping to guide drug class choice, and considering pharmaceuticals in the broader context of the multidisciplinary treatment of pediatric pain. Furthermore, we highlight important directions for future research on pediatric neuropathic pain treatment.
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Affiliation(s)
- Lisa M Einhorn
- Department of Anesthesiology, Pediatric Division, Duke University School of Medicine, Durham, North Carolina, United States
| | - Jonathan Hudon
- Division of Secondary Care, Department of Family Medicine, McGill University Health Centre, Montreal, Qc, Canada
- Palliative Care Division, Jewish General Hospital, Montreal, Qc, Canada
- Alan Edwards Pain Management Unit, Montreal General Hospital, McGill University Health Center, Montreal, Qc, Canada
- Alan Edwards Centre for Pain Research, McGill University, Montreal, Canada
- Edwards Family Interdisciplinary Centre for Complex Pain, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada
| | - Pablo Ingelmo
- Alan Edwards Centre for Pain Research, McGill University, Montreal, Canada
- Edwards Family Interdisciplinary Centre for Complex Pain, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada
- Research Institute of the McGill University Health Center, Montreal, Canada
- Department of Pediatric Anesthesia, Montreal Children's Hospital, McGill University Health Center, Montréal, QC, Canada
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3
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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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Shan X, Zhang L, Yang B. Review of LC techniques for determination of methadone and its metabolite in the biological samples. Prep Biochem Biotechnol 2021; 51:953-960. [PMID: 34365899 DOI: 10.1080/10826068.2021.1952598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Methadone (MTD) is a synthetic analgesic drug used for treating opioid dependence and effectively used clinically for patients with severe pain. The abuse of MTD may lead to poisoning, disorder in the central nervous system and even death. The regular monitoring of MTD in biological matrices including serum, plasma and urine samples is an effective way to control abuse of MTD. In this manner, the selection of analytical monitoring of MTD in biological matrices is of paramount importance. This study was conducted to review high-performance liquid chromatography (HPLC) techniques carried out on MTD and its main metabolite 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) in the biological samples during 2015-June 2021.
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Affiliation(s)
- Xiaoyue Shan
- Hangzhou Occupational Disease Prevention and Control Hospital, Hangzhou, China
| | - Lei Zhang
- Hangzhou Occupational Disease Prevention and Control Hospital, Hangzhou, China
| | - Bingsheng Yang
- Hangzhou Occupational Disease Prevention and Control Hospital, Hangzhou, China
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Simon JDHP, Schepers SA, Grootenhuis MA, Mensink M, Huitema AD, Tissing WJE, Michiels EMC. Reducing pain in children with cancer at home: a feasibility study of the KLIK pain monitor app. Support Care Cancer 2021; 29:7617-7626. [PMID: 34136954 PMCID: PMC8550558 DOI: 10.1007/s00520-021-06357-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/09/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE This study assessed adherence to, feasibility of, and barriers and facilitators of implementation of an app developed to monitor and follow-up with pain in children with cancer at home. METHODS Children (8-18 years) receiving cancer treatment (all diagnoses) or their parents (of children aged 0-7 years) used the KLIK Pain Monitor app for 3 weeks. Pain was assessed twice daily using an 11-point numeric rating scale (NRS-11) (ranging from 0 to 10). Healthcare professionals (HCP's) from the hospital's Pediatric Pain Service were instructed to follow-up with clinically significant pain scores (≥ 4) within 120 min (scores 4-6) or 30 min (scores 7-10). Adherence, feasibility, and implementation outcomes were assessed using questionnaires, app log data, and interviews. RESULTS Twenty-seven children (M age = 7.3 years, 51.8% male) and six HCP's participated. Sixty-three percent (N = 17) of families used the app on a daily basis during three weeks, and 18.5% (N = 5) reported pain scores twice daily during that time (family adherence). Twelve out of 27 children (44.4%) reported a clinically significant pain score at least once. In 70% (14/20) of clinically significant pain scores, HCP's followed-up with families within the set timeframe (HCP adherence). Outcomes reveal feasibility for the majority of app functions (i.e., positive evaluation by ≥ 70% families/HCP's), and non-feasible aspects could be resolved. Identified barriers and facilitators were used to improve future implementation efforts. CONCLUSION Use of the KLIK Pain Monitor app seems feasible. Future research will determine its effectiveness in reducing pain in children with cancer at home.
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Affiliation(s)
- Julia D H P Simon
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands.
| | - Sasja A Schepers
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - Martha A Grootenhuis
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - Maarten Mensink
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - Angelique D Huitema
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
| | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
- Department of Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erna M C Michiels
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, The Netherlands
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Alleviating Terminal Pediatric Cancer Pain. CHILDREN-BASEL 2021; 8:children8030239. [PMID: 33808534 PMCID: PMC8003275 DOI: 10.3390/children8030239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 12/30/2022]
Abstract
Terminal cancer pain remains one of the most distressing aspects of pediatric oncology practice. Opioids are the cornerstone of cancer pain management at end-of-life and fortunately, most pain at end-of-life can be managed successfully. This article presents a practical step-by-step approach to alleviating pediatric terminal cancer pain, which can be delivered across settings.
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Palat G, Algotsson C, Rayala S, Haridass V, Nethagani J, Rapelli V, Medhin MG, Brun E, Segerlantz M. The Use of Methadone in Pediatric Cancer Pain - A Retrospective Study from a Governmental Cancer Center in India. Indian J Palliat Care 2021; 27:133-138. [PMID: 34035631 PMCID: PMC8121219 DOI: 10.4103/ijpc.ijpc_109_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 01/07/2020] [Accepted: 02/10/2020] [Indexed: 01/22/2023] Open
Abstract
Background: The management of cancer-related pain relies on access to opioids. When regular opioids are not tolerated, or are insufficient, methadone is an affordable and effective analgesic. Aim: The aim of the project was to describe the pattern of use and clinical experience of methadone in pediatric cancer pain at a governmental cancer hospital in Hyderabad, one of the four Indian cancer centers with permission to prescribe methadone. Methods: This was a retrospective study of medical records of all children, under the age of 18, who had been prescribed methadone from September 9, 2017, to November 19, 2019. Data on analgesic effect, prior and concomitant analgesic treatment, opioid side effects, and the handling of methadone were analyzed. Results: A total of 11 children were identified and studied. Methadone was introduced mainly when pain was uncontrolled by regular opioids. Initial daily doses ranged from 1 to 15 mg. The duration of treatment ranged from 7 to 307, with a median of 50 days in the nine patients where treatment exceeded one single dosage. Good analgesic effect was reported in 5/9 children, unchanged from previous analgesic treatment in three patients and without any effect in one child. No severe side effects were reported. Conclusion: Low-dose methadone in the treatment of pediatric cancer pain at a low-resource cancer center was safe and well tolerated by the patients, with long treatment durations. It was safely managed, administered with single to double daily dosages, hence easy for patients and family to handle, and an affordable treatment option.
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Affiliation(s)
- Gayatri Palat
- Department of Palliative Access (PAX) Program, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada.,Department of Palliative Access (PAX) Program, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada.,Department of Palliative Access (PAX) Program, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | | | - Spandana Rayala
- Department of Pediatric Palliative Care, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada.,Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Vikranth Haridass
- Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Jayalatha Nethagani
- Department of Radiology, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Vineela Rapelli
- Department of Pain Relief and Palliative Care Society, MNJ Institute of Oncology and Regional Cancer Centre, Vancouver, British Columbia, Canada
| | - Maria Gebre Medhin
- Department of Clinical Sciences, Oncology and Pathology, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Oncology, Skane University Hospital, Region Skane, Lund, Sweden
| | - Eva Brun
- Department of Clinical Sciences, Oncology and Pathology, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Oncology, Skane University Hospital, Region Skane, Lund, Sweden
| | - Mikael Segerlantz
- Department of Clinical Sciences, Oncology and Pathology, Institute for Palliative Care, Faculty of Medicine, Lund University, Lund, Sweden.,Department of Palliative Care and Advanced Home Health Care, Primary Health Care Skane, Region Skane, Lund, Sweden
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8
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Pain Management in Childhood Leukemia: Diagnosis and Available Analgesic Treatments. Cancers (Basel) 2020; 12:cancers12123671. [PMID: 33297484 PMCID: PMC7762342 DOI: 10.3390/cancers12123671] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/04/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022] Open
Abstract
Pain is one of the most common symptoms in children suffering from leukemia, who are often misdiagnosed with other childhood painful diseases such as juvenile idiopathic arthritis. Corticosteroid-induced osteonecrosis (ON) and vincristine-induced peripheral neuropathy (VIPN) are the most common painful manifestations. Additionally, ongoing pain may continue to impact quality of life in survivorship. This narrative review focuses on the pathophysiological mechanisms of pain in childhood leukemia and current available indications for analgesic treatments. Pain management in children is often inadequate because of difficulties in pain assessment, different indications across countries, and the lack of specific pediatric trials. Analgesic drugs are often prescribed off-label to children by extrapolating information from adult guidelines, with possible increased risk of adverse events. Optimal pain management should involve a multidisciplinary team to ensure assessment and interventions tailored to the individual patient.
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Simon JDHP, Van Loon FRAA, Van Amstel J, Elmont GS, Zwaan CM, Fiocco M, Schepers SA, Tissing WJE, Michiels EMC. Pain at home during childhood cancer treatment: Severity, prevalence, analgesic use, and interference with daily life. Pediatr Blood Cancer 2020; 67:e28699. [PMID: 32926551 DOI: 10.1002/pbc.28699] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pain is a common symptom in childhood cancer. Since children spend more time at home, families are increasingly responsible for pain management. This study aimed at assessing pain at home. PROCEDURE In this longitudinal observational study (April 2016-January 2017), pain severity and prevalence, analgesic use, and pain interference with daily life (Brief Pain Inventory Short Form) were assessed for 4 consecutive days around the time of multiple chemotherapy appointments. Descriptive statistics (frequencies and percentages) were used to report pain severity (with clinically significant pain defined as: score ≥ 4 on "worst pain" or "average pain in the last 24 h"), pain prevalence, and analgesic use. Mixed models were estimated to assess whether patient characteristics were associated with pain severity, and whether pain severity was associated with interference with daily life. RESULTS Seventy-three children (50.7% male) participated (1-18 years). A majority (N = 57, 78%) experienced clinically significant pain at least once, and 30% reported clinically significant pain at least half the time. In 33.6% of scores ≥ 4, no medication was used. We found an association between pain severity and interference with daily life: the higher the pain, the bigger the interference (estimated regression coefficient = 1.01 [95% CI 0.98-1.13]). CONCLUSIONS The majority of children experienced clinically significant pain at home, and families frequently indicated no medication use. A stronger focus on education and coaching of families seems essential, as well as routine screening for pain in the home setting.
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Affiliation(s)
- Julia D H P Simon
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Femke R A A Van Loon
- Erasmus Medical Center, Department of Pediatric Oncology, Rotterdam, The Netherlands
| | - Juul Van Amstel
- Erasmus Medical Center, Department of Pediatric Oncology, Rotterdam, The Netherlands
| | - Gina S Elmont
- Erasmus Medical Center, Department of Pediatric Oncology, Rotterdam, The Netherlands
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Erasmus Medical Center, Department of Pediatric Oncology, Rotterdam, The Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Mathematical Institute, Leiden University, Leiden, The Netherlands
| | - Sasja A Schepers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Wim J E Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pediatric Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erna M C Michiels
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Erasmus Medical Center, Department of Pediatric Oncology, Rotterdam, The Netherlands
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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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12
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Friciu MM, Alarie H, Beauchemin M, Forest JM, Leclair G. Stability of Methadone Hydrochloride for Injection in Saline Solution. Can J Hosp Pharm 2020; 73:141-144. [PMID: 32362671 PMCID: PMC7182366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Until October 2014, methadone hydrochloride for injection (10 mg/mL) was available in Canada through Health Canada's Special Access Programme. Diluted to 5 mg/mL in saline, it was used in pediatrics for acute and cancer-related pain. More recently, the department of pharmacy of the Centre hospitalier universitaire Sainte-Justine in Montréal, Quebec, proposed compounding a solution of methadone hydrochloride for injection (5 mg/mL) from bulk powder and saline solution for pediatric administration. OBJECTIVE To assess the stability of the proposed compounded preparation. METHODS Solutions of methadone hydrochloride in saline were prepared from bulk powder and stored in clear glass vials for up to 180 days at room temperature (25 °C) or with refrigeration (5 °C), with testing on days 0, 7, 14, 30, 60, 90, and 180. The appearance of the solutions and presence of particulate matter were assessed. A stability-indicating high-performance liquid chromatography (HPLC) method was developed to assay the concentration of methadone over time. RESULTS No notable changes in appearance of the methadone solution were observed, particle counts did not exceed limits specified by the United States Pharmacopeia, and no microbial growth was observed. The HPLC analysis showed that the concentration of methadone remained above 90% on all study days. CONCLUSIONS Methadone hydrochloride for injection prepared from bulk powder in saline solution at a concentration of 5 mg/mL remained chemically stable for at least 180 days when stored in clear glass vials at 5 °C and at 25 °C.
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Affiliation(s)
- M Mihaela Friciu
- , MSc, is a Research Associate with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, BSc, is a Master of Science candidate in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, PharmD, MSc, is a Pharmacist with the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, DPH, MSc, is a Pharmacist with the Compounding Service (Fabrication) in the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, PhD, is an Associate Professor with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec
| | - Hugo Alarie
- , MSc, is a Research Associate with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, BSc, is a Master of Science candidate in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, PharmD, MSc, is a Pharmacist with the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, DPH, MSc, is a Pharmacist with the Compounding Service (Fabrication) in the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, PhD, is an Associate Professor with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec
| | - Mylène Beauchemin
- , MSc, is a Research Associate with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, BSc, is a Master of Science candidate in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, PharmD, MSc, is a Pharmacist with the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, DPH, MSc, is a Pharmacist with the Compounding Service (Fabrication) in the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, PhD, is an Associate Professor with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec
| | - Jean-Marc Forest
- , MSc, is a Research Associate with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, BSc, is a Master of Science candidate in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, PharmD, MSc, is a Pharmacist with the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, DPH, MSc, is a Pharmacist with the Compounding Service (Fabrication) in the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, PhD, is an Associate Professor with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec
| | - Grégoire Leclair
- , MSc, is a Research Associate with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, BSc, is a Master of Science candidate in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec, PharmD, MSc, is a Pharmacist with the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, DPH, MSc, is a Pharmacist with the Compounding Service (Fabrication) in the Department of Pharmacy, Centre hospitalier universitaire Sainte-Justine, Montréal, Quebec, BPharm, PhD, is an Associate Professor with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec
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Abstract
Methadone has been an unique, versatile, cost effective, synthetic opioid utilized in nociceptive as well as neuropathic pain. Pain and palliative care physicians started accepting methadone in treatment of complex pain associated with advanced cancer and neuropathic pain syndromes in which conventional opioids were no longer effective. The challenge is in accepting methadone as a main stream first line opioid, from being considered as a second line replacement/substitution drug all these years. Methadone has a significant role as opioid rotation in refractory cancer pain, especially when started early leading to successful conversion. Advantages of methadone in paediatric patients with advanced cancer were its safety and efficacy as a first-choice opioid, availability as a liquid formulation and its infrequent dose requirements. Methadone is neither recommended nor justified to be used as an anti-cancer drug and its role as an anti-cancer agent is a misconception. Many guidelines were proposed after 2008 to address methadone safety. Most of them emphasized on prevention of cardiac arrhythmia and association of methadone with QTc prolongation rather than address the real issue. Methadone has been established to be safe when used in opioid naïve patients with careful titration instituted in an ambulatory setting and has equal success in opioid rotation in outpatient setup. Methadone prescription should be carried out by experienced pain and palliative care providers with careful dose titration and clinical monitoring.
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Affiliation(s)
- S Ramkiran
- Department of Anaesthesiology, Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Vishakapatnam, Andhra Pradesh, India
| | - Raghu S Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Edmonds KP, Saunders IM, Willeford A, Ajayi TA, Atayee RS. Emerging Challenges to the Safe and Effective Use of Methadone for Cancer-Related Pain in Paediatric and Adult Patient Populations. Drugs 2019; 80:115-130. [PMID: 31820362 DOI: 10.1007/s40265-019-01234-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Methadone continues to be an important medication for the treatment of paediatric and adult cancer-related pain. Appropriate patient selection to ensure safe and effective treatment by a team of clinicians who appreciate and are familiar with methadone and its unique pharmacology is crucial. Unlike morphine and other more common opioids, methadone is purported to have involvement with delta-opioid receptor and higher affinity as an N-methyl-D-aspartate-receptor antagonist. Clinically this gives it the advantage of being effective for both nociceptive and neuropathic pain, but also may be useful in the setting of tolerance to other opioids. Methadone also comes in multiple available formulations that can be administrated through a variety of routes beyond the oral route. Challenges with methadone in treating cancer-related pain include drug interactions specifically as it relates to new targeted cancer therapies. Recent guidelines recommend electrocardiogram monitoring with methadone and there is potential for additive cardiac toxicity in the oncology setting. Appropriate dosing of methadone for pain management given age, organ dysfunction, and patients who are on methadone maintenance therapy are also key factors. This article aims to provide clinicians with evidence and clinical practice guidelines for safe and appropriate use of methadone including indication, initiation, and monitoring given its complexity for management of pain in the dynamic oncology setting.
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Affiliation(s)
- Kyle P Edmonds
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
| | - Ila M Saunders
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Andrew Willeford
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Toluwalase A Ajayi
- Digital Medicine, Scripps Research Translational Institute, La Jolla, CA, 92037, USA
| | - Rabia S Atayee
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA.
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA.
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA.
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15
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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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16
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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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