Focal subdermal toxicity with subcutaneous opioid infusion in patients with cancer pain

Comparison of continuous subcutaneous hydromorphone hydrochloride and morphine hydrochloride injection on skin disorders incidence: a retrospective study

BACKGROUND

Continuous subcutaneous administration of injectable opioids is simple and effective; however, skin disorders may occur when high opioid dosages are used. Therefore, we investigated opioid injection drugs with a low risk of skin disorders.

METHODS

A retrospective study was conducted using the electronic medical records of patients prescribed 1% hydromorphone hydrochloride or 4% morphine hydrochloride with instructions for continuous subcutaneous administration at Shizuoka Cancer Center from January 2017 to December 2021. The primary endpoint was skin disorders incidence, and the two groups were compared using Cox proportional hazards model analyses and Fisher's exact test at 5% significance level. Patient background factors expected to influence skin disorders were also investigated, and multivariate logistic analysis of skin disorders incidence was performed.

RESULTS

The incidence of skin disorders in the hydromorphone hydrochloride and morphine hydrochloride groups were 3.7% (1/27 patients) and 28.1% (9/32 patients), respectively, showing a significant difference in two statistical analyses between the two groups (Cox proportional hazards model analyses HR: 0.09, 95% CI: 0.01-0.70, P = 0.022. Fisher's exact test OR: 0.10, 95% CI: 0.01-0.84, P = 0.016). In the multivariate analysis, the administration of hydromorphone hydrochloride (OR: 0.04, 95% CI: 0.003-0.48, P = 0.012) was also found to have a significant negative correlation with the occurrence of skin disorders. On the contrary, administration period ≥ 28 days (OR: 18.16, 95% CI: 2.22-148.60, P = 0.007) was a factor with a significant positive correlation.

CONCLUSIONS

Subcutaneous 1% hydromorphone hydrochloride administration had a lower risk of skin disorders than 4% morphine hydrochloride injection. Moreover, prolonging the administration period increased the risk of developing skin disorders. This suggests that a 1% hydromorphone hydrochloride Injection is a good clinical decision for patients who are likely to have a longer administration period and require a higher dosage of injectable opioids.

TRIAL REGISTRATION

Retrospectively registered.

Subcutaneous administration of paracetamol-Good local tolerability in palliative care patients: An observational study

BACKGROUND

The subcutaneous route is widely used in both palliative care and geriatrics. Numerous compounds are administered by this route, including paracetamol. However, there is no recommendation on which to base this latter practice and, in the absence of published evidence, nothing is known regarding its local tolerability in palliative care patients.

AIM

The main objective of this study was to assess the local tolerability of paracetamol when administered subcutaneously for analgesic or antipyretic purposes in patients hospitalized in the palliative care unit. The secondary objective was to identify the factors favoring the occurrence of local adverse events.

DESIGN

This is a prospective multicenter observational study (NCT02884609).

PARTICIPANTS

Study conducted in 160 patients hospitalized in the palliative care units of three hospitals in metropolitan France from 2014 to 2017.

RESULTS

Of the 160 patients, 44 (28%) presented at least one non-serious local adverse event (edema in 29, erythema in 5, pain in 15, hematoma in 2, pruritus in 1, and local heat in 2). No serious adverse events were observed. Factors associated with the occurrence of local adverse events were younger age, administration in the arm and thorax, and a high number of daily administrations.

CONCLUSION

This first ever study carried out on this subject reveals that subcutaneous administration of paracetamol in palliative care patients was well tolerated locally.

Hydromorphone

Hydromorphone is a semi-synthetic opioid that has been used widely for acute pain, chronic cancer pain and to a lesser extent, in chronic nonmalignant pain. Its pharmacokinetics and pharmacodynamics have been well studied, including immediate release oral preparations, a variety of slow release oral preparations, as well as administration through intravenous, subcutaneous, epidural, intrathecal and other routes. It is known to be metabolized to analgesically inactive metabolites that have been associated with neuroexcitatory states and other toxicity. There is no evidence that hydromorphone has any greater abuse liability than other opioids. Further research is needed to address remaining areas of uncertainty: equianalgesic ratios; relative risk of toxicity compared with other opioids, its use in nonmalignant pain, and the role of specific hydromorophone metabolites in the development of toxicity, particularly in association with organ failure.

A small observational study of the longevity of syringe driver sites in palliative care

Although the use of portable syringe drivers is common in palliative care, problems do occur. A small observational study of local practice was undertaken to establish the rate of syringe driver reactions and duration of sites; to determine whether a predictable relationship existed between the number of days on a syringe driver and the number of sites used consecutively; and to discover whether the location of a syringe driver site influenced the site longevity. Eighty-six syringe driver sites were established in 27 patients during the 3-month study period. Site duration ranged between 1 hour and 9 days (mean 2 days). An association was found between the number of days on a syringe driver and the number of sites used. However, this relationship is not close enough to predict when a site may be discontinued. Thirty-eight syringe drivers (44%) were discontinued because of site reactions. The location of a syringe driver site appeared to be an important factor influencing the site longevity, with cannula dislodgment three times more prevalent from the chest wall than the upper arm (P=0.05). However, the findings suggest that if it is possible to prevent dislodgement from the chest wall, then this site can be used for significantly longer before a site reaction develops (P=0.02). In view of the unpredictability of site reactions, it is concluded that sites must be assessed regularly and changed as soon as problems develop. As this was a small study in one unit without standardization of site reaction assessment, the results should be interpreted with caution. However, given the lack of published work in this area, this study contributes to the evidence base and raises important questions for both clinical practice and future research.

Subcutaneous drug infusions: a review of problems and solutions

Subcutaneous drug infusion using a portable syringe driver has had a significant impact on patient comfort in palliative care. It permits the continuous delivery of a range of drug therapies, so bypassing problems of dysphagia, weakness and the inability of many patients in the terminal phase to take oral medication. The devices are not problem-free, however. Mechanical problems, reactions at the infusion site and difficulties with the mixing of drugs in the syringe are all widely recognized. This article reviews some general issues with the operation of portable syringe drivers, and discusses a range of potential problems and their solutions.

Subcutaneous methadone in terminally ill patients: manageable local toxicity

Methadone has been found to be useful in pain uncontrolled by large doses of conventional opioids such as hydromorphone and morphine. While the subcutaneous route is effective and may afford cost-savings over the intravenous route in patients unable to take oral medication, its utility for the administration of methadone may be hampered by local toxicity, specifically erythema and induration. To examine the issue of limiting toxicity, we analyzed our inpatient hospice experience in six consecutive patients who received subcutaneous methadone for severe cancer pain. We confirm the high incidence of local toxicity, but note that the severity is subject to considerable individual variation. Furthermore, toxicity is uniformly manageable by site rotation and the use of dexamethasone infused concurrently with the methadone. We recommend that the infusion of subcutaneous methadone should be considered in the appropriate patients who can be closely monitored.

Spinal analgesia in terminal care: risk versus benefit

Cancer pain treatment is well established. The World Health Organization provides clinicians an "analgesic ladder" scheme to optimize cancer pain treatment. At the beginning of the pain treatment, oral analgesic administration is preferred. The analgesic dose must be individualized. Many published papers describe the spinal administration of opioids in combination with various other drugs such as bupivacaine in selected patients with cancer pain. Although complications have been reported to be few, some recent reports debate this idea. We first describe a population of 92 cancer patients, 13 of whom received intrathecal morphine. We then present our experience with a separate group of 33 cancer patients who were also managed using intrathecal morphine. Based on this experience, the generally accepted indications for the technique appeared to be justified. Concern about spinal infection is well considered, however. Three out of those patients developed meningitis, a complication rate that is far too high.

A prospective comparison study between a butterfly needle and a Teflon cannula for subcutaneous narcotic administration

To evaluate the hypothesis that subcutaneous sites initiated with the Teflon cannula would have longer durations and be more comfortable for the patient than the butterfly needle, we performed a prospective randomized crossover trial to compare the 25-gauge butterfly needle to a Teflon cannula with a 26-gauge introducer needle and a 24-gauge cannula. The analysis of 20 patients showed that duration of the subcutaneous site was significantly longer with the Teflon cannula. Both patients and nurses preferred the Teflon cannula because it did not need to be changed as frequently. There was no difference reported in the level of comfort.

Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer

Twenty-six patients with extensive gynecologic, colorectal or genitourinary cancer who suffered uncontrolled, incapacitating pelvic pain were enrolled in this study during a 1-year period. All the patients receiving oral opioids who developed poor pain response due to the progression of disease or untoward side effects necessitating other modes of therapy were eligible to participate. Bilateral percutaneous neurolytic superior hypogastric plexus blocks with 10% phenol were performed in every patient, 1 day after receiving successful diagnostic blocks using 0.25% bupivacaine (BUP). All patients reported a visual analog pain score (VAPS) of 10 of 10 before the block. Eighteen patients (69%) had satisfactory pain relief (VAPS < 4 of 10): 15 (57%) after 1 block and 3 (12%) after a second block. The remaining 8 patients (31%) had moderate pain control (VAPS 4-7 of 10) after 2 blocks and received epidural bupivacaine-morphine (BUP-MS) therapy with good results. Both groups experienced significant reductions in oral opioid therapy after the neurolytic blocks. No additional blocks were required by patients who had a good response during a follow-up period of 6 months. No complications related to the block were experienced by any patient. In conclusion, neurolytic superior hypogastric plexus block was both effective in relieving pain in 69% of the patients studied (95% confidence interval of 48-85%). Additional neurolytic blocks using higher volumes of the neurolytic agent may be needed in patients with extensive retroperitoneal disease, a group in whom moderate or poor results should be expected.

Systemic contact dermatitis from subcutaneous hydromorphone

We report a patient who developed a generalized dermatitis after a period of progressive local intolerance to continuous subcutaneous infusion of hydromorphone for cancer pain. Sensitization to hydromorphone was proved by a positive patch test. Infusions with an equianalgesic dose of diacetylmorphine were well tolerated, without local or systemic side-effects, and prolonged the duration of infusion sites.

Use of the subcutaneous route of administration of morphine in the intensive care unit

Subcutaneous morphine was administered to 13 consecutive patients admitted to an intensive care unit. Intermittent injections via a butterfly needle and via continuous infusion were used in 11 and 2 cases, respectively. The mean daily dose of morphine and mean duration of treatment were 108 +/- 128mg and 5 +/- 4 days, respectively. Only 3 episodes of local irritation were detected in 60 patient days. We conclude that the subcutaneous route is safe and effective for patients receiving morphine in the intensive care unit setting, and it allows for continuation of treatment when patients are discharged to the general hospital wards.

Decreased local toxicity with subcutaneous diamorphine (heroin): a preliminary report

We report the cases of 5 patients who developed severe local toxicity during the subcutaneous administration of morphine sulphate and hydromorphone hydrochloride. All patients required site changes more frequently than once every 24 h due to redness, swelling, or pain while receiving morphine or hydromorphone. All patients showed prolongation in the duration of sites of infusion once an equianalgesic dose of diamorphine hydrochloride (heroin) was started. No change in pain control or systemic toxicity was detected with diamorphine. These findings suggest that diamorphine could be a useful alternative for patients who develop severe toxicity to subcutaneous morphine or hydromorphone.