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Mütherig A, Scheffler G, Schuler US. [Pharmacological pain management in cancer patients]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:497-506. [PMID: 38597946 DOI: 10.1007/s00120-024-02347-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Pharmacological pain therapy in cancer patients is based on guideline recommendations, which, however, do not fully coincide in all aspects due to varying weighting of evidence. The present article discusses current issues including the decreasing significance of the World Health Organization (WHO) analgesic ladder, with its distinction between step 2 and 3 being increasingly questioned. Risks of nonopioid analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in older populations, are discussed. Paracetamol may potentially reduce the effectiveness of immunotherapies. Aspects of administering analgesics via a feeding tube are considered. Recommendations for the treatment of episodic pain, transitioning between different opioids, and some relevant interactions are also discussed.
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Affiliation(s)
- Anke Mütherig
- Palliativ-Zentrum, Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Gesine Scheffler
- Klinik-Apotheke, Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Deutschland
| | - Ulrich S Schuler
- Palliativ-Zentrum, Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
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Abdel Shaheed C, Hayes C, Maher CG, Ballantyne JC, Underwood M, McLachlan AJ, Martin JH, Narayan SW, Sidhom MA. Opioid analgesics for nociceptive cancer pain: A comprehensive review. CA Cancer J Clin 2024; 74:286-313. [PMID: 38108561 DOI: 10.3322/caac.21823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/05/2023] [Accepted: 10/20/2023] [Indexed: 12/19/2023] Open
Abstract
Pain is one of the most burdensome symptoms in people with cancer, and opioid analgesics are considered the mainstay of cancer pain management. For this review, the authors evaluated the efficacy and toxicities of opioid analgesics compared with placebo, other opioids, nonopioid analgesics, and nonpharmacologic treatments for background cancer pain (continuous and relatively constant pain present at rest), and breakthrough cancer pain (transient exacerbation of pain despite stable and adequately controlled background pain). They found a paucity of placebo-controlled trials for background cancer pain, although tapentadol or codeine may be more efficacious than placebo (moderate-certainty to low-certainty evidence). Nonsteroidal anti-inflammatory drugs including aspirin, piroxicam, diclofenac, ketorolac, and the antidepressant medicine imipramine, may be at least as efficacious as opioids for moderate-to-severe background cancer pain. For breakthrough cancer pain, oral transmucosal, buccal, sublingual, or intranasal fentanyl preparations were identified as more efficacious than placebo but were more commonly associated with toxicities, including constipation and nausea. Despite being recommended worldwide for the treatment of cancer pain, morphine was generally not superior to other opioids, nor did it have a more favorable toxicity profile. The interpretation of study results, however, was complicated by the heterogeneity in the study populations evaluated. Given the limited quality and quantity of research, there is a need to reappraise the clinical utility of opioids in people with cancer pain, particularly those who are not at the end of life, and to further explore the effects of opioids on immune system function and quality of life in these individuals.
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Affiliation(s)
- Christina Abdel Shaheed
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher Hayes
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
| | - Christopher G Maher
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Jane C Ballantyne
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- University Hospitals of Coventry and Warwickshire, Coventry, United Kingdom
| | - Andrew J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia
| | - Jennifer H Martin
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
| | - Sujita W Narayan
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia
| | - Mark A Sidhom
- Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Mercadante S. An overview of the current drug treatment strategies for moderate to severe, chronic malignant tumor-related pain. Expert Opin Pharmacother 2024; 25:171-179. [PMID: 37016731 DOI: 10.1080/14656566.2023.2200137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/04/2023] [Indexed: 04/06/2023]
Abstract
INTRODUCTION The pharmacological management of cancer pain is a complex issue that requires knowledge and experience in the use of analgesics. The aim of this expert review is to provide a panorama of the pharmacological strategies in cancer pain management. AREAS COVERED Opioid dose titration is a delicate process regarding the start of opioid treatment in different clinical conditions. How to improve the opioid response is a fundamental step, which includes different strategies when an initial treatment with opioids fails. The use of adjuvants is another relevant issue that should be considered in some specific circumstances to optimize the management of cancer pain management. Some clinical conditions, such as neuropathic pain and breakthrough pain, deserve a special attention. Relevant literature was selected to provide an overview of cancer pain management strategies. EXPERT OPINION Opioid therapy still remains the cornerstone of pharmacological management of cancer pain. Opioids should be used according to the level of tolerance, also personalizing the treatment (route, drug, and dosing). Adjuvant drugs may help in specific conditions, although their use should be balanced with the adverse effects. Breakthrough pain requires expertise in tailoring a treatment according to patient's profile and characteristics of episodes.
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Affiliation(s)
- Sebastiano Mercadante
- Main regional center of pain relief and supportive/palliative care, La Maddalena Cancer Center, Palermo, Italy
- Home palliative care program, Regional Home care program, SAMOT, Palermo, Italy
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Paice JA, Bohlke K, Barton D, Craig DS, El-Jawahri A, Hershman DL, Kong LR, Kurita GP, LeBlanc TW, Mercadante S, Novick KLM, Sedhom R, Seigel C, Stimmel J, Bruera E. Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline. J Clin Oncol 2023; 41:914-930. [PMID: 36469839 DOI: 10.1200/jco.22.02198] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To provide guidance on the use of opioids to manage pain from cancer or cancer treatment in adults. METHODS A systematic review of the literature identified systematic reviews and randomized controlled trials of the efficacy and safety of opioid analgesics in people with cancer, approaches to opioid initiation and titration, and the prevention and management of opioid adverse events. PubMed and the Cochrane Library were searched from January 1, 2010, to February 17, 2022. American Society of Clinical Oncology convened an Expert Panel to review the evidence and formulate recommendations. RESULTS The evidence base consisted of 31 systematic reviews and 16 randomized controlled trials. Opioids have primarily been evaluated in patients with moderate-to-severe cancer pain, and they effectively reduce pain in this population, with well-characterized adverse effects. Evidence was limited for several of the questions of interest, and the Expert Panel relied on consensus for these recommendations or noted that no recommendation could be made at this time. RECOMMENDATIONS Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Opioids should be initiated PRN (as needed) at the lowest possible dose to achieve acceptable analgesia and patient goals, with early assessment and frequent titration. For patients with a substance use disorder, clinicians should collaborate with a palliative care, pain, and/or substance use disorder specialist to determine the optimal approach to pain management. Opioid adverse effects should be monitored, and strategies are provided for prevention and management.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
- Judith A Paice
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Debra Barton
- University of Michigan School of Nursing, Ann Arbor, MI
| | - David S Craig
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | | | - Dawn L Hershman
- Mailman School of Public Health and Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY
| | - Lynn R Kong
- Ventura County Hematology Oncology Specialists, Oxnard, CA
| | - Geana P Kurita
- Rigshospitalet Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Kristina L M Novick
- Penn Radiation Oncology Chester County, Chester County Hospital, West Chester, PA
| | - Ramy Sedhom
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | | | | | - Eduardo Bruera
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Kwon MY, Lee MY, Han YJ, Lee SH, Kim EJ, Park S, Lee Y, Koo DH. Predicting tolerability of high-dose fentanyl buccal tablets in cancer patients. PLoS One 2023; 18:e0280212. [PMID: 36608031 PMCID: PMC9821425 DOI: 10.1371/journal.pone.0280212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND & AIMS Fentanyl buccal tablets (FBTs) are a rapid-onset opioid indicated for breakthrough cancer pain (BTcP) and FBT titration is needed to optimize BTcP management. We aimed to predict which patients could tolerate a high dose of FBT (400 μg or more at a time). METHODS A retrospective analysis was performed to assess the final FBT dose. The final FBT doses were compared according to the clinical features. The prediction accuracy of patients tolerant of 400 μg or higher FBT was compared using the area under the receiver operating characteristic (ROC) curves. A risk scoring model based on the odds ratio (OR) was developed from the final multivariable model, and patients were assigned into two groups: low tolerance (0-1 point) and high tolerance (2-3 points). RESULTS Among 131 patients, the most frequently effective dose of FBT was 200 μg (54%), followed by 100 μg (30%). The median value of morphine equivalent daily doses (MEDD) was 60 mg/day, and the most common daily use was 3-4 times/day. In multivariable analysis, male sex, younger age, and use of FBTs three or more times per day were independently associated with high-dose FBT. According to the risk scoring model, the patients with a final FBT of 400 μg or higher were significantly more in the high tolerance group (17%) compared to the low tolerance group (3%; p = 0.023). CONCLUSIONS According to the dose relationship between the final FBT dose and the clinical features, three factors (sex, age, daily use of FBT) were independently associated with the final dose of FBT. Our risk score model could help predict tolerance to high-dose FBT and guide the titration plan for BTcP.
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Affiliation(s)
- Mi-Young Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Mi-Yeon Lee
- Division of Biostatistics, Department of R&D Management, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Jae Han
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eo Jin Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Songyi Park
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun‑Gyoo Lee
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Hoe Koo
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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Abstract
Management of cancer pain is challenging. Despite the poor evidence, opioid therapy still remains the cornerstone for the management of cancer-related pain. Opioids should be given according to the clinical presentation in the different stages of disease. There is no drug of choice, as most opioids are effective. Thus, the choice should be based on the individual characteristics of patients. Optimization of opioid therapy may allow individual treatment according to the patient's characteristics and pain syndromes, providing timely alternatives in the different stages of disease. While most patients respond to an appropriate treatment associated with a comprehensive assessment and symptom control, a high level of experience and knowledge is necessary in determining conditions to maximize the analgesic response, eventually adding adjuvants in some specific circumstances. Alternative opioids may improve the balance between analgesia and adverse effects in the presence of a poor response to the first opioid in a large number of patients. Finally, a selected population can benefit from some interventional procedures.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center of Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
- Regional Home Care Program, SAMOT, Palermo, Italy.
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Mawatari H, Shinjo T, Morita T, Kohara H, Yomiya K. Revision of Pharmacological Treatment Recommendations for Cancer Pain: Clinical Guidelines from the Japanese Society of Palliative Medicine. J Palliat Med 2022; 25:1095-1114. [PMID: 35363057 DOI: 10.1089/jpm.2021.0438] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Pain is one of the most common symptoms in cancer patients. The Japanese Society for Palliative Medicine (JSPM) first published its clinical guidelines for the management of cancer pain in 2010. Since then, more research on cancer pain management has been reported, and new drugs have become available in Japan. Thus, the JSPM has now revised the clinical guidelines using a validated methodology. Methods: This guideline was developed through a systematic review, discussion, and the Delphi method, following a formal guideline development process. Results: Thirty-five recommendations were created: 19 for the pharmacological management of cancer pain, 6 for the management of opioid-induced adverse effects, and 10 for pharmacological treatment procedures. Due to the lack of evidence that directly addressed our clinical questions, most of the recommendations had to be based on consensus among committee members and other guidelines. Discussion: It is critical to continue to build high-quality evidence in cancer pain management, and revise these guidelines accordingly.
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Affiliation(s)
- Hironori Mawatari
- Department of Palliative and Supportive Care, Yokohama Minami Kyosai Hospital, Yokohama City, Japan
| | - Takuya Shinjo
- Department of Palliative Medicine, Shinjo Clinic, Kobe City, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu City, Japan
| | - Hiroyuki Kohara
- Department of Palliative Medicine, Hiroshima Prefectural Hospital, Hiroshima City, Japan
| | - Kinomi Yomiya
- Department of Palliative Care, Saitama Cancer Center, Ina-machi, Japan
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Wang Z, Jiang L, Wang J, Chai Z, Xiong W. Morphine promotes angiogenesis by activating PI3K/Akt/HIF-1α pathway and upregulating VEGF in hepatocellular carcinoma. J Gastrointest Oncol 2021; 12:1761-1772. [PMID: 34532126 DOI: 10.21037/jgo-20-394] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 05/16/2021] [Indexed: 12/24/2022] Open
Abstract
Background Hepatocellular carcinoma (HCC) is characterized by the neo-angiogenesis induced by tumor and adjacent cells. It is a leading cancer-related cause of death. Morphine has effects on angiogenesis with pro-angiogenic or anti-angiogenic phonotypes. This study explores the function of morphine on cancer cell growth, angiogenesis and the underlying mechanism in HCC. Methods Morphine was used to treat BEL-7402 or HCC-LM3 cells and human umbilical vein endothelial cells (HUVECs) were subsequently incubated in the conditioned media (CM) of HCC cells. The potential effects of cell proliferation, migration and tube formation of CM-treated HUVECs were investigated. Furthermore, the angiogenesis regulated factors of VEGFA, PIGF, ANG-1, ANG-2, FGF-1 and FGF-2 were assessed. siRNA and LY294002 were further used to explore the mechanism mediating the effects of morphine on the angiogenesis pathway. The neovascularization effect by morphine was confirmed through the use of human HCC cancer heterotopic mouse model in vivo. Results A significantly increased cell proliferation, migration, and tube formation effect of HUVECs induced by the CM from HCC cell lines treated with morphine was observed. More VEGFA secretion in CM from LM3 or BEL-7402 cell lines was found than the controls (P=0.03 and P=0.027, respectively). VEGFA knock-down could significantly reverse cell proliferation, migration and tube formation induced by the CM from HCC cell lines with morphine treatment. Further molecular experiments indicated that VEGFA secretion was activated by morphine potentially through the PI3K/Akt/HIF-1α pathway. Morphine-induced neovascularization was also observed by the IHC of CD31 and VEGFA. Conclusions Morphine promotes angiogenesis in hepatocellular carcinoma possibly through the activation of the PI3K/Akt/HIF-1α pathway and VEGFA stimulation.
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Affiliation(s)
- Zhiyao Wang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Linghui Jiang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie Wang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zongtao Chai
- Department of Hepatic Surgery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Wanxia Xiong
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
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Manirakiza A, Irakoze L, Manirakiza S, Bizimana P. Efficacy and Safety of Fentanyl Compared With Morphine among Adult Patients with Cancer: A Meta-Analysis. East Afr Health Res J 2020; 4:8-16. [PMID: 34308214 PMCID: PMC8279272 DOI: 10.24248/eahrj.v4i1.617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 04/29/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Cancer pain is experienced by numerous patients; thus, the main pain-relieving opioid analgesics, fentanyl and morphine, are of great importance. However, their analgesic efficacy and safety are different among individuals and are still controversial. The aim of this study was to compare the safety and efficacy of fentanyl and morphine among patients with cancer. Methods: We performed a meta-analysis by searching PubMed and the Cochrane Library up to 01 April 2019. The search terms were fentanyl, morphine, opioids and cancer pain. All randomised controlled trials comparing fentanyl and morphine were included in the analysis. Results: Overall, the initial search identified 2970 published studies; among them, 9 studies were included in the efficacy analysis and 8 studies were included in the safety analysis. The oral morphine versus oral transmucosal fentanyl subgroup analysis showed a mean difference(MD)=0.47[Confidence interval(CI):0.35-0.58] with an overall effect, Z=8.10, P<.00001. The outcome of the oral morphine versus nasal/transdermal fentanyl subgroup indicated a MD=0.20[CI:0.3-0.37] with an overall effect, Z=2.24 and P=.02. For the oral morphine versus buccal/sublingual fentanyl subgroup, the analysis revealed a MD=1.80[CI:1.35-2.25] with an overall effect, Z=7.87 and P<.00001. The oral morphine versus other forms of fentanyl subgroup showed a MD=0.70[95%CI:0.34-1.06] with the test for the overall effect, Z=3.81 and P=.0001. Constipation, drowsiness, confusion and dry mouth were more common in the morphine group than in the fentanyl group, with a risk ratio=0.60[CI:0.37-0.97]; 0.93[CI:0.69-1.25]; 0.85[CI:0.23-3.13] and 0.54[CI:0.05-6.43], respectively. Conclusions: Compared with oral morphine, fentanyl is safer and more effective. Moreover, fentanyl presents fewer side effects than morphine, especially constipation, drowsiness, confusion and dry mouth.
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Effects of age and gender in patients receiving doses of opioids for breakthrough pain proportional to background opioid doses. Support Care Cancer 2019; 28:3813-3818. [PMID: 31832823 DOI: 10.1007/s00520-019-05227-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
AIM To identify the role of age and gender in analgesic and adverse effects after administering fentanyl products for breakthrough pain (BT), given in doses proportional to opioid doses given for background pain. METHODS Data from nine studies, in which patients with BP were given fentanyl products in doses proportional to their basal opioid regimen, were analyzed. RESULTS A total 462 patients presenting 1905 episodes of BP were included in this analysis. In older patients, the decrease in pain intensity was more pronounced 15 min after administration of a BP medication. No gender differences were found. No significant differences in frequency and intensity of adverse effects for age and gender were found. CONCLUSION Fentanyl products given for BP in doses proportional to background opioid regimen were more effective in older patients without adding risks of adverse effects. Gender did not influence analgesia and adverse effects of fentanyl products.
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Hui D, Hernandez F, Larsson L, Liu D, Kilgore K, Naberhuis J, Virgilio A, Reddy S, Reddy A, Dalal S, Haider A, Driver L, Azhar A, Dev R, Bruera E. Prophylactic Fentanyl Sublingual Spray for Episodic Exertional Dyspnea in Cancer Patients: A Pilot Double-Blind Randomized Controlled Trial. J Pain Symptom Manage 2019; 58:605-613. [PMID: 31276809 PMCID: PMC6754768 DOI: 10.1016/j.jpainsymman.2019.06.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 12/22/2022]
Abstract
CONTEXT The optimal dose of fentanyl sublingual spray (FSS) for exertional dyspnea has not been determined. OBJECTIVES We examined the effect of two doses of prophylactic FSS on exertional dyspnea. METHODS In this parallel, dose-finding, double-blind randomized clinical trial, opioid-tolerant cancer patients completed a shuttle walk test at baseline. Patients completed a second shuttle walk test 10 minutes after a single dose of FSS equivalent to either 35%-45% (high dose) or 15%-25% (low dose) of the total daily opioid dose. The primary outcome was change in modified dyspnea Borg scale (0-10) between the first and second shuttle walk tests. Secondary outcomes included adverse events as well as changes in walk distance, vital signs, and neurocognitive function. RESULTS Thirty of the 50 enrolled patients completed the study. High-dose FSS (n = 13) resulted in significantly lower dyspnea (mean change -1.42; 95% CI -2.37, -0.48; P = 0.007) and greater walk distance (mean change 44 m; P = 0.001) compared to baseline. Low-dose FSS (n = 17) resulted in a nonsignificant reduction in dyspnea (mean change -0.47; 95% CI -1.26, 0.32; P = 0.24) and significant increase in walk distance (mean change 24 m; P = 0.01) compared to baseline. Global evaluation showed high-dose group was more likely to report at least somewhat better improvement (64% vs. 24%; P = 0.06). No significant adverse events or detriment to vital signs or neurocognitive function was detected. CONCLUSION Prophylactic FSS was well tolerated and demonstrated a dose-response relationship in improving both dyspnea and walk distance. High-dose FSS should be tested in confirmatory trials.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA.
| | - Farley Hernandez
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Liliana Larsson
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Kelly Kilgore
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jane Naberhuis
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Avery Virgilio
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Suresh Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Larry Driver
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Rony Dev
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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Ricchini F, Caraceni A, Zecca E, Pigni A, Centurioni F, Manzoni A, Kaasa S, Brunelli C. Effect of Opioid Exposure on Efficacy and Tolerability of Sublingual Fentanyl and Subcutaneous Morphine for Severe Cancer Pain Episodes. Secondary Analysis From a Double-Blind Double-Dummy, Randomized Trial. J Pain Symptom Manage 2019; 58:587-595. [PMID: 31233843 DOI: 10.1016/j.jpainsymman.2019.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022]
Abstract
CONTEXT Few studies have addressed the impact of previous opioid exposure on the effect of opioids for the treatment of severe cancer pain episodes. OBJECTIVES We aimed to test whether previous exposure to higher opioid doses was associated with a reduced analgesic effect of fentanyl sublingual tablets (FST) and subcutaneous morphine (SCM) and whether it had an influence on their relative effect. METHODS This is a secondary analysis of a placebo-controlled randomized trial comparing 100 μg FST with 5 mg SCM for the acute treatment of severe cancer pain episodes. The effect of previous opioid exposure (oral morphine equivalent daily dose from 20 to 120 mg) on pain intensity difference (PID) and side effects at 30 and 60 minutes after administration (PID 0-30 minutes, PID 0-60 minutes, and adverse events 30-60 minutes) and on re-medication for inefficacy, was studied by multivariable linear and logistic regression models and statistical tests for interaction. RESULTS A total of 114 patients were enrolled. Results indicate modest and nonstatistically significant effect of previous opioid exposure on all the outcomes examined (P = 0.11, P = 0.35, P = 0.07, and P = 0.52, respectively, for PID 0-30 minutes, re-medication, PID 0-60 minutes, and adverse events 30-60 minutes). Nonstatistically significant tests for interaction for all models indicated a lack of impact of previous opioid exposure on the difference in the analgesic effect between treatments. CONCLUSION In this study, we could not demonstrate an effect of previous opioid exposure, from 20 to 120 mg oral morphine equivalent daily dose, on the absolute and relative efficacy and tolerability of 100 μg FST and 5 mg SCM for severe cancer pain episodes.
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Affiliation(s)
- Francesca Ricchini
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Ernesto Zecca
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.
| | - Alessandra Pigni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Fabio Centurioni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Andrea Manzoni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Stein Kaasa
- Department of Cancer Research and Molecular Medicine, European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; Department of Cancer Research and Molecular Medicine, European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Brząkała J, Leppert W. The role of rapid onset fentanyl products in the management of breakthrough pain in cancer patients. Pharmacol Rep 2019; 71:438-442. [DOI: 10.1016/j.pharep.2019.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 12/09/2018] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
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Azhar A, Kim YJ, Haider A, Hui D, Balankari VR, Epner MC, Park M, Liu DD, Williams J, Frisbee-Hume SE, Allo JA, Bruera E. Response to Oral Immediate-Release Opioids for Breakthrough Pain in Patients with Advanced Cancer with Adequately Controlled Background Pain. Oncologist 2019; 24:125-131. [PMID: 30254187 PMCID: PMC6324637 DOI: 10.1634/theoncologist.2017-0583] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 05/31/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is limited evidence about the response of breakthrough pain (BTP) to the most commonly used oral immediate-release (IR) opioids. Our aim was to determine response rate to oral IR opioids for BTP control in patients with advanced cancer. MATERIALS AND METHODS In this prospective study, palliative care outpatients, with advanced cancer and adequately managed background pain, were asked to complete a self-administered survey. We assessed patients' baseline demographics, pain characteristics, alcoholism (CAGE questionnaire), tobacco and substance abuse, and Edmonton Symptom Assessment Scores (ESAS). We determined the effectiveness of oral IR BTP opioids by using a 7-point Likert scale ranging from "very ineffective" to "very effective." "Effective" and "very effective" were defined a priori as a good response to IR opioids for BTP. RESULTS Of 592 evaluable patients, 192 (32%) had background pain of ≤3 (ESAS pain scale 0-10). Among these 192 patients, 152 (79%) reported BTP, 143/152 (94%) took oral IR opioids for BTP, and 127/143 (89%) responded to a median dose of 10% of the total morphine equivalent daily dose. In univariate logistic regression analysis, younger age (odds ratio [OR], 0.94 per year; p = .008), higher ESAS scores for pain (OR, 1.32; p = .012), anxiety (OR, 1.24; p = .017), and dyspnea (OR, 1.31; p = .007) had statistically significant association with poor response to IR opioids for BTP. In multicovariate logistic regression, adjusted for age, a higher ESAS dyspnea score was significantly associated with poor response to oral IR opioids (OR, 1.44; p = .002). CONCLUSION The vast majority of patients with advanced cancer with adequately controlled background pain reported a good response to oral IR opioids for BTP, supporting their use in clinical practice. IMPLICATIONS FOR PRACTICE Oral immediate-release opioids are standard treatment for cancer breakthrough pain. However, information regarding treatment response to these commonly used opioids is limited. This study provides information that the vast majority of patients with advanced cancer, with adequately controlled background pain, reported good response to oral immediate release opioids for managing their breakthrough pain episodes. Results of this study support the use of conventional oral immediate release opioids that are relatively inexpensive and readily available for management of breakthrough pain in patients with advanced cancer.
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Affiliation(s)
- Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vishidha R Balankari
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Margeaux Chiou Epner
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Janet Williams
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan E Frisbee-Hume
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julio A Allo
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Fallon M, Giusti R, Aielli F, Hoskin P, Rolke R, Sharma M, Ripamonti CI. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv166-iv191. [PMID: 30052758 DOI: 10.1093/annonc/mdy152] [Citation(s) in RCA: 423] [Impact Index Per Article: 70.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Fallon
- Edinburgh Cancer Research Centre, IGMM, University of Edinburgh, Edinburgh, UK
| | - R Giusti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome
| | - F Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, Hertfordshire, UK
| | - R Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - M Sharma
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - C I Ripamonti
- Department of Onco-Haematology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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Goyal AK, Singh R, Chauhan G, Rath G. Non-invasive systemic drug delivery through mucosal routes. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2018; 46:539-551. [DOI: 10.1080/21691401.2018.1463230] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Amit K. Goyal
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, India
| | - Ranjit Singh
- Department of Pharmaceutics, Shobhit University, Meerut, India
| | - Gaurav Chauhan
- Centre for Nanosciences, Indian Institute of Technology Kanpur, Kanpur, India
- Instituto Tecnologico y de Estudios Superiores de Monterrey, Sensors and Devices Research Group, School of Engineering and Sciences, Monterrey, Mexico
| | - Goutam Rath
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, India
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Brant JM, Rodgers BB, Gallagher E, Sundaramurthi T. Breakthrough Cancer Pain: A Systematic Review of Pharmacologic Management
. Clin J Oncol Nurs 2018; 21:71-80. [PMID: 28524907 DOI: 10.1188/17.cjon.s3.71-80] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Breakthrough cancer pain (BtCP), defined as a transient exacerbation of pain that occurs in conjunction with well-controlled background pain, is a common and burdensome problem in patients with cancer.
. OBJECTIVES The aim of this systematic review is to identify evidence-based pharmacologic modalities for adequate management of BtCP.
. METHODS PubMed and CINAHL® databases were searched to identify literature regarding pharmacologic strategies for BtCP published from January 2006 to June 2016. These studies were then synthesized by the Oncology Nursing Society Putting Evidence Into Practice pain team.
. FINDINGS Forty-four studies provide evidence for the use of opioids for the management of BtCP. Transmucosal immediate-release fentanyl (TIRF) was found to have the most evidence for BtCP. Five studies and guidelines also suggest that oral opioids (not including TIRF products) be dosed proportionally to baseline opioids at 10%-20% of the 24-hour, around-the-clock dose.
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Abstract
This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and CUNY Neuroscience Collaborative, Queens College, City University of New York, Flushing, NY 11367, United States.
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19
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Hui D, Kilgore K, Frisbee-Hume S, Park M, Liu D, Balachandran DD, Bruera E. Effect of Prophylactic Fentanyl Buccal Tablet on Episodic Exertional Dyspnea: A Pilot Double-Blind Randomized Controlled Trial. J Pain Symptom Manage 2017; 54:798-805. [PMID: 28803087 PMCID: PMC5705410 DOI: 10.1016/j.jpainsymman.2017.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/31/2017] [Accepted: 08/03/2017] [Indexed: 01/21/2023]
Abstract
CONTEXT Episodic dyspnea is one of the most common, debilitating, and difficult-to-treat symptoms. OBJECTIVE We conducted a pilot study to examine the effect of prophylactic fentanyl buccal tablet (FBT) on exercise-induced dyspnea. METHODS In this parallel, double-blind randomized placebo-controlled trial, opioid-tolerant patients were asked to complete a six-minute walk test (6MWT) at baseline and then a second 6MWT 30 minutes after a single dose of FBT (equivalent to 20-50% of their total opioid dose) or matching placebo. We compared dyspnea Numeric Rating Scale (NRS, 0-10, primary outcome), walk distance, vital signs, neurocognitive function, and adverse events between the two 6MWTs. RESULTS Among 22 patients enrolled, 20 (91%) completed the study. FBT was associated with a significant within-arm reduction in dyspnea NRS between 0 and six minutes (mean change -2.4, 95% CI -3.5, -1.3) and respiratory rate (mean change -2.6, 95% CI -4.7, -0.4). Placebo was also associated with a nonstatistically significant decrease in dyspnea (mean change -1.1). Between-arm comparison of dyspnea scores in the second 6MWT favored FBT, albeit not statistically significant (estimate -0.25, P = 0.068). Global impression revealed more patients in the FBT group than placebo group reporting their dyspnea was at least "somewhat better" in the second 6MWT (4 of 9 vs. 0 of 11, P = 0.03). The other secondary outcomes did not differ significantly between arms. CONCLUSIONS This study supports that prophylactic FBT was associated with a reduction of exertional dyspnea and was well tolerated. Our findings support the need for larger trials to confirm the therapeutic potential of rapid-onset opioids.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA.
| | - Kelly Kilgore
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan Frisbee-Hume
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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Giusti R, Bossi P, Mazzotta M, Filetti M, Iacono D, Marchetti P. The use of fentanyl in pain management in head and neck cancer patients: a narrative review. Br J Pain 2017; 12:155-162. [PMID: 30057760 DOI: 10.1177/2049463717736787] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Head and neck (H&N) cancers account for about 5% of all malignant tumours. Pain is one of the most feared consequences of H&N neoplasms and is experienced by up to 80% of patients and worsens their quality of life inhibiting speaking, eating, drinking or swallowing. Nevertheless, pain is still often underestimated and undertreated. Objectives The role of opioids in cancer pain has been well established but evidences about the role and the relative effectiveness of opioids such as fentanyl in the context of H&N cancer pain remains unclear. Methods A literature review based on the guidance of the Centre for Reviews and Dissemination was conducted. An iterative approach was used starting with an electronic search in the MEDLINE database. The search terms (('Neoplasms'[Mesh]) AND 'Head and Neck Neoplasms'[Mesh]) AND 'Fentanyl'[Mesh] were used. Results A total of 18 publications were found by the first performed search on PubMed. Other publications concordant with our aim were found by cross-reference. Considering inclusion and exclusion criteria for our review, eight papers resulted eligible for analysis. Conclusion Fentanyl transdermal therapeutic system (TTS) seems to be an important option, thanks to the way of administration, the good safety and tolerability profiles to control baseline pain. For breakthrough cancer pain (BTcP), several formulations of transmucosal fentanyl are available. All the formulations seem to be active and safety but we lack head-to-head studies of fentanyl versus other strong opioids, as well as with different formulation of fentanyl, particularly for BTcP where H&N cancer population is very poorly represented.
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Affiliation(s)
- Raffaele Giusti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome, Italy
| | - Paolo Bossi
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Marco Mazzotta
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome, Italy
| | - Marco Filetti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome, Italy
| | - Daniela Iacono
- Pulmonary Oncology Unit, San Camillo Forlanini Hospital, Rome, Italy
| | - Paolo Marchetti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome, Italy
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The use of rapid onset fentanyl in children and young people for breakthrough cancer pain. Scand J Pain 2017; 17:256-259. [DOI: 10.1016/j.sjpain.2017.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/19/2017] [Accepted: 07/05/2017] [Indexed: 11/20/2022]
Abstract
Abstract
Background and aims
No published studies have looked at the dosing and use of rapid onset fentanyl preparations in children. The primary aim of this study was to assess whether there is a correlation between effective dose of rapid onset fentanyl and background oral morphine equivalent analgesia in children less than 18 years old. Secondary objectives included establishing whether there is a correlation between effective dose of rapid onset fentanyl and age and weight. Reported side effects were also reviewed.
Methods
This study is a retrospective case note review of all children less than 18 years old who received rapid onset fentanyl products in a tertiary paediatric oncology centre in England between 2010 and 2015. Correlations were analysed using Spearman’s correlation coefficient as data was non-parametric.
Results
Data on 26 children (5-17 yrs; 13-100 kg) was analysed. The most common diagnosis in children being given rapid onset fentanyl products was a solid tumour (84.6%). Eleven children used sublingual tablets, 17 used lozenges and one used a fentanyl nasal spray (three patients used two different preparations). The only significant correlation found was between dose of fentanyl lozenge and weight (r
s
= 0.81, p < 0.001). Very few side effects were reported with the most frequent being nausea (8%) and sleepiness (8%).
Conclusions
Fentanyl lozenges seem to be safe and well tolerated in children as young as five years old, weighing as little as 13 kg. Results suggest that children should always be started on the lowest available dose of chosen preparation and that this dose should be titrated according to response.
This study demonstrates that there is no correlation between background opioid dose and effective dose of rapid onset fentanyl in children. This mirrors findings of similar studies in adults. There was a strong correlation between effective dose of fentanyl lozenge and weight. This may be in part due to clinicians being more inclined to increase fentanyl lozenge doses as the child is in control of when they have had enough medication. In contrast, buccal tablets are absorbed quickly and the child always receives the full dose, making clinicians more reluctant to titrate the dose.
Implications
This article presents initial evidence for feasibility and tolerability of fentanyl lozenges in children as young as five years old, who are on relatively low doses of background opioids. This could be of interest to clinicians who are looking for alternatives to oral opioids to manage breakthrough pain in children with cancer.
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Fentanyl buccal tablet for breakthrough cancer pain in clinical practice: results of the non-interventional prospective study ErkentNIS. Support Care Cancer 2017; 26:491-497. [PMID: 28849261 PMCID: PMC5752740 DOI: 10.1007/s00520-017-3853-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/15/2017] [Indexed: 12/25/2022]
Abstract
Purpose Several patients with advanced cancer suffer from breakthrough cancer pain (BTcP). BTcP is pain exacerbation despite opioid baseline therapy. Fentanyl buccal tablet (FBT) is a rapid-onset opioid for the treatment of BTcP. The aim of this study is to document the feasibility of FBT in patients with BTcP. Methods The study was performed in 64 centers. Basic pain score was rated on a numeric rating scale (NRS) before and after treatment. BTcP episodes, baseline opioid therapy, and FBT dose were rated as well as individual dose titration, findings on tolerability, patient satisfaction, and safety of the drug. Results Two hundred sixty-three patients were available for analysis. Patients rated a basic pain score of 6 (range 2–10) points on an NRS and described an average of 2 to 5 BTcP episodes per day. After titration of FBT, BTcP control was achieved within 5 min in 36%, within 10 min in 68%, and within 15 min in 95%. Basic pain score decreased to a mean NRS of 4 and BTcP episodes decreased to < 1 to 3 episodes per day. BTcP control, onset of action of FBT, potency of FBT, tolerability of FBT, and safety of FBT were rated as excellent or good by 89 to 99% of the patients. Adverse drug reactions were registered in 3%. Conclusions Treatment with FBT led to rapid pain relief and reductions in the number of BTcP episodes and patient satisfaction was rated as excellent or good.
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Palliative care in ovarian carcinoma patients-a personalized approach of a team work: a review. Arch Gynecol Obstet 2017; 296:691-700. [PMID: 28803353 DOI: 10.1007/s00404-017-4484-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/01/2017] [Indexed: 01/06/2023]
Abstract
Most ovarian cancer patients are diagnosed in an advanced stage; and after the initial treatment experience disease recurrence, which eventually becomes palliative. Many questions arise in this setting including how to address patients in the palliative setting, how to discuss end-of-life issues, and how to manage symptoms. In this review, we discuss the timing and setting of end-of-life discussion in the context of end-stage ovarian cancer. We review the approach to relieving disease burden by improving and decreasing symptoms. These symptoms include recurrent ascites, bowel obstruction, pain, pulmonary effusion, and deep vein thrombosis.
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Malotte KL, Groninger H. Comparison of Fentanyl Oral and Nasal Formulations #331. J Palliat Med 2017; 20:784-786. [DOI: 10.1089/jpm.2017.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Zecca E, Brunelli C, Centurioni F, Manzoni A, Pigni A, Caraceni A. Fentanyl Sublingual Tablets Versus Subcutaneous Morphine for the Management of Severe Cancer Pain Episodes in Patients Receiving Opioid Treatment: A Double-Blind, Randomized, Noninferiority Trial. J Clin Oncol 2017; 35:759-765. [DOI: 10.1200/jco.2016.69.9504] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Fentanyl sublingual tablets (FST) are a potentially useful alternative to parenteral opioids such as subcutaneous morphine (SCM) to treat severe cancer pain episodes. No direct comparison between FST and SCM is available. The aim of this study was to test noninferiority of FST versus SCM during the first 30 min postadministration. Methods Patients receiving stable opioid therapy and experiencing a severe pain episode were randomly assigned to either 100 µg FST or 5 mg SCM in a double-blind, double-dummy trial. Average pain intensity (PI) assessed on a 0 to 10 numerical rating scale at 10, 20, and 30 min postadministration was the main end point. Analysis of covariance, adjusted by baseline PI, was the main analysis. The noninferiority margin (NIm) for the between-group difference was set at −0.6, that is, equal to one third of the minimum clinically important PI difference of two points. Results A total of 114 patients were randomly assigned to either FST (n = 58) or SCM (n = 56). One patient (in the FST group) withdrew consent before drug administration and was excluded from analysis. Baseline mean PIs were 7.5 in both groups; mean average PIs assessed at 10, 20, and 30 min postadministration were 5.0 and 4.5 for FST and SCM, respectively, with the 95% CI of the between-group difference including the NIm (−0.49; 95% CI, −1.10 to 0.09). Patients taking FST received a second drug dose after 30 min more frequently than did patients taking SCM (51% v 37%, respectively; risk difference, −13%; 95% CI, −30% to 3%). Both treatments were well tolerated, with average follow-up adverse event scores below the response of “A Little.” Ninety-three percent of patients preferred the sublingual administration. Conclusion This trial did not show noninferiority of FST versus SCM within the chosen NIm. Both treatments were safe, and patients preferred the sublingual route of administration. FST provides analgesia with modest to moderate increased risk of lower efficacy compared with SCM.
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Affiliation(s)
- Ernesto Zecca
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cinzia Brunelli
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Fabio Centurioni
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Andrea Manzoni
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Alessandra Pigni
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Augusto Caraceni
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
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Mercadante S, Adile C, Cuomo A, Aielli F, Marinangeli F, Casuccio A. The use of low doses of a sublingual fentanyl formulation for breakthrough pain in patients receiving low doses of opioids. Support Care Cancer 2016; 25:645-649. [PMID: 27744534 DOI: 10.1007/s00520-016-3457-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/10/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to prospectively assess the efficacy and safety of low doses of sublingual fentanyl (SLF) for the treatment of breakthrough pain (BTP) in cancer patients in patients who were receiving low opioid doses for background analgesia. METHODS A sample of cancer patients presenting BTP episodes and receiving stable low doses of opioids for background pain (less than 60 mg of oral morphine equivalents) was selected to assess the efficacy and safety of low doses of SLF (67 μg). For each patient, data from four consecutive episodes were collected. For each episode, changes in pain intensity and adverse effects when pain got severe (T0), and 5, 10, and 15 min after SLF administration (T5-T30) were recorded. The occurrence of serious effects occurring within 2 h of SLF administration were also considered. RESULTS Fifty-one patients were recruited for the study. The mean age was 66.8 (SD 12.9). A mean of 3.3 episodes/patient were recorded. Four patients did not have episodes of BTP. 147 episodes were evaluated. Six episodes (4.1 %) required a rescue medication at T30. Pain intensity significantly decreased at T5, T10, T15 and T30 (p < 0.0005 in all cases). A high percentage of patients had a pain reduction of more than 33 and 50 % at T5, T10, T15 and T30. Adverse effects were mild and generally already present, due to basal opioid treatment or disease. No serious adverse effects were observed for the subsequent 2 h. CONCLUSION This study suggests that SLF given in low doses in patients receiving lower doses of opioids for background analgesia is safe and effective in clinical practice.
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Affiliation(s)
- Sebastiano Mercadante
- Pain relief and Palliative/supportive care unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Claudio Adile
- Pain relief and Palliative/supportive care unit, La Maddalena Cancer Center, Palermo, Italy
| | - Arturo Cuomo
- Pain Therapy, National Cancer Institute "Pascale", Naples, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
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Mercadante S, Prestia G, Casuccio A. Nurse-based monitoring and management of breakthrough pain in an acute pain relief and palliative care unit. Hosp Pract (1995) 2016; 44:203-206. [PMID: 27477690 DOI: 10.1080/21548331.2016.1216715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To assess the nurses' performance in assessing, treating, and documenting breakthrough pain (BTP) in a palliative care unit where traditionally there is continuous training. METHODS The study was performed in an acute palliative care unit. Once a week, a research nurse examined the documentation regarding all the episodes of BTP registered in a specific pain chart, designed by the institutional nurse board, as part of the routine nurse activity. RESULTS The charts of 50 consecutive eligible patients (32 M/18 F), were analysed. The mean number of episodes/patient was 3.3 (SD 1.61; range 1-7). 166 episodes occurred. The main BTP pain intensity was 7.06 (SD 0.82). In 7 episodes, pain intensity was not evaluated at T0. The pain intensity after 15 minutes after BTP medication was 3.01 (SD1.19). In 28 episodes, pain intensity was not evaluated at T15. The change in pain intensity was highly significant (P < 0.0005). BTP episodes were distributed normally through different day intervals. No relevant adverse event attributable to BTP medication was reported in the nurse diary. CONCLUSION Training in a research environment allows a good nurse capability in evaluating and treating BTP, and above all, providing documentation for each BTP episode. The theoretical work and recommendations around BTP need to be translated into day-to-day clinical practice.
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Affiliation(s)
| | - Giovanna Prestia
- b Palliative Care , Casa di Cura La Maddalena SpA Ringgold Standard Institution , Palermo , Italy
| | - Alessandra Casuccio
- c Hygiene , Universita degli Studi di Palermo Dipartimento di Scienze e Tecnologie Biologiche Chimiche e Farmaceutiche Ringgold Standard Institution , Palermo , Italy
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Mercadante S, Cuomo A. Breakthrough Cancer Pain: Ten Commandments. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:531-536. [PMID: 27565269 DOI: 10.1016/j.jval.2016.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/03/2016] [Accepted: 03/05/2016] [Indexed: 06/06/2023]
Abstract
The term "breakthrough cancer pain" (BTcP) was introduced about 25 years ago. Peaks of pain intensity reported in patients with cancer had been invariably examined in the past years, providing relevant information for a better knowledge of this phenomenon and its treatment. The aim of this critical review was to provide the golden rules, namely, the 10 commandments, for a correct diagnostic pathway of BTcP and a consequent personalized pharmacological treatment. These are as follows: 1) assessment of background analgesia, 2) drugs used for background analgesia, 3) BTcP is a frequent phenomenon, 4) characteristics of BTcP, 5) diagnosis of BTcP, 6) continuous assessment, 7) tailored pharmacological treatment of BTcP, 8) selection of BTcP medication, 9) dosing BTcP medications, and 10) education. These steps may help clinicians to recognize and treat BTcP adequately.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Arturo Cuomo
- Anesthesia, Intensive care and Pain Therapy, National Cancer Institute, "Pascale", Naples, Italy
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Mercadante S, Aielli F, Adile C, Costanzi A, Casuccio A. Fentanyl Pectin Nasal Spray Versus Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Comparative Study. J Pain Symptom Manage 2016; 52:27-34. [PMID: 27208863 DOI: 10.1016/j.jpainsymman.2016.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/14/2016] [Accepted: 02/13/2016] [Indexed: 11/21/2022]
Abstract
CONTEXT Fentanyl products have shown superiority over oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use an appropriate patient selection, and drugs have been compared using a different rationale. OBJECTIVES The aim of this randomized, crossover, controlled study was to compare the efficacy and safety of fentanyl pectin nasal spray (FPNS) and oral morphine (OM), given in doses proportional to opioid daily doses. METHODS Cancer patients with pain receiving ≥60 mg of OM equivalents/day and presenting with ≤3 episodes of BTcP/day were included. Patients received, in a randomized, crossover manner, FPNS or OM at doses proportional to the daily opioid regimen in four consecutive episodes of BTcP. Pain intensity was measured before (T0), 15 (T15), and 30 minutes (T30) after study drugs. RESULTS A total of 167 episodes were treated, 82 with FNPS and 85 with OM. A statistical difference in pain intensity between the two groups was observed at T15, but not at T30 (P = 0.018 and P = 0.204, respectively). In a greater number of episodes treated with FPNS, there was a pain decrease of ≥33% in comparison with OM after 15 and 30 minutes (76.5% vs. 32.8%, and 89% vs. 54.9%, respectively). Similar differences were found in the decrease in pain intensity of ≥50% after 15 and 30 minutes (52.3% vs. 11.4%, and 75% vs. 45.8%, respectively). The difference was highly significant at T15 (P < 0.0005). The mean (SD) pain difference at T15 of FPNS and OM were 3.24 (1.7) and 2.70 (1.2), respectively, whereas the mean (SD) SPIDs30 of FPNS and OM were 4.87 (1.7) and 4.54 (1.5), respectively. The difference was highly significant at T15 (P = 0.019). No severe adverse effects after study drug administration were observed. CONCLUSION When used in doses proportional to the basal opioid regimen, FPNS showed a superior analgesic effect over OM for the management of BTcP. Only minor adverse effects were found with both medications.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Andrea Costanzi
- Department of Oncology, Hospital Sant'Andrea, University of Rome, Rome, Italy
| | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
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Alberts DS, Smith CC, Parikh N, Rauck RL. Fentanyl sublingual spray for breakthrough cancer pain in patients receiving transdermal fentanyl. Pain Manag 2016; 6:427-34. [PMID: 27020837 DOI: 10.2217/pmt-2015-0009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To investigate the relationship between effective fentanyl sublingual spray (FSS) doses for breakthrough cancer pain (BTCP) and around-the-clock (ATC) transdermal fentanyl patch (TFP). METHODS Adults tolerating ATC opioids received open-label FSS for 26 days, followed by a 26-day double-blind phase for patients achieving an effective dose (100-1600 µg). RESULTS Out of 50 patients on ATC TFP at baseline, 32 (64%) achieved an effective dose. FSS effective dose moderately correlated with mean TFP dose (r = 0.4; p = 0.03). Patient satisfaction increased during the study. Common adverse event included nausea (9%) and peripheral edema (9%). CONCLUSION FSS can be safely titrated to an effective dose for BTCP in patients receiving ATC TFP as chronic cancer pain medication. ClinicalTrials.gov identifier: NCT00538850.
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Affiliation(s)
| | | | | | - Richard L Rauck
- Carolinas Pain Institute, & The Center for Clinical Research, Winston-Salem, NC 27103, USA
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Development, validation and psychometric properties of a diagnostic/prognostic tool for breakthrough pain in mixed chronic-pain patients. Clin Neurol Neurosurg 2016; 141:23-9. [DOI: 10.1016/j.clineuro.2015.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/09/2015] [Accepted: 12/06/2015] [Indexed: 11/30/2022]
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