1
|
Uehara Y, Matsumoto Y, Kosugi T, Sone M, Nakamura N, Mizushima A, Miyashita M, Morita T, Yamaguchi T, Satomi E. Availability of and factors related to interventional procedures for refractory pain in patients with cancer: a nationwide survey. Palliat Care 2022; 21:166. [PMID: 36154936 PMCID: PMC9511722 DOI: 10.1186/s12904-022-01056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/15/2022] [Indexed: 11/22/2022] Open
Abstract
Background Cancer pain may be refractory to standard pharmacological treatment. Interventional procedures are important for quality of analgesia. The aim of the present study was to clarify the availability of four interventional procedures (celiac plexus neurolysis/splanchnic nerve neurolysis, phenol saddle block, epidural analgesia, and intrathecal analgesia), the number of procedures performed by specialists, and their associated factors. In addition, we aimed to establish how familiar home hospice physicians and oncologists are with the different interventional procedures available to manage cancer pain. Methods A cross-sectional survey using a self-administered questionnaire was conducted. Subjects were certified pain specialists, interventional radiologists, home hospice physicians, and clinical oncologists. Results The numbers of valid responses/mails were 545/1,112 for pain specialists, 554/1,087 for interventional radiology specialists, 144/308 for home hospice physicians, and 412/800 for oncologists. Among pain specialists, depending on intervention, 40.9-75.2% indicated that they perform each procedure by themselves, and 47.5-79.8% had not performed any of the procedures in the past 3 years. Pain specialists had performed the four procedures 4,591 times in the past 3 years. Among interventional radiology specialists, 18.1% indicated that they conduct celiac plexus neurolysis/splanchnic nerve neurolysis by themselves. Interventional radiology specialists had performed celiac plexus neurolysis/splanchnic nerve neurolysis 202 times in the past 3 years. Multivariate analysis revealed that the number of patients seen for cancer pain and the perceived difficulty in gaining experience correlated with the implementation of procedures among pain specialists. Among home hospice physicians and oncologists, depending on intervention, 3.5-27.1% responded that they were unfamiliar with each procedure. Conclusions Although pain specialists responded that the implementation of each intervention was possible, the actual number of the interventions used was limited. As interventional procedures are well known, it is important to take measures to ensure that pain specialists and interventional radiology physicians are sufficiently utilized to manage refractory cancer pain.
Collapse
Affiliation(s)
- Yuko Uehara
- Department of Palliative Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.,Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan; 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yoshihisa Matsumoto
- Department of Palliative Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan. .,Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan; 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan. .,Department of Palliative Therapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan; 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Toshifumi Kosugi
- Department of Palliative Care, Saga-ken Medical Centre Koseikan, Saga, Japan; 400 Kasemachinakabaru, Saga, Saga, 840-8571, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology/Interventional Radiology Center, National Cancer Center Hospital, Tokyo, Japan; 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Naoki Nakamura
- Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan; 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Akio Mizushima
- Department of Palliative Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan; 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Tatsuya Morita
- Division of Supportive and Palliative Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan; 3453 Mikatahara-cho, Hamamatsu, Shizuoka, 433-8558, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University School of Medicine, Sendai, Japan; 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Eriko Satomi
- Department of Palliative Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.,Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan; 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| |
Collapse
|
2
|
Straube C, Derry S, Jackson KC, Wiffen PJ, Bell RF, Strassels S, Straube S. Codeine, alone and with paracetamol (acetaminophen), for cancer pain. Cochrane Database Syst Rev 2014; 2014:CD006601. [PMID: 25234029 PMCID: PMC6513650 DOI: 10.1002/14651858.cd006601.pub4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Pain is very common in patients with cancer. Opioid analgesics, including codeine, play a significant role in major guidelines on the management of cancer pain, particularly for mild to moderate pain. Codeine is widely available and inexpensive, which may make it a good choice, especially in low-resource settings. Its use is controversial, in part because codeine is not effective in a minority of patients who cannot convert it to its active metabolite (morphine), and also because of concerns about potential abuse, and safety in children. OBJECTIVES To determine the efficacy and safety of codeine used alone or in combination with paracetamol for relieving cancer pain. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2014, Issue 2), MEDLINE and EMBASE from inception to 5 March 2014, supplemented by searches of clinical trial registries and screening of the reference lists of the identified studies and reviews in the field. SELECTION CRITERIA We sought randomised, double-blind, controlled trials using single or multiple doses of codeine, with or without paracetamol, for the treatment of cancer pain. Trials could have either parallel or cross-over design, with at least 10 participants per treatment group. Studies in children or adults reporting on any type, grade, and stage of cancer were eligible. We accepted any formulation, dosage regimen, and route of administration of codeine, and both placebo and active controls. DATA COLLECTION AND ANALYSIS Two review authors independently read the titles and abstracts of all studies identified by the searches and excluded those that clearly did not meet the inclusion criteria. For the remaining studies, two authors read the full manuscripts and assessed them for inclusion. We resolved discrepancies between review authors by discussion. Included studies were described qualitatively, since no meta-analysis was possible because of the small amount of data identified, and clinical and methodological between-study heterogeneity. MAIN RESULTS We included 15 studies including 721 participants with cancer pain due to diverse types of malignancy. All studies were performed on adults; there were no studies on children. The included studies were of adequate methodological quality, but all except for one were judged to be at a high risk of bias because of small study size, and six because of methods used to deal with missing data or high withdrawal rates. Three studies used a parallel group design; the remainder were cross-over trials in which there was an adequate washout period, but only one reported results for treatment periods separately.Twelve studies used codeine as a single agent and three combined it with paracetamol. Ten studies included a placebo arm, and 14 included one or more of 16 different active drug comparators or compared different routes of administration. Most studies investigated the effect of a single dose of medication, while five used treatment periods of one, seven or 21 days. Most studies used codeine at doses of 30 mg to 120 mg.There were insufficient data for any pooled analysis. Only two studies reported our preferred responder outcome of 'participants with at least 50% reduction in pain' and two reported 'participants with no worse than mild pain'. Eleven studies reported treatment group mean measures of pain intensity or pain relief; overall for these outcome measures, codeine or codeine plus paracetamol was numerically superior to placebo and equivalent to the active comparators.Adverse event reporting was poor: only two studies reported the number of participants with any adverse event specified by treatment group and only one reported the number of participants with any serious adverse event. In multiple-dose studies nausea, vomiting and constipation were common, with somnolence and dizziness frequent in the 21-day study. Withdrawal from the studies, where reported, was less than 10% except in two studies. There were three deaths, in all cases due to the underlying cancer. AUTHORS' CONCLUSIONS We identified only a small amount of data in studies that were both randomised and double-blind. Studies were small, of short duration, and most had significant shortcomings in reporting. The available evidence indicates that codeine is more effective against cancer pain than placebo, but with increased risk of nausea, vomiting, and constipation. Uncertainty remains as to the magnitude and time-course of the analgesic effect and the safety and tolerability in longer-term use. There were no data for children.
Collapse
Affiliation(s)
- Carmen Straube
- University Medical Center GöttingenDepartment of Haematology and OncologyRobert‐Koch‐Straße 40GöttingenGermany37075
| | - Sheena Derry
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)Pain Research UnitChurchill HospitalOxfordOxfordshireUKOX3 7LE
| | - Kenneth C Jackson
- *US pharmaceutical company*625 Winter Wren LaneBlythewoodSouth CarolinaUSA29016
| | - Philip J Wiffen
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)Pain Research UnitChurchill HospitalOxfordOxfordshireUKOX3 7LE
| | - Rae Frances Bell
- Haukeland University HospitalRegional Centre of Excellence in Palliative CareBergenNorway
| | | | - Sebastian Straube
- University of AlbertaDepartment of Medicine, Division of Preventive Medicine5‐30 University Terrace8303‐112 StreetEdmontonABCanadaT6G 2T4
| | | |
Collapse
|
3
|
Abstract
Buprenorphine (BUP) is a semisynthetic derivative of the opium alkaloid thebaine found in the poppy Papaver somniferum. Its chemical structure contains the morphine structure but differs by having a cyclopropylmethyl group. Buprenorphine is a potent µ opioid agonist. Buprenorphine undergoes extensive first-pass metabolism in the liver and gut. The development of a transdermal BUP formulation in 2001 led to its evaluation in cancer pain. This article provides the practitioner with an update on the current role of BUP in cancer care. It highlights data suggesting effectiveness in various types of cancer pain. The article reviews pharmacology, routes of administration, adverse effects, drug interactions, and cost considerations.
Collapse
|
4
|
Kestenbaum MG, Vilches AO, Messersmith S, Connor SR, Fine PG, Murphy B, Davis M, Muir JC. Alternative routes to oral opioid administration in palliative care: a review and clinical summary. PAIN MEDICINE 2014; 15:1129-53. [PMID: 24995406 DOI: 10.1111/pme.12464] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages. METHODS We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations. RESULTS Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed. CONCLUSIONS This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.
Collapse
|
5
|
Honey CR, Yeomans W, Isaacs A, Honey CM. The Dying Art of Percutaneous Cordotomy in Canada. J Palliat Med 2014; 17:624-8. [DOI: 10.1089/jpm.2013.0664] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
6
|
Schremmer C, Derry S, Jackson KC, Wiffen PJ, Bell RF, Strassels S, Straube S. Codeine, alone and with paracetamol (acetaminophen), for cancer pain. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd006601.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
7
|
Jackson KC, Wiffen PJ. Codeine, alone and with paracetamol (acetaminophen), for cancer pain. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd006601.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
8
|
|
9
|
Negro S, Martín A, Azuara L, Sánchez Y, Barcia E. Compatibility and stability of ternary admixtures of tramadol, haloperidol, and hyoscine N-butyl bromide: retrospective clinical evaluation. J Palliat Med 2010; 13:273-7. [PMID: 20078209 DOI: 10.1089/jpm.2009.0187] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Combination of drugs for subcutaneous infusion is common practice in palliative medicine, however, there is no information pertaining to the compatibility and stability of tramadol combined in ternary admixtures and no information exists regarding its clinical performance. METHODS Tramadol hydrochloride, haloperidol lactate, and hyoscine N-butyl bromide have been examined for compatibility and stability when combined in solution under conditions mimicking their potential use via subcutaneous infusion in terminal oncology patients. Concentration ranges were 8.8-33.3 mg/mL, 0.208-0.624 mg/mL, and 3.33-6.67 mg/mL for tramadol hydrochloride, haloperidol lactate, and hyoscine N-butyl bromide. With these, 27 different admixtures were prepared and stored at 25 degrees C using 0.9% saline as diluent. Quantification was performed by high-performance liquid chromatography (HPLC). The clinical performance of the admixture was retrospectively assessed in 28 terminal oncology patients exhibiting Karnofsky's indexes of 10%-20%. RESULTS All three drugs were very stable (>92%) at 25 degrees C for 15 days. Pain was completely controlled in all patients. Fifty percent of the patients suffered from 3-5 vomiting episodes per day and of these, 75% experienced complete control of the episodes. None of the patients showed local reactions after subcutaneous administration of the admixture. RESULTS Our results confirm the compatibility and stability of the ternary admixture and its utility in highly vulnerable patients exhibiting moderate symptoms.
Collapse
Affiliation(s)
- Sofia Negro
- Department of Pharmaceutics, School of Pharmacy, University Complutense of Madrid, Spain.
| | | | | | | | | |
Collapse
|
10
|
Bryson J, Coe G, Swami N, Murphy-Kane P, Seccareccia D, Le LW, Rodin G, Zimmermann C. Administrative Outcomes Five Years after Opening an Acute Palliative Care Unit at a Comprehensive Cancer Center. J Palliat Med 2010; 13:559-65. [DOI: 10.1089/jpm.2009.0373] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John Bryson
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Canada
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
| | - Gary Coe
- Department of Medical Oncology, Princess Margaret Hospital, University Health Network, Canada
| | - Nadia Swami
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
- Ontario Cancer Institute, Princess Margaret Hospital, University Health Network, Canada
| | - Patricia Murphy-Kane
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
| | - Dori Seccareccia
- Department of Family and Community Medicine, University of Toronto, Canada
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
| | - Lisa W. Le
- Department of Biostatistics, Princess Margaret Hospital, University Health Network, Canada
| | - Gary Rodin
- Department of Psychiatry, University of Toronto, Canada
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
- Ontario Cancer Institute, Princess Margaret Hospital, University Health Network, Canada
| | - Camilla Zimmermann
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Canada
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada
- Ontario Cancer Institute, Princess Margaret Hospital, University Health Network, Canada
| |
Collapse
|
11
|
Affiliation(s)
- Eric Prommer
- Department of Hematology/Oncology/Palliative Care, Mayo Clinic Arizona, Phoenix, Arizona
| |
Collapse
|
12
|
Rigby A, Krzyzanowska M, Le LW, Swami N, Coe G, Rodin G, Moore M, Zimmermann C. Impact of opening an acute palliative care unit on administrative outcomes for a general oncology ward. Cancer 2008; 113:3267-74. [DOI: 10.1002/cncr.23909] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
13
|
Silvestri B, Bandieri E, Del Prete S, Ianniello GP, Micheletto G, Dambrosio M, Sabbatini G, Endrizzi L, Marra A, Aitini E, Calorio A, Garetto F, Nastasi G, Piantedosi F, Sidoti V, Spanu P. Oxycodone controlled-release as first-choice therapy for moderate-to-severe cancer pain in Italian patients: results of an open-label, multicentre, observational study. Clin Drug Investig 2008; 28:399-407. [PMID: 18544000 DOI: 10.2165/00044011-200828070-00001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVES Cancer pain affects patients at all stages of the disease and there are clear guidelines for its management. Morphine is considered the first-choice strong opioid in the treatment of moderate-to-severe pain; however, numerous studies have shown that oxycodone controlled-release (CR) has a similar efficacy and safety profile. The purpose of this study was to evaluate the efficacy and tolerability of oxycodone CR as a first-line strong opioid for the treatment of moderate-to-severe pain in Italian cancer patients. METHODS This was a prospective, open-label, multicentre, observational trial carried out at 15 locations across Italy. Patients with a referral for cancer-related pain of > or =5 on a 10-point numerical rating scale were enrolled. Patients were treated with oral oxycodone CR and monitored for 21 days. Dosage was individualized for each patient and up-titrated until effective pain control was achieved. Pain, adverse events and quality-of-life scores were assessed throughout the study. RESULTS 390 patients (174 females and 216 males) with a mean age of 66 +/- 11 years were evaluated. The average daily dose ranged from 22.84 on day 1 to 40 mg/day on day 21. Pain intensity (assessed on a 10-point numerical rating scale) decreased significantly within 1 day of treatment commencement (p = 0.00001) and continued to decrease throughout the study period (from a mean 7.22 at baseline to a mean 2.11 points on day 21). Adverse events were mild to moderate in intensity and consisted of common opioid-related events. Ten patients (2.6%) discontinued the study because of adverse events and four (1%) because of uncontrolled pain. All aspects of activities of daily life assessed were improved by study end. CONCLUSIONS Oxycodone CR is efficacious and well tolerated as a first-line strong opioid for the treatment of moderate-to-severe cancer-related pain in Italian patients.
Collapse
|
14
|
Brown W. Opioid use in dying patients in hospice and hospital, with and without specialist palliative care team involvement. Eur J Cancer Care (Engl) 2008; 17:65-71. [PMID: 18181893 DOI: 10.1111/j.1365-2354.2007.00810.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Newspapers claim that patients in hospices have their opioid doses increased to a point at which doctors know that they will die. However, research has produced conflicting results about whether hospice patients receive higher doses of opioids. This study investigated the differences in opioid prescribing between cancer patients dying in hospice and hospital with and without hospital palliative care team (HPCT) involvement and non-cancer patients dying in hospital, in Dundee, UK. The only statistically significant difference in the mean dose of opioids was that the cancer patients were prescribed and received higher doses of opioids than non-cancer patients. There was no statistically significant difference in the mean dose of opioids prescribed to and given to the different groups of cancer patients dying in different settings, indicating that the claims of the press are untrue. The cancer patients dying in hospital who were not on the HPCT records more commonly received Tramadol, which may indicate a reluctance of hospital doctors to move from weak opioids to strong opioids.
Collapse
Affiliation(s)
- W Brown
- University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
| |
Collapse
|
15
|
Barcia E, Martín A, Azuara ML, Sánchez Y, Negro S. Tramadol and hyoscine N-butyl bromide combined in infusion solutions: compatibility and stability. Support Care Cancer 2006; 15:57-62. [PMID: 16847606 DOI: 10.1007/s00520-006-0101-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Accepted: 06/01/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND More than two-thirds of patients with metastatic cancer experience pain. Tramadol is one of the most interesting and useful weak opioids used by palliative care units to treat moderate to moderately severe pain. Relief of distressful symptoms in terminally ill patients is of prime importance; a common practice is to administer opioid analgesics in conjunction with other drugs as hyoscine N-butyl bromide, which is very useful in reducing secretions in patients with inoperable malignant bowel obstruction. The pursuit for excellence in symptom control in patients unable to take oral medication has led to the administration of medications by other routes such as the subcutaneous route. PURPOSE The purpose of this study was to fulfill the lack of information regarding the compatibility and physical stability of tramadol hydrochloride and hyoscine N-butyl bromide combined in infusion solutions. METHODS The stability of nine admixtures (stored in polypropylene syringes) at 4 and 25 degrees C was assessed over a period of 15 days. RESULTS Nonstatistically significant losses of tramadol HCl and a maximum loss of 7% for hyoscine N-butyl bromide were obtained. Therefore, tramadol HCl (dose range, 100-400 mg/day) can be formulated together in saline with hyoscine N-butyl bromide (dose range 40-80 mg/day) for s.c. infusion using a 60-ml drug infuser for a duration of 7 days.
Collapse
Affiliation(s)
- Emilia Barcia
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Universidad Complutense de Madrid, Ciudad Universitaria s/n, 28040, Madrid, Spain.
| | | | | | | | | |
Collapse
|
16
|
Auret K, Roger Goucke C, Ilett KF, Page-Sharp M, Boyd F, Oh TE. Pharmacokinetics and Pharmacodynamics of Methadone Enantiomers in Hospice Patients With Cancer Pain. Ther Drug Monit 2006; 28:359-66. [PMID: 16778720 DOI: 10.1097/01.ftd.0000211827.03726.e4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Racemic methadone is increasingly used to manage cancer pain. The authors studied 13 terminally ill patients with cancer pain, who underwent switching (rotation) from morphine to methadone. The relationship between initial morphine dose and final methadone dose, the pharmacokinetics of R- and S- methadone, and the degree of pain control and side effects were investigated. Preswitching serum morphine concentrations and second daily plasma concentrations of methadone were measured. The brief pain inventory (BPI) was used to assess pain every second day. "Worst pain" as measured by the BPI improved by >/=20% in 6 of the 13 patients. The mean morphine to methadone conversion ratio was 5.2 with wide interpatient variability (range 1.3 to 11). Average steady-state concentrations were 197 (98 to 379) mug/L and 272 (55 to 378) mug/L for R- and S-methadone, respectively. Mean population pharmacokinetic parameters for a 1-compartment model were 455 L and 338 L for apparent volume of distribution and 53.3 hours and 31.5 hours for half-life for R- and S- methadone, respectively. Bayesian estimates of apparent oral clearance for individual patients were 0.082 (0.052 to 0.112) L/kg/h and 0.117 (0.061 to 0.173) L/kg/h for R- and S- methadone, respectively (mean and 95% confidence interval). The low and variable clearance values generally resulted in slow achievement of steady-state concentrations over several days; inappropriately high plasma methadone levels occurred in 1 patient. Whereas optimal pain control was achieved in 46% of patients, there was no relationship with plasma concentrations of methadone. Best practice for methadone use in this patient group should include monitoring of both pain and methadone concentration.
Collapse
Affiliation(s)
- Kirsten Auret
- Palliative Care Unit Hollywood Private Hospital, Nedlands, Australia
| | | | | | | | | | | |
Collapse
|
17
|
Abstract
Buprenorphine is a broad spectrum, highly lipophilic, and long-acting partial mu opioid receptor agonist that is noncross tolerant to other opioids. Buprenorphine can be given by several routes. Metabolism is through CYP3A4 and CYP2C8 and by conjugases. Constipation and sexual dysfunction appear to be less with buprenorphine than with other opioids. The recent development of a polymer matrix patch delivery system for buprenorphine prevents "dose dumping" and facilitates pain management in those unable to take oral analgesics. Sublingual buprenorphine has been combined with naloxone to prevent illicit conversion to parenteral administration. Buprenorphine has been used extensively to control cancer pain. In certain clinical situations, buprenorphine may have particular advantages over other opioids.
Collapse
|
18
|
Pryma DA, Ravizzini G, Amar D, Richards VL, Patel JB, Strauss HW. Cardiovascular risk assessment in cancer patients undergoing major surgery. J Nucl Cardiol 2005; 12:151-7. [PMID: 15812368 DOI: 10.1016/j.nuclcard.2005.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|