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Amin T, Sharma RP, Mir KB, Slathia N, Chhabra S, Tsering D, Kotwal P, Bhagat M, Nandi U, Parkesh R, Kapoor KK, Goswami A. Quinoxalinone substituted pyrrolizine (4h)-induced dual inhibition of AKT and ERK instigates apoptosis in breast and colorectal cancer by modulating mitochondrial membrane potential. Eur J Pharmacol 2023; 957:175945. [PMID: 37541376 DOI: 10.1016/j.ejphar.2023.175945] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/08/2023] [Accepted: 07/31/2023] [Indexed: 08/06/2023]
Abstract
AKT and ERK 1/2 play a pivotal role in cancer cell survival, proliferation, migration, and angiogenesis. Therefore, AKT and ERK 1/2 are considered crucial targets for cancer intervention. In this study, we envisaged the role of AKT and ERK signaling in apoptosis regulation in presence of compound 4h, a novel synthetic derivative of quinoxalinone substituted spiropyrrolizines exhibiting substantial antiproliferative activity in various cancer cell lines. Structurally 4h is a spiropyrrolizine derivative. Molecular docking analysis revealed that compound 4h shows strong binding affinity with AKT-1 (-9.5 kcal/mol) and ERK2 (-9.0 kcal/mol) via binding at allosteric sites of AKT and active site of ERK2. The implications of 4h binding with these two survival kinases resulted in the obstruction for ATP binding, hence, hampering their phosphorylation dependent activation. We demonstrate that 4h mediated apoptotic induction via disruption in the mitochondrial membrane potential of MCF-7 and HCT-116 cells and 4h-mediated inhibition of survival pathways occurred in a wild type PTEN background and is diminished in PTEN-/- cells. In 4T1 mammary carcinoma model, 4h exhibited pronounced reduction in the tumor size and tumor volume at significantly low doses. Besides, 4h reached the highest plasma concentration of 5.8 μM within a period of 1 h in mice model intraperitoneally. Furthermore, 4h showed acceptable clearance with an adequate elimination half-life and satisfactory pharmacokinetic behaviour, thus proclaiming as a potential lead molecule against breast and colorectal cancer by specifically inhibiting simultaneously AKT and ERK1/2 kinases.
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Affiliation(s)
- Tanzeeba Amin
- Pharmacology Division, CSIR-Indian Institute of Integrative Medicine, Jammu, 180001, India; Academy of Scientific & Innovative Research (AcSIR), Ghaziabad, India
| | | | - Khalid Bashir Mir
- Pharmacology Division, CSIR-Indian Institute of Integrative Medicine, Jammu, 180001, India; Academy of Scientific & Innovative Research (AcSIR), Ghaziabad, India
| | - Nancy Slathia
- Department of Chemistry, University of Jammu, Jammu 180006, India
| | - Sonali Chhabra
- Academy of Scientific & Innovative Research (AcSIR), Ghaziabad, India; CSIR-Institute of Microbial Technology, Chandigarh, 160036, India
| | - Dolma Tsering
- Department of Chemistry, University of Jammu, Jammu 180006, India
| | - Pankul Kotwal
- Pharmacology Division, CSIR-Indian Institute of Integrative Medicine, Jammu, 180001, India; Academy of Scientific & Innovative Research (AcSIR), Ghaziabad, India
| | - Madhulika Bhagat
- School of Biotechnology, University of Jammu, J&K, 181143, India
| | - Utpal Nandi
- Pharmacology Division, CSIR-Indian Institute of Integrative Medicine, Jammu, 180001, India; Academy of Scientific & Innovative Research (AcSIR), Ghaziabad, India
| | - Raman Parkesh
- Academy of Scientific & Innovative Research (AcSIR), Ghaziabad, India; CSIR-Institute of Microbial Technology, Chandigarh, 160036, India
| | - Kamal K Kapoor
- School of Biotechnology, University of Jammu, J&K, 181143, India.
| | - Anindya Goswami
- Pharmacology Division, CSIR-Indian Institute of Integrative Medicine, Jammu, 180001, India; Academy of Scientific & Innovative Research (AcSIR), Ghaziabad, India.
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2
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Suraj D, Zhang A, Appelbaum T, Ahmed N, Shih S, Gofman J, Kalenja K, Abrigo JN, Shaporova V, Mannan A, Jacobs RJ. Clinical Presentation and Management of Malignant Psoas Syndrome: A Scoping Review of Case Reports and Case Series. Cureus 2023; 15:e41522. [PMID: 37551242 PMCID: PMC10404467 DOI: 10.7759/cureus.41522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 07/06/2023] [Indexed: 08/09/2023] Open
Abstract
Malignant psoas syndrome (MPS) is a rare and underreported clinical syndrome that significantly impacts the quality of life of cancer patients through metastatic infiltration of the iliopsoas muscle. Patients suffering from MPS often present with painful hip flexion, loss of mobility, and immense pain in their legs and back. The current literature describing the clinical presentation, management, and prognosis of MPS is limited primarily to case reports and outdated literature reviews. There remains a gap in the current knowledge of MPS and in the management of this complex cancer-related pain syndrome. Thus, this scoping review aimed to map current case reports and case series on MPS for clinical presentation, treatment modalities, and resulting prognoses of MPS in late-stage cancer patients. A systemized search using the databases Embase and PubMed (Medline) was conducted to access case reports and case series published between January 1990 and October 2022 that met the study's inclusion criteria: (1) adult patients with metastatic cancer; (2) MPS symptoms secondary to infiltration of iliopsoas; (3) clinical presentation, treatment modality, and prognosis; and (4) English-language text. Our search strategy yielded 1926 citations. After removing 629 duplicates, 1,283 reports were excluded due to failure to meet eligibility criteria (n=1,271) or inaccessibility (n=12). Using the JBI appraisal tools for case reports and case series, a total of 14 articles remained for the final review. With histories of either genitourinary, hepatic, gastric, or skin cancer, each case reported new onset intense pain in the legs, back, abdomen, or pelvis with associated symptoms such as flexion of the hip or gait disorder. A computerized tomography (CT) scan, magnetic resonance imaging (MRI), or positron emission tomography (PET) scan typically confirmed metastasis into the iliopsoas causing these symptoms, which suggested MPS. Each case utilized two to seven different pain management strategies to alleviate MPS symptoms. Many cases first used opioids for pain relief. Following a necessitated increase in morphine equivalent daily dose, a subsequent increase in the strength of analgesic, change in route of administration, and integration of combination drug therapy were generally added to the treatment regime. Many cases reported successful management of symptoms through utilizing methadone, radiation therapy, botulinum toxin injection, increased opioid dosage, or epidural catheter administration of opioids. A unified clinical definition of MPS may be required to inform physicians of this syndrome to help support clinical decisions regarding treatments for patients. The studies indicated that a clearer guideline for treatment protocol may be warranted as most cases reported utilizing various treatment medication dosages and procedures with vastly differing results.
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Affiliation(s)
- Delwin Suraj
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Angel Zhang
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Taylor Appelbaum
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Nahiyan Ahmed
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Susana Shih
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Joseph Gofman
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Klea Kalenja
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Juanito N Abrigo
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Valeriya Shaporova
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Arhum Mannan
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Robin J Jacobs
- Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
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3
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Kaya S, Kondolot Solak E. Development of ketorolac tromethamine loaded biocompatible polymeric microspheres and matrix films: designing for topical application. INT J POLYM MATER PO 2022. [DOI: 10.1080/00914037.2022.2097679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Seçil Kaya
- Department of Advanced Technologies, Gazi University, Ankara, Turkey
- Department of Material and Material Processing Technologies, Technical Sciences Vocational School, Gazi University, Ankara, Turkey
| | - Ebru Kondolot Solak
- Department of Advanced Technologies, Gazi University, Ankara, Turkey
- Department of Chemistry and Chemical Processing Technologies, Technical Sciences Vocational School, Gazi University, Ankara, Turkey
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4
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Butcher B, Hutchings E, Fazekas B, Clark K, Rowett D, Currow D. Opioid-sparing effects of ketorolac in palliative care patients receiving opioids for chronic cancer-related pain: A systematic literature review. Palliat Med 2022; 36:71-80. [PMID: 34633250 DOI: 10.1177/02692163211045310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Standard of care in treatment of cancer-related pain involves opioids in combination with non-steroidal anti-inflammatory drugs (NSAID). Ketorolac, a NSAID, has demonstrated opioid-sparing effects in other clinical settings. AIM This systematic literature review investigated ketorolac's opioid-sparing effects in patients receiving opioids for chronic, cancer-related pain. DESIGN The primary outcome was total daily dose of opioids. Secondary outcomes included frequency of opioid use, use and frequency of 'rescue' medication and adverse events. Outcomes were described, and meta-analysed where possible. PROSPERO registration CRD42019130894. DATA SOURCES Articles included original research, from any study phase or methodology, published in English in a peer-reviewed journal or conference between 1990 and 2020; included subjects >18 years; had chronic cancer-related pain and described the use of opioid-sparing effect of ketorolac. RESULTS Nine articles were included. While there was significant heterogeneity, ketorolac may have an opioid-sparing effect, with significant reductions in total daily dose of morphine observed in a single randomised controlled trial (SMD -4.30 mg, 95% CI -5.36 to -3.25), but the changes in the before and after studies were not statistically significant -0.46 mg (95% CI -1.14 to 0.22). Ketorolac was associated with greater likelihood of complete pain relief, but the data were heterogeneous. Insufficient data were available to analyse frequency of opioid use, or rescue medication requirements. CONCLUSIONS Given the heterogeneity of the data, adequately powered, randomised controlled trials are required to establish any opioid-sparing effect of ketorolac. For patients not responding to conventional pain management, ketorolac may have a role in treatment augmentation.
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Affiliation(s)
- Belinda Butcher
- WriteSource Medical Pty Ltd, Lane Cove, NSW, Australia.,University of New South Wales, Kensington, NSW, Australia
| | | | - Belinda Fazekas
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Australian national Palliative Care Clinical Studies Collaboration (PaCCSC), Sydney, NSW, Australia
| | - Katherine Clark
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Australian national Palliative Care Clinical Studies Collaboration (PaCCSC), Sydney, NSW, Australia.,Cancer and Palliative Care Network, Northern Sydney Local Health District, Sydney, NSW, Australia.,Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Debra Rowett
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - David Currow
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Australian national Palliative Care Clinical Studies Collaboration (PaCCSC), Sydney, NSW, Australia
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In Silico Approach Using Free Software to Optimize the Antiproliferative Activity and Predict the Potential Mechanism of Action of Pyrrolizine-Based Schiff Bases. Molecules 2021; 26:molecules26134002. [PMID: 34209011 PMCID: PMC8271847 DOI: 10.3390/molecules26134002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 01/11/2023] Open
Abstract
In the current study, a simple in silico approach using free software was used with the experimental studies to optimize the antiproliferative activity and predict the potential mechanism of action of pyrrolizine-based Schiff bases. A compound library of 288 Schiff bases was designed based on compound 10, and a pharmacophore search was performed. Structural analysis of the top scoring hits and a docking study were used to select the best derivatives for the synthesis. Chemical synthesis and structural elucidation of compounds 16a–h were discussed. The antiproliferative activity of 16a–h was evaluated against three cancer (MCF7, A2780 and HT29, IC50 = 0.01–40.50 μM) and one normal MRC5 (IC50 = 1.27–24.06 μM) cell lines using the MTT assay. The results revealed the highest antiproliferative activity against MCF7 cells for 16g (IC50 = 0.01 μM) with an exceptionally high selectivity index of (SI = 578). Cell cycle analysis of MCF7 cells treated with compound 16g revealed a cell cycle arrest at the G2/M phase. In addition, compound 16g induced a dose-dependent increase in apoptotic events in MCF7 cells compared to the control. In silico target prediction of compound 16g showed six potential targets that could mediate these activities. Molecular docking analysis of compound 16g revealed high binding affinities toward COX-2, MAP P38α, EGFR, and CDK2. The results of the MD simulation revealed low RMSD values and high negative binding free energies for the two complexes formed between compound 16g with EGFR, and CDK2, while COX-2 was in the third order. These results highlighted a great potentiality for 16g to inhibit both CDK2 and EGFR. Taken together, the results mentioned above highlighted compound 16g as a potential anticancer agent.
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6
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Ethyl benzoate bearing pyrrolizine/indolizine moieties: Design, synthesis and biological evaluation of anti-inflammatory and cytotoxic activities. Bioorg Chem 2020; 94:103371. [DOI: 10.1016/j.bioorg.2019.103371] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/07/2019] [Accepted: 10/16/2019] [Indexed: 12/19/2022]
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Sivaramakrishnan G, Sridharan K. Oral Ketorolac with Inferior Alveolar Nerve Block for Irreversible Pulpitis: A Systematic Review and Meta-analysis. Open Dent J 2018; 12:340-346. [PMID: 29875886 PMCID: PMC5958292 DOI: 10.2174/1874210601812010340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 04/13/2018] [Accepted: 04/24/2018] [Indexed: 11/23/2022] Open
Abstract
Background: Ketorolac has advantages over other analgesics as a pre-anaesthetic medication. Considering this in mind, the present meta-analysis aims to identify the effect of oral ketorolac premedication on the anaesthetic efficacy of Inferior Alveolar Nerve Block (IANB) in patients with irreversible pulpitis. Methods: Full-texts of eligible studies were obtained from electronic databases. The extracted data was analysed using non-Cochrane mode in RevMan 5.0 software. Relative risk [95% CI] was calculated for the success of IANB. Results: Four studies were included for the final review. The success rate of IANB on 221 patients with relative risk of 1.87 [1.36, 2.56] was statistically significant favouring ketorolac. The mean difference for VAS in 171 patients was not statistically significant {-13.55 [-33.91, 6.82]}. Conclusion: Oral ketorolac can be successfully administered as a premedication before conventional inferior alveolar nerve block for endodontic treatment for irreversible pulpitis.
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Affiliation(s)
- Gowri Sivaramakrishnan
- Department of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Brown Street, Suva, Fiji
| | - Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
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8
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Peterson SE, Selvaggi KJ, Scullion BF, Blinderman CD. Pain Management and Antiemetic Therapy in Hematologic Disorders. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00091-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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9
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Russo R, De Caro C, Avallone B, Magliocca S, Nieddu M, Boatto G, Troiano R, Cuomo R, Cirillo C, Avagliano C, Cristiano C, La Rana G, Sarnelli G, Calignano A, Rimoli MG. Ketogal: A Derivative Ketorolac Molecule with Minor Ulcerogenic and Renal Toxicity. Front Pharmacol 2017; 8:757. [PMID: 29163153 PMCID: PMC5681857 DOI: 10.3389/fphar.2017.00757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/05/2017] [Indexed: 12/20/2022] Open
Abstract
Ketorolac is a powerful non-steroidal anti-inflammatory drug (NSAID), with a great analgesic activity, present on the Italian market since 1991. Despite the excellent therapeutic activity, the chronic use of ketorolac has long been limited owing to the high incidence of gastrointestinal and kidney side events. In our previous study, we demonstrated that ketorolac-galactose conjugate (ketogal), synthesized and tested in a single-dose study, was able to reduce ulcerogenicity, while preserving the high pharmacological efficacy of its parent drug. In this paper, in order to verify the suitability of this compound, for repeated administration, ex vivo experiments on naïve mice were performed. Mice were treated for 5 or 7 days with the highest doses of two drugs (ketorolac 10 mg/kg and ketogal 16.3 mg/kg), and the expression of both gastric COX-1 and PGsyn was evaluated. Results showed that oral ketorolac treatment significantly reduced both enzymes; surprisingly, oral treatment with ketogal did not produce significant variation in the expression of the two constitutive enzymes. Moreover, histological experiments on stomach and kidneys clearly indicated that repeated administration of ketogal induced lower toxicity than ketorolac. At same time, in vivo results clearly showed that both ketorolac and ketogal had a similar therapeutic activity in a model of inflammation and in pain perception. These effects were accompanied by the reduction of enzyme expression such as COX-2 and iNOS, and by the modulation of levels of nuclear NF-κB and cytosolic IκB-α in the inflamed paws. These very encouraging results demonstrate for the first time that ketogal could represent a valid and novel therapeutic alternative to the ketorolac and might pave the way for clinical studies.
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Affiliation(s)
- Roberto Russo
- Department of Pharmacy, University of Naples Federico II, Naples, Italy
| | - Carmen De Caro
- Department of Pharmacy, University of Naples Federico II, Naples, Italy.,Science of Health Department, School of Medicine, Magna Graecia University, Catanzaro, Italy
| | - Bice Avallone
- Department of Biology, University of Naples Federico II, Naples, Italy
| | | | - Maria Nieddu
- Department of Chemistry and Pharmacy, University of Sassari, Sassari, Italy
| | - Gianpiero Boatto
- Department of Chemistry and Pharmacy, University of Sassari, Sassari, Italy
| | - Roberta Troiano
- Department of Biology, University of Naples Federico II, Naples, Italy
| | - Rosario Cuomo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Carla Cirillo
- Laboratory for Enteric Neuroscience, KU Leuven, Leuven, Belgium
| | - Carmen Avagliano
- Department of Pharmacy, University of Naples Federico II, Naples, Italy
| | - Claudia Cristiano
- Department of Pharmacy, University of Naples Federico II, Naples, Italy
| | - Giovanna La Rana
- Department of Pharmacy, University of Naples Federico II, Naples, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Antonio Calignano
- Department of Pharmacy, University of Naples Federico II, Naples, Italy
| | - Maria G Rimoli
- Department of Pharmacy, University of Naples Federico II, Naples, Italy
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10
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Shah S, Hardy J. Non-Steroidal Anti-inflammatory Drugs in Cancer Pain: A Review of the Literature as Relevant to Palliative Care. PROGRESS IN PALLIATIVE CARE 2016. [DOI: 10.1080/09699260.2001.11746896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.
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Affiliation(s)
- Peter J. S. Koo
- Departments of Clinical Pharmacy and Pharmaceutical Services, University of California, San Francisco, San Francisco, California
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12
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Shibata H, Kato S, Sekine I, Abe K, Araki N, Iguchi H, Izumi T, Inaba Y, Osaka I, Kato S, Kawai A, Kinuya S, Kodaira M, Kobayashi E, Kobayashi T, Sato J, Shinohara N, Takahashi S, Takamatsu Y, Takayama K, Takayama K, Tateishi U, Nagakura H, Hosaka M, Morioka H, Moriya T, Yuasa T, Yurikusa T, Yomiya K, Yoshida M. Diagnosis and treatment of bone metastasis: comprehensive guideline of the Japanese Society of Medical Oncology, Japanese Orthopedic Association, Japanese Urological Association, and Japanese Society for Radiation Oncology. ESMO Open 2016; 1:e000037. [PMID: 27843593 PMCID: PMC5070259 DOI: 10.1136/esmoopen-2016-000037] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/02/2016] [Indexed: 01/14/2023] Open
Abstract
Diagnosis and treatment of bone metastasis requires various types of measures, specialists and caregivers. To provide better diagnosis and treatment, a multidisciplinary team approach is required. The members of this multidisciplinary team include doctors of primary cancers, radiologists, pathologists, orthopaedists, radiotherapists, clinical oncologists, palliative caregivers, rehabilitation doctors, dentists, nurses, pharmacists, physical therapists, occupational therapists, medical social workers, etc. Medical evidence was extracted from published articles describing meta-analyses or randomised controlled trials concerning patients with bone metastases mainly from 2003 to 2013, and a guideline was developed according to the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Multidisciplinary team meetings are helpful in diagnosis and treatment. Clinical benefits such as physical or psychological palliation obtained using the multidisciplinary team approaches are apparent. We established a guideline describing each specialty field, to improve understanding of the different fields among the specialists, who can further provide appropriate treatment, and to improve patients’ outcomes.
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Affiliation(s)
- H Shibata
- Department of Clinical Oncology , Akita University Graduate School of Medicine , Akita , Japan
| | - S Kato
- Department of Clinical Oncology , Juntendo University , Tokyo , Japan
| | - I Sekine
- Department of Clinical Oncology , University of Tsukuba , Tsukuba , Japan
| | - K Abe
- Department of Rehabilitation , Chiba Prefectural University of Health Sciences , Chiba , Japan
| | - N Araki
- Department of Orthopedic Surgery , Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
| | - H Iguchi
- Department of Gastroenterology , National Hospital Organization Shikoku Cancer Center , Matsuyama , Japan
| | - T Izumi
- Division of Hematology , Tochigi Cancer Center , Utsunomiya , Japan
| | - Y Inaba
- Department of Diagnostic and Interventional Radiology , Aichi Cancer Center Hospital , Nagoya , Japan
| | - I Osaka
- Division of Palliative Medicine , Shizuoka Cancer Center , Sunto-gun , Japan
| | - S Kato
- Department for Cancer Chemotherapy , Iwate Prefectural Central Hospital , Morioka , Japan
| | - A Kawai
- Division of Musculoskeletal Oncology , National Cancer Center Hospital , Tokyo , Japan
| | - S Kinuya
- Department of Nuclear Medicine , Kanazawa University Hospital , Kanazawa , Japan
| | - M Kodaira
- Department of Breast and Medical Oncology , National Cancer Center Hospital , Tokyo , Japan
| | - E Kobayashi
- Division of Musculoskeletal Oncology , National Cancer Center Hospital , Tokyo , Japan
| | - T Kobayashi
- Department of Diagnostic and Interventional Radiology , Ishikawa Prefectural Central Hospital , Kanazawa , Japan
| | - J Sato
- Department of Clinical Pharmaceutics , School of Pharmacy, Iwate Medical University , Morioka , Japan
| | - N Shinohara
- Department of Renal and Genitourinary Surgery , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - S Takahashi
- Department of Medical Oncology , Cancer Institute Hospital of Japanese Foundation for Cancer Research , Tokyo , Japan
| | - Y Takamatsu
- Division of Medical Oncology , Hematology and Infectious Diseases, Fukuoka University Hospital , Fukuoka , Japan
| | - K Takayama
- Seirei Christopher University , Hamamatsu , Japan
| | - K Takayama
- Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - U Tateishi
- Department of Diagnostic Radiology and Nuclear Medicine , Tokyo Medical and Dental University , Tokyo , Japan
| | - H Nagakura
- Department of Radiology , KKR Sapporo Medical Center , Sapporo , Japan
| | - M Hosaka
- Department of Orthopaedic Surgery , Tohoku University Graduate School of Medicine , Sendai , Japan
| | - H Morioka
- Department of Orthopaedic Surgery , Keio University School of Medicine , Tokyo , Japan
| | - T Moriya
- Department of Pathology 2 , Kawasaki Medical School , Kurashiki , Japan
| | - T Yuasa
- Department of Urology , Cancer Institute Hospital, Japanese Foundation for Cancer Research , Tokyo , Japan
| | - T Yurikusa
- Division of Dentistry and Oral Surgery , Shizuoka Cancer Center , Sunto-gun , Japan
| | - K Yomiya
- Department of Palliative Care , Saitama Cancer Center , Kitaadachi-gun , Japan
| | - M Yoshida
- Department of Hemodialysis and Surgery , Chemotherapy Research Institute, International University of Health and Welfare , Ichikawa , Japan
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13
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Affiliation(s)
- Eric E. Prommer
- Division of Hematology/Oncology, Veterans Integrated Palliative Care Program, Veterans Integrated Palliative Care, David Geffen School of Medicine, University of California, Los Angeles, California
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14
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El-Setouhy DA, Ahmed S, Badawi AAEL, El-Nabarawi MA, Sallam N. Preclinical evaluation of dual action intranasal formulation intended for postoperative/cancer associated therapies. Eur J Pharm Sci 2015; 76:48-56. [DOI: 10.1016/j.ejps.2015.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 03/31/2015] [Accepted: 04/20/2015] [Indexed: 10/23/2022]
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15
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Kenner DJ, Bhagat S, Fullerton SL. Daily subcutaneous parecoxib injection for cancer pain: an open label pilot study. J Palliat Med 2015; 18:366-72. [PMID: 25695199 DOI: 10.1089/jpm.2014.0249] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nonsteroidal anti-inflammatory analgesics (NSAIDs) are useful in cancer pain but the specific use of subcutaneous parecoxib has not been previously reported. OBJECTIVE This pilot study aimed to establish the efficacy and side effect profile of short-term sequential single daily dose subcutaneous parecoxib sodium in patients with severe cancer bone pain. METHODS Nineteen hospitalized patients with advanced cancer and uncontrolled malignant bone pain (9 males, 10 females) received 24 courses of one, two, or three days sequential therapy with 'off-label' daily subcutaneous parecoxib. All patients were receiving opioid therapy; the median baseline daily oral equivalent dose (OED) of morphine was 180 mg. Pain was assessed at baseline, 24 hours, 48 hours, and 72 hours. Pain scores as assessed on an 11-point numeric pain rating scale (NPRS), any side effects including subcutaneous site reactions, as well as patient satisfaction rating with analgesia were recorded. A clinically significant decrease in pain scores was defined as a reduction of two or more points on the NPRS. RESULTS Median pain score of all patient treatments decreased from 7 to 4.5 at 24 hours (p<0.001) and 4.0 at 48 hours. A response was seen in 17 (71%) of the 24 treatments at 24 hours. There was no difference between median negative change in pain scores in 19 (79%) treatments where pain was either strongly movement related, or in 22 (94%) treatments where local bone tenderness was more pronounced. No major side effects were observed during treatment. One patient died from pulmonary embolism after cessation of concurrent prophylactic low molecular weight heparin prior to staging liver biopsy. Subcutaneous site reactions occurred in 2 (8%) treatments and were mild and self limiting. CONCLUSIONS Short-term daily subcutaneous parecoxib injection was effective for malignant bone pain when added to existing analgesic therapy and was well tolerated. Further research is warranted into the short-term use of parecoxib in hospitalized patients with intractable malignant bone pain.
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Affiliation(s)
- David J Kenner
- 1 Palliative Care Services , Eastern Health, Wantirna Health, Melbourne, Australia
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Shinde S, Gordon P, Sharma P, Gross J, Davis MP. Use of non-opioid analgesics as adjuvants to opioid analgesia for cancer pain management in an inpatient palliative unit: does this improve pain control and reduce opioid requirements? Support Care Cancer 2014; 23:695-703. [PMID: 25168780 DOI: 10.1007/s00520-014-2415-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 08/18/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cancer pain is complex, and despite the introduction of the WHO cancer pain ladder, few studies have looked at the prevalence of adjuvant medication use in an inpatient palliative medicine unit. In this study, we evaluate the use of adjuvant pain medications in patients admitted to an inpatient palliative care unit and whether their use affects pain scores or opiate dosing. METHODS In this retrospective observational study, patients admitted to the inpatient palliative care unit over a 3-month period with a diagnosis of cancer on opioid therapy were selected. Data pertaining to demographics, diagnosis, oral morphine dose equivalent of the opioid at the time of discharge, adjuvant analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and pain scores as reported by nurses and physicians were collected. RESULTS Seventy-seven patients were eligible over a 3-month period, out of which 65 (84 %) were taking an adjuvant medication. The most commonly prescribed adjuvant was gabapentin (70 %). Fifty-seven percent were taking more than one adjuvant. There were more women in the group receiving adjuvants (57 vs. 17%, p = 0.010). Those without adjuvants compared with those on adjuvants did not have worse pain scores on discharge as reported by physicians (0.8 ± 0.8 vs. 1.0 ± 0.7, p = 0.58) or nurses (2.0 ± 2.7 vs. 2.1 ± 2.6, p = 0.86). There was no difference in morphine equivalent doses of the opioid in both groups (median (min, max); 112 (58, 504) vs. 200 (30, 5,040)) at the time of discharge; 75-80 % of patients had improvement in pain scores as measured by a two-point reduction in numerical rating scale (NRS). DISCUSSION This study shows that adjuvant medications are commonly used for treating pain in patients with cancer. More than half of study population were on two adjuvants or an adjuvant plus NSAID along with an opioid. We did not demonstrate any benefit in terms of improved pain scores or opioid doses with adjuvants, but this could reflect confounding variables and physician choice. Larger prospective studies are needed to define the opioid-sparing effects of adjuvants. CONCLUSION Adjuvant agents are used in over 80 % of those treated for cancer pain.
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Affiliation(s)
- Shivani Shinde
- The Harry R Horvitz Center for Palliative Medicine, Division of Solid Tumor, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, R35, Cleveland, OH, 44195, USA
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Vadivelu N, Gowda AM, Urman RD, Jolly S, Kodumudi V, Maria M, Taylor R, Pergolizzi JV. Ketorolac tromethamine - routes and clinical implications. Pain Pract 2014; 15:175-93. [PMID: 24738596 DOI: 10.1111/papr.12198] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/27/2014] [Indexed: 11/29/2022]
Abstract
Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
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Gupta M, Davis M, LeGrand S, Walsh D, Lagman R. Nausea and vomiting in advanced cancer: the Cleveland Clinic protocol. ACTA ACUST UNITED AC 2013; 11:8-13. [PMID: 23137588 DOI: 10.1016/j.suponc.2012.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 09/19/2012] [Accepted: 10/04/2012] [Indexed: 12/31/2022]
Abstract
Nausea and vomiting are common and distressing symptoms in advanced cancer. Both are multifactorial and cause significant morbidity, nutritional failure, and reduced quality of life. Assessment includes a detailed history, physical examination and investigations for reversible causes. Assessment and management will be influenced by performance status, prognosis, and goals of care. Several drug classes are effective with some having the added benefit of multiple routes of administration. It is our institution's practice to recommend metoclopramide as the first drug with haloperidol as an alternative antiemetic. Dexamethasone should be used for patients with central nervous system metastases or bowel obstruction. If your patient is near death, empiric metoclopramide, haloperidol or chlorpromazine is used without further investigation. For patients with a better prognosis, we exclude reversible causes and use the same first-line antiemetics, metoclopramide and haloperidol. For those who do not respond to first-line single antiemetics, olanzapine is second line and ondansetron is third. Rarely do we use combination therapy or cannabinoids. Olanzapine as a single agent has a distinct advantage over antiemetic combinations. It improves compliance, reduces drug interactions and has several routes of administration. Antiemetics, anticholinergics, octreotide and dexamethasone are used in combination to treat bowel obstruction. In opiod-na'ive patients, we prefer haloperidol, glycopyrrolate and an opioid as the first-line treatment and add or substitute octreotide and dexamethasone in those who do not respond. Non-pharmacologic interventions (mechanical stents and percutaneous endoscopic gastrostomy tubes) are used when nausea is refractory to medical management or for home-going management to relieve symptoms, reduce drug costs and rehospitalization.
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Affiliation(s)
- Mona Gupta
- The Harry R. Horvitz Center for Palliative Medicine, Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Tausig Cancer Institute, Ohio, USA
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Destro M, Ottolini L, Vicentini L, Boschetti S. Physical compatibility of binary and ternary mixtures of morphine and methadone with other drugs for parenteral administration in palliative care. Support Care Cancer 2012; 20:2501-9. [DOI: 10.1007/s00520-011-1363-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 12/26/2011] [Indexed: 11/30/2022]
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Abstract
BACKGROUND Narcotic bowel syndrome is characterized by chronic or recurrent abdominal pain associated with escalating doses of narcotic pain medications. It may occur in as many as 4% of all patients taking opiates, and yet few physicians are aware that the syndrome exists. OBJECTIVES The objectives of this case report are to raise awareness of narcotic bowel syndrome among emergency physicians, as well as review the clinical features, diagnosis, pathophysiology, and emergency department (ED) management of the syndrome. CASE REPORT We report a case of narcotic bowel syndrome diagnosed in a 24-year-old woman after > 1 year of ED visits for recurrent abdominal pain of unknown origin. CONCLUSIONS It is particularly important for emergency physicians to be familiar with this syndrome, as many patients with narcotic bowel syndrome seek evaluation and treatment in the ED. Although the diagnosis is unlikely to be made in the ED, timely referral for evaluation of this syndrome may help patients to receive definitive treatment for their recurrent and chronic pain.
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Abstract
Adjuvant analgesics (co-analgesics) are medications whose primary indication is the management of a medical condition with secondary effects of analgesia. Cancer pain is multifactorial and often involves inflammatory, nociceptive, and neuropathic pain subtypes. Adjuvant analgesics used in conjunction with opioids have been found to be beneficial in the management of many cancer pain syndromes; however, they are currently underutilized. Antidepressants, anticonvulsants, local anesthetics, topical agents, steroids, bisphosphonates, and calcitonin are all adjuvants which have been shown to be effective in the management of cancer pain syndromes. When utilizing analgesic adjuvants in the treatment of cancer pain, providers must take into account the particular side effect profile of the medication. Ideally, adjuvant analgesics will be initiated at lower dosages and escalated as tolerated until efficacy or adverse effects are encountered.
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Affiliation(s)
- Raj Mitra
- Stanford Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Redwood City, CA 94063, USA.
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Turner CL, Eggleston GW, Lunos S, Johnson N, Wiedmann TS, Bowles WR. Sniffing out endodontic pain: use of an intranasal analgesic in a randomized clinical trial. J Endod 2011; 37:439-44. [PMID: 21419286 DOI: 10.1016/j.joen.2010.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 12/10/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Orofacial pain is a common encounter in dentistry (affecting 12% of the population) and is a primary reason for patients seeking emergency care. Dentists often prescribe oral analgesics, which have disadvantages of decreased absorption rates and delayed onset. Intranasal (IN) delivery takes advantage of a large surface area of mucosal tissue for rapid absorption. The purpose of this study was to evaluate the efficacy of IN ketorolac for endodontic pain using a randomized, double-blind, placebo-controlled parallel design study. METHODS Twenty-two patients presenting with moderate to severe endodontic pain were selected to receive IN treatment with placebo (n = 11) or ketorolac (n = 11) 30 minutes before endodontic treatment was started and immediately after the completion of endodontic treatment. Baseline pain levels were recorded before IN treatment. Pain levels were also recorded at 15 and 30 minutes after the initial IN dosing (before endodontic treatment); 30 minutes after completion of endodontic treatment; and 4, 8, and 12 hours after the initial IN spray. Primary analysis was a repeated-measures analysis of variance. RESULTS IN ketorolac alone or with endodontic treatment showed significantly better pain relief compared with IN placebo spray alone or with endodontic treatment at 30 minutes after the first or second intranasal dose and at 4 hours after the first intranasal dose (P = .03). CONCLUSIONS These results suggest that IN ketorolac may provide a novel and efficacious method for pain relief in endodontic pain patients.
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Ogata K, Takamura N, Tokunaga J, Kawai K, Arimori K, Higuchi S. Dosage plan of a flurbiprofen injection product using inhibition of protein binding by lipid emulsion in rats. J Pharm Pharmacol 2010; 60:15-20. [DOI: 10.1211/jpp.60.1.0002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
Flurbiprofen-axetil (FP-ax), a bolus injection product of a non-steroidal anti-inflammatory drug (NSAID), is a prodrug of flurbiprofen, an NSAID. As flurbiprofen strongly binds to site II of human serum albumin (HSA), the free (unbound) concentration of flurbiprofen after injection of FP-ax is low. We have examined the inhibitory effect of free fatty acid (FFA), a binding inhibitor for site II of HSA, on the binding of flurbiprofen in-vitro and in-vivo by ultrafiltration, to establish an effective dosage of FP-ax. In-vitro, fatty acid mixtures (FAs) inhibited the binding of flurbiprofen to rat serum albumin. The free fraction of flurbiprofen was remarkably increased by FAs in rat serum. In-vivo, FP-ax was injected into a control group (low FFA concentration in serum) and a lipid emulsion group (high FFA concentration in serum). The area under the curve of the free concentration of flurbiprofen during the alpha phase and the distribution volume of the central compartment of flurbiprofen were significantly higher in the lipid emulsion group than the control group (5.0- and 1.2-times, respectively). When FP-ax was administered at high FFA concentration, the free concentration of flurbiprofen and distribution of flurbiprofen to tissues increased transiently. This administration method may be useful for patients with cancer pain, having a potent analgesic effect.
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Affiliation(s)
- Kenji Ogata
- Second Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Kyushu University of Health and Welfare, 1714-1 Yoshino, Nobeoka, Miyazaki, 882–8508, Japan
- Clinical Pharmacokinetics, Division of Clinical Pharmacy, Department of Medico-Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812–8582, Japan
| | - Norito Takamura
- Second Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Kyushu University of Health and Welfare, 1714-1 Yoshino, Nobeoka, Miyazaki, 882–8508, Japan
| | - Jin Tokunaga
- Second Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Kyushu University of Health and Welfare, 1714-1 Yoshino, Nobeoka, Miyazaki, 882–8508, Japan
| | - Keiichi Kawai
- School of Health Sciences, Faculty of Medical, Kanazawa University, 5–11-80 Kadatsuno, Kanazawa, Ishikawa, 920–0942, Japan
| | - Kazuhiko Arimori
- Department of Pharmacy, Miyazaki Medical College Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889–1692, Japan
| | - Shun Higuchi
- Clinical Pharmacokinetics, Division of Clinical Pharmacy, Department of Medico-Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812–8582, Japan
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El-Setouhy DA, Ahmed El-Ashmony SM. Ketorolac trometamol topical formulations: release behaviour, physical characterization, skin permeation, efficacy and gastric safety. J Pharm Pharmacol 2010; 62:25-34. [DOI: 10.1211/jpp.62.01.0002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
Objectives
The objective of this study was to improve systemic delivery of the highly analgesic ketorolac trometamol (ketorolac tromethamine) via the transdermal route, through cost-effective topical formulations, to avoid most of the problems associated with ketorolac trometamol therapy.
Methods
In-vitro release behaviour of the drug from different microemulsion and emulgel formulations was evaluated. E2 emulgel (based on isopropyl myristate as penetration enhancer) and E7 emulgel (based on Brij 92 as penetration enhancer) were evaluated for their physical properties, rat skin permeation, in-vivo analgesic effect (hot-plate test and the paw pressure test), acute and chronic anti-inflammatory activity and gastric safety.
Key findings
Isopropyl myristate and the synergistic effect of the two known penetration enhancers (propylene glycol and Brij 92) significantly modulated drug permeation and may be a promising approach for the transdermal delivery of ketorolac trometamol and other drugs. Selected in-vivo tested formulae (E2 and E7) caused significantly less ulcer score and less gastric erosion compared with oral ketorolac trometamol. E7 showed significantly higher analgesic and anti-inflammatory activity compared with E2 with no significant difference compared with oral ketorolac trometamol.
Conclusions
The developed ketorolac trometamol E7 emulgel appeared promising for dermal and transdermal delivery of ketorolac trometamol, which would circumvent most of the problems associated with drug therapy.
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The narcotic bowel syndrome: clinical features, pathophysiology, and management. Clin Gastroenterol Hepatol 2007; 5:1126-39; quiz 1121-2. [PMID: 17916540 PMCID: PMC2074872 DOI: 10.1016/j.cgh.2007.06.013] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Narcotic bowel syndrome (NBS) is a subset of opioid bowel dysfunction that is characterized by chronic or frequently recurring abdominal pain that worsens with continued or escalating dosages of narcotics. This syndrome is underrecognized and may be becoming more prevalent. In the United States this may be the result of increases in using narcotics for chronic nonmalignant painful disorders, and the development of maladaptive therapeutic interactions around its use. NBS can occur in patients with no prior gastrointestinal disorder who receive high dosages of narcotics after surgery or acute painful problems, and among patients with functional gastrointestinal disorders or other chronic gastrointestinal diseases who are managed by physicians who are unaware of the hyperalgesic effects of chronic opioids. The evidence for the enhanced pain perception is based on the following: (1) activation of excitatory antianalgesic pathways within a bimodal opioid regulation system, (2) descending facilitation of pain at the rostral ventral medulla and pain facilitation via dynorphin and cholecystokinin activation, and (3) glial cell activation that produces morphine tolerance and enhances opioid-induced pain. Treatment involves early recognition of the syndrome, an effective physician-patient relationship, graded withdrawal of the narcotic according to a specified withdrawal program, and the institution of medications to reduce withdrawal effects.
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Lin FS, Lin TF, Yeh YC, Lin CP, Sun WZ. Compatibility and stability of ketorolac tromethamine and morphine hydrochloride in 0.9% sodium chloride injection. THE PAIN CLINIC 2007; 19:99-103. [DOI: 10.1179/016911107x268701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
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Kausar F, Davis MP. Ketorolac in neuropathic pain. J Pain Symptom Manage 2006; 32:202-4. [PMID: 16939842 DOI: 10.1016/j.jpainsymman.2006.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Revised: 05/08/2006] [Accepted: 05/11/2006] [Indexed: 10/24/2022]
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Bicanovsky LK, Lagman RL, Davis MP, Walsh D. Managing nonmalignant chronic abdominal pain and malignant bowel obstruction. Gastroenterol Clin North Am 2006; 35:131-42. [PMID: 16530116 DOI: 10.1016/j.gtc.2006.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Evaluation of abdominal pain requires an understanding of the possible causes(benign or malignant) and recognition of typical patterns and clinical presentation. Abdominal pain has multiple causes; associated signs and symptoms may aid in the diagnosis. Remember that some patients will not have a textbook presentation, and unusual causes for pain must be considered. Those with chronic pancreatitis with structural complications should be operated on early, whereas those with other types of chronic pancreatitis should receive medical therapy focusing on alleviating symptoms. Control of the most troublesome symptoms will provide the best management for IBS. Pharmacologic success in bowel obstruction depends on the level and degree of obstruction. Decision making is based on reasonable expectations of survival, treatment-related success, performance status, and goals of care. Quality of life will be enhanced by appropriate symptom management.
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Affiliation(s)
- Lesley K Bicanovsky
- The Harry R. Horvitz Center for Palliative Medicine, Taussig Cancer Center, Cleveland Clinic, 9500 Euclid Avenue, M76, OH 44195, USA
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Ripamonti C, Grosso MI. Palliative medical management. EJC Suppl 2005. [DOI: 10.1016/s1359-6349(05)80277-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Good P, Tullio F, Jackson K, Goodchild C, Ashby M. Prospective audit of short-term concurrent ketamine, opioid and anti-inflammatory (‘triple-agent’) therapy for episodes of acute on chronic pain. Intern Med J 2005; 35:39-44. [PMID: 15667467 DOI: 10.1111/j.1445-5994.2004.00727.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM This prospective audit was undertaken in order to document the analgesic response and adverse effects of concurrent short-term ('burst') triple-agent analgesic (ketamine, an opioid and an anti-inflammatory agent--either steroidal or non-steroidal) administration, for episodes of acute on chronic pain. The clinical hypothesis in this study is that better pain control may be obtained by simultaneous multiple target receptor blockade. METHOD The response of 18 patients is reported. The pain and analgesic requirement data for the 24 h before starting triple-agent therapy were compared with the last 24 h on the triple-agent therapy. Patients were then classified as responders or non-responders. RESULTS According to stringent clinical criteria, 12 out of the 18 patients were classified as responders. The response rate was highest for somatic pain (7/9) and appeared to decrease with duration of prior uncontrolled pain. Only four out of the 18 patients reported adverse effects and all of these were minor. CONCLUSIONS The results suggest that this 'burst' triple-agent approach is safe and effective in an inpatient palliative care population during episodes of poorly controlled acute on chronic pain, and warrants further investigation to ascertain whether it gives superior results compared to the 'gold-standard' WHO ladder approach.
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Affiliation(s)
- P Good
- Department of Medicine, Southern Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University and Medicine Program, Southern Health, McCulloch House, Monash Medical Centre, Melbourne, Victoria, Australia
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Potluri V, Zhukovsky DS. Recent advances in malignant bowel obstruction: an interface of old and new. Curr Pain Headache Rep 2003; 7:270-8. [PMID: 12828876 DOI: 10.1007/s11916-003-0047-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Malignant bowel obstruction continues to be a difficult problem for patients with abdominal and pelvic primary tumors and tumors originating in other sites. The main treatment options consist of surgery, stenting, and pharmacotherapy. Despite recent advances, the impact of available treatment modalities on symptom control, longevity, quality of life, and associated health care costs have not been evaluated rigorously. This article reviews the available data and suggests an approach to the management of this challenging patient population.
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Affiliation(s)
- Vinaya Potluri
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 8, Houston, TX 77030, USA
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Reale C, Vernaglione E, Reale C, Mancini A, Prologo M, Campisi C. Advantages of Totally Implanted Port over Impromptu Short-Term Central Venous Catheter in Oncological Pain Therapy. J Vasc Access 2003. [DOI: 10.1177/112972980300400204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The aim of this paper is to determine if patient controlled analgesia (PCA) by means of programmable pumps improves patients' autonomy and to verify if the short-term central venous catheter - implanted when pain is first evident - makes the quality of life worse in comparison with an early implanted port. Forty non-terminally ill patients affected by urinary malignant pathologies with visceral and bone metastases were enrolled in a prospective and randomised study at the Urology Department of “La Sapienza” University in Rome, Italy. Intensity of pain and tolerability of venous access were assessed for the first 7 days, and weekly for 3 months. Such data were used to adjust drug therapy. In this study we hypothesized that a delayed central venous catheter implant, when the pain is at first considerably evident, can interfere negatively with drug treatment. The visual analogue scale (VAS) and the brief pain inventory (BPI) were administered to the patients, and these showed good levels of analgesia in both groups and a greater comfort to the patients with the previously implanted port in comparison with a short-term central venous catheter. In conclusion, PCA achieves a constant level of drugs and enables the patient to voluntary control the pain by means of supplemental boluses. Both central devices seem to provide similar technical benefits, but the port is much more easily tolerated and the quality of life is increased if it is already available when pain is first evident.
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Affiliation(s)
- C. Reale
- Institute of Anesthesiology, Resuscitation and Pain Therapy, University of Rome “La Sapienza”, Rome - Italy
| | - E. Vernaglione
- Institute of Anesthesiology, Resuscitation and Pain Therapy, University of Rome “La Sapienza”, Rome - Italy
| | - C.A. Reale
- Institute of Anesthesiology, Resuscitation and Pain Therapy, University of Rome “La Sapienza”, Rome - Italy
| | - A. Mancini
- Institute of Anesthesiology, Resuscitation and Pain Therapy, University of Rome “La Sapienza”, Rome - Italy
| | - M. Prologo
- Institute of Anesthesiology, Resuscitation and Pain Therapy, University of Rome “La Sapienza”, Rome - Italy
| | - C. Campisi
- National Research Council, Institute of Biomedical Engineering, Biomedical Technologies Section, Rome - Italy
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White PF, Eshima RW, Maurer A, King T, Lin BK, Heavner JE, Bogetz MS, Kaye AD. A comparison of airway responses during desflurane and sevoflurane administration via a laryngeal mask airway for maintenance of anesthesia. Anesth Analg 2003; 96:701-705. [PMID: 12598249 DOI: 10.1213/01.ane.0000048978.40522.ab] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPLICATIONS Although sevoflurane is less pungent than desflurane at larger concentrations, neither anesthetic seems to irritate the airway when administered at the smaller concentrations often used during maintenance of anesthesia. Both anesthetics may be delivered effectively via a laryngeal mask airway, with minimal evidence of airway irritation.
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Affiliation(s)
- Paul F White
- *Department of Anesthesia and Perioperative Care, University of California, San Francisco; and †Department of Anesthesiology, Texas Tech University Health Science Center, Lubbock
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Mercadante S, Fulfaro F, Casuccio A. A randomised controlled study on the use of anti-inflammatory drugs in patients with cancer pain on morphine therapy: effects on dose-escalation and a pharmacoeconomic analysis. Eur J Cancer 2002; 38:1358-63. [PMID: 12091067 DOI: 10.1016/s0959-8049(02)00102-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The role of non-steroidal anti-inflammatory drugs (NSAIDs) in cancer pain has been well established in the treatment of mild pain and in association with opioids in the treatment of moderate to severe pain. The aim of this study was to verify the effects of NSAIDs on morphine escalation in advanced cancer patients with pain followed-up at home and to assess the pharmacoeconomic implications. A prospective randomised controlled study was carried out in 156 consecutive advanced cancer patients with pain followed-up at home in the period December 1999-December 2000. In this group of patients, 47 were selected with pain progression after 1 week of opioid stabilisation. Patients were randomly assigned to one of two groups: group 'O' patients were treated with continuing opioid escalation according to their clinical needs; group 'OK' received ketorolac 60 mg/daily orally (p.o.) in three doses and then continued opioid escalation according to their clinical situation. Performance status, doses of morphine before and after starting treatment, mean weekly pain intensity (assessed by means of a numerical scale from 0 to 10), mean weekly symptoms intensity, adverse effects and pain mechanisms were recorded. Moreover, drug costs per day in both groups were calculated. Patients who received ketorolac in addition to morphine showed a better analgesia after a week in comparison to the group treated with morphine only (P=0.005). Thereafter, morphine escalation was slower and the maximum morphine dose was lower in the group treated with ketorolac. The incidence and the severity of gastric discomfort was more evident in patients treated with ketorolac, while constipation was significantly increased in patients who received morphine only. Drug costs per day were similar in both groups; statistical differences were observed in patients who started on lower morphine doses (<100 mg/daily) in the two groups (4.3 in the ketorolac-morphine group versus 3.4 in the morphine group; P=0.012). The use of NSAIDs reduces the need for an opioid dose escalation or allows the use of lower doses. Their use is associated with a more intense gastric discomfort, but results in less opioid-related constipation. The eventual additive cost for NSAIDs therapy is negligible, especially in patients taking high doses of morphine.
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Affiliation(s)
- S Mercadante
- Anesthesia and Intensive Care Unit, Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, via San Lorenzo Colli no. 312, 90146, Palermo, Italy.
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38
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Abstract
This article reviews how to assess and manage several symptoms commonly encountered by neurologists who care for patients with advanced illness. Scientifically validated guidelines are reviewed and practical advice is offered on how to manage pain, nausea and vomiting, dyspnea, and respiratory secretions at the end of life. The role of the neurologist as a provider of end of life care is discussed including suggestions for communicating with patients and families. This article concludes with a review of when sedation may be offered within the purview of good palliative care to patients who are imminently dying.
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Affiliation(s)
- A C Carver
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York 10021, USA.
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39
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Abstract
Control of malignant pain and related symptoms is paramount to clinical success in caring for cancer patients. To achieve the best quality of life for patients and families, oncologists and palliative care clinicians must work together to understand problems related to psychologic, social, and spiritual pain. Pain is the primary problem targeted for control using the World Health Organization's (WHO) analgesic ladder. This article focuses on increased knowledge of analgesic action that may enable expansion of the WHO analgesic ladder to fulfill the broader objectives of palliative medicine. We discuss clinical experience with several classes of drugs that are currently used to treat cancer pain: 1) nonsteroidal anti-inflammatory drugs, with emphasis on cyclooxygenase-2 inhibitors; 2) opioid analgesics, with specific emphasis on methadone and its newly recognized value in cancer pain; 3) ketamine, an antagonist at N-methyl-d-aspartate receptors; and 4) bisphosphonates, used for pain resulting from bone metastases. New concepts that compare molecular actions of morphine at excitatory opioid receptors, and methadone at nonopioid receptor systems, are presented to underscore the importance of balancing central nervous system excitatory (anti-analgesic) versus inhibitory (analgesic) influences.
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Affiliation(s)
- F J McDonnell
- Palliative Care Service, Department of Anesthesiology, University of Kentucky College of Medicine, Rose Street, Lexington, KY 40536, USA.
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40
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Abstract
Malignant-associated bowel obstruction remains a common and perplexing problem for patients with advanced gynecologic and gastrointestinal malignancies. The ability to locate and define its cause preoperatively has improved with the advent of computed tomography. Initial clinical experience with half-Fourier acquisition single-shot turbo spin-echo magnetic resonance imaging (HASTE MRI) and virtual colonoscopy is exciting. The surgical approach for primary obstructing colon cancer has become more aggressive, with experienced surgical groups doing one-stage procedures. Yet to be defined are guidelines for surgical management of obstructions occurring in the face of recurrent disease. Stent placement for upper and lower bowel obstructions is an option in nonoperable patients. Pharmacologic symptom management for intestinal obstructions consists of an opioid, an anticholinergic, and an antiemetic. Octreotide, either alone or added to the original regimen, will palliate symptoms that are resistant to the three-drug combination.
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Affiliation(s)
- M P Davis
- Harry R. Horvitz Center for Palliative Medicine (A World Health Organization Demonstration Project).
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41
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Abstract
Assessment and management of pain is crucial to the success of any program of care for dying patients and their families. With appropriate assessment and management, often using home health or hospice teams, pain can be controlled in more than 90% of patients. This article focuses on the symptomatic care of patients who are dying. The legal and regulatory issues that may inhibit delivery of adequate opioid therapy are also reviewed.
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Affiliation(s)
- J L Abrahm
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.
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42
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Cherny N, Ripamonti C, Pereira J, Davis C, Fallon M, McQuay H, Mercadante S, Pasternak G, Ventafridda V. Strategies to manage the adverse effects of oral morphine: an evidence-based report. J Clin Oncol 2001; 19:2542-54. [PMID: 11331334 DOI: 10.1200/jco.2001.19.9.2542] [Citation(s) in RCA: 413] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Successful pain management with opioids requires that adequate analgesia be achieved without excessive adverse effects. By these criteria, a substantial minority of patients treated with oral morphine (10% to 30%) do not have a successful outcome because of (1) excessive adverse effects, (2) inadequate analgesia, or (3) a combination of both excessive adverse effects along with inadequate analgesia. The management of excessive adverse effects remains a major clinical challenge. Multiple approaches have been described to address this problem. The clinical challenge of selecting the best option is enhanced by the lack of definitive, evidence-based comparative data. Indeed, this aspect of opioid therapeutics has become a focus of substantial controversy. This study presents evidence-based recommendations for clinical-practice formulated by an Expert Working Group of the European Association of Palliative Care (EAPC) Research NETWORK: These recommendations highlight the need for careful evaluation to distinguish between morphine adverse effects from comorbidity, dehydration, or drug interactions, and initial consideration of dose reduction (possibly by the addition of a co analgesic). If side effects persist, the clinician should consider options of symptomatic management of the adverse effect, opioid rotation, or switching route of systemic administration. The approaches are described and guidelines are provided to aid in selecting between therapeutic options.
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Affiliation(s)
- N Cherny
- Cancer Pain and Palliative Medicine Service, Department of Oncology, Shaare Zedek Medical Center, Jerusalem, Israel.
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43
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Joishy SK. The Relationship Between Surgery and Medicine in Palliative Care. Surg Oncol Clin N Am 2001. [DOI: 10.1016/s1055-3207(18)30085-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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44
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Abstract
Malignant associated bowel obstruction remains a common and perplexing problem for patients with advanced gynecologic and gastrointestinal malignancies. The ability to locate and define its cause preoperatively has improved with the advent of computed tomography. Initial clinical experience with half-Fourier acquisition single-shot turbo spin-echo magnetic resonance imaging (HASTE MRI) and virtual colonoscopy is exciting. The surgical approach for primary obstructing colon cancer has become more aggressive, with experienced surgical groups doing one-stage procedures. Yet to be defined are guidelines for surgical management of obstructions occurring in the face of recurrent disease. Stent placement for upper and lower bowel obstructions is an option in nonoperable patients. Pharmacologic symptom management for intestinal obstructions consists of an opioid, an anticholinergic, and an anti-emetic. Octreotide, either alone or added to the original regimen, will palliate symptoms that are resistant to the three-drug combination.
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Affiliation(s)
- M P Davis
- Harry R. Horvitz Center for Palliative Medicine (A World Health Organization Demonstration Project), Taussig Cancer Center of The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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45
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Abstract
Control of malignant pain and related symptoms is paramount to clinical success in caring for cancer patients. To achieve the best quality of life for patients and families, oncologists and palliative care clinicians must work together to understand problems related to psychologic, social, and spiritual pain. Pain is the primary problem targeted for control using the World Health Organization's (WHO) analgesic ladder. This article focuses on increased knowledge of analgesic action that may enable expansion of the WHO analgesic ladder to fulfill the broader objectives of palliative medicine. We discuss clinical experience with several classes of drugs that are currently used to treat cancer pain: 1) nonsteroidal anti-inflammatory drugs (NSAIDs), with emphasis on cyclooxygenase-2 (COX-2) inhibitors; 2) opioid analgesics, with specific emphasis on methadone and its newly recognized value in cancer pain; 3) ketamine, an antagonist at N-methyl d-aspartate (NMDA) receptors; and 4) bisphosphonates, used for pain resulting from bone metastases. New concepts that compare molecular actions of morphine at excitatory opioid receptors, and methadone at non-opioid receptor systems, are presented to underscore the importance of balancing central nervous system excitatory (anti-analgesic) versus inhibitory (analgesic) influences.
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Affiliation(s)
- F J McDonnell
- Palliative Care Service, Department of Anesthesiology, University of Kentucky College of Medicine, Rose Street, Lexington, KY 40536, USA.
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46
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Abstract
Management of pain is crucial to the success of any program of care and support for dying patients and their families. Pain can be controlled in more than 90% of older adults. Components of an effective program include comprehensive, repeated pain assessment; detection and treatment of complicating medical and psychological disorders (e.g., delirium); spiritual concerns; and the judicious use of nonpharmacologic and pharmacologic therapies, radiation, and radiopharmaceuticals. Strategies that enable clinicians to prevent and treat the expected complications of nonsteroidal anti-inflammatory and opioid therapies are reviewed. Strategies to change opioid agents or routes to minimize opioid-induced side effects and to provide effective pain relief as death nears are presented.
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Affiliation(s)
- J L Abrahm
- Division of Hematology/Oncology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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