1
|
Sakaguchi T. Cancer-related breathlessness: opioids other than morphine - comprehensive literature review. BMJ Support Palliat Care 2024; 13:e715-e729. [PMID: 37468224 DOI: 10.1136/spcare-2022-004115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/06/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Although there is low-quality evidence, there has been an increase in publications on the experience of evaluating and managing cancer-related breathlessness using opioids other than morphine. METHODS The author conducted a non-systematic literature review in the PubMed/Medline and Embase until 4 October 2022. Eligible studies have evaluated the efficacy of opioids other than morphine for cancer-related breathlessness. Studies focused on sedation, anaesthesia, paediatric patients, opioid toxicity or basic research were excluded. Reviews/meta-analyses and non-English language publications were also excluded. RESULTS A total of 1556 records were identified, of which 23 studies including 469 patients who were treated with fentanyl (n=223), oxycodone (n=171) and hydromorphone (n=75) were considered eligible. Six phase II randomised clinical trials (RCTs), four observational studies and four case reports of fentanyl were found. For breathlessness on exertion, fentanyl yielded promising results, but no RCT showed significant superiority of fentanyl to placebo or morphine. For terminal breathlessness, three RCTs, five non-randomised or observational studies and one case report on oxycodone or hydromorphone were found. Although the results of the observational studies suggested that oxycodone and hydromorphone might be effective alternatives to morphine, the superiority over placebo or non-inferiority to morphine had not been demonstrated in the RCTs. CONCLUSION As an alternative to morphine, the author recommends fentanyl for breathless crisis or breathlessness on exertion, and oxycodone or hydromorphone for terminal breathlessness in advanced cancer. Larger and well-designed studies based on firm research policies are needed to confirm this current knowledge.
Collapse
Affiliation(s)
- Tatsuma Sakaguchi
- Department of Palliative Care, Kitano Hospital, Osaka, Japan
- Palliative Care Centre, Aichi Medical University, Nagakute, Japan
| |
Collapse
|
2
|
Obarzanek L, Wu W, Tutag-Lehr V. Opioid Management of Dyspnea at End of Life: A Systematic Review. J Palliat Med 2022; 26:711-726. [PMID: 36453988 DOI: 10.1089/jpm.2022.0311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: The objective of this systematic review is to consolidate the existing evidence on opioid use, including administration, dosing, and efficacy, for the relief of dyspnea at end of life. The overarching goal is to optimize clinical management of dyspnea by identifying patterns in opioid use, improving opioid management of dyspnea, and to prioritize future research. Background: Opioids are commonly used in the management of dyspnea at end of life, yet specific administration guidelines are limited. A greater understanding of the effectiveness of opioids in relieving end-of-life dyspnea with consideration of study design, patients, and opioids, including dyspnea evaluation tools and outcomes, will leverage development of standardized administration and dosing. Methods: A PRISMA-guided systematic review using six databases identified quality studies of opioid management for patients with dyspnea at end of life. Results: Twenty-three references met review inclusion criteria, which included terminally ill cancer and noncancer patients with various diagnoses. Studies included two randomized controlled trials, and three nonrandomized experimental, three prospective observational, one cross-sectional, and one case series. Thirteen retrospective chart reviews were also included due to the limited rigorous studies rendered by the search. Thirteen studies evaluated morphine, followed by fentanyl (6), oxycodone (5), general opioid use (4), and hydromorphone (2). Routes of administration were parenteral, oral, combination, and nebulization. Dyspnea was evaluated using self-reporting and non-self-reporting evaluation tools. Sedation was the most reported opioid-related adverse effect. Discussion: Challenges persist in conducting end-of-life research, preventing consensus on standardization of opioid treatment for dyspnea within this specific palliative time frame. Future robust prospective trials using specific, accurate assessment with reassessment of dyspnea/respiratory distress, and consideration of opioid tolerance, polypharmacy, and comorbidities are required.
Collapse
Affiliation(s)
| | - Wendy Wu
- Shiffman Medical Library, Wayne State University, Detroit, Michigan, USA
| | - Victoria Tutag-Lehr
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| |
Collapse
|
3
|
Luo N, Tan S, Li X, Singh S, Liu S, Chen C, Huang Z, Feng S, Lin Y, Lin Y, Cen H, Liang M, Chen M. Efficacy and Safety of Opioids in Treating Cancer-Related Dyspnea: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials. J Pain Symptom Manage 2021; 61:198-210.e1. [PMID: 32730950 DOI: 10.1016/j.jpainsymman.2020.07.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/14/2020] [Accepted: 07/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dyspnea is one of the most distressing symptoms encountered by advanced cancer patients. In this study, we aimed to evaluate the role of opioids in the management of cancer-related dyspnea. METHODS A systematic review and meta-analysis based on Randomized Controlled Trials was conducted in the databases PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials testing the effect of opioids in relieving cancer-related dyspnea. Subgroup and sensitivity analyses were performed to evaluate various types of opioids in dyspnea management and stabilization of the study respectively. RESULTS Eleven RCTs fulfilled the eligibility criteria and had a total of 290 participants. Nine of these studies were included in meta-analyses. Compared with control, opioid therapy showed a small positive effect in dyspnea, SMD-0.82 (95%CI = -1.54 to -0.10) and Borg score, WMD-0.95 (95%CI = -1.83 to -0.06); Opioid therapy did not increase the risk of somnolence, OR0.93 (95%CI = 0.34 to 2.58), whereas a negative effect on respiratory rate was observed,WMD-1.89 (95%CI = -3.36 to -0.43); Also, there was no evidence to suggest improved performance of the 6MWT test, WMD6.49 (95%CI = -34.23 to 47.21), or the level of peripheral oxygen saturation, WMD0.33 (95%CI = -0.59 to 1.24) after opioid therapy. Subgroup analysis yielded a small positive effect for morphine on dyspnea, SMD-0.78 (95%CI = -1.45 to -0.10), whereas fentanyl showed no improvement in dyspnea, SMD-0.44 (95%CI = -0.89 to 0.02). Sensitivity analysis showed no changes in the direction of effect when any one study was excluded from the meta-analyses. CONCLUSIONS Our systematic review and meta-analysis indicated low quality evidence for a small positive effect of opioids in cancer-related dyspnea. Evidence for safety is insufficient as comprehensive adverse events were not adequately reported in studies.
Collapse
Affiliation(s)
- Ning Luo
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Shifan Tan
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Xiaocai Li
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | | | - Si Liu
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Chunjie Chen
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Zhuangzhi Huang
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Shuangshuang Feng
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Yacong Lin
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Yuemei Lin
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Hongdan Cen
- Department of Otolaryngology, Maoming People's Hospital, Maoming, China
| | - Min Liang
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China.
| | - Mafeng Chen
- Department of Otolaryngology, Maoming People's Hospital, Maoming, China.
| |
Collapse
|
4
|
Boyden JY, Connor SR, Otolorin L, Nathan SD, Fine PG, Davis MS, Muir JC. Nebulized Medications for the Treatment of Dyspnea: A Literature Review. J Aerosol Med Pulm Drug Deliv 2015; 28:1-19. [DOI: 10.1089/jamp.2014.1136] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | - Steven D. Nathan
- Advanced Lung Disease & Transplant Program, Inova Fairfax Hospital, Falls Church, VA 22042
| | - Perry G. Fine
- Department of Anesthesiology, School of Medicine, Pain Research Center, University of Utah, Salt Lake City, UT 84108
| | | | | |
Collapse
|
5
|
Effect of nebulized morphine on dyspnea of mustard gas-exposed patients: a double-blind randomized clinical trial study. Pulm Med 2012; 2012:610921. [PMID: 22530119 PMCID: PMC3316967 DOI: 10.1155/2012/610921] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 01/20/2012] [Accepted: 01/20/2012] [Indexed: 11/17/2022] Open
Abstract
Background. Dyspnea is one of the main complaints in a group of COPD patients due to exposure to sulfur mustard (SM) and is refractory to conventional therapies. We designed this study to evaluate effectiveness of nebulized morphine in such patients. Materials and Methods. In a double-blind clinical trial study, 40 patients with documented history of exposure to SM were allocated to two groups: group 1 who received 1 mg morphine sulfate diluted by 4 cc normal saline 0.5% using nebulizer once daily for 5 days and group 2 serving as control who received normal saline as placebo. They were visited by pulmonologist 7 times per day to check symptoms and signs and adverse events. Different parameters including patient-scored peak expiratory flow using pick flow meter, visual analogue scale (VAS) for dyspnea, global quality of life and cough, and number of respiratory rate, night time awaking for dyspnea and cough have been assessed. Results. The scores of VAS for dyspnea, cough and quality of life and also respiratory rate, heart rate, and night time awaking due to dyspnea and night time awaking due to cough improved significantly after morphine nebulization without any major adverse events. Also pick expiratory flow has been improved significantly after nebulization in each day. Conclusion. Our results showed the clinical benefit of nebulized morphine on respiratory complaints of patients due to exposure to SM without significant side effects.
Collapse
|
6
|
Comparaison prospective et randomisée de la morphine nébulisée versus la péridurale thoracique dans la prise en charge de la douleur des traumatisés thoraciques. ACTA ACUST UNITED AC 2010; 29:415-8. [DOI: 10.1016/j.annfar.2010.02.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Accepted: 02/24/2010] [Indexed: 11/20/2022]
|
7
|
Charles MA, Reymond L, Israel F. Relief of incident dyspnea in palliative cancer patients: a pilot, randomized, controlled trial comparing nebulized hydromorphone, systemic hydromorphone, and nebulized saline. J Pain Symptom Manage 2008; 36:29-38. [PMID: 18358689 DOI: 10.1016/j.jpainsymman.2007.08.016] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Revised: 08/23/2007] [Accepted: 08/31/2007] [Indexed: 10/22/2022]
Abstract
Acute episodic breathlessness in patients receiving palliative care is a distressing symptom with little evidence-base to inform management. This pilot, double-blind, controlled, crossover study compared the effects of nebulized hydromorphone, systemic hydromorphone and nebulized saline for the relief of episodic breathlessness in advanced cancer patients. On three occasions of acute breathlessness, patients randomly received either nebulized hydromorphone, a systemic breakthrough dose of hydromorphone or nebulized saline together with a blinding agent. Breathlessness was scored before and 10, 20, 30, and 60 minutes post-treatment completion using a 100 mm visual analog scale. Twenty patients completed the trial. Ratings did not differ significantly across pretest treatments. Change in ratings from pretest to 10 minutes after completion of nebulization (about 20 minutes after administration of systemic hydromorphone) indicated that each of the treatments resulted in statistically significant improvements in breathlessness, with no significant differences between treatments. Over time, breathlessness decreased significantly for all treatments, with no significant differences between treatments. Only nebulized hydromorphone produced a rapid improvement in breathlessness that reached a magnitude considered to be clinically important. Interpretation of these results is considered in relation to our definition of clinical significance, the dose of hydromorphone used and the possibility of a placebo effect. This study can serve to inform the design of future trials to investigate the management of incident breathlessness.
Collapse
Affiliation(s)
- Margaret A Charles
- School of Psychology, Sydney University, Sydney, New South Wales, Australia.
| | | | | |
Collapse
|
8
|
Clemens KE, Klaschik E. Effect of hydromorphone on ventilation in palliative care patients with dyspnea. Support Care Cancer 2007; 16:93-9. [DOI: 10.1007/s00520-007-0310-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 07/11/2007] [Indexed: 11/29/2022]
|
9
|
Ullrich CK, Mayer OH. Assessment and management of fatigue and dyspnea in pediatric palliative care. Pediatr Clin North Am 2007; 54:735-56, xi. [PMID: 17933620 DOI: 10.1016/j.pcl.2007.07.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fatigue is one of the most prevalent symptoms in patients with a life-threatening illness. Untreated, fatigue can impair quality of life and prohibit addressing practical needs, psychosocial and spiritual distress, and opportunities for growth and closure at life's end. To this end addressing fatigue is a crucial component of the provision of effective palliative care. Dyspnea is the sensation of breathlessness. The challenge in treating it, however, is that it can come from various different abnormalities so understanding the underlying disorder and the acute abnormality are critical. With that understanding several different treatments can be offered to treat the cause of the dyspnea or palliate the symptom itself.
Collapse
|
10
|
Abstract
OBJECTIVES To review the current state of evidence for the nursing treatment of cancer-related dyspnea. DATA SOURCES Nursing and medical literature, published guidelines, and Cochrane Systematic reviews. CONCLUSION Limited evidence exists for the current strategies used to treat dyspnea among persons with cancer. IMPLICATIONS FOR NURSING PRACTICE Nurses must be cognizant of the level of evidence or the lack of scientific evidence supporting treatment strategies used. Keeping abreast of the developments in the area of dyspnea management is imperative as research adds to the current body of evidence. Nurses are uniquely positioned to add to the body of evidence through collaboration with nurse researchers.
Collapse
|
11
|
Shirk MB, Donahue KR, Shirvani J. Unlabeled uses of nebulized medications. Am J Health Syst Pharm 2007; 63:1704-16. [PMID: 16960254 DOI: 10.2146/ajhp060015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The uses, dosing recommendations, benefits, and disadvantages of unlabeled drugs administered by nebulization are reviewed. SUMMARY Nebulization is gaining popularity as a treatment alternative, and many drugs are used unlabeled in a nebulized form, including the opioids, lidocaine, magnesium sulfate, amphotericin B, and colistin. The opioids are frequently used to treat dyspnea in end-stage diseases. Common dosages include 1-2 mg every two hours as needed for hydromorphone and 25-50 microg every two hours for fentanyl citrate. Lidocaine can be used to relieve bronchoconstriction and cough symptoms as well as acting as a local anesthetic. It is typically given in a dose between 20 and 160 mg. Nebulized magnesium sulfate can be used in managing acute asthma and is given in dosages between 125 and 250 mg every 20 minutes, with no more than four consecutive doses. Nebulized amphotericin B can be used to prevent infections in immunocompromised patients. A typical amphotericin B regimen is 25 mg every 24 hours. Nebulized colistin is being studied in the prevention and treatment of gram-negative infections and in patients awaiting lung transplants. Colistin is often given as 75 mg every 12 hours to combat infections. CONCLUSION Unlabeled nebulization of opioids, lidocaine, magnesium, amphotericin B, and colistin is an alternative method of treatment for patients with pulmonary problems or infections or for those undergoing bronchoscopy. More research is needed to develop guidelines for their use since nebulization may provide benefits to many patients who otherwise cannot be treated or would be at risk of systemic adverse effects of the drugs.
Collapse
Affiliation(s)
- Mary Beth Shirk
- Department of Pharmacy, The Ohio State University Medical Center (OSUMC), Columbus, OH 43210-1228, USA.
| | | | | |
Collapse
|
12
|
Abstract
Dyspnea, defined as uncomfortable or labored breathing, is a common and often devastating cause of distress for patients and their caregivers with advanced cancer and other life-threatening illnesses. The mechanism by which dyspnea develops is not fully understood, but it involves integration of the central respiratory complex with the sensory (perceptual) cortex. The gold standard of diagnosis is patient self-report. Careful assessment should be undertaken to identify reversible existing causes. Systemic opioids are the first-line therapy for symptomatic management, along with other general comfort measures (positioning, cool air, calming environment). Medical or surgical management can be directed toward underlying causes. Advanced care planning should include discussions concerning the burdens and benefits of medical/surgical management of underlying causes of dyspnea to more effectively direct goals of care. This article reviews current literature on dyspnea, with a focus on items published since 2000.
Collapse
|
13
|
Herndon CM, Kalauokalani DAK, Cunningham AJ, Jackson KC, Dunteman ED. Anticipating and treating opioid-associated adverse effects. Expert Opin Drug Saf 2003; 2:305-19. [PMID: 12904108 DOI: 10.1517/14740338.2.3.305] [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: 11/05/2022]
Abstract
Opioids are frequently avoided as viable tools in the management of pain due to perceived dangerous or untoward adverse drug events. Whilst they are relatively safe options for the treatment of pain, side effects and toxicities do exist and should be anticipated by the provider. The central nervous, gastrointestinal, genito-urinary, integumentary, metabolic/endocrine, cardiovascular, pulmonary, hepatic/renal, ocular and immune systems all manifest changes associated with opioid therapy. These adverse events, ranging from nuisance to therapy-limiting, are manageable when addressed quickly and appropriately. Opioids are safe and efficacious analgesics when these effects are considered.
Collapse
|
14
|
Doorley J, Hobbs M, Delaney E, Murphy J. The role of nebulized opioids in managing terminal dyspnea: implications for the clinical nurse specialist. CLIN NURSE SPEC 2003; 17:19-21. [PMID: 12544116 DOI: 10.1097/00002800-200301000-00015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Jane Doorley
- Palliative Care Team, Miami Valley Hospital, Ohio, USA.
| | | | | | | |
Collapse
|