1
|
Guitart-Vela J, Magrone Á, González G, Folch J. Effectiveness and Safety of Sublingual Fentanyl in the Treatment of Breakthrough Cancer Pain in Older Patients with Cancer: Results from a Retrospective Observational Study. J Pain Palliat Care Pharmacother 2024:1-12. [PMID: 39115710 DOI: 10.1080/15360288.2024.2385680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 06/03/2024] [Accepted: 07/20/2024] [Indexed: 08/10/2024]
Abstract
The study assessed sublingual fentanyl citrate (SFC) effectiveness and safety for breakthrough cancer pain (BtCP) in older patients. A multicenter, retrospective, observational study was conducted in three subgroups of cancer patients aged over 65 years with BtCP. The reports were collected by 20 oncologists across 12 hospitals. The primary goal was to measure changes in BtCP intensity with SFC treatment over 30 days; secondary objectives included pain relief onset and adverse events. A total of 127 patients with long-term cancer (mean: 3.3 years) were recruited. All of them had BtCP, mostly of mixed origin (62.5%). A significantly lower dose was needed in the high-age group at the final visit compared to baseline (212.90 ± 200.45 mcg vs. 206 ± 167.08 mcg; p = 0.000). Pain intensities at the beginning of the flare and at 30 min after SFC administration were significantly lower when the last and first visits were compared (1.9 vs. 2.3, p = 0.000; and 6.2 vs. 6.8 p = 0.006, respectively). The onset of analgesia was significantly more rapid for half of the patients ≥75 years, compared with 65-69 and 70-74 age groups. SFC appears then to be effective, well-tolerated, and safe to treat BtCP in older cancer patients.
Collapse
Affiliation(s)
| | | | | | - Jordi Folch
- Servicio de Patología del Dolor, Hospital Plató, Barcelona, Spain
| |
Collapse
|
2
|
Rozman de Moraes A, Erdogan E, Azhar A, Reddy SK, Lu Z, Geller JA, Graves DM, Kubiak MJ, Williams JL, Wu J, Bruera E, Yennurajalingam S. Scheduled and Breakthrough Opioid Use for Cancer Pain in an Inpatient Setting at a Tertiary Cancer Hospital. Curr Oncol 2024; 31:1335-1347. [PMID: 38534934 PMCID: PMC10969060 DOI: 10.3390/curroncol31030101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Our aim was to examine the frequency and prescription pattern of breakthrough (BTO) and scheduled (SCH) opioids and their ratio (BTO/SCH ratio) of use, prior to and after referral to an inpatient supportive care consult (SCC) for cancer pain management (CPM). Methods and Materials: Patients admitted at the MD Anderson Cancer Center and referred to a SCC were retrospectively reviewed. Cancer patients receiving SCH and BTO opioids for ≥24 h were eligible for inclusion. Patient demographics and clinical characteristics, including the type and route of SCH and BTO opioids, daily opioid doses (MEDDs) of SCH and BTO, and BTO/SCH ratios were reviewed in patients seen prior to a SCC (pre-SCC) and during a SCC. A normal BTO ratio was defined as 0.5-0.2. Results: A total of 665/728 (91%) patients were evaluable. Median pain scores (p < 0.001), BTO MEDDs (p < 0.001), scheduled opioid MEDDs (p < 0.0001), and total MEDDs (p < 0.0001) were higher, but the median number of BTO doses was fewer (2 vs. 4, p < 0.001), among patients seen at SCC compared to pre-SCC. A BTO/SCH ratio over the recommended ratio (>0.2) was seen in 37.5% of patients. The BTO/SCH ratios in the pre-SCC and SCC groups were 0.10 (0.04, 0.21) and 0.17 (0.10, 0.30), respectively, p < 0.001. Hydromorphone and Morphine were the most common BTO and SCH opioids prescribed, respectively. Patients in the early supportive care group had higher pain scores and MEDDs. Conclusions: BTO/SCH ratios are frequently prescribed higher than the recommended dose. Daily pain scores, BTO MEDDs, scheduled opioid MEDDs, and total MEDDs were higher among the SCC group than the pre-SCC group, but the number of BTO doses/day was lower.
Collapse
Affiliation(s)
- Aline Rozman de Moraes
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Elif Erdogan
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Suresh K. Reddy
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Zhanni Lu
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Joshua A. Geller
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - David Mill Graves
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Michal J. Kubiak
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Janet L. Williams
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Jimin Wu
- Department of Biostatistics, UT MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Sriram Yennurajalingam
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| |
Collapse
|
3
|
Cuomo A. Fentanyl in cancer pain management: avoiding hasty judgments and discerning its potential benefits. Drugs Context 2023; 12:2023-10-2. [PMID: 38148830 PMCID: PMC10751104 DOI: 10.7573/dic.2023-10-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/14/2023] [Indexed: 12/28/2023] Open
Abstract
Cancer pain is an important challenge in treatment and requires a rapid onset of action for its control. In particular, breakthrough cancer pain (BTcP) should be adequately controlled with a stable dose of a short-acting oral opioid. Fentanyl is a synthetic, highly selective opioid with many advantageous chemical properties, including high lipophilicity and distinct pharmacokinetic properties. It is recommended for pain management in a variety of settings, including acute pain, chronic pain and BTcP. To date, its variously designed formulations allow non-invasive administration; amongst others, sublingual fentanyl has proven useful in the management of BTcP and in improving the quality of life of patients with cancer. This review provides an update on the management of BTcP with fentanyl, with consideration of safety, as it remains an important tool in the treatment of cancer pain.
Collapse
Affiliation(s)
- Arturo Cuomo
- Istituto Nazionale dei Tumori, IRCCS Fondazione G. Pascale, Naples,
Italy
| |
Collapse
|
4
|
Mercadante S. Once again... breakthrough cancer pain: an updated overview. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2023; 3:23. [PMID: 37480136 PMCID: PMC10360268 DOI: 10.1186/s44158-023-00101-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/26/2023] [Indexed: 07/23/2023]
Abstract
Breakthrough cancer pain (BTcP) is a complex and variegate phenomenon that may change its presentation during the course of patients' disease in the same individual. An appropriate assessment is fundamental for depicting the pattern of BTcP. This information is determinant for a personalized management of BTcP. The use of opioids as needed is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective. The most controversial point regards the opioid dose to be used. The presence of opioid tolerance suggests to use a dose proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested to use the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never ended question.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Anesthetics, Main Regional Center for Pain Relief & Palliative Care Unit, La Maddalena Cancer Center, Acute Supportive/Palliative Care Unit & Hospice, 90146, Palermo, Italy.
| |
Collapse
|
5
|
Batistaki C, Graczyk M, Janecki M, Lewandowska AA, Moutinho R, Vagdatli K. Relationship between breakthrough cancer pain, background cancer pain and analgesic treatment - case series and review of the literature. Drugs Context 2022; 11:dic-2022-9-4. [PMID: 36660261 PMCID: PMC9828877 DOI: 10.7573/dic.2022-9-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/17/2022] [Indexed: 12/30/2022] Open
Abstract
The assessment and treatment of breakthrough cancer pain (BTcP) remain a major challenge in medicine due to its high impact on several aspects of health-related quality of life. BTcP should be carefully monitored in all cancer care settings by a multidisciplinary team to provide an appropriate and personalized clinical approach. The aim of this paper is to provide healthcare professionals involved in cancer pain management with a review of the relevant literature on the relationship between background cancer pain and BTcP which, by definition, occurs despite adequately controlled background cancer pain. The clinical cases presented contribute to a better understanding of this issue and underline its impact in daily clinical practice. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.
Collapse
Affiliation(s)
| | - Michal Graczyk
- Department of Palliative Care, Faculty of Health Sciences, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Marcin Janecki
- Department of Palliative Care and Palliative Medicine, Medical University of Silesia, Katowice, Poland
| | | | - Rita Moutinho
- Multidisciplinary Pain Unit, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Porto, Portugal
| | - Kiriaki Vagdatli
- Anaesthesia Department General Hospital of Athens “G. Gennimatas”, Athens, Greece
| |
Collapse
|
6
|
Smith AE, Muralidharan A, Smith MT. Prostate cancer induced bone pain: pathobiology, current treatments and pain responses from recent clinical trials. Discov Oncol 2022; 13:108. [PMID: 36258057 PMCID: PMC9579264 DOI: 10.1007/s12672-022-00569-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022] Open
Abstract
PURPOSE Metastatic spread of prostate cancer to the skeleton may result in debilitating bone pain. In this review, we address mechanisms underpinning the pathobiology of metastatic prostate cancer induced bone pain (PCIBP) that include sensitization and sprouting of primary afferent sensory nerve fibres in bone. We also review current treatments and pain responses evoked by various treatment modalities in clinical trials in this patient population. METHODS We reviewed the literature using PubMed to identify research on the pathobiology of PCIBP. Additionally, we reviewed clinical trials of various treatment modalities in patients with PCIBP with pain response outcomes published in the past 7 years. RESULTS Recent clinical trials show that radionuclides, given either alone or in combination with chemotherapy, evoked favourable pain responses in many patients and a single fraction of local external beam radiation therapy was as effective as multiple fractions. However, treatment with chemotherapy, small molecule inhibitors and/or immunotherapy agents, produced variable pain responses but pain response was the primary endpoint in only one of these trials. Additionally, there were no published trials of potentially novel analgesic agents in patients with PCIBP. CONCLUSION There is a knowledge gap for clinical trials of chemotherapy, small molecule inhibitors and/or immunotherapy in patients with PCIBP where pain response is the primary endpoint. Also, there are no novel analgesic agents on the horizon for the relief of PCIBP and this is an area of large unmet medical need that warrants concerted research attention.
Collapse
Affiliation(s)
- A. E. Smith
- St Vincent’s Hospital, Darlinghurst, Sydney, NSW Australia
| | - A. Muralidharan
- Neurobiology of Chronic Pain, The Charles Perkins Centre, Faculty of Science, The University of Sydney, Sydney, NSW 2006 Australia
| | - M. T. Smith
- Centre for Integrated Preclinical Drug Development, School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, St Lucia Campus, Brisbane, QLD 4072 Australia
| |
Collapse
|
7
|
Li L, Wang J, Geng S, Liu F, Ping L, Gu X, Fan X, Yang M, Liang L, Guo W. Efficacy of adenosylmethionine combined with Si Mo Tang in treatment of neonatal jaundice. Am J Transl Res 2022; 14:3926-3935. [PMID: 35836853 PMCID: PMC9274584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 05/08/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To investigate the efficacy of S-adenosylmethionine (SAM-e) combined with Si Mo Tang in the treatment of neonatal jaundice and its effect on liver function, cardiac enzymes, immune function, serum transferrin (TRF) and C-reactive protein (CRP) levels. METHODS The clinical data of 149 infants with neonatal jaundice were collected retrospectively. The infants were grouped according to the treatment methods. All neonates were treated with blue light phototherapy. Besides, group A was treated with SAM-e, group B was treated with Si Mo Tang, and group C was treated with SAM-e combined with Si Mo Tang. The treatment efficacy, serum bilirubin level, neonatal behavioral neurological assessment (NBNA) score, liver function, cardiac enzymes, immune function, serum TRF and CRP level were compared among the three groups before and after treatment. RESULTS The total effective rate of treatment in group C was 96.00%, which was higher than group A (73.47%) and group B (78.00%) (P < 0.05), but no significant difference was observed between groups A and B (P > 0.05). Compared with groups A and B, group C had higher NBNA scores, lower serum bilirubin levels, and lower serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), creatine kinase (CK) and creatine kinase-MB (CK-MB) levels (all P < 0.05); however, there was no statistical differences in NBNA scores, serum bilirubin levels, serum AST and ALT, LDH, CK and CK-MB levels between group A and group B (all P > 0.05). Compared with groups A and B, group C showed higher CD4+, CD4+/CD8+, TRF levels and lower serum CRP levels (P < 0.05), while there was no statistical differences in CD4+, CD4+/CD8+, CD8+, TRF levels and serum CRP levels between group A and group B (all P > 0.05). CONCLUSION SAM-e combined with Si Mo Tang promoted the regression of jaundice, improved liver function, neurodevelopmental conditions and the myocardial enzyme spectrum, reduced the level of inflammation, and improved the immunity of newborns with neonatal jaundice.
Collapse
Affiliation(s)
- Ling Li
- Department of Neonatology, Xingtai People’s HospitalXingtai, Hebei, China
| | - Jingqun Wang
- Department of Neonatology, Xingtai People’s HospitalXingtai, Hebei, China
| | - Shuxia Geng
- Department of Neonatology, Xingtai People’s HospitalXingtai, Hebei, China
| | - Fang Liu
- Department of Neonatology, Bethune International Peace HospitalShijiazhuang, Hebei, China
| | - Lili Ping
- Department of Neonatology, Handan Central HospitalHandan, Hebei, China
| | - Xiaohong Gu
- Department of Neonatology, Zhangjiakou Maternal and Child Health Care HospitalZhangjiakou, Hebei, China
| | - Xueai Fan
- Department of Neonatology, Xingtai Third HospitalXingtai, Hebei, China
| | - Mei Yang
- Department of Neonatology, Baoding First Central HospitalBaoding, Hebei, China
| | - Lixia Liang
- Department of Neonatology, Hengshui Harrison International Peace HospitalHengshui, Hebei, China
| | - Wei Guo
- Department of Neonatology, Xingtai People’s HospitalXingtai, Hebei, China
| |
Collapse
|
8
|
Check DK, Avecilla RAV, Mills C, Dinan MA, Kamal AH, Murphy B, Rezk S, Winn A, Oeffinger KC. Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies. J Pain Symptom Manage 2022; 63:e397-e417. [PMID: 34748896 DOI: 10.1016/j.jpainsymman.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/12/2022]
Abstract
CONTEXT Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear. OBJECTIVES To provide an evidence synthesis. METHODS We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods. RESULTS Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14). CONCLUSIONS We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.
Collapse
Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine (D.K.C.), Durham, North Carolina; Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina.
| | - Renee A V Avecilla
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Coleman Mills
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health (M.A.D.), New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center (M.A.D.), New Haven, Connecticut
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University Medical Center (A.H.K.), Durham, North Carolina
| | - Beverly Murphy
- Duke University Medical Center Library & Archives, Duke University School of Medicine (B.M.), Durham, North Carolina
| | - Salma Rezk
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy (S.R.), Chapel Hill, North Carolina
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin (A.W.), Milwaukee, Wisconsin
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University School of Medicine (K.C.O.), Durham, North Carolina
| |
Collapse
|
9
|
Characterizing Breakthrough Cancer Pain Using Ecological Momentary Assessment with a Smartphone App: Feasibility and Clinical Findings. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115991. [PMID: 34204871 PMCID: PMC8199778 DOI: 10.3390/ijerph18115991] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND mobile applications (apps) facilitate cancer pain ecological momentary assessment (EMA) and provide more reliable data than retrospective monitoring. The aims of this study are (a) to describe the status of persons with cancer pain when assessed ecologically, (b) to analyze the utility of clinical alarms integrated into the app, and (c) to test the feasibility of implementing an app for daily oncological pain monitoring. METHODS in this feasibility study, 21 patients (mean age = 56.95 years, SD = 10.53, 81.0% men) responded to an app-based evaluation of physical status (baseline and breakthrough cancer pain (BTcP)) and mental health variables (fatigue, mood, and coping) daily during 30 days. RESULTS cancer pain characterization with the app was similar to data from the literature using retrospective assessments in terms of BTcP duration and perceived medication effectiveness. However, BTcP was less frequent when evaluated ecologically. Pain, fatigue, and mood were comparable in the morning and evening. Passive coping strategies were the most employed daily. Clinical alarms appear to be useful to detect and address adverse events. App implementation was feasible and acceptable. CONCLUSION apps reduce recall bias and facilitate a rapid response to adverse events in oncological care. Future efforts should be addressed to integrate EMA and ecological momentary interventions to facilitate pain self-management via apps.
Collapse
|
10
|
Mercadante S, Maltoni M, Russo D, Adile C, Ferrera P, Rossi R, Rosati M, Casuccio A. The Prevalence and Characteristics of Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain. Cancers (Basel) 2021; 13:cancers13051058. [PMID: 33801478 PMCID: PMC7958843 DOI: 10.3390/cancers13051058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. This prospective study showed that in this population, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes. Abstract The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. A consecutive sample of advanced cancer patients receiving less than 60 mg/day of oral morphine equivalent (OME) was selected. Epidemiological data, background pain intensity, and current analgesic therapy were recorded. The presence of BTcP was diagnosed according to a standard algorithm. The number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, satisfaction with BTcP medication, and time to meaningful pain relief were collected. A total of 126 patients were screened. The mean intensity of background pain was 2.71 (1.57), and the mean OME was 28.5 mg/day (SD15.8). BTP episodes were recorded in 88 patients (69.8%). The mean number/day of BTP episodes was 4.1 (SD 7.1, range 1–30). In a significant percentage of patients, BTcP was both predictable and unpredictable (23%). The BTcP onset was less than 20 min in the majority of patients. The mean duration of untreated episodes was 47.5 (SD 47.6) minutes. The mean time to meaningful pain relief after taking a BTcP medication was >20 min in 44.5% of patients. The efficacy of BTcP medication was not considered good in more than 63% of patients. Gender (females) (OR = 4.16) and lower Karnofsky (OR = 0.92) were independently associated with BTcP. A higher number of BTcP episodes/day was associated with gender (females) (p = 0.036), short duration of BTcP (p = 0.005), poorer efficacy of BTcP medication (none or mild) (p = 0.001), and late meaningful pain relief (p = 0.024). The poor efficacy of BTcP medication was independently associated with a higher number of episodes/day (OR = 0.22). In patients who were receiving low doses of opioids, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
- Correspondence:
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Domenico Russo
- Hospice and the Palliative Care Service, Clinica San Marco, 04100 Latina, Italy;
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Marta Rosati
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy;
| |
Collapse
|
11
|
Mercadante S, Portenoy RK. Understanding the Chameleonic Breakthrough Cancer Pain. Drugs 2021; 81:411-418. [PMID: 33515376 DOI: 10.1007/s40265-021-01466-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Abstract
Breakthrough cancer pain (BTcP) is a variegated phenomenon, that often presents in different ways in each individual, and may change its presentation in the same individual during the course of disease. An appropriate assessment is fundamental for depicting the pattern of BTcP in individuals. This information is determinant for a personalised management of BTcP. The use of opioids as needed, is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective, providing analgesia in 5-15 min. The most controversial point regards the opioid dose to be used. The presence of tolerance suggests using a dose that is proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested using the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never-ending question.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative Care Unit, La Maddalena Cancer Centre, Via San Lorenzo 312, 90146, Palermo, Italy. .,Regional Home Care Programme, SAMOT, Palermo, Italia.
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, 39 Broadway, 3rd Floor, New York, NY, 10006, USA. .,Neurology and Family and Social Medicine, Albert Einstein College of Medicine, New York, USA.
| |
Collapse
|
12
|
Zhang WJ, Luo C, Pu FQ, Zhu JF, Zhu Z. The role and pharmacological characteristics of ATP-gated ionotropic receptor P2X in cancer pain. Pharmacol Res 2020; 161:105106. [DOI: 10.1016/j.phrs.2020.105106] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 02/07/2023]
|
13
|
Mercadante S. The Endless Question of Opioid Doses for Breakthrough Pain. Oncologist 2020; 25:e1134-e1135. [PMID: 32400063 PMCID: PMC7356757 DOI: 10.1634/theoncologist.2020-0312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 11/17/2022] Open
Abstract
This letter to the editor responds to comments in the still open debate regarding the use of breakthrough pain medications in cancer patients.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain and Supportive Palliative Care, La Maddalena Cancer CenterPalermoItaly
| |
Collapse
|
14
|
Currow DC, Clark K. Opioids for Breakthrough Cancer Pain. Oncologist 2020; 25:e1133. [PMID: 32400059 DOI: 10.1634/theoncologist.2020-0280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/16/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- David C Currow
- IMPACCT, Faculty of Health, University of Technology, Sydney, Ultimo, New South Wales, Australia
- Australian National Palliative Care Clinical Studies Collaborative, University of Technology, Sydney, Ultimo, New South Wales, Sydney, Australia
| | - Katherine Clark
- Australian National Palliative Care Clinical Studies Collaborative, University of Technology, Sydney, Ultimo, New South Wales, Sydney, Australia
- University of Sydney, Northern Clinical School, Royal North Shore Hospital, St Leonard's, New South Wales, Australia
| |
Collapse
|