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Bossi P, Pietrzyńska T, Margarit Ferri C, Mansilla I, Tellone V, Fioravanti S, Di Loreto G, Comandini A. Compliance with the breakthrough cancer pain European guidelines and impact on patients' quality of life: an observational prospective study. FRONTIERS IN PAIN RESEARCH 2024; 5:1388837. [PMID: 39006759 PMCID: PMC11239570 DOI: 10.3389/fpain.2024.1388837] [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: 02/20/2024] [Accepted: 06/10/2024] [Indexed: 07/16/2024] Open
Abstract
Introduction This study aimed to assess the percentage of patients treated according to the European Society for Medical Oncology (ESMO) 2018 guidelines for breakthrough cancer pain (BTcP) and the impact of guidelines adherence on patients' quality of life (QoL). Methods Adult opioid-tolerant patients diagnosed with BTcP and locally advanced or recurrent metastatic cancer with a life expectancy of >3 months prospectively were included. Patients were followed up for 28 days. Results Of 127 patients included, 37 were excluded due to the impossibility to establish adherence to the ESMO guidelines. Among the evaluable patients [51.1% female; with mean (SD) age of 66.4 (11.8) years], all were adherent. BTcP was diagnosed by the Association for Palliative Medicine algorithm in 47.8% of patients and by clinical experience in 52.2% of patients. The mean number of daily BTcP episodes ranged between 1 and 8, with a mean (95% CI) severity of 7.3 (7.0; 7.6) at week 0 and 6.2 (5.8; 6.6) at week 4. Time to maximum pain intensity was 3-15 min in 52.2% of patients, and BTcP lasted 30-60 min in 14.4% of patients at week 0 and 4.4% of patients at week 4. Mean (95% CI) treatment effectiveness was 6.6 (6.1; 7.1) at week 0 and 7.4 (7.0; 7.8) at week 4. Median (Q1-Q3) patients' global impression of clinical condition was 4.0 (4.0-4.0) at week 0 and 3.0 (2.0-3.0) at week 4. Conclusion A clear BTcP assessment and strict follow-up could be crucial to guidelines adherence and for patient's QoL.
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Affiliation(s)
- Paolo Bossi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Tatiana Pietrzyńska
- Palliative Care Ward, Czeladz Hospital, Czeladz, Poland
- Palliative Care Association “Hope”, Bedzin, Poland
- Home Hospice “Panaceum”, Dabrowa Gornicza, Poland
| | | | - Irene Mansilla
- Medical Writing Department, TFS Health Science, Barcelona, Spain
| | - Valeria Tellone
- Global Medical Department, Angelini Pharma S.p.A., Rome, Italy
| | - Sara Fioravanti
- Pharmacometrics & Clinical Supply, Angelini Pharma S.p.A., Rome, Italy
| | - Giorgio Di Loreto
- Pharmacometrics & Clinical Supply, Angelini Pharma S.p.A., Rome, Italy
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2
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Sharifi N, Mortazavi SA, Rabbani S, Torshabi M, Talimi R, Haeri A. Fast dissolving nanofibrous mats for diclofenac sodium delivery: Effects of electrospinning polymer and addition of super-disintegrant. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103356] [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]
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3
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Bossi P, Escobar Y, Pea F. Rapid-Onset Opioids for Management of Breakthrough Cancer Pain: Considerations for Daily Practice. FRONTIERS IN PAIN RESEARCH 2022; 3:893530. [PMID: 35721659 PMCID: PMC9204512 DOI: 10.3389/fpain.2022.893530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background and Objective Rapid-onset opioids (ROOs) are effective treatments for breakthrough cancer pain (BTcP) given their rapid onset of action and relatively short duration of analgesia. The aim of this article is to describe specific considerations for the use of ROOs in daily practice, focusing on dose titration and treatment of specific populations. Type of Review We conducted a narrative review on the use of ROOs for BTcP. We selected papers according to the following search terms: “breakthrough cancer pain” and “rapid onset opioids”. Results ROOs may be considered as the most suitable drugs to treat BTcP and can be used “on-demand”. Several fentanyl formulations are available and have been associated with control of BTcP and with improvement in quality of life. Various titration schemes have been used to optimize ROO dosing; however, a dose-proportional scheme could be considered safe and effective in most patients. Specific formulations may be more suitable for specific patient subgroups; for example, patients with oral mucositis may prefer intranasal to oral formulations. Moreover, elderly patients or those without caregivers should be clearly educated on the use of these formulations. A key element in achieving successful treatment of BTcP is awareness of the barriers to pain management, including poor overall assessment, patient reluctance to take opioids or report pain, and physician reluctance to prescribe opioids. Conclusion A personalized approach is fundamental when prescribing a medication for BTcP, and careful attention should be given to drug choice and route of administration, and to the need for alternative therapeutic options.
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Affiliation(s)
- Paolo Bossi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health - Medical Oncology, ASST-Spedali Civili, University of Brescia, Brescia, Italy
- *Correspondence: Paolo Bossi
| | - Yolanda Escobar
- Medical Oncology, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero Universitaria Sant'Orsola, Bologna, Italy
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4
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Marinangeli F, Saetta A, Lugini A. Current management of cancer pain in Italy: Expert opinion paper. Open Med (Wars) 2021; 17:34-45. [PMID: 34950771 PMCID: PMC8651060 DOI: 10.1515/med-2021-0393] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 09/20/2021] [Accepted: 10/21/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Chronic pain and breakthrough cancer pain (BTcP) have a high prevalence in all cancer types and cancer stages, combined with a significant physical, psychological, and economic burden. Despite efforts to improve appropriate management of cancer pain, a poor assessment and guilty undertreatment are still reported in many countries. The purpose of this expert opinion paper is to contribute to reduce and clarify these issues with a multidisciplinary perspective in order to share virtuous paths of care. Methods Common questions about cancer pain assessment and treatment were submitted to a multidisciplinary pool of Italian clinicians and the results were subsequently discussed and compared with the findings of the published literature. Conclusion Despite a dedicated law in Italy and effective treatments available, a low percentage of specialists assess pain and BTcP, defining the intensity with validated tools. Moreover, in accordance with the findings of the literature in many countries, the undertreatment of cancer pain is still prevalent. A multidisciplinary approach, more training programs for clinicians, personalised therapy drug formulations, and virtuous care pathways will be essential to improve cancer pain management.
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Affiliation(s)
- Franco Marinangeli
- Department of Anesthesiology Intensive Care and Pain Treatment, University of L'Aquila, Località Coppito, Piazzale Salvatore Tommasi, 1-67100, L'Aquila, Italy
| | - Annalisa Saetta
- Department of Oncology and Hematology, Humanitas Clinical and Research Center, 20089 Rozzano (Milan), Italy
| | - Antonio Lugini
- Department of Oncology, San Giovanni-Addolorata Hospital, 00184, Rome, Italy
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5
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Rogers AH, Zvolensky MJ, Ditre JW, Buckner JD, Asmundson GJG. Association of opioid misuse with anxiety and depression: A systematic review of the literature. Clin Psychol Rev 2021; 84:101978. [PMID: 33515811 DOI: 10.1016/j.cpr.2021.101978] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 11/19/2020] [Accepted: 11/29/2020] [Indexed: 12/14/2022]
Abstract
The opioid epidemic is a public health problem associated with a host of negative outcomes. Although clinicians recognize covariation between opioid misuse with anxiety and depressive symptoms and disorders, research on this topic has only recently accumulated. Progress in this domain is impeded by the lack of systematic and integrative research to better understand and treat these co-occurring problems. This paper represents the first attempt to systematically review the empirical literature examining relations between opioid use and misuse, and anxiety and depression. In the first section, we define key terms and describe the article selection strategy. In the second section, we review the prevalence of anxiety and depressive symptoms among individuals who use and misuse prescription and illicit opioids. In the third section, we review the magnitude of associations between anxiety and depressive symptoms and disorders with opioid misuse, as well as highlight studies examining the longitudinal and temporal sequence of the relations between these variables. In the fourth section, we focus on experimental therapeutics, reviewing what is known about individual difference and transdiagnostic vulnerability factors for anxiety and depression that might contribute to opioid misuse and its symptoms. Finally, we discuss current knowledge gaps and present a heuristic model to guide future research.
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Affiliation(s)
- Andrew H Rogers
- Department of Psychology, University of Houston, Houston, TX, United States
| | - Michael J Zvolensky
- Department of Psychology, University of Houston, Houston, TX, United States; Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, United States; HEALTH Institute, University of Houston, Houston, TX, United States.
| | - Joseph W Ditre
- Department of Psychology, Syracuse University, Syracuse, NY, United States
| | - Julia D Buckner
- Department of Psychology, Louisiana State University, Baton Rouge, LA, United States
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Mori T, Takemura Y, Arima T, Iwase Y, Narita M, Miyano K, Hamada Y, Suda Y, Matsuzawa A, Sugita K, Matsumura S, Sasaki S, Yamauchi T, Higashiyama K, Uezono Y, Yamazaki M, Kuzumaki N, Narita M. Further investigation of the rapid-onset and short-duration action of the G protein-biased μ-ligand oliceridine. Biochem Biophys Res Commun 2020; 534:988-994. [PMID: 33139013 DOI: 10.1016/j.bbrc.2020.10.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/18/2020] [Indexed: 02/06/2023]
Abstract
TRV130 (oliceridine), a G protein-biased ligand for μ-opioid receptor, has recently been synthesized. It is considered to have strong antinociceptive effects and only minor adverse effects. However, whether or not oliceridine actually exhibits an ideal pharmacological profile as an analgesic has not yet been fully clarified in animal studies. This study examined the pharmacological profile of oliceridine in cells and animals. Oliceridine (10 μM) did not produce any μ-opioid receptor internalization in cells even though it increased impedance, which reflects the activation of Gi protein using the CellKey™ system, and inhibited the formation of cAMP. In mice, oliceridine (0.3-10 mg/kg) produced a dose-dependent antinociceptive effect with a rapid-onset and short-duration action in the hot-plate test, as well as antihyperalgesia after sciatic nerve ligation without the development of antinociceptive tolerance using the thermal hyperalgesia test. On the other hand, oliceridine inhibited gastrointestinal transit. Furthermore, oliceridine produced rapid-onset hyperlocomotion at antinociceptive doses; sensitization developed in mice and an emetic effect was observed in ferrets. These results indicate that, although oliceridine may produce dopamine-related behaviors even through selective stimulation of the G-protein-biased μ-opioid receptor pathway, it still offers advantages for breakthrough pain without antinociceptive tolerance with adequate doses.
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Affiliation(s)
- Tomohisa Mori
- Department of Pharmacology, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan
| | - Yoshinori Takemura
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama, 930-0194, Japan
| | - Takamichi Arima
- Department of Pharmacy, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yoshiyuki Iwase
- Department of Pharmacology, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan
| | - Michiko Narita
- Department of Molecular and Cellular Medicine, Institute of Medical Science, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan; Division of Cancer Pathophysiology, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Kanako Miyano
- Division of Cancer Pathophysiology, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yusuke Hamada
- Department of Pharmacology, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan; Division of Cancer Pathophysiology, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yukari Suda
- Department of Pharmacology, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan; Division of Cancer Pathophysiology, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Akinobu Matsuzawa
- Department of Synthetic Medicinal Chemistry, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan
| | - Kazuyuki Sugita
- Department of Synthetic Medicinal Chemistry, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan
| | - Shoki Matsumura
- Institute of Medicinal Chemistry, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan
| | - Shigeru Sasaki
- Institute of Medicinal Chemistry, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan
| | - Takayasu Yamauchi
- Institute of Medicinal Chemistry, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan
| | - Kimio Higashiyama
- Institute of Medicinal Chemistry, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan
| | - Yasuhito Uezono
- Department of Pain Control Research, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mitsuaki Yamazaki
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama, 930-0194, Japan
| | - Naoko Kuzumaki
- Department of Pharmacology, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan.
| | - Minoru Narita
- Department of Pharmacology, Hoshi University School of Pharmacy and Pharmaceutical Sciences, 2-4-41, Ebara, Shinagawa-ku, Tokyo, 142-8501, Japan; Division of Cancer Pathophysiology, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
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7
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Magnani C, Giannarelli D, Calvieri A, Dardeli A, Eusepi G, Restuccia MR, Mastroianni C, Casale G. Breakthrough cancer pain tailored treatment: which factors influence the medication choice? An observational, prospective and cross-sectional study in patients with terminal cancer. Postgrad Med J 2018; 94:566-570. [DOI: 10.1136/postgradmedj-2018-135659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 09/07/2018] [Accepted: 09/15/2018] [Indexed: 11/04/2022]
Abstract
BackgroundVarious options for the pharmacological treatment of breakthrough cancer pain (BTcP) are available. International guidelines on BTcP treatment are not univocal. A tailored treatment should be based on the assessment of different variables such as BTcP characteristics, oral mucositis, chronic rhinitis and a patient’s ability to take medication.ObjectiveThe goal of this study is to assess the relationship between these variables and the medication treatment for BTcP in a sample of patients with terminal cancer.MethodsA prospective, cross-sectional study was carried out among 1180 patients who were receiving palliative care programmes. Patients were recruited if they had a diagnosis of BTcP and had been prescribed rescue opioids. Variables that might influence the BTcP treatment were assessed.ResultsOne hundred and forty-nine eligible patients were enrolled; 59.1% of patients received short-acting oral morphine (OM), 27.5% transmucosal immediate-release fentanyl (TIRF) and 13.4% parenteral morphine for BTcP treatment. Short-acting OM prescription was related to background pain treatment with OM <60 mg daily (p<0.0001) and to home-care setting of assistance (p=0.004). Continuous intravenous morphine infusion and the presence of a vascular access were the main factors related to intravenous morphine prescription for BTcP. TIRF use was mainly related to background opioid dosage and the patient’s self-sufficiency in taking medication.ConclusionIn clinical practice, the factors that most influenced the pharmacological treatment for BTcP were baseline opioid dosage, setting of assistance and self-ability to take medication. Further research is needed to improve the knowledge on tailored BTcP treatment.
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The efficacy of oral piroxicam fast-dissolving tablets versus sublingual fentanyl in incident breakthrough pain due to bone metastases: a double-blinded randomized study. Support Care Cancer 2018; 27:2171-2177. [PMID: 30306325 DOI: 10.1007/s00520-018-4469-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Breakthrough pain (BTP) is a transient exacerbation of pain occurring in a patient with chronic, persistent pain. The most common type is incident pain that is mostly related to bone metastases. The oral mucosa is an attractive route for drug delivery. Sublingual fentanyl preparations are a very attractive agent in controlling attacks of BTP due to its rapid absorption through the oral mucosa. Non-steroidal anti-inflammatory drugs (NSAIDs) play a key role as a first step in treatment of cancer pain; piroxicam sublingual formulations could be a useful alternative in controlling incident pain. Our study hypothesis is to evaluate the efficacy of sublingual fentanyl versus oral piroxicam fast-dissolving tablets in patients with incident pain and its impact on functional status. PATIENTS AND METHODS A cohort of 100 adults of both genders suffering from bone metastases. Patients were assigned to receive either sublingual fentanyl tablet (group 1) or oral piroxicam fast-dissolving tablets (group 2). The pain intensity reduction on a 0-10 visual analog scale (VAS), frequency of BTP attacks, and onset of pain relief. Secondary end points included the functional interference items of the Brief Pain Inventory (BPI). RESULTS There is no significant difference between the two groups regarding the patients' demographics. Significant decline of the VAS in each group in comparison to the pretreatment values (p = 0.001). Non-significant changes of the VAS, duration of pain attacks, and number of rescue doses in comparing both groups were measured. There was significant reduction in group 2 BPI regarding the relation with others, sleep pattern and enjoyment of life parameters at 2 and 4 weeks (p = 0.001). CONCLUSION Our study demonstrated that oral piroxicam fast-dissolving tablet is an analgesic alternative to sublingual fentanyl in patients with bone metastasis to control incidental BTP attacks with more favorable cost-benefit values.
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9
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Cabezón-Gutiérrez L, Viloria-Jiménez MA, Pérez-Cajaraville J, Álamo-González C, López-Trigo JA, Gil-Gregorio P. [Breakthrough cancer pain in the elderly]. Rev Esp Geriatr Gerontol 2017; 52:271-277. [PMID: 27979661 DOI: 10.1016/j.regg.2016.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 10/15/2016] [Accepted: 10/24/2016] [Indexed: 11/24/2022]
Abstract
Breakthrough pain is defined as an acute exacerbation of pain with rapid onset, short duration and moderate or high intensity, which occurs spontaneously or in connection with a predictable or unpredictable event despite there being stabilised and controlled baseline pain. However, there are doubts about the definition, terminology, epidemiology, and assessment of breakthrough pain, with no clear answers or consensus, especially in the elderly population. This non-systematic review summarises the most important aspects of breakthrough pain in the elderly, based on the limited publications there are in that population group.
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Affiliation(s)
| | | | | | | | - José Antonio López-Trigo
- Servicio de Geriatría, Hospital Quirón de Málaga, Málaga, España; Presidente de la Sociedad Española de Geriatría y Gerontología
| | - Pedro Gil-Gregorio
- Servicio de Geriatría, Hospital Clínico Universitario San Carlos, Madrid, España; Coordinador del Comité de Expertos del Dolor de la Sociedad Española de Geriatría y Gerontología
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10
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Vellucci R, Fanelli G, Pannuti R, Peruselli C, Adamo S, Alongi G, Amato F, Consoletti L, Lamarca L, Liguori S, Lo Presti C, Maione A, Mameli S, Marinangeli F, Marulli S, Minotti V, Miotti D, Montanari L, Moruzzi G, Palermo S, Parolini M, Poli P, Tirelli W, Valle A, Romualdi P. What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion. Drugs 2016; 76:315-30. [PMID: 26755179 PMCID: PMC4757619 DOI: 10.1007/s40265-015-0519-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Clinical management of breakthrough cancer
pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five ‘things to do’ and five ‘things not to do’ in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.
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Affiliation(s)
| | - R Vellucci
- SOD Cure Palliative e Terapia del Dolore, Ospedale Universitario Careggi, Florence, Italy.
| | - G Fanelli
- SC Anestesia, Rianimazione e Terapia Antalgica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - R Pannuti
- Fondazione ANT Italia Onlus, Andria, Italy
| | - C Peruselli
- SC Cure Palliative, Ospedale di Biella, Ponderano, BI, Italy
| | - S Adamo
- UO Terapia del Dolore, ARNAS Civico di Palermo, Palermo, Italy
| | - G Alongi
- Hospice e Cure Palliative, ASP 1di Agrigento, Agrigento, Italy
| | - F Amato
- UOC Terapia del Dolore e Cure Palliative, Azienda ospedaliera di Cosenza, Cosenza, Italy.,Past President Feder Dolore-SICD, Cosenza, Italy
| | - L Consoletti
- Struttura di Medicina del Dolore, Ospedale Universitario "Ospedali Riuniti", Foggia, Italy
| | - L Lamarca
- UOS Cure Palliative e Terapia Antalgica, Azienda ULSS N. 10 "Veneto Orientale", San Donà di Piave, VE, Italy
| | - S Liguori
- USC Cure Palliative Terapia del Dolore, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - C Lo Presti
- UOD Terapia del Dolore e Cure Palliative, ACO San Filippo Neri, ASLRME, Rome, Italy
| | - A Maione
- Terapia antalgica e Cure Palliative, Presidio Ospedaliero "S. Maria della Pietà", Nola, NA, Italy
| | - S Mameli
- SC Terapia del Dolore, Presidio Ospedaliero "A. Businco", Cagliari, Italy
| | - F Marinangeli
- Scuola di Specializzazione di Anestesia, Rianimazione e Terapia Intensiva, Università dell'Aquila, L'Aquila, Italy
| | - S Marulli
- OC Anestesia, Rianimazione e Terapia Iperbarica, UOS-I Gruppo Operatorio, Ospedale "Vito Fazzi", Lecce, Italy
| | - V Minotti
- SC Oncologia Medica, Azienda Ospedaliera "S.M. della Misericordia", Perugia, Italy
| | - D Miotti
- UO Cure Palliative e Terapia del Dolore, Fondazione Salvatore Maugeri-IRCCS, Pavia, Italy
| | - L Montanari
- UO Semplice Cure Palliative, Ravenna, Italy.,Dipartimento Onco-ematologico, AUSL della Romagna c/o Presidio Ospedaliero Umberto I, Lugo di Ravenna, Italy
| | - G Moruzzi
- UOS Hospice, Azienda Sanitaria Provinciale di Siracusa, Siracuse, Italy
| | - S Palermo
- UOC Terapia Antalgica, IRCCS San Martino-IST, Genoa, Italy
| | - M Parolini
- UOC Anestesia e Rianimazione B, Azienda Universitaria integrata di Verona, Verona, Italy
| | - P Poli
- UO Terapia del Dolore, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - W Tirelli
- Centro di Terapia del Dolore, Hospice "Fondazione Roma Sanità", Rome, Italy.,Centro di Rianimazione e Terapia del Dolore e Cure Palliative, Istituto Nazionale Tumori "Regina Elena", Rome, Italy
| | - A Valle
- Fondazione FARO, Turin, Italy
| | - P Romualdi
- Dipartimento di Farmacia e Biotecnologie, Alma mater studiorum, Università di Bologna, Bologna, Italy
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11
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Daeninck P, Gagnon B, Gallagher R, Henderson J, Shir Y, Zimmermann C, Lapointe B. Canadian recommendations for the management of breakthrough cancer pain. Curr Oncol 2016; 23:96-108. [PMID: 27122974 PMCID: PMC4835001 DOI: 10.3747/co.23.2865] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Breakthrough cancer pain (btcp) represents an important element in the spectrum of cancer pain management. Because most btcp episodes peak in intensity within a few minutes, speed of medication onset is crucial for proper control. In Canada, several current provincial guidelines for the management of cancer pain include a brief discussion about the treatment of btcp; however, there are no uniform national recommendations for the management of btcp. That lack, accompanied by unequal access to pain medication across the country, contributes to both regional and provincial variability in the management of btcp. Currently, immediate-release oral opioids are the treatment of choice for btcp. This approach might not always offer optimal speed for onset of action and duration to match the rapid nature of an episode of btcp. Novel transmucosal fentanyl formulations might be more appropriate for some types of btcp, but limited access to such drugs hinders their use. In addition, the recognition of btcp and its proper assessment, which are crucial steps toward appropriate treatment selection, remain challenging for many health care professionals. To facilitate appropriate management of btcp, a group of prominent Canadian specialists in palliative care, oncology, and anesthesiology convened to develop a set of recommendations and suggestions to assist Canadian health care providers in the treatment of btcp and the alleviation of the suffering and discomfort experienced by adult cancer patients.
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Affiliation(s)
| | - B. Gagnon
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, QC
| | - R. Gallagher
- University of British Columbia, Vancouver, BC, and Division of Palliative Care, Providence Health Care, Toronto, ON
| | - J.D. Henderson
- Colchester East Hants Palliative Care Program, Truro, and Atlantic Palliative Medicine Group and Dalhousie University, Halifax, NS
| | - Y. Shir
- Alan Edwards Pain Management Unit, McGill University, Montreal, QC
| | - C. Zimmermann
- Palliative Services, University Health Network, University of Toronto, Toronto, ON
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13
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Martini CH, Proto P, Olofsen E, van Velzen M, Aarts L, Dahan A, Niesters M. A randomized controlled trial and novel mathematical analysis of the analgesic effect of oxycodone versus paracetamol orodispersible tablets. Eur J Pain 2015; 19:295-304. [PMID: 24947675 DOI: 10.1002/ejp.546] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND For effective treatment of acute pain, a rapid onset of action is important. Here we quantify the antinociceptive profile of an orodispersible oxycodone tablet (OOT) in a randomized, double-blind, active comparator (paracetamol orodispersible tablet, POT), crossover study design in a population of healthy volunteers. METHODS Twelve female volunteers were randomized to receive 20 mg OOT and 500 mg POT sublingually on two occasions. The electrical pain threshold (EPTh), electrical pain tolerance (EPTol) and pressure pain threshold (PPT) were obtained at regular intervals for 5 h. Time-response data were analysed with a longitudinal pharmacodynamic model characterized by rate constants for analgesia onset (kON ), offset (kOFF ), potency parameter (EFF) and validated with a bootstrap analysis. Values are the median (95% CI) as derived from the bootstrap analysis. RESULTS OOT produced a rapid increase in response values. For electrical pain analgesia onset, t½kON , 44 (25-67) versus analgesia offset, t½kOFF , 156 (63-552) min, p < 0.01. For pressure pain, t½kON equalled t½kOFF : 30 (16-48) min. OOT was most potent on EPTol: EFF 0.95 (0.39-1.71), p < 0.01, with similar potencies on EPTh, 0.43 (0.19-0.87) and PPT, 0.40 (0.21-0.67). Paracetamol displayed 14% of the analgesic efficacy of oxycodone. CONCLUSIONS The analgesic effect of orodispersible oxycodone was successfully quantified using a mathematical model of analgesia evolution. This method allows quantification of a variety of responses times from sparse data sets. Response times as defined by a 30% increase in response thresholds varied significantly among end points: EPTol 15 min, PPTh 18 min and EPTh 41 min.
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Affiliation(s)
- C H Martini
- Department of Anesthesiology, Leiden University Medical Center, The Netherlands
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Shellard SE, Ram FSF. Comparing the effectiveness of intranasal fentanyl spray with oral transmucosal fentanyl citrate in breakthrough pain. Int J Palliat Nurs 2015; 21:475-8. [PMID: 26505081 DOI: 10.12968/ijpn.2015.21.10.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Breakthrough cancer pain (BTCP) is complex and severe, affecting quality of life and increasing hospitalisation. BTCP has a rapid onset that requires fast acting medication with minimal side effects. AIM This article compares the effectiveness of intranasal fentanyl spray (INFS) and oral transmucosal fentanyl citrate (OTFC) and their alleviation of BTCP within 10 minutes of administration. METHOD The article considers pharmacokinetic and bioavailability studies demonstrating the efficacy of the route of administration, time-based effects of pain relief as well as patient preference. CONCLUSION The data collected indicates that INFS is more effective than OTFC for BTCP.
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Affiliation(s)
- Sarah E Shellard
- Clinical Nurse Specialist, Te Omanga Hospice, Lower Hutt, New Zealand
| | - Felix S F Ram
- Senior Lecturer and Clinical Pharmacologist, College of Health - Massey University, Auckland, New Zealand
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Ravula R, Herwadkar AK, Abla MJ, Little J, Banga AK. Formulation optimization of a drug in adhesive transdermal analgesic patch. Drug Dev Ind Pharm 2015; 42:862-70. [DOI: 10.3109/03639045.2015.1071832] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Ranadheer Ravula
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, USA,
| | - Anushree K. Herwadkar
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, USA,
| | - Mehtab J. Abla
- University of the Arts London, London College of Fashion, London, UK, and
| | | | - Ajay K. Banga
- Department of Pharmaceutical Sciences, College of Pharmacy, Mercer University, Atlanta, GA, USA,
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16
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De Franceschi L, Mura P, Schweiger V, Vencato E, Quaglia FM, Delmonte L, Evangelista M, Polati E, Olivieri O, Finco G. Fentanyl Buccal Tablet: A New Breakthrough Pain Medication in Early Management of Severe Vaso-Occlusive Crisis in Sickle Cell Disease. Pain Pract 2015; 16:680-7. [PMID: 26009799 DOI: 10.1111/papr.12313] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 03/24/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) is a worldwide distributed hereditary red cell disorder. The principal clinical manifestations of SCD are the chronic hemolytic anemia and the acute vaso-occlusive crisis (VOCs), which are mainly characterized by ischemic/reperfusion tissue injury. Pain is the main symptom of VOCs, and its management is still a challenge for hematologists, requiring a multidisciplinary approach. METHODS We carried out a crossover study on adult SCD patients, who received two different types of multimodal analgesia during two separate severe VOCs with time interval between VOCs of at least 6 months. The first VOC episode was treated with ketorolac (0.86 mg/kg/day) and tramadol (7.2 mg/kg/day) (TK treatment). In the second VOC episode, fentanyl buccal tablet (FBT; 100 μg) was introduced in a single dose after three hours from the beginning of TK analgesia (TKF treatment). We focused on the first 24 hours of acute pain management. The primary efficacy measure was the time-weighted-sum of pain intensity differences (SPID24). The secondary efficacy measures included the pain intensity difference (PID), the total pain relief (TOTPAR), and the time-wighted sum of anxiety (SAID24). RESULTS SPID24 was significantly higher in TKF than in TK treatment. All the secondary measures were significantly ameliorated in TKF compared to TK treatment, without major opioid side effects. Patients satisfaction was higher with TKF treatment than with TK one. CONCLUSIONS We propose that VOCs might require breakthrough pain drug strategy as vaso-occlusive phenomena and enhanced vasoconstriction promoting acute ischemic pain component exacerbate the continuous pain of VOCs. FBT might be a powerful and feasible tool in early management of acute pain during VOCs in emergency departments.
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Affiliation(s)
- Lucia De Franceschi
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Paolo Mura
- Department of Medical Science "M. Aresu", Section of Anesthesia, Intensive Care and Pain Therapy, University of Cagliari, Cagliari, Italy
| | - Vittorio Schweiger
- Department of Surgical Science, Anesthesiology, Intensive Care and Pain therapy Center, University of Verona-AOUI-Verona, Verona, Italy
| | - Elisa Vencato
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Francesca Maria Quaglia
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Letizia Delmonte
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Maurizio Evangelista
- Department of Emergency, Institute of Anesthesia, Resuscitation and Pain Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Enrico Polati
- Department of Surgical Science, Anesthesiology, Intensive Care and Pain therapy Center, University of Verona-AOUI-Verona, Verona, Italy
| | - Oliviero Olivieri
- Department of Medicine, Section of Internal Medicine, University of Verona-AOUI-Verona, Verona, Italy
| | - Gabriele Finco
- Department of Medical Science "M. Aresu", Section of Anesthesia, Intensive Care and Pain Therapy, University of Cagliari, Cagliari, Italy
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Cabezón-Gutiérrez L, Gómez-Pavón J, Pérez-Cajaraville J, Viloria-Jiménez MA, Álamo-González C, Gil-Gregorio P. [Update on oncological pain in the elderly]. Rev Esp Geriatr Gerontol 2015; 50:289-97. [PMID: 25777946 DOI: 10.1016/j.regg.2015.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 02/04/2015] [Indexed: 01/05/2023]
Abstract
Pain is a prevalent symptom in cancer geriatric patients, appearing in up to 90% of patients with terminal cancer. This requires a multidimensional approach, as there is a high percentage of inappropriate assessments and treatments. Unrecognized or poorly treated pain in the geriatric population, especially in cancer patients, leads to the development of disabling symptoms such as depression, anxiety, isolation, sleep disturbances, and appetite, and very especially, loss of functional capacity and quality of life. In this review an analysis is made on the most relevant studies on the diagnosis and management of cancer pain in the geriatric population.
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Affiliation(s)
- Luis Cabezón-Gutiérrez
- Servicio de Oncología Médica, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, España.
| | | | | | | | | | - Pedro Gil-Gregorio
- Servicio de Geriatría, Unidad de Cuidados Paliativos, Hospital Clínico Universitario San Carlos, Madrid, España; Coordinador del Comité de Expertos del Dolor de la Sociedad Española de Geriatría y Gerontología, España
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18
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Zakrzewska JM. Temporomandibular disorders, headaches and chronic pain. J Pain Palliat Care Pharmacother 2015; 29:61-3; discussion 63. [PMID: 25643229 DOI: 10.3109/15360288.2014.1003678] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Temporomandibular disorders (TMDs) are a major cause of non-dental orofacial pain with a suggested prevalence of 3% to 5% in the general population. TMDs present as unilateral or bilateral pain centered round the pre-auricular area and can be associated with clicking and limitation in jaw movements. It is important to ascertain if there are other comorbid factors such as headaches, widespread chronic pain and mood changes. A biopsychosocial approach is crucial with a careful explanation and self-care techniques encouraged.
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Affiliation(s)
- Joanna M Zakrzewska
- Joanna M Zakrzewska, BDS, MB BChir, MD, FDSRCS, FFDRCSI, FFPM RCA, FHEA, is Professor and Facial Pain lead consultant at Eastman Dental Hospital, University College London Hospitals NHS Foundation Trust , London , UK
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19
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Sperlinga R, Campagna S, Berruti A, Laciura P, Ginosa I, Paoletti S, Giuliano P, Tucci M, Rosato R, Scagliotti G, Saini A. Alberta Breakthrough Pain Assessment Tool: A validation multicentre study in cancer patients with breakthrough pain. Eur J Pain 2014; 19:881-8. [DOI: 10.1002/ejp.612] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2014] [Indexed: 11/09/2022]
Affiliation(s)
- R. Sperlinga
- School of Nursing; Catholic University of the Sacred Heart - Little House of Divine Providence; Cottolego Hospital; Turin Italy
| | - S. Campagna
- School of Nursing; ‘San Luigi Gonzaga’; University of Torino; Italy
| | - A. Berruti
- Medical Oncology; Department of Medical and Surgical Specialties; Radiological Sciences and Public Health; ‘Spedali Civili’ Hospital; University of Brescia; Italy
| | | | - I. Ginosa
- School of Nursing; Catholic University of the Sacred Heart - Little House of Divine Providence; Cottolego Hospital; Turin Italy
| | - S. Paoletti
- School of Nursing; Catholic University of the Sacred Heart - Little House of Divine Providence; Cottolego Hospital; Turin Italy
| | - P.L. Giuliano
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
| | - M. Tucci
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
| | - R. Rosato
- Cancer Epidemiology Unit; ‘Città della Salute e della Scienza’ Hospital; Turin Italy
| | - G.V. Scagliotti
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
| | - A. Saini
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
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20
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Long-term efficacy and tolerability of intranasal fentanyl in the treatment of breakthrough cancer pain. Support Care Cancer 2014; 23:1349-54. [DOI: 10.1007/s00520-014-2491-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 10/17/2014] [Indexed: 11/27/2022]
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21
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Channaiah VB, Kurek NS, Moses R, Chandra SB. Attenuation of Hemodynamic Response to Laryngoscopy and Endotracheal Intubation with Pre Induction IV Fentanyl Versus Combination of IV Fentanyl and Sub Lingual Nitroglycerin Spray. Med Arch 2014; 68:339-44. [PMID: 25568568 PMCID: PMC4269544 DOI: 10.5455/medarh.2014.68.339-344] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/05/2014] [Indexed: 12/27/2022] Open
Abstract
Introduction: Endotracheal intubation is one of the most invasive stimuli in anesthesia and it's often accompanied by a hemodynamic pressor response. The purpose of this study was to investigate the efficacy of a single pre-induction 2 µg/kg bolus injection of fentanyl followed by two puffs of nitroglycerin sub lingual spray (400 µg /spray) with a thiopentone/suxamethonium sequence in the attenuation of the hemodynamic response to endotracheal intubation in normotensive patients. Material and methods: The study consisted of 80 randomly selected ASA physical status I/II male/female adults who were aged between 18 through 60 years and scheduled for elective surgery. Group I received a single 2 µg/kg IV bolus of fentanyl diluted to 5 ml with normal saline 5 min prior to laryngoscopy followed by two puffs of nitroglycerin sub lingual spray (400 µg/spray) 2 minutes prior to intubation (n=40). Group II received a single 2 µg/kg IV bolus of fentanyl diluted to 5 ml with normal saline 5 min prior to laryngoscopy (n=40). Heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure and rate pressure product were compared to basal values at pre-induction, induction, intubation and post-intubation as well as at time increments of 1, 3, 5, 7 and 10 min. Results: Fentanyl combined with nitroglycerin did not attenuate hemodynamic pressor responses more than fentanyl alone. Increases of HR (7.9%), DBP (4.0%), MAP (3.6%) and RPP (6.0%) along with attenuation of SBP (2.7%) were observed in the fentanyl-nitroglycerin group as compared to the equivalent control measured values. Conclusions: A single pre-induction bolus injection of fentanyl followed by two puffs of nitroglycerin sub lingual spray in a thiopentone/suxamethonium anesthetic sequence neither successfully attenuates nor successfully suppresses the hemodynamic pressor response more effectively than fentanyl alone in normotensive patients resulting from endotracheal intubation.
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Affiliation(s)
- Vijayalakshmi B Channaiah
- Krishna Rajendra Hospital and Cheluvamba Hospital, Mysore Medical College, Rajiv Gandhi University, India
| | - Nicholas S Kurek
- Department of Biological, Chemical and Physical Sciences, Roosevelt University, Chicago, IL 60605, USA
| | - Ryder Moses
- Department of Biological, Chemical and Physical Sciences, Roosevelt University, Chicago, IL 60605, USA
| | - Sathees B Chandra
- College of Nursing and Health Sciences, Barry University, Miami, FL 33161, USA
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22
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Chen C, Gupta A. Clinical and pharmacokinetic considerations of novel formulations of fentanyl for breakthrough cancer pain. Pain Manag 2014; 4:339-50. [DOI: 10.2217/pmt.14.32] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
SUMMARY This review will provide an overview of pharmacokinetics and clinical practice considerations of the novel formulations of fentanyl for the treatment of breakthrough cancer pain. First, we provide a brief description of the physicochemical properties of fentanyl. Second, we describe the basic pharmacokinetics of fentanyl, the specifics of various formulations and how they affect pharmacokinetics of fentanyl. Finally, we offer the perspectives on clinical practices in the proper uses of these products. Advancements in the formulations and delivery of fentanyl have provided a safer and more effective treatment for breakthrough cancer pain. These dosage forms offer overlapping yet distinct pharmacokinetic advantages to allow more choices for physicians and patients in the management of breakthrough cancer pain.
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Affiliation(s)
- Cuiping Chen
- Pharmacokinetics & Clinical Pharmacology, Depomed Inc., Newark, CA, USA
| | - Anita Gupta
- Division of Pain Medicine & Regional Anesthesiology, Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
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Breakthrough cancer pain (BTcP): a synthesis of taxonomy, pathogenesis, therapy, and good clinical practice in adult patients in Italy. Adv Ther 2014; 31:657-82. [PMID: 25005168 PMCID: PMC4115180 DOI: 10.1007/s12325-014-0130-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Indexed: 11/04/2022]
Abstract
Pain presents in 80% of patients with advanced cancer, and 30% have periods of increased pain due to fluctuating intensity, known as breakthrough cancer pain (BTcP). BTcP is high-intensity, short-duration pain occurring in several episodes per day and is non-responsive to treatment. The clinical approach to BTcP is variable. A review of the literature was performed to provide clinicians and practitioners with a rational synthesis of the ongoing scientific debate on BTcP and to provide a basis for optimal clinical approach to BTcP in adult Italian patients. Data show that circadian exacerbations of pain should be carefully monitored, differentiating, if possible, between fluctuations of background pain (BP), end-of-dose effect, and BTcP. BTcP should be monitored in all care contexts in clinical practice and each care facility must have all the medications and products approved for use in BTcP at their disposal. Data show that knowledge about medications for BTcP is lacking: medications for BTcP treatment are not interchangeable, although containing the same active substance; each physician must know the specific characteristics of each medication, its pharmacological properties, limitations in clinical practice, specifics relating to titration and repeatability of administration, and technical specifics relating to the accessibility and delivery. Importantly, before choosing a rapid-onset opioid (ROO), it is essential to deeply understand the status of patient and the characteristics of their family unit/caregivers, taking into account the patient’s progressive loss of autonomy and/or cognitive-relational functionality. When BTcP therapy is initiated or changed, special attention must be paid to training the patient and family members/caregivers, providing clear instructions regarding the timing of drug administration. The patient must already be treated effectively with opioids before introducing ROOs for control of BTcP.
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Breakthrough pain in patients with controlled or uncontrolled basal pain: an observational study. Pain Res Manag 2014; 19:e168-71. [PMID: 24945289 PMCID: PMC4273716 DOI: 10.1155/2014/646312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recently, there has been debate regarding the definition of ‘breakthrough pain’ and the patients to whom the term applies, with suggestions made to broaden the definition to include both patients with uncontrolled and controlled baseline pain, rather than only patients with controlled pain. To contribute to this discussion, the authors assessed the occurrence and characteristics of breakthrough pain among patients with controlled and uncontrolled baseline pain. BACKGROUND: Breakthrough pain (BTP) is traditionally defined as a pain exacerbation in patients with chronic controlled pain. However, this definition has recently been challenged. OBJECTIVES: To evaluate the prevalence of unsatisfactory control in patients with chronic cancer pain, and investigate the frequency and intensity of BTP episodes. METHODS: A total of 665 patients with chronic cancer pain attending 21 pain therapy units in Italy were evaluated for baseline pain intensity and number of BTP episodes over a 30-day period. All patients started, continued or modified treatment for BTP at enrollment, according to medical judgment. RESULTS: The number of BTP events was higher in patients with uncontrolled baseline pain, although the intensity and duration of episodes were similar. In patients with uncontrolled baseline pain, the number of events decreased with time and reached values comparable with those reported in patients with controlled pain. Both the intensity of the pain and the duration of the BTP events exhibited similar values in the two groups at all time points, following increased monitoring and the prescription of analgesic medication. CONCLUSION: Patients with uncontrolled baseline pain experienced BTP flares with higher frequency, but similar intensity and duration with respect to patients with controlled pain at baseline. Notably, a close follow-up and adequate management of the BTP episodes led to an improvement of BTP in the observed patients.
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Velázquez Rivera I, Muñoz Garrido JC, García Velasco P, España Ximénez de Enciso I, Velázquez Clavarana L. Efficacy of sublingual fentanyl vs. oral morphine for cancer-related breakthrough pain. Adv Ther 2014; 31:107-17. [PMID: 24385406 DOI: 10.1007/s12325-013-0086-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Breakthrough cancer pain (BTcP) is recognized as a clinically significant complication of chronic cancer pain with most BTcP episodes peaking in intensity within a few minutes and lasting for approximately 30 min. Although a number of rapid-onset fentanyl preparations have been developed in the last decade, BTcP is still typically managed through the use of rescue doses of oral morphine but a comparative study of sublingual fentanyl and oral morphine is still lacking. The aim of this study was to determine the efficacy, tolerability, and patient satisfaction of sublingual fentanyl citrate (SLF) and oral morphine solution (OM) in the treatment of BTcP. METHODS In this prospective, longitudinal, controlled-study, 40 patients with BTcP were allocated to receive oral morphine (OM) or sublingual fentanyl (SLF). Pain intensity level on a 0-10 numerical rating visual analog scale (VAS), frequency of BTcP throughout the day, onset of relief (0-5, 6-10, 11-15, or over 16 min), time required for dose titration, patient satisfaction and adverse effects were assessed at 3, 7, 15, and 30 days after starting the treatment. RESULTS Mean doses of opioids for BTcP were 235 ± 23.4 μg (SLF) and 38 ± 5.2 mg (OM). The mean pain intensity levels were significantly lower with SLF than OM at 3 days (6.0 vs. 6.95; p = 0,001), 7 days (4.15 vs. 6.25, p < 0.001), 15 days (3.45 vs. 5.35, p < 0.001), and 30 days (3.05 vs. 4.45, p < 0.001). SLF provided significantly faster relief for BTcP than OM (p < 0.001) with a shorter dose titration period (mean 6.6 ± 3.3 vs. 13.3 ± 4.9 days; p < 0.001) and better satisfaction scores and with a very good safety profile. CONCLUSIONS Administration of SLF might provide a more effective treatment option than oral morphine for BTcP.
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Sousa AM, de Santana Neto J, Guimaraes GMN, Cascudo GM, Neto JOB, Ashmawi HA. Safety profile of intravenous patient-controlled analgesia for breakthrough pain in cancer patients: a case series study. Support Care Cancer 2013; 22:795-801. [DOI: 10.1007/s00520-013-2036-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 10/28/2013] [Indexed: 11/27/2022]
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Perelman M, Leake S. Considerations in selecting rapid-onset opioids for the management of breakthrough pain. J Pain Res 2013; 6:435-6. [PMID: 23785243 PMCID: PMC3682851 DOI: 10.2147/jpr.s45774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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