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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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2
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Maljean L, Gavazzi G, Gibert P, Grevy A, Payen M, Zerhouni N, Tiffet T, Cracowski JL, Mitha N, Maindet C, Baudrant M, Bedouch P, Drevet S. Tolerance of Fentanyl Pectin Nasal Spray for Procedural Pain in Geriatric Patients. J Am Med Dir Assoc 2022; 23:1005-1010. [DOI: 10.1016/j.jamda.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
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Lam JKW, Cheung CCK, Chow MYT, Harrop E, Lapwood S, Barclay SIG, Wong ICK. Transmucosal drug administration as an alternative route in palliative and end-of-life care during the COVID-19 pandemic. Adv Drug Deliv Rev 2020; 160:234-243. [PMID: 33137363 PMCID: PMC7603972 DOI: 10.1016/j.addr.2020.10.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 12/28/2022]
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic has led to a surge in need for alternative routes of administration of drugs for end of life and palliative care, particularly in community settings. Transmucosal routes include intranasal, buccal, sublingual and rectal. They are non-invasive routes for systemic drug delivery with the possibility of self-administration, or administration by family caregivers. In addition, their ability to offer rapid onset of action with reduced first-pass metabolism make them suitable for use in palliative and end-of-life care to provide fast relief of symptoms. This is particularly important in COVID-19, as patients can deteriorate rapidly. Despite the advantages, these routes of administration face challenges including a relatively small surface area for effective drug absorption, small volume of fluid for drug dissolution and the presence of a mucus barrier, thereby limiting the number of drugs that are suitable to be delivered through the transmucosal route. In this review, the merits, challenges and limitations of each of these transmucosal routes are discussed. The goals are to provide insights into using transmucosal drug delivery to bring about the best possible symptom management for patients at the end of life, and to inspire scientists to develop new delivery systems to provide effective symptom management for this group of patients.
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Affiliation(s)
- Jenny K W Lam
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region.
| | - Chucky C K Cheung
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region; School of Pharmacy, University of Nottingham, University Park, Nottingham, United Kingdom
| | - Michael Y T Chow
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region; Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Australia
| | - Emily Harrop
- Helen and Douglas House, Oxford University Hospitals NHS Foundation Trust, United Kingdom
| | - Susie Lapwood
- Oxford University Hospitals NHS Foundation Trust, United Kingdom
| | - Stephen I G Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, United Kingdom
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region; Centre for Medicines Optimisation Research and Education (CMORE), Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
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Chiou TJ, Chao TC, Chao TY, Huang JS, Chang YF, Wang CH. A dose titration study of fentanyl buccal soluble film for breakthrough cancer pain in Taiwan. Cancer Rep (Hoboken) 2020; 2:e1179. [PMID: 32721110 DOI: 10.1002/cnr2.1179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/22/2019] [Accepted: 03/27/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Fentanyl buccal soluble film (FBSF), a new formulation of fentanyl, is developed for the treatment of breakthrough pain (BTP) in opioid-tolerant patients with cancer. AIMS This study aimed to assess the feasible dose range of FBSF required for Taiwanese population. METHODS AND RESULTS This was an open-label, multicenter, noncomparative study. Cancer patients who were aged 20 years or older and had a stable regimen equivalent to 60 to 1000 mg/day of oral morphine, 20 to 120 mg/day of intravenous morphine, or 25 to 300 μg/h of transdermal fentanyl for at least 1 week were enrolled. The primary endpoint was the feasible dose range of FBSF. Secondary endpoints included difference in pain intensity at 30 minutes (PID30), percentage of episodes requiring rescue medication, and overall satisfaction. Adverse events (AEs) and serious AEs (SAEs) were recorded for safety measurements. The final effective dose in the per-protocol (PP) population (n = 30) ranged from 200 to 800 μg, of which 26 subjects (86.7%) achieved an effective dose range of 200 to 400 μg. Among the 283 BTP episodes recorded in the maintenance period, the mean PID30 was 4.0, and only 13 events (4.6%) required rescue medication. For 63.6% of the BTP episodes, patients rated their satisfaction as good to excellent. Only 5% of AEs were considered drug-related. CONCLUSIONS Individualized dose titration is recommended for BTP management for patients' benefit. Overall, FBSF was effective and well tolerated and was positively correlated with patients' background opioid dose for persistent pain management.
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Affiliation(s)
- Tzeon-Jye Chiou
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ta-Chung Chao
- Division of Medical Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Oncology and Comprehensive Breast Health Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsu-Yi Chao
- Division of Hematology & Oncology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Jen-Seng Huang
- Division of Hemato-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Fang Chang
- Division of Hematology and Oncology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Cheng-Hsu Wang
- Division of Hemato-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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5
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Is pain part of a systemic syndrome in head and neck cancer? Support Care Cancer 2019; 28:451-459. [PMID: 31713692 DOI: 10.1007/s00520-019-05147-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/21/2019] [Indexed: 12/13/2022]
Abstract
Head and neck cancers (HNC) represent 5% of all malignancies worldwide with about 180,000 cancer deaths per year. Patients with HNC are characterized by a systemic inflammatory state, generally associated with worse outcomes. Treatment-related toxicity is common among HNC patients and causes systemic consequences such as fatigue or cognitive dysfunction. The therapeutic treatments of HNC involve the release in circulation of inflammatory systemic mediators, whose effects trigger a vicious circle that may lead to functional and behavioral alterations. The areas of the head and neck are highly sensitive to pain. Literature data confirm that in HNC patients, pain is one of the most distressing symptoms across all the phases of treatment. Pain is associated with worse general conditions, depression, fatigue, impaired cognitive functions, and lower survival rate. The treatment of advanced HNC cases is multimodal and requires a multidisciplinary psycho-socio-pharmacological approach mediated by a team of experts. The pharmacological approach in management of HNC patients with pain is fundamental and involves the use of opioids, NSAIDs, steroids, or other drugs. Opioids in pain management therapy in patients with HNC could allow the pain level to be adequately monitored, thus improving quality of life. The integration of opioid and non-opioid therapy as well as non-pharmacological interventions is essential for the rehabilitation of physical, social, and psychological functions and to achieve pain control in patients with HNC. Opioid treatment is the mainstay for pain control, being used both for background and breakthrough cancer pain (BTcP) episodes. Fentanyl, easily absorbed and generally well tolerated, appears to be a possible choice due to its versatility. Non-pharmacological interventions, such as tailored yoga, physical exercise, and acupuncture, may have a role in pain management in patients with HNC.
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Janssen DJA, van den Beuken-van Everdingen MHJ, Verberkt CA, Creemers JPHM, Wouters EFM. Fentanyl nasal spray in a patient with end-stage COPD and severe chronic breathlessness. Breathe (Sheff) 2019; 15:e122-e125. [PMID: 31777575 PMCID: PMC6876137 DOI: 10.1183/20734735.0183-2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Chronic breathlessness syndrome, defined as breathlessness that persists despite optimal treatment of the underlying pathophysiology, resulting in disability, is a major problem for patients with advanced chronic lung disease, and can be difficult to manage [1, 2]. Opioids should be considered for treatment of these patients [3]. Episodic breathlessness is severe worsening of breathlessness intensity, which can be predictable or unpredictable [4]. Episodic breathlessness can have a major impact on activities of daily life, but ∼90% of episodes last for 20 min or less [5]. Therefore, the selection of appropriate palliative pharmacological therapy is a complex issue. Indeed, the onset of action of short-acting oral opioids is between 15 and 30 min [6]. The rapid onset of action (between 1 and 4 min [7]) is the major advantage of fentanyl nasal spray. This case report relates the experience and insight gained when fentanyl nasal spray was prescribed to a patient with end-stage chronic obstructive pulmonary disease (COPD) and the lessons we have learned. Written informed consent for publication of the clinical details was obtained from the deceased patient's spouse. Insufficient control of chronic breathlessness may induce excessive use of fentanyl nasal spray in COPD patients. Prescription of fentanyl nasal spray for breathlessness should only be done as part of palliative treatment and requires close follow-up.http://bit.ly/2YdOjJ1
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Affiliation(s)
- Daisy J A Janssen
- CIRO, Horn, The Netherlands.,Centre of Expertise for Palliative Care, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | | | - Cornelia A Verberkt
- Dept of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | | | - Emiel F M Wouters
- CIRO, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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Yen TY, Chiou JF, Chiang WY, Su WH, Huang MY, Hu MH, Wu SC, Lai YL. Proportional dose of rapid-onset opioid in breakthrough cancer pain management: An open-label, multicenter study. Medicine (Baltimore) 2018; 97:e11593. [PMID: 30045291 PMCID: PMC6078661 DOI: 10.1097/md.0000000000011593] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The management of breakthrough pain (BTP) in cancer patients is a challenge. It is clinically useful to evaluate the effectiveness of rapid-onset opioid at a starting dose in proportional to the background opioid regimen. This open-label, multicenter, noncomparative study aimed to assess the efficacy and safety of proportional doses of fentanyl buccal soluble film (FBSF) in patients with breakthrough cancer pain. METHODS Thirty patients aged 20 to 70, experiencing 1 to 3 BTP per day, receiving regimens equivalent to 60 to 360 mg/day of oral morphine or 25 to 150 μg/h of transdermal fentanyl ≥1 week, were prospectively recruited. FBSF was administered proportionally based on their current opioid regimen for baseline pain. The percentage of patients requiring dose titration was evaluated. For each BTP episode, changes in pain intensity at 30 minutes (PID30) after dosing, patient's satisfaction, the percentage of episodes requiring rescue medication, and adverse events (AEs) were recorded. RESULTS The percentage of patients who required dose titration was 21.4% (6/28) and 12.0% (3/25) in the full analysis set and per-protocol populations, respectively. The average PID30 was 3.9, and a pain score ≤3 was achieved in 95.1% of the events. Eight out of 367 (2.2%) BTP episodes needed rescue medication. The majority of subjects (75.8%) rated their experience of pain management as good to excellent. A total of 6 drug-related AEs were reported by 3 (10.7%) patients in the safety population. CONCLUSIONS FBSF dose in proportional to the regimen of opioid for baseline pain management is efficacious and well tolerated for the treatment of cancer patients with BTP.
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Affiliation(s)
- Tsung-Yu Yen
- Department of Radiation Oncology
- Hospice and Palliative Care Center, MacKay Memorial Hospital
| | - Jeng-Fong Chiou
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University
- Department of Radiation Oncology, Taipei Medical University Hospital
- Taipei Cancer Center, Taipei Medical University
- Cancer Center, Taipei Medical University Hospital, Taipei
| | | | - Wen-Hao Su
- Hospice and Palliative Care Center, MacKay Memorial Hospital
| | - Ming-Yuan Huang
- Hospice and Palliative Care Center, MacKay Memorial Hospital
| | - Ming-Hung Hu
- Division of Hematology and Oncology, Department of Medicine, Cardinal Tien Hospital
- School of Medicine, Fu Jen Catholic University, New Taipei
| | - Shen-Chi Wu
- Cancer Center, Taipei Medical University Hospital, Taipei
- Department of Hospice and Palliative Care, Taipei
| | - Yuen-Liang Lai
- Department of Radiation Oncology
- Hospice and Palliative Care Center, MacKay Memorial Hospital
- MacKay Medical College, New Taipei, Taiwan
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8
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Giusti R, Bossi P, Mazzotta M, Filetti M, Iacono D, Marchetti P. The use of fentanyl in pain management in head and neck cancer patients: a narrative review. Br J Pain 2017; 12:155-162. [PMID: 30057760 DOI: 10.1177/2049463717736787] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Head and neck (H&N) cancers account for about 5% of all malignant tumours. Pain is one of the most feared consequences of H&N neoplasms and is experienced by up to 80% of patients and worsens their quality of life inhibiting speaking, eating, drinking or swallowing. Nevertheless, pain is still often underestimated and undertreated. Objectives The role of opioids in cancer pain has been well established but evidences about the role and the relative effectiveness of opioids such as fentanyl in the context of H&N cancer pain remains unclear. Methods A literature review based on the guidance of the Centre for Reviews and Dissemination was conducted. An iterative approach was used starting with an electronic search in the MEDLINE database. The search terms (('Neoplasms'[Mesh]) AND 'Head and Neck Neoplasms'[Mesh]) AND 'Fentanyl'[Mesh] were used. Results A total of 18 publications were found by the first performed search on PubMed. Other publications concordant with our aim were found by cross-reference. Considering inclusion and exclusion criteria for our review, eight papers resulted eligible for analysis. Conclusion Fentanyl transdermal therapeutic system (TTS) seems to be an important option, thanks to the way of administration, the good safety and tolerability profiles to control baseline pain. For breakthrough cancer pain (BTcP), several formulations of transmucosal fentanyl are available. All the formulations seem to be active and safety but we lack head-to-head studies of fentanyl versus other strong opioids, as well as with different formulation of fentanyl, particularly for BTcP where H&N cancer population is very poorly represented.
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Affiliation(s)
- Raffaele Giusti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome, Italy
| | - Paolo Bossi
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Marco Mazzotta
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome, Italy
| | - Marco Filetti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome, Italy
| | - Daniela Iacono
- Pulmonary Oncology Unit, San Camillo Forlanini Hospital, Rome, Italy
| | - Paolo Marchetti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome, Italy
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Fentanyl buccal tablet for breakthrough cancer pain in clinical practice: results of the non-interventional prospective study ErkentNIS. Support Care Cancer 2017; 26:491-497. [PMID: 28849261 PMCID: PMC5752740 DOI: 10.1007/s00520-017-3853-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/15/2017] [Indexed: 12/25/2022]
Abstract
Purpose Several patients with advanced cancer suffer from breakthrough cancer pain (BTcP). BTcP is pain exacerbation despite opioid baseline therapy. Fentanyl buccal tablet (FBT) is a rapid-onset opioid for the treatment of BTcP. The aim of this study is to document the feasibility of FBT in patients with BTcP. Methods The study was performed in 64 centers. Basic pain score was rated on a numeric rating scale (NRS) before and after treatment. BTcP episodes, baseline opioid therapy, and FBT dose were rated as well as individual dose titration, findings on tolerability, patient satisfaction, and safety of the drug. Results Two hundred sixty-three patients were available for analysis. Patients rated a basic pain score of 6 (range 2–10) points on an NRS and described an average of 2 to 5 BTcP episodes per day. After titration of FBT, BTcP control was achieved within 5 min in 36%, within 10 min in 68%, and within 15 min in 95%. Basic pain score decreased to a mean NRS of 4 and BTcP episodes decreased to < 1 to 3 episodes per day. BTcP control, onset of action of FBT, potency of FBT, tolerability of FBT, and safety of FBT were rated as excellent or good by 89 to 99% of the patients. Adverse drug reactions were registered in 3%. Conclusions Treatment with FBT led to rapid pain relief and reductions in the number of BTcP episodes and patient satisfaction was rated as excellent or good.
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Bossi P, Cossu Rocca M, Corvò R, Depenni R, Guardamagna V, Marinangeli F, Miccichè F, Trippa F. The vicious circle of treatment-induced toxicities in locally advanced head and neck cancer and the impact on treatment intensity. Crit Rev Oncol Hematol 2017; 116:82-88. [DOI: 10.1016/j.critrevonc.2017.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/22/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022] Open
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Cost-effectiveness analysis of oral fentanyl formulations for breakthrough cancer pain treatment. PLoS One 2017; 12:e0179523. [PMID: 28654672 PMCID: PMC5487011 DOI: 10.1371/journal.pone.0179523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 05/31/2017] [Indexed: 11/30/2022] Open
Abstract
Breakthrough cancer Pain (BTcP) has a high prevalence in cancer population. Patients with BTcP reported relevant health care costs and poor quality of life. The study assessed the cost-effectiveness of the available Oral Fentanyl Formulations (OFFs) for BTcP in Italy. A decision-analytical model was developed to estimate costs and benefits associated with treatments, from the Italian NHS perspective. Expected reductions in pain intensity per BTcP episodes were translated into, percentage of BTcP reduction, resource use and Quality-Adjusted-Life-Years (QALYs). Relative efficacy, resources used and unit costs data were derived from the literature and validated by clinical experts. Probabilistic and deterministic sensitivity analyses were performed. At base-case analysis, Sublingual Fentanyl Citrate (FCSL) compared to other oral formulations reported a lower patient’s cost (€1,960.8) and a higher efficacy (18.7% of BTcP avoided and 0.0507 QALYs gained). The sensitivity analyses confirmed the main results in all tested scenarios, with the highest impact reported by BTcP duration and health care resources consumption parameters. Between OFFs, FCSL is the cost-effective option due to faster reduction of pain intensity. However, new research is needed to better understand the economic and epidemiologic impact of BTcP, and to collect more robust data on economic and quality of life impact of the different fentanyl formulations. Different fentanyl formulations are available to manage BTcP in cancer population. The study is the first that assesses the different impact in terms of cost and effectiveness of OFFs, providing new information to better allocate the resources available to treat BTcP and highlighting the need of better data.
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