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Roberto A, Greco MT, Legramandi L, Galli F, Galli M, Corli O. A comparison between the administration of oral prolonged-release oxycodone-naloxone and transdermal fentanyl in patients with moderate-to-severe cancer pain: a propensity score analysis. J Pain Res 2017; 10:2123-2133. [PMID: 28919810 PMCID: PMC5590764 DOI: 10.2147/jpr.s141928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Opioids are the most important pharmacological treatment for moderate-to-severe cancer pain, but side effects limit their use. Transdermal fentanyl (TDF) and oral prolonged-release oxycodone-naloxone (OXN-PR) are effective in controlling chronic pain, with less constipation compared to other opioids. However, TDF and OXN-PR have never been directly compared. PATIENTS AND METHODS Cancer patients with moderate-to-severe chronic pain were consecutively enrolled in two prospective 28-day trials, received either TDF or OXN-PR, and were assessed at baseline and after 7, 14, 21, and 28 days. The primary endpoint was 28-day analgesic response rate (average pain intensity decrease ≥30% from baseline). Other outcome measures included opioid daily dose changes over time; need for adjuvant analgesics; number of switches; premature discontinuation; presence and severity of constipation; and other adverse drug reactions. To compare the efficacy and the safety of TDF and OXN-PR, we used the propensity score analysis to adjust for heterogeneity between the two patient groups. RESULTS Three hundred ten out of 336 patients originally treated (119 TDF and 191 OXN-PR) were included in the comparative analysis. The amount of responders was comparable after TDF (75.3%) and OXN-PR administration (82.9%, not significant [NS]). The final opioid daily dose expressed as morphine equivalent was 113.6 mg for TDF and 44.5 mg for OXN-PR (p<0.0001). A daily opioid dose escalation >5% was less common after OXN-PR (19.3%) than after TDS administration (37.9%, p<0.0001). Opioid switches and discontinuation were similar in both groups. Severe constipation in the two groups was comparable (32.6% after TDF vs 24.7% after OXN-PR, NS). Nausea, vomiting, and dry mouth were significantly less frequent in the OXN-PR group than in the TDF group. CONCLUSION Despite a similar analgesic activity in moderate-to-severe cancer pain, OXN-PR is characterized by lower daily dosages, less need for drug escalation, and fewer side effects compared to TDF.
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Affiliation(s)
- A Roberto
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - M T Greco
- Department of Clinical Sciences and Community, University of Milan, Milan, Italy
| | - L Legramandi
- Methodology for Clinical Research Laboratory, Oncology Department, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - F Galli
- Methodology for Clinical Research Laboratory, Oncology Department, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - M Galli
- Scientific Medical Communication srl, Novara, Italy
| | - O Corli
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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Corli O, Floriani I, Roberto A, Montanari M, Galli F, Greco MT, Caraceni A, Kaasa S, Dragani TA, Azzarello G, Luzzani M, Cavanna L, Bandieri E, Gamucci T, Lipari G, Di Gregorio R, Valenti D, Reale C, Pavesi L, Iorno V, Crispino C, Pacchioni M, Apolone G. Are strong opioids equally effective and safe in the treatment of chronic cancer pain? A multicenter randomized phase IV 'real life' trial on the variability of response to opioids. Ann Oncol 2016; 27:1107-1115. [PMID: 26940689 DOI: 10.1093/annonc/mdw097] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/16/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Guidelines tend to consider morphine and morphine-like opioids comparable and interchangeable in the treatment of chronic cancer pain, but individual responses can vary. This study compared the analgesic efficacy, changes of therapy and safety profile over time of four strong opioids given for cancer pain. PATIENT AND METHODS In this four-arm multicenter, randomized, comparative, of superiority, phase IV trial, oncological patients with moderate to severe pain requiring WHO step III opioids were randomly assigned to receive oral morphine or oxycodone or transdermal fentanyl or buprenorphine for 28 days. At each visit, pain intensity, modifications of therapy and adverse drug reactions (ADRs) were recorded. The primary efficacy end point was the proportion of nonresponders, meaning patients with worse or unchanged average pain intensity (API) between the first and last visit, measured on a 0-10 numerical rating scale. (NCT01809106). RESULTS Forty-four centers participated in the trial and recruited 520 patients. Worst pain intensity and API decreased over 4 weeks with no significant differences between drugs. Nonresponders ranged from 11.5% (morphine) to 14.4% (buprenorphine). Appreciable changes were made in the treatment schedules over time. Each group required increases in the daily dose, from 32.7% (morphine) to 121.2% (transdermal fentanyl). Patients requiring adjuvant analgesics ranged from 68.9% (morphine) to 81.6% (oxycodone), switches varied from 22.1% (morphine) to 12% (oxycodone), discontinuation of treatment from 27% ( morphine) to 14.5% (fentanyl). ADRs were similar except for effects on the nervous system, which significantly prevailed with morphine. CONCLUSION The main findings were the similarity in pain control, response rates and main adverse reactions among opioids. Changes in therapy schedules were notable over time. A considerable proportion of patients were nonresponders or poor responders. CLINICAL TRIAL REGISTRATION NCT01809106 (https://clinicaltrials.gov/ct2/show/NCT01809106?term=cerp&rank=2).
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Affiliation(s)
- O Corli
- Department of Oncology, Unità di Ricerca nel Dolore e Cure Palliative.
| | - I Floriani
- Department of Oncology, Laboratorio di Ricerca Clinica, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan
| | - A Roberto
- Department of Oncology, Unità di Ricerca nel Dolore e Cure Palliative
| | - M Montanari
- Department of Oncology, Unità di Ricerca nel Dolore e Cure Palliative
| | - F Galli
- Department of Oncology, Laboratorio di Ricerca Clinica, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan
| | - M T Greco
- Department of Oncology, Unità di Ricerca nel Dolore e Cure Palliative; Department of Statistics, Università di Milano, Milan
| | - A Caraceni
- Palliative Care Complex Structure, Terapia del dolore e Riabilitazione, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - S Kaasa
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Norway
| | - T A Dragani
- S.S.D. Epidemiology, Genetics and Pharmacogenomics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan
| | - G Azzarello
- Department of Hematology and Oncology, Ospedale di U.O.C. di Oncologia Mirano-ASL 13 Regione Veneto, Mirano
| | - M Luzzani
- Department of Orthogeriatrics, S.S.D. Cure Palliative, riabilitazione e stabilizzazione E.O. Ospedali Galliera, Genova
| | - L Cavanna
- Oncology Unit, Ospedale di Piacenza, Piacenza
| | - E Bandieri
- Unit of Supportive and Simultaneous Care, Medical Oncology Division USL, Modena
| | - T Gamucci
- UOC Medical Oncology, Ospedale SS Trinità, Sora
| | - G Lipari
- Palliative Care, P.O. di Salemi-ASP 9, Trapani
| | - R Di Gregorio
- U.O.S Obstetric Anasthesia and Pain Therapy, Opedale Sacro Cuore di Gesù - Fatebenefratelli, Benevento
| | - D Valenti
- Palliative Care Unit, Azienda Ospedaliera Valtellina e Valchiavenna, Morbegno
| | - C Reale
- Department of Cardiovascular Sciences, Respiratory, Nephrological, Anaesthetics and Geriatrics, Policlinico Universitario Umberto I, Rome
| | - L Pavesi
- Unit of Oncology, RCCS-Fondazione Salvatore Maugeri, Pavia
| | - V Iorno
- Centre for Pain Medicine M. TIENGO, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan
| | - C Crispino
- UOSD Treatment of Lung Cancer Complications, AO Dei Colli Monaldi Cotugno CTO Ospedale Monaldi, Napoli
| | - M Pacchioni
- Department of Oncology, Ospedale San Raffaele IRCCS, Milan
| | - G Apolone
- Scientific Direction, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Apolone G, Deandrea S, Montanari M, Corli O, Greco MT, Cavuto S. Evaluation of the comparative analgesic effectiveness of transdermal and oral opioids in cancer patients: a propensity score analysis. Eur J Pain 2011; 16:229-38. [PMID: 22323375 DOI: 10.1002/j.1532-2149.2011.00020.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2011] [Indexed: 11/05/2022]
Abstract
BACKGROUND Transdermal delivery systems containing fentanyl or buprenorphine, despite the relatively lack of comparative studies, have reached an impressive share of the market in several countries. In the context of a wider observational study, we applied the propensity score to test the comparative effectiveness of the two routes of administration (oral vs. transdermal). METHODS We applied the propensity score in a subgroup of patients (starting the World Health Organization third step therapy during the scheduled follow-up of 28 days) using pre-planned primary (pain intensity change) and secondary endpoints, such as increase in doses, need for switching and safety profile. Univariate and multivariate analyses were carried out. RESULTS Three-hundred sixty-six eligible cases were analysed. We found a difference among the two groups in terms of variables potentially associated with therapy choice and outcomes. After adjusting for propensity score, results were in favour of transdermal delivery systems for the primary endpoint (odds ratio 1.68; p = 0.04). A similar trend was also present for the other secondary endpoints. Only in the case of nausea and vomiting, patients receiving transdermal delivery systems reported a higher frequency of events. CONCLUSION The application of the propensity score has helped understand better the actual effectiveness of transdermal delivery systems that are at least equivalent to the oral opioids, and even more effective for pain intensity reduction.
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Affiliation(s)
- G Apolone
- Direzione Scientifica, Azienda Ospedaliera Arcispedale Santa Maria Nuova, IRCCS, Reggio-Emilia, Italy.
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