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Mercadante S, Caraceni A, Cuomo A, Mammucari M, Marchetti P, Mediati RD, Natoli S, Tonini G. Breakthrough pain in patients with multiple myeloma: a secondary analysis of IOPS MS study. Eur Rev Med Pharmacol Sci 2023; 27:1134-1139. [PMID: 36808361 DOI: 10.26355/eurrev_202302_31219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
OBJECTIVE The aim of this study was to characterize breakthrough pain (BTcP) in patients with multiple myeloma (MM). PATIENTS AND METHODS This was a secondary analysis of a large multicenter study of patients with BTcP. Background pain intensity and opioid doses were recorded. The BTcP characteristics, including the number of BTcP episodes, intensity, onset, duration, predictability, and interference with daily activities were recorded. Opioids prescribed for BTcP, time to achieve a meaningful pain relief after taking a medication, adverse effects, and patients' satisfaction were assessed. RESULTS Fifty-four patients with MM were examined. In comparison with other tumors, in patients with MM BTcP was more predictable (p=0.04), with the predominant trigger being the physical activity (p<0.001). Other BTcP characteristics, pattern of opioids used for background pain and BTcP, satisfaction and adverse effects did not differ. CONCLUSIONS Patients with MM have their own peculiarities. Given the peculiar involvement of the skeleton, BTcP was highly predictable and triggered by movement.
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Affiliation(s)
- S Mercadante
- Anesthesia and Intensive Care and Pain Relief and Supportive Care, La Maddalena Cancer Center, Palermo, Italy.
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Mammucari M, Paolucci T, Russo D, Maggiori E, Di Marzo R, Migliore A, Massafra U, Ronconi G, Ferrara PE, Gori F, Bifarini B, Brauneis S, Vellucci R, Mediati RD, Violo B, Natoli S, Pediliggieri C, Di Campli C, Collina MC. A Call to Action by the Italian Mesotherapy Society on Scientific Research. Drug Des Devel Ther 2021; 15:3041-3047. [PMID: 34285471 PMCID: PMC8285234 DOI: 10.2147/dddt.s321215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/22/2021] [Indexed: 01/22/2023] Open
Abstract
Mesotherapy (local intradermal therapy, LIT) is a technique used to slowly spread drugs in tissues underlying the site of injection to prolong the pharmacological effect with respect to intramuscular injection. Recommendations for proper medical use of this technique have been made for pain medicine and rehabilitation, chronic venous disease, sport medicine, musculoskeletal disorders, several dermatological conditions, skin ageing, and immune-prophylaxis. Although mesotherapy is considered a valid technique, unresolved questions remain, which should be answered to standardize methodology and dosing regimen as well as to define the right indications in clinical practice. New randomized controlled trials are needed to test single products (dose, frequency of administration, efficacy and safety). Even infiltration of substances for dermo-cosmetic purposes must be guided by safety and efficacy tests before being proposed by mesotherapy. In this article, we put forth a preclinical and clinical research plan and a health technology assessment as a call to action by doctors, researchers and scientific societies to aid national health authorities in considering mesotherapy for prevention, treatment and rehabilitation paths.
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Affiliation(s)
| | - Teresa Paolucci
- Unit of Physical Medicine and Rehabilitation, G. D’ Annunzio University of Chieti-Pescara, Department of Oral Medical Science and Biotechnology (DSMOB), Chieti, Italy
| | | | | | | | - Alberto Migliore
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Umberto Massafra
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Gianpaolo Ronconi
- Physical Medicine and Rehabilitation Unit, IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Paola Emilia Ferrara
- Physical Medicine and Rehabilitation Unit, IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Fabio Gori
- Section of Anaesthesia, Intensive Care, and Pain Medicine, University Hospital Santa Maria Della Misericordia, Perugia, Italy
| | - Barbara Bifarini
- Section of Anaesthesia, Intensive Care, and Pain Medicine, University Hospital Santa Maria Della Misericordia, Perugia, Italy
| | - Stefano Brauneis
- Pain Centre “Enzo BorzomatI”, University Hospital of Rome “Policlinico Umberto I”, Rome, Italy
| | - Renato Vellucci
- Anaesthesiology Department, University Hospital Careggi, Florence, Italy
| | | | - Bartolomeo Violo
- Pain Therapy Unit, S. Spirito Nuovo Regina Margherita Hospital, Rome, Italy
| | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, Tor Vergata University, Rome, Italy
| | - Carmen Pediliggieri
- Department of Vascular Surgery, Limb Salvage and Diabetic Foot, IDI-IRCCS, Rome, Italy
| | - Cristiana Di Campli
- Department of Vascular Surgery, Limb Salvage and Diabetic Foot, IDI-IRCCS, Rome, Italy
| | - Maria Chiara Collina
- Department of Vascular Surgery, Limb Salvage and Diabetic Foot, IDI-IRCCS, Rome, Italy
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Mammucari M, Russo D, Maggiori E, Paolucci T, Di Marzo R, Brauneis S, Bifarini B, Ronconi G, Ferrara PE, Gori F, Mediati RD, Vellucci R, Migliore A, Natoli S. Evidence based recommendations on mesotherapy: an update from the Italian society of Mesotherapy. Clin Ter 2021; 171:e37-e45. [PMID: 33346324 DOI: 10.7417/ct.2021.2278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Mesotherapy, also known as local intradermal therapy, widely used all over the world, is a technique used to inject substances into the surface layer of the skin. There are no international guidelines for the correct use of this technique and in many countries, it is still applied empirically without valid patient consent. The Italian society of mesotherapy has planned a study to assess the rationale and clinical applications based on current evidence. METHODS An independent steering committee, based on the available scientific literature, has formulated a series of clinical questions. 21 experts responded by writing an evidence-based document. From this document 30 statements were obtained which were presented to 114 experts using the Delphi method. RESULTS 28 statements reached a broad agreement on definition, technique, pharmacological rationale, indications and some crucial ethical aspect. CONCLUSIONS Although further studies are needed to establish the clinical role of this technique in each field of application, our statements recommend the correct application according to the needs of the individual patient in full respect of ethics.
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Affiliation(s)
| | - D Russo
- San Marco Hospice and Palliative Care, Latina
| | | | - T Paolucci
- University G. D'Annunzio Chieti, Department of Medical and Oral Sciences and Biotechnologies, Chieti-Pescara
| | - R Di Marzo
- Member of the Italian Society of Mesotherapy, Rome
| | - S Brauneis
- Pain Center "Enzo Borzomati", University Hospital of Rome "Policlinico Umberto I", Rome
| | - B Bifarini
- Section of Anesthesia, Intensive Care, and Pain Medicine, Azienda Ospedaliera-Universitaria Santa Maria Della Misericordia, Perugia
| | - G Ronconi
- University Policlinic Foundation A. Gemelli IRCCS, Rome
| | - P E Ferrara
- University Policlinic Foundation A. Gemelli IRCCS, Rome
| | - F Gori
- Section of Anesthesia, Intensive Care, and Pain Medicine, Azienda Ospedaliera-Universitaria Santa Maria Della Misericordia, Perugia
| | - R D Mediati
- Department of Anesthesia of Careggi University Hospital, Florence
| | - R Vellucci
- Department of Anesthesia of Careggi University Hospital, Florence
| | - A Migliore
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome
| | - S Natoli
- Dept of Clinical Science and Translational Medicine, University of Rome Tor Vergata AND Unit of Pain Therapy, Polyclinic of Tor Vergata - Rome, Italy
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De Santis S, Simone MD, Mercadante S, Mediati RD, Vellucci R, Marchetti P, Tonini G, Cuomo A, Caraceni A, Natoli S, Armento G, Blasi L, Mammucari M. Oxycodone/Acetaminophen: The Tailoring Combination Treatment for Specific Clinical Profile of Opioid Well-Responsive Cancer Pain. Cancer Manag Res 2021; 13:1747-1756. [PMID: 33642876 PMCID: PMC7903954 DOI: 10.2147/cmar.s290551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/31/2021] [Indexed: 11/23/2022] Open
Abstract
Background International guidelines recommend moderate-to-severe cancer pain to be treated with strong opioids. However, pain management remains an unsolved matter, at least in the demanding oncology and palliative care setting. Although cancer pain consists of multiple components, which interact in complex ways where combination therapy can better intercept multiple pain characteristics, few studies have used a non-opioid/opioid association to exploit possible synergistic actions. Even the efforts of a recent approach emphasizing appropriate pain assessment and accurate classification to obtain personalized pain management have not produced a satisfactory analgesic strategy. Objective This analysis was intended to evaluate the effectiveness of the immediate release fixed combination of oxycodone/acetaminophen (OxyIR/Par) for the treatment of moderate-to-severe intensity background pain used alone or in combination with other strong opioids in cancer patients with breakthrough cancer pain (BTcP). This is a secondary analysis of a wider observational, prospective, multicenter study [Italian Oncologic Pain multiSetting Multicentric Survey (IOPS-MS)] performed on 179 patients treated with opioids for cancer pain who received the fixed combination of oxycodone/acetaminophen (OxyIR/Par) for the treatment of background pain (BGP). Results Cancer patients with breakthrough cancer pain and controlled BGP (Background Pain) were classified according to the presence of analgesic therapy with tablets of fixed combination OxyIR/Par alone (group A, n=120) or tablets of fixed combination OxyIR/Par combined with other strong opioids (group B, n=59). Clinical features of group A were different to group B: higher mean Karnofsky Performance Status Index 70.3% (95% CI=67.2–73.5; median=70, CI=60–80) vs 58.3 (95% CI=53.4–63.2; median=50, CI=45–70) (P<0.001), and mainly group A patients were treated in an ambulatory setting (55.0% group A vs 33.9% group B) (p<0.001). Both groups had managed BGP with similar mean dosages (group A: 12.0, CI=10.5–13.4; group B: 13.1, CI=11.0–15.1) and frequencies of OxyIR/Par alone for group A and in association to other opioids for group B, but Breakthrough cancer Pain (BTcP) exhibited different characteristics in the two groups, showing a lower mean intensity numerical rating scale (NRS) of 7.5 (95% CI=7.2–7.7; median=7, CI=7–8 group A) vs 7.9 (95% CI=7.6, 8.2; median= 8, CI=7–9 group B) (P=0.04) and a higher percentage of patients had a faster onset, defined as the maximum intensity reached in less than 10 minutes, 81.7% (N=98) in group A vs 59.3% (n=35) in group B (P=0.002). Conclusion This is the first analysis about the efficacy of an immediate-release fixed combination of OxyIR/Par in the real world for moderate-to-severe background cancer pain and breakthrough cancer pain. The oral fixed combination OxyIR/Par provided an adequate level of analgesia for moderate–severe background cancer pain, in a different cohort of cancer patients with different performance status, both in ambulatory and palliative settings. The low dosage of fixed combination OxyIR/Par was effective alone or in association with other opioids.
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Affiliation(s)
- Stefano De Santis
- Palliative Care and Oncologic Pain Service, S. Camillo-Forlanini Hospital, Rome, Italy
| | | | - Sebastiano Mercadante
- Anesthesia and Intensive Care & Pain Relief and Supportive Care, La Maddalena, Palermo, Italy
| | | | - Renato Vellucci
- Palliative Care and Pain Therapy Unit, Careggi Hospital, Florence, Italy
| | - Paolo Marchetti
- Molecular and Clinical Medicine Medical Oncology, La Sapienza University of Rome, Rome, Italy
| | - Giuseppe Tonini
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Arturo Cuomo
- Anesthesiology, Resuscitation, and Pain Therapy Department, National Cancer Institute, IRCCS Foundation, Naples, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation, National Cancer Institute, IRCCS Foundation, Milan, Italy
| | - Silvia Natoli
- Department of Clinical Science and Translational Medicine - University of Rome Tor Vergata and Department of Emergency, Admission and Critical Area - Policlinic of Tor Vergata, Rome, Italy
| | - Grazia Armento
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Livio Blasi
- Medical Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
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Pantano F, Manca P, Armento G, Zeppola T, Onorato A, Iuliani M, Simonetti S, Vincenzi B, Santini D, Mercadante S, Marchetti P, Cuomo A, Caraceni A, Mediati RD, Vellucci R, Mammucari M, Natoli S, Lazzari M, Dauri M, Adile C, Airoldi M, Azzarello G, Blasi L, Chiurazzi B, Degiovanni D, Fusco F, Guardamagna V, Liguori S, Palermo L, Mameli S, Masedu F, Mazzei T, Melotti RM, Menardo V, Miotti D, Moroso S, Pascoletti G, De Santis S, Orsetti R, Papa A, Ricci S, Scelzi E, Sofia M, Aielli F, Valle A, Tonini G. Breakthrough Cancer Pain Clinical Features and Differential Opioids Response: A Machine Learning Approach in Patients With Cancer From the IOPS-MS Study. JCO Precis Oncol 2020; 4:2000158. [PMID: 33283139 PMCID: PMC7713587 DOI: 10.1200/po.20.00158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A large proportion of patients with cancer suffer from breakthrough cancer pain (BTcP). Several unmet clinical needs concerning BTcP treatment, such as optimal opioid dosages, are being investigated. In this analysis the hypothesis, we explore with an unsupervised learning algorithm whether distinct subtypes of BTcP exist and whether they can provide new insights into clinical practice. METHODS Partitioning around a k-medoids algorithm on a large data set of patients with BTcP, previously collected by the Italian Oncologic Pain Survey group, was used to identify possible subgroups of BTcP. Resulting clusters were analyzed in terms of BTcP therapy satisfaction, clinical features, and use of basal pain and rapid-onset opioids. Opioid dosages were converted to a unique scale and the BTcP opioids-to-basal pain opioids ratio was calculated for each patient. We used polynomial logistic regression to catch nonlinear relationships between therapy satisfaction and opioid use. RESULTS Our algorithm identified 12 distinct BTcP clusters. Optimal BTcP opioids-to-basal pain opioids ratios differed across the clusters, ranging from 15% to 50%. The majority of clusters were linked to a peculiar association of certain drugs with therapy satisfaction or dissatisfaction. A free online tool was created for new patients’ cluster computation to validate these clusters in future studies and provide handy indications for personalized BTcP therapy. CONCLUSION This work proposes a classification for BTcP and identifies subgroups of patients with unique efficacy of different pain medications. This work supports the theory that the optimal dose of BTcP opioids depends on the dose of basal opioids and identifies novel values that are possibly useful for future trials. These results will allow us to target BTcP therapy on the basis of patient characteristics and to define a precision medicine strategy also for supportive care.
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Affiliation(s)
- Francesco Pantano
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Paolo Manca
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy.,IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Grazia Armento
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Tea Zeppola
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Angelo Onorato
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Michele Iuliani
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sonia Simonetti
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Bruno Vincenzi
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Daniele Santini
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Supportive Care, La Maddalena, Palermo, Italy
| | - Paolo Marchetti
- Molecular and Clinical Medicine Medical Oncology, La Sapienza University of Rome, Rome, Italy
| | - Arturo Cuomo
- Anesthesiology, Resuscitation, and Pain Therapy Department, National Cancer Institute, IRCCS Foundation Pascale, Naples, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy, and Rehabilitation, National Cancer Institute, IRCCS Foundation, Milan, Italy
| | | | - Renato Vellucci
- Palliative Care and Pain Therapy Unit, Careggi Hospital, Florence, Italy
| | | | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Marzia Lazzari
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Claudio Adile
- Anesthesia and Intensive Care and Pain Relief and Supportive Care, La Maddalena, Palermo, Italy
| | - Mario Airoldi
- Second Medical Oncology Division, Città della Salute e della Scienza Hospital of Turin, Turin, Italy
| | - Giuseppe Azzarello
- Medical Specialties Department, Oncology and Oncologic Hematology, ASL 13 Mirano, Venice, Italy
| | - Livio Blasi
- Medical Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | | | | | - Flavio Fusco
- Palliative Care Unit, Department of Primary and Community Care, ASL 3 Genovese, Genoa, Italy
| | - Vittorio Guardamagna
- Palliative Care and Pain Therapy Unit, European Oncology Institute IRCCS, Milan, Italy
| | - Simeone Liguori
- Palliative Care and Pain Therapy Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Loredana Palermo
- Medical Oncology Unit, National Cancer Research Center "Giovanni Paolo II", Bari, Italy
| | - Sergio Mameli
- Pain Therapy Unit, "A. Businco" Hospital, ASL 8, Cagliari, Italy
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Teresita Mazzei
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Rita Maria Melotti
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy
| | | | - Danilo Miotti
- Pain Therapy ICS Maugeri, IRCCS Foundation, Pavia, Italy
| | - Stefano Moroso
- Medical Oncology, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Gaetano Pascoletti
- Medical Oncology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Stefano De Santis
- Palliative Care and Oncologic Pain Service, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Remo Orsetti
- Pain Medicine Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Alfonso Papa
- Pain Relief, A.O. Dei Colli, Monaldi Hospital, Naples, Italy
| | - Sergio Ricci
- Division of Medical Oncology, Department of Oncology, S. Chiara University Hospital, Pisa, Italy
| | - Elvira Scelzi
- Medical Oncology, Castelfranco Veneto Hospital, Treviso, Italy
| | - Michele Sofia
- Department of Palliative Care, Hospice and Pain Therapy Unit, "G. Salvini" Hospital, Milan, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Giuseppe Tonini
- Medical Oncology Department, Campus Bio-Medico University of Rome, Rome, Italy
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Cuomo A, Cascella M, Forte CA, Bimonte S, Esposito G, De Santis S, Cavanna L, Fusco F, Dauri M, Natoli S, Maltoni M, Morabito A, Mediati RD, Lorusso V, Barni S, Porzio G, Mercadante S, Crispo A. Careful Breakthrough Cancer Pain Treatment through Rapid-Onset Transmucosal Fentanyl Improves the Quality of Life in Cancer Patients: Results from the BEST Multicenter Study. J Clin Med 2020; 9:jcm9041003. [PMID: 32252426 PMCID: PMC7230287 DOI: 10.3390/jcm9041003] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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] [Received: 02/11/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To explore the effect of breakthrough cancer pain (BTcP) treatment on quality of sleep and other aspects of the health-related quality of life (HRQoL) in patients with cancer pain. METHODS In an observational, multicenter, cohort study, cancer patients from palliative care units, oncology departments, and pain clinics and affected by BTcP were included. Enrolled patients were assessed at the four visits: T0 (baseline), T7, T14, and T28. Stable chronic background pain (numeric rating scale, NRS ≤ 4) during the whole study period was mandatory. BTcP was treated through transmucosal fentanyl. Three questionnaires were used to measure the HRQoL: EORTC QLQ-C15-PAL, Pittsburgh Sleep Quality Index (PSQI), and the Edmonton Symptom Assessment System (ESAS). RESULTS In 154 patients, the HRQoL showed a significant improvement for all physical and emotional characteristics in the EORTC QLQ-C15-PAL, except for nausea and vomiting (linear p-value = 0.1) and dyspnea (Linear p-value = 0.05). The ESAS and PSQI questionnaires confirmed these positive results (p < 0.0001 and p = 0.002, respectively). CONCLUSIONS This prospective investigation by an Italian expert group, has confirmed that careful management of BTcP induces a paramount improvement on the HRQoL. Because in cancer patients there is a high prevalence of BTcP and this severe acute pain has deleterious consequences, this information can have an important clinical significance.
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Affiliation(s)
- Arturo Cuomo
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS. Fondazione G. Pascale, 80131 Napoli, Italy; (A.C.); (C.A.F.); (S.B.); (G.E.)
| | - Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS. Fondazione G. Pascale, 80131 Napoli, Italy; (A.C.); (C.A.F.); (S.B.); (G.E.)
- Correspondence: ; Tel./Fax: +39-081-5903-778
| | - Cira Antonietta Forte
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS. Fondazione G. Pascale, 80131 Napoli, Italy; (A.C.); (C.A.F.); (S.B.); (G.E.)
| | - Sabrina Bimonte
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS. Fondazione G. Pascale, 80131 Napoli, Italy; (A.C.); (C.A.F.); (S.B.); (G.E.)
| | - Gennaro Esposito
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS. Fondazione G. Pascale, 80131 Napoli, Italy; (A.C.); (C.A.F.); (S.B.); (G.E.)
| | - Stefano De Santis
- Palliative Care and Oncologic Pain Service, S. Camillo-Forlanini Hospital, 00149 Rome, Italy;
| | - Luigi Cavanna
- Department of Oncology-Hematology, G. da Saliceto Hospital, 29121 Piacenza, Italy;
| | - Flavio Fusco
- Palliative Home Care Unit, ASL 3, 16153 Genova, Italy;
| | - Mario Dauri
- Department of Anesthesiology and Resuscitation, II University of Rome, Tor Vergata, 00133 Roma, Italy; (M.D.); (S.N.)
| | - Silvia Natoli
- Department of Anesthesiology and Resuscitation, II University of Rome, Tor Vergata, 00133 Roma, Italy; (M.D.); (S.N.)
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy;
| | - Alessandro Morabito
- Medical Oncology Unit, Istituto Nazionale Tumori, IRCCS. Fondazione G. Pascale, 80131 Napoli, Italy;
| | - Rocco Domenico Mediati
- Palliative Care and Pain Therapy Unit, University Hospital Careggi, 50134 Firenze, Italy;
| | - Vito Lorusso
- UO Oncologia Medica, Istituto Tumori “G Paolo II”, 70124 Bari, Italy;
| | - Sandro Barni
- Oncology Unit, ASST Bergamo Ovest, 24047 Treviglio, Italy;
| | - Giampiero Porzio
- Medical Oncology Unit, San Salvatore Hospital, University of L’Aquila, 67100 L’Aquila, Italy;
| | - Sebastiano Mercadante
- Main regional center for Pain Relief & Supportive Care, La Maddalena Cancer Center, 90146 Palermo, Italy;
| | - Anna Crispo
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori, IRCCS. Fondazione G. Pascale, 80131 Napoli, Italy;
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Vellucci R, Terenzi R, Kanis JA, Kress HG, Mediati RD, Reginster JY, Rizzoli R, Brandi ML. Understanding osteoporotic pain and its pharmacological treatment: supplementary presentation. Osteoporos Int 2018; 29:2153-2154. [PMID: 29992509 DOI: 10.1007/s00198-018-4536-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 04/16/2018] [Indexed: 11/24/2022]
Abstract
Osteoporosis, a disorder that affects millions of people worldwide, is characterized by decreased bone mass and microstructural alterations giving rise to an increased risk of fractures. Osteoporotic fractures can cause acute and chronic nociceptive and neuropathic pain that mainly affects elderly patients with multiple comorbidities and commonly on different drug regimens. Central sensitization seems to play a pivotal role in developing and maintaining chronicity of post-fracture pain in osteoporosis. Antiosteoporosis drugs are able to partially control pain, but additional analgesics are always necessary for pain due to bone fractures. Nonsteroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors reduce acute pain but with a poor effect on the chronic neuropathic component of pain and with relevant side effects. Opioid drugs can control the whole spectrum of acute and chronic bone pain, but they differ with respect to their efficacy on neuropathic components, their tolerability and safety. Chronic pain after osteoporotic fractures requires a multifaceted approach, which includes a large spectrum of drugs (antiosteoporosis treatment, acetaminophen, NSAIDs, selective COX-2 inhibitors, weak and strong opioids) and non-pharmacological treatment. Based on a better understanding of the pathogenesis of osteoporotic and post-fracture pain, a guided stepwise approach to post-fracture osteoporotic pain will also better meet the needs of these patients.
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Affiliation(s)
- R Vellucci
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - R Terenzi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - J A Kanis
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - H G Kress
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - R D Mediati
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - J-Y Reginster
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - R Rizzoli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - M L Brandi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy.
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Vellucci R, Terenzi R, Kanis JA, Kress HG, Mediati RD, Reginster JY, Rizzoli R, Brandi ML. Understanding osteoporotic pain and its pharmacological treatment. Osteoporos Int 2018; 29:1477-1491. [PMID: 29619540 DOI: 10.1007/s00198-018-4476-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/06/2018] [Indexed: 01/09/2023]
Abstract
Osteoporosis, a disorder that affects millions of people worldwide, is characterized by decreased bone mass and microstructural alterations giving rise to an increased risk of fractures. Osteoporotic fractures can cause acute and chronic pain that mainly affects elderly patients with multiple comorbidities and commonly on different drug regimens. The aim of this paper is to summarize the pathogenesis and systemic treatment of osteoporotic pain. This narrative review summarizes the main pathogenetic aspects of osteoporotic pain and the cornerstones of its treatment. Osteoporotic fractures induce both acute and chronic nociceptive and neuropathic pain. Central sensitization seems to play a pivotal role in developing and maintaining chronicity of post-fracture pain in osteoporosis. Antiosteoporosis drugs are able to partially control pain, but additional analgesics are always necessary for pain due to bone fractures. Nonsteroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors reduce acute pain but with a poor effect on the chronic neuropathic component of pain and with relevant side effects. Opioid drugs can control the whole spectrum of acute and chronic bone pain, but they differ with respect to their efficacy on neuropathic components, their tolerability and safety. Chronic pain after osteoporotic fractures requires a multifaceted approach, which includes a large spectrum of drugs (antiosteoporosis treatment, acetaminophen, NSAIDs, selective COX-2 inhibitors, weak and strong opioids) and non-pharmacological treatment. Based on a better understanding of the pathogenesis of osteoporotic and post-fracture pain, a guided stepwise approach to post-fracture osteoporotic pain will also better meet the needs of these patients.
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Affiliation(s)
- R Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence, Italy
| | - R Terenzi
- Department of Surgery and Translational Medicine, University of Florence, AOU Careggi Largo Brambilla n.3, 50134, Florence, Italy
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Australia
| | - H G Kress
- Department of Special Anaesthesia and Pain Medicine, Medical University/AKH of Vienna, Vienna, Austria
| | - R D Mediati
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence, Italy
| | | | - R Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, 1211, Geneva 14, Switzerland
| | - M L Brandi
- Department of Surgery and Translational Medicine, University of Florence, AOU Careggi Largo Brambilla n.3, 50134, Florence, Italy.
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Vellucci R, Mediati RD, Gasperoni S, Mammucari M, Marinangeli F, Romualdi P. Assessment and treatment of breakthrough cancer pain: from theory to clinical practice. J Pain Res 2017; 10:2147-2155. [PMID: 29066928 PMCID: PMC5604430 DOI: 10.2147/jpr.s135807] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 11/30/2022] Open
Abstract
Breakthrough cancer pain (BTcP) is a common condition in oncological patients. However, its management is still suboptimal. Improved knowledge of BTcP and its management in clinical practice may have immediate importance for all physicians involved in the supportive care of cancer patients. This review critically discusses the most important concepts for the correct diagnosis of BTcP and presents some intriguing cases of the management of this condition in clinical practice. Overall, the most appropriate therapeutic choice appears to be a rapid-onset opioid (ROO), and in particular, the nasal route of administration is the quickest and most convenient mode of administration for the management of BTcP, especially when the patient needs rapid resolution of pain. To this end, intranasal fentanyl spray may have a particular relevance in clinical practice. Future research should focus on accepted definitions of BTcP to investigate the optimal management of this highly heterogeneous pain condition. Therapeutic decision-making of patients, clinicians, and payers will likely be driven from results of well-designed clinical trials of ROOs.
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Affiliation(s)
- Renato Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence
| | | | - Silvia Gasperoni
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence
| | | | - Franco Marinangeli
- Department of Life, Health and Environmental Sciences, University of L'Aquila, l'Aquila
| | - Patrizia Romualdi
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
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Mercadante S, Marchetti P, Cuomo A, Caraceni A, Mediati RD, Mammucari M, Natoli S, Lazzari M, Dauri M, Airoldi M, Azzarello G, Bandera M, Blasi L, Cartenì G, Chiurazzi B, Costanzo BVP, Degiovanni D, Fusco F, Guardamagna V, Iaffaioli V, Liguori S, Lorusso V, Mameli S, Mattioli R, Mazzei T, Melotti RM, Menardo V, Miotti D, Moroso S, De Santis S, Orsetti R, Papa A, Ricci S, Sabato AF, Scelzi E, Sofia M, Tonini G, Aielli F, Valle A. Breakthrough Cancer Pain: Preliminary Data of The Italian Oncologic Pain Multisetting Multicentric Survey (IOPS-MS). Adv Ther 2017; 34:120-135. [PMID: 27873235 PMCID: PMC5216057 DOI: 10.1007/s12325-016-0440-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Indexed: 11/29/2022]
Abstract
Introduction An ongoing national multicenter survey [Italian Oncologic Pain multiSetting Multicentric Survey (IOPS-MS)] is evaluating the characteristics of breakthrough cancer pain (BTP) in different clinical settings. Preliminary data from the first 1500 cancer patients with BTP enrolled in this study are presented here. Methods Thirty-two clinical centers are involved in the survey. A diagnosis of BTP was performed by a standard algorithm. Epidemiological data, Karnofsky index, stage of disease, presence and sites of metastases, ongoing oncologic treatment, and characteristics of background pain and BTP and their treatments were recorded. Background pain and BTP intensity were measured. Patients were also questioned about BTP predictability, BTP onset (≤10 or >10 min), BTP duration, background and BTP medications and their doses, time to meaningful pain relief after BTP medication, and satisfaction with BTP medication. The occurrence of adverse reactions was also assessed, as well as mucosal toxicity. Results Background pain was well controlled with opioid treatment (numerical rating scale 3.0 ± 1.1). Patients reported 2.5 ± 1.6 BTP episodes/day with a mean intensity of 7.5 ± 1.4 and duration of 43 ± 40 min; 977 patients (65.1%) reported non-predictable BTP, and 1076 patients (71.7%) reported a rapid onset of BTP (≤10 min). Higher patient satisfaction was reported by patients treated with fast onset opioids. Conclusions These preliminary data underline that the standard algorithm used is a valid tool for a proper diagnosis of BTP in cancer patients. Moreover, rapid relief of pain is crucial for patients’ satisfaction. The final IOPS-MS data are necessary to understand relationships between BTP characteristics and other clinical variables in oncologic patients. Funding Molteni Farmaceutici, Italy.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Supportive Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
| | - Paolo Marchetti
- Molecular and Clinical Medicine, Medical Oncology, La Sapienza University of Rome, Rome, Italy
| | - Arturo Cuomo
- Anesthesiology, Resuscitation, and Pain Therapy Department, National Cancer Institute, IRCCS Foundation Pascale, Naples, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation, National Cancer Institute IRCCS Foundation, Milan, Italy
| | | | | | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Marzia Lazzari
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Mario Airoldi
- 2nd Medical Oncology Division, Città della Salute e della Scienza Hospital of Turin, Turin, Italy
| | - Giuseppe Azzarello
- Medical Specialties Department, Oncology and Oncologic Hematology, ASL 13 Mirano, Venice, Italy
| | - Mauro Bandera
- Medical Oncology Unit, Ospedale di Circolo e Fondazione Macchi Hospital, Varese, Italy
| | - Livio Blasi
- Medical Oncology Unit, ARNAS Ospedale Civico, Di Cristina, Benfratelli, Palermo, Italy
| | | | | | | | | | - Flavio Fusco
- Palliative Care Unit, Department of Primary and Community Care, ASL3 Genovese, Genoa, Italy
| | - Vittorio Guardamagna
- Palliative Care and Pain Therapy Unit, European Oncology Institute IRCCS, Milan, Italy
| | - Vincenzo Iaffaioli
- Abdominal Medical Oncology, National Cancer Institute, IRCCS Foundation Pascale, Naples, Italy
| | - Simeone Liguori
- Palliative Care and Pain Therapy Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Vito Lorusso
- Medical Oncology Unit, National Cancer Research Centre "Giovanni Paolo II", Bari, Italy
| | - Sergio Mameli
- Pain Therapy Unit, "A. Businco" Hospital, ASL 8, Cagliari, Italy
| | | | - Teresita Mazzei
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Rita Maria Melotti
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy
| | | | - Danilo Miotti
- Palliative Care Unit, Salvatore Maugeri-IRCCS Foundation, Pavia, Italy
| | - Stefano Moroso
- Medical Oncology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Stefano De Santis
- Palliative Care and Oncologic Pain Service, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Remo Orsetti
- Pain Medicine Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Alfonso Papa
- Pain Relief, A.O. Dei Colli, Monaldi Hospital, Naples, Italy
| | - Sergio Ricci
- Division of Medical Oncology, Department of Oncology, S. Chiara University Hospital, Pisa, Italy
| | - Alessandro Fabrizio Sabato
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Elvira Scelzi
- Medical Oncology, Castelfranco Veneto Hospital, Treviso, Italy
| | - Michele Sofia
- Department of Palliative Care with Hospice and Pain Therapy Unit, "G.Salvini" Hospital, Garbagnate Milanese, Milan, Italy
| | - Giuseppe Tonini
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Abstract
Bone loss is asymptomatic and will progress without pain and other symptoms until the occurrence of a fracture. The occurrence of a breaking bone induce acute pain determined and supported by a mechanical, inflammatory and neuropathic component. Very often the acute component evolves in a chronic musculoskeletal component. Overall objectives of the analgesic therapy can be summarized in pain relief, improving sleep, improve mobility, reduce anxiety, emotional component and depression. Osteoporosis is predominantly a condition of the elderly, more likely to have coexisting cardiovascular disease and age-related decline in renal function, receiving treatment for one or more comorbid conditions, taking multiple medications. Analgesic treatment with NSAIDs has negative effects on skeletal health and healing of the injured skeleton and increase risk of adverse events especially in older patients. Despite all opioids therapy represents a mainstay in the treatment of patients with moderate to severe pain, it can induce an endocrinopathy, which may affect bone metabolism. The negative effects of opioids on hormonal axis are not the same for all molecule and the choice of drug can be crucial in the treatment of patients with chronic pain.
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Affiliation(s)
- Renato Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital of Careggi, Florence, Italy
| | - Consalvo Mattia
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anesthesiology, Intensive care Medicine and Pain Therapy, Faculty of Pharmacy and Medicine, "Polo Pontino", "Sapienza" University of Rome, Latina, Italy
| | - Ludovica Celidonio
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anesthesiology, Intensive care Medicine and Pain Therapy, Faculty of Pharmacy and Medicine, "Polo Pontino", "Sapienza" University of Rome, Latina, Italy
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Mediati RD, Vellucci R, Dodaro L. Pathogenesis and clinical aspects of pain in patients with osteoporosis. Clin Cases Miner Bone Metab 2014; 11:169-172. [PMID: 25568647 PMCID: PMC4269137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Bone pain is one of the most frequent kinds of chronic pain, mainly in elderly patients. It causes a significant worsening of functional capacity and deterioration in the quality of life in people affected. Mechanisms of pain in osteoporosis are poorly known and often extrapolated by other pathologies or other experimental model. One of principal causes would be a "hyper-remodeling" of bone, that involves osteoclasts activity and pathological modifications of bone innervation. Several studies show that osteoclasts play a significant role in bone pain etiology. Pain in osteoporosis is mainly nociceptive, if it become persistent a sensitization of peripheral and central nervous system can occur, so underlining the transition to a chronic pain syndrome. Central sensitization mechanisms are complex and involve several neuromediators and receptors (Substance P, NMDA, etc.). Most common manifestations of osteoporosis are vertebral compression fractures that cause persistent pain, though to differentiate from pain originating in structures as joint or muscle. First manifestation can be an acute pain due to pathological fracture, those of hip often causes disability. Pain in osteoporosis is an important clinical challenge. Often its complications and consequences on patient quality of life are underestimated with not negligible social implications. A balanced and early multimodal pain therapy including opioids as necessary, even in cases of acute pain, improve the functional capacity of patients and helps to prevent neurological alterations that seems to contribute in significant way in causing irreversible pain chronic syndromes.
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Affiliation(s)
- Rocco Domenico Mediati
- Address for correspondence: Rocco Domenico Mediati, MD, Palliative Care and Pain Therapy Unit, Oncologic Department, “AOU Careggi”, Florence, Italy, Phone: +39 055 7947734, E-mail:
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13
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Vellucci R, Mediati RD, Ballerini G. Use of opioids for treatment of osteoporotic pain. Clin Cases Miner Bone Metab 2014; 11:173-6. [PMID: 25568648 PMCID: PMC4269138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The prevalence of osteoporosis increases markedly with age: currently it is estimated that over 200 million people suffer from osteoporosis worldwide. One of the most feared and more frequent complications of osteoporosis is pain, which affects 85% of patients. Commonly in the treatment of chronic pain the therapeutic strategy is based on a three-ladder approach, involving opioids for moderate and severe pain. As proposed by the World Health Organization (WHO), according to the intensity of chronic pain, analgesic treatment can be established. Despite the debate and updates to the analgesic ladder for pain published in 1986 by the WHO, the benefits resulting from its worldwide use are uncontested. In case the pain was not responsive to drugs of pain ladder, is necessary to resort to specialized practices (e.g. subarachnoid infusion of drugs). The oral route for administering analgesics should be preferred, provided that the patients are able to use it. About 50% of all opioid users experience at least one side effect, and more than 20% discontinued treatment due to a serious adverse event. Despite published guidelines and WHO's pain ladder for the management of chronic pain, the treatment of this condition remains suboptimal. Given the physiopsychopathology and complexity of the problems of chronic osteoporotic pain, a multimodal and multidisciplinary approach is still considered the best way to diagnose and treat this disease.
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Affiliation(s)
- Renato Vellucci
- Palliative Care and Pain Therapy Unit, University Hospital Careggi, Florence, Italy
| | | | - Giovanna Ballerini
- Palliative Care and Pain Therapy Unit, University Hospital Careggi, Florence, Italy
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14
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15
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Affiliation(s)
- Leonardo Fei
- Unit of Psycho-Oncology, University Hospital Careggi, viale Morgagni 85, Firenze, 50134, Italy
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16
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Gatti A, Reale C, Luzi M, Canneti A, Mediati RD, Vellucci R, Mammucari M, Sabato AF. Effects of opioid rotation in chronic pain patients: ORTIBARN study. Clin Drug Investig 2010; 30 Suppl 2:39-47. [PMID: 20670048 DOI: 10.2165/1158413-s0-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Opioid rotation is currently the subject of considerable debate for two reasons: firstly as a strategy for pain treatment, and secondly because of the difficulty in determining equianalgesic doses. Switching from one slow-release (SR) opioid analgesic to another raises a number of critical issues, and there are no widespread studies that support a standard protocol. Initiation of opioid therapy must consider gradual dose titration of the drug until the minimum effective and maximum tolerated dosage for each patient is found. OBJECTIVE This study aimed to evaluate the effects of SR opioid rotation after a stabilization period with normal-release (NR) morphine ('start therapy') in patients with cancer or non-cancer pain not controlled with their current SR opioid. METHODS This is a multicentre, open-label, prospective study. A total of 326 consecutive patients were enrolled who were affected by chronic cancer or non-cancer pain that was not controlled by an SR opioid administered as either monotherapy or in combination with other analgesic drugs. Following start therapy with oral NR morphine at a dosage of 5 mg or 10 mg every 4 hours, rotation to an SR opioid of a different type from that previously administered was carried out. RESULTS After about 3 days of start therapy with NR morphine, rotation to an SR opioid allowed a significant decrease of both baseline pain and daily episodes of breakthrough pain. No significant difference was detected between dosages and type of opioid administered, both prior to and after the start therapy period with NR morphine. CONCLUSIONS Rotation to another opioid preceded by a brief period of opioid receptor resetting by start therapy with NR morphine allows a good level of pain control and avoids rotation to inappropriate opioid dosages or combinations analgesics.
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Affiliation(s)
- Antonio Gatti
- Emergency Care, Critical Care Medicine, Pain Medicine and Anaesthesiology Department at Tor Vergata Polyclinic, University of Rome-Tor Vergata, Rome, Italy.
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Campiglia L, Cappellini I, Consales G, Borracci T, Vitali L, Gallerani E, Boninsegni P, Domenico Mediati R, Raffaele De Gaudio A. Premedication with sublingual morphine sulphate in abdominal surgery. Clin Drug Investig 2009; 29 Suppl 1:25-30. [PMID: 19445552 DOI: 10.2165/0044011-200929001-00004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Treatment with analgesics before surgery may be effective in reducing post-operative pain. This approach is defined as "pre-emptive analgesia" and recent reviews show conflicting results. OBJECTIVES The aim of this study was to investigate the efficacy of pre-emptive analgesia with sublingual morphine sulphate, compared with sublingual midazolam in patients undergoing elective abdominal surgery. METHODS Prior to surgery, 29 patients were randomized and premedicated with sublingual morphine sulphate 0.5 mg/kg (Group A; n = 15) or with sublingual midazolam 0.03 mg/kg (Group B; n = 14). General anaesthesia was maintained with sevoflurane and fentanyl. Post-operatively, intravenous (IV) acetaminophen 0.02 mg/kg was given to all patients and a bolus of IV morphine 0.1 mg/kg was given to Group B patients. Post-operative pain was controlled by IV morphine via a patient-controlled analgesia (PCA) device. IV acetaminophen 0.02 mg/kg was also administered four times daily. Efficacy was assessed using static Visual Analogue Scale (sVAS) scores, dynamic VAS (dVAS) scores, number of PCA doses administered and number of failed doses registered from the PCA device at 4, 6, 24 and 48 hours after surgery. Results were statistically analysed using the Student t-test; a value of p < 0.05 was considered significant. RESULTS Significantly lower sVAS and dVAS scores were observed in Group A patients than in Group B at all assessment periods (p < 0.05 for all time points). There were less PCA administered and failed doses in Group A, compared with Group B (all time points p < 0.05). There was no difference in the occurrence of common side effects between the two treatments. CONCLUSIONS In patients undergoing elective abdominal surgery, premedication with sublingual morphine sulphate results in a better control of post-operative pain, compared to premedication with sublingual midazolam. The beneficial effect of pre-operative sublingual morphine sulphate was apparent in the immediate post-operative period and was sustained over the 48-hour assessment period.
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Affiliation(s)
- Laura Campiglia
- Department of Anaesthesia, Critical Care and Pain Therapy, Misericordia and Dolce Hospital, Prato, Italy
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18
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Bonetti L, Mediati RD, Minoni C, Carlà R, Catinelli S, Novelli GP. [Unexpected accumulation of nitrogen in a circuit during low-flow anesthesia. Presentation of two clinical cases]. Minerva Anestesiol 1995; 61:515-7. [PMID: 8919989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The authors report two cases of unexpected nitrogen accumulation in the circuit during low flow anaesthesia with a fresh gas flow of 600 ml/min (O2:N2O = 1.1). Though the presence in the anaesthesia circuit of nitrogen eliminated by the patient is a common feature of closed circuit and low flow techniques, the magnitude and the speed of increase of inert gas concentration (compared with data from previous experiences) were highly suspicious for an external source. This was readily identified as a "mini" leak (30 ml/min of N2) from the air flowmeter, although his valve was in fully closed position. The report depicts an uncommon cause of air entry in the anaesthesia circuit and confirms the need for monitoring gases and vapours when closed circuit and low flow techniques are employed.
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Affiliation(s)
- L Bonetti
- Istituto di Anestesiologia e Rianimazione, Università degli Studi-Firenze
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Casali R, Girardi G, Mediati RD, Livi P, Novelli GP. [Evaluation of the synergism between ketorolac and morphine in the treatment of postoperative pain]. Minerva Anestesiol 1995; 61:501-7. [PMID: 8919987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of the study is to determine what concentration of ketorolac and morphine administered together i.v. achieve best synergic effect between NSAID antiinflammatory and opioids analgesic properties. DESIGN Randomized comparative study was carried out on 180 patients, ASA II-IV, undergoing major general surgery, in an University Clinic. METHODS Postoperative pain therapy by i.v. PCA: group 1 morphine 0.75 mg.ml + ketorolac 0.75 mg.ml; group 2 morphine 0.50 mg.ml + ketorolac 1.50 mg.ml; group 3 morphine 0.25 mg.ml + ketorolac 1.50 mg.ml; in saline solution. Initial bolus: 2 ml. Continuous infusion 1.5 ml.h. Demand bolus: 0.2 ml. Lockout time: 30 minutes. Evaluations included: pain intensity (T0, T3, T18); total amount of infused drugs (T18); number of valid demands and attempts (T18); amount of autoadministered analgesic drugs in percent of highest available amount (T18); side effects (T18); patient's judgment. DATA ANALYSIS ANOVA and Student's "t"-test. RESULTS A statistically significant reduction of pain intensity was found after 3 and 18 hours in the three groups, no differences were found among the groups. Group 2 required an amount of autoadministered drugs significantly lower than other groups. Rare side effects. Patient's judgment was generally positive. CONCLUSIONS Results suggest a greater synergetic effect between morphine and ketorolac in concentrations used in group 2.
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Affiliation(s)
- R Casali
- Istituto di Anestesiologia e Rianimazione, Università degli Studi-Firenze
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