A Survey of the Status of Methadone Switching in Japan Using a Hospital-Based Administrative Claims Database

Methadone is generally used for the management of cancer pain in patients who cannot obtain adequate analgesia from other strong opioids; however, it has a complicated and inconsistent conversion ratio from pre-switching opioid dosage to methadone. This issue may be pronounced in Japan because only oral tablets are commercially available. We aimed to elucidate the status of methadone switching in Japan, focusing on its dosage. Using a Japanese hospital-based administrative claims database, we included patients who switched to methadone between April 2008 and January 2021. The proportion of methadone switching completion that required more than the defined conversion ratio in the Japanese package insert (called "high-dose methadone switching") was evaluated as a primary endpoint. Other endpoints included "the duration from initiation to completion of methadone switching" and "factors affecting high-dose methadone switching by using multivariate logistic regression analysis". Of 1585 patients who received methadone, 370 were enrolled. Among those, 130 (35.1%) received high-dose methadone switching. The median duration of methadone switching completion (12 days) was longer in the high-dose methadone switching group than in other patients. Four variables were identified as factors affecting high-dose methadone switching. Younger age and outpatient status increased the risk of requiring high-dose methadone switching, whereas the concomitant use of nonsteroidal anti-inflammatory drugs and fentanyl as a pre-switching opioid decreased the risk. In conclusion, more than 30% of the patients underwent high-dose methadone switching and required long completion periods, suggesting that methadone switching remains challenging in Japan.

Quality Characteristics of Black Soldier Flies Produced by Different Substrates

Black soldier fly (BSF; Hermetia illucens) has a high capacity for amino acids and fatty acid accumulation. This study was conducted to assess the effectiveness of tofu by-products, food waste, and vegetables for BSF growth and conversion efficiency. BSFs under tofu by-product treatments showed the greatest weight at d 12 and the harvest period. Moreover, BSF larval weight was greater in the food waste treatment compared with the vegetable treatment at d 12 and harvest. The larva yield result was greater in the vegetable treatment compared with the tofu by-product. The bioconversion rate was higher in the tofu by-product treatment compared with the food waste and vegetable treatments. The protein conversion rate and lipid conversion rate were the highest in the vegetable treatment. The protein yield and lipid yield were greatest in the tofu by-product treatment. The lauric acid content was increased in BSFs fed tofu by-products compared with the food waste treatment. The concentration of C16:1 was the highest in the tofu by-product treatment. The content of oleic acid and α-linolenic acid was higher in BSFs fed tofu by-products compared with the vegetable treatment. In conclusion, the tofu by-products show benefits for larval growth and nutrient accumulation, which can improve larval quality for livestock feed ingredients.

[Pollution Characteristics and Sources of Water-soluble Ions in PM2.5 in Zhengzhou City]

In order to explore the pollution characteristics, seasonal variations, and sources of water-soluble inorganic ions (WSIIs) in PM_2.5 in Zhengzhou, PM_2.5 samples were seasonally collected from December 2020 to October 2021; then, combining gaseous pollutants (SO₂, NO₂, and O₃) and meteorological parameters (temperature and relative humidity), nine WSIIs (NO₃^-, NH₄⁺, SO₄^2-, Ca²⁺, K⁺, Na⁺, Mg²⁺, F^-, and Cl^-) were analyzed. The results showed that the annual average concentration of the total water-soluble ions (TWSIIs) was (39.34±21.56) μg·m^-3for the four seasons, showing obvious seasonal variations with the maximum value in winter and the minimum value in summer. Annual PM_2.5 was slightly alkaline in Zhengzhou, and NH₄⁺ most likely existed in the form of NH₄NO₃ and (NH₄)₂SO₄. The average sulfur oxidation ratio (SOR) and nitrogen oxidation ratio (NOR) were 0.35 and 0.19, respectively, indicating that SO₄^2- and NO₃^- mainly derived from secondary formation. The main potential source regions of WSIIs obtained by the concentration weight trajectory (CWT) model showed temporal and spatial variations. The significant sources of WSIIs based on principal component analysis (PCA) were dust, secondary generation, combustion, and industrial activities, which were obviously influenced by wind direction and speed in Zhengzhou.

Levorphanol as a Second Line Opioid in Cancer Patients Presenting to an Outpatient Supportive Care Center: An Open-label Study

CONTEXT

Levorphanol is a potent opioid agonist and NMDA receptor blocker with minimal drug interactions, and there are few reports of its use in cancer patients.

OBJECTIVES

We aimed to determine the frequency of successful opioid rotation (OR) to levorphanol and the median opioid rotation ratio (ORR) from Morphine Equivalent Daily Dose (MEDD).

METHODS

This is a prospective, single-group, interventional study. Cancer outpatients requiring an OR and receiving a MEDD of 60-300 mg were rotated to levorphanol using a ratio of 10:1 and assessed daily for 10-day. Successful OR was defined as a 2-point improvement in the Edmonton Symptom Assessment System (ESAS) pain score on day 10 or achieving the personalized pain goal between days 3-10 in patients with uncontrolled pain or resolution of opioid side effects (OSE) in those undergoing OR for OSE alone. The ORR to levorphanol was calculated using net-MEDD (MEDD before OR minus the MEDD of the breakthrough opioid used along with levorphanol after OR).

RESULTS

Forty patients underwent OR to levorphanol, and uncontrolled pain 35/40 (87.5%) was the most common indication. The median net-MEDD and levorphanol doses were 95 and 10 mg, respectively, and 33/40 (82.5%) had a successful OR with a median (IQR) ORR of 8.56 (7.5-10). Successful OR was associated with significant improvement in ESAS and OSE scale scores. There was a strong association between MEDD and levorphanol dose.

CONCLUSION

This study provided preliminary data that cancer patients could be successfully rotated to levorphanol using an ORR of 8.5. Levorphanol was associated with improved pain and symptom control and was well- tolerated.

Opioid Rotation and Conversion Ratios Used by Palliative Care Professionals: An International Survey

Background: The opioid rotation ratios (ORRs) and conversion ratios (CRs) used worldwide among palliative care (PC) professionals to perform opioid rotations (ORs) and route conversions may have a wide variation. Methods: We surveyed PC professionals on opioid ratios used through email to the Multinational Association of Supportive Care in Cancer's PC study group and Twitter and Facebook posts between September and November 2020. Results: We received 370 responses from respondents from 53 countries: 276 (76%) were physicians, 46 (13%) advanced practice providers, 39 (11%) pharmacists, and 9 respondents did not report their profession. There were statistically significant variations in median CR from intravenous (IV) to oral morphine (2-3), IV to oral hydromorphone (2-4.5), ORR from IV hydromorphone to oral morphine (10-20), and ORR from transdermal fentanyl mcg/hour to oral morphine (2-3.5) across various groups. Conclusion: This survey highlights the wide variation in ORRs and CRs among PC clinicians worldwide and the need for further research to standardize practice.

Tacrolimus Dose-Conversion Ratios Based on Switching of Formulations for Patients with Solid Organ Transplants

Background

Tacrolimus may be administered during hospitalization as an IV formulation or oral suspension. However, literature suggesting appropriate ratios for conversion from these formulations to capsules is limited.

Objective

To evaluate conversion ratios after a switch in formulation of tacrolimus for solid-organ transplant recipients.

Methods

This single-centre observational longitudinal study involved hospitalized patients who underwent a switch in formulation of tacrolimus according to 1 of 3 possible scenarios: IV to oral suspension, IV to capsule, or oral suspension to capsule. Data were collected from the earliest accessible electronic file (January 2009) to January 1, 2019. Conversion ratios were calculated for each of the 3 groups using data for blood concentrations and doses before and after the switch. The calculated ratios were then compared with recommended conversion ratios: 1:5 (i.e., 1 mg of IV tacrolimus is converted to 5 mg of oral tacrolimus, expressed as "5") for either of the switches involving an IV formulation and 1:1 (i.e., same amount, expressed as "1") for the switch from oral formulation to capsules.

Results

For the group who underwent switching from the IV formulation to oral suspension, the mean calculated conversion ratio was 3.04, which was significantly different from the recommended ratio of 5. For the group who underwent switching from the IV formulation to capsules, the calculated conversion ratio was 5.18, which was not significantly different from the recommended ratio of 5. For the group who underwent switching from oral suspension to capsules, the calculated conversion ratio was 1.17, which was not significantly different from the recommended ratio of 1.

Conclusion

In this small retrospective study of tacrolimus therapy, the calculated conversion ratio was significantly different from the recommended ratio for patients who were switched from IV administration to oral suspension, but not for those switched from IV administration or oral suspension to capsules. Therapeutic drug monitoring therefore appears indispensable, regardless of conversion ratios.

Conversion ratio of tacrolimus switching from intravenous infusion to oral administration after lung transplantation

Background

To investigate the conversion ratio of tacrolimus switching from intravenous infusion to oral administration in patients after lung transplantation.

Methods

We retrospectively recruited patients received lung transplantation in the First Affiliated Hospital of Guangzhou Medical Hospital from January 2015 to June 2019. The blood concentration of tacrolimus administrated through intravenous infusion and oral administration were collected. The blood concentration, concentration/dose ratio (C/D), and (C/Dpo)/(C/Div) ratio were analyzed to explore the conversion ratio of tacrolimus switching from intravenous infusion to oral administration, as combined medication of tacrolimus and caspofungin were used.

Results

The concentration of intravenously administered tacrolimus was significantly higher than that of oral administration; the C/D ratio of intravenously administrated tacrolimus (C/Div) was significantly higher than that of the oral administration (C/Dpo). There was a significant correlation between C/Dpo and C/Div (R² =0.774, P<0.001). The conversion ratio of tacrolimus from intravenous administration to oral administration was 1:7.4, as combined medication of tacrolimus and caspofungin were used.

Conclusions

The conversion ratio of tacrolimus switching from intravenous to oral administration is 1:7.4 in the combination treatment of tacrolimus and caspofungin after lung transplantation.

[Characteristics of Hydrogen and Oxygen Isotopes in Different Water Bodies in Hilly and Gully Regions of the Loess Plateau]

Studying the isotope characteristics and water body transformation relationships among different water bodies in the hilly and gully region of the Loess Plateau can provide a theoretical foundation for evaluating regional climate, ecology, and water resources. In this study, daily and monthly averaged δD and δ¹⁸O in precipitation, river water, and shallow groundwater were measured in 2017 in the Jiuyuangou watershed, which has a good ecological condition. The compositional relationship between the stable hydrogen and oxygen isotopes in difference water bodies was explored, the influence factors and spatio-temporal variation of δ¹⁸O in precipitation and river water were analyzed, and the stable isotope conversion ratios between different water bodies in the study area were calculated using the two-terminal mixed model. The main conclusions of the study are as follows:the d-excess of river water showed an increasing trend with elevation during the observation period; the δ¹⁸O of river water was enriched with increasing distance from the river source and decreased with increasing altitude; temperature, wind speed, and relative humidity had significant effects on the hydrogen and oxygen isotopes of precipitation; precipitation and shallow groundwater replenish the river during the non-flood period, the proportions of which were 46% and 54%, respectively; and during the flood season, the shallow groundwater is replenished by river water and precipitation, the proportions were 60% and 40%, respectively. These results indicate that there is a good conversion relationship between "precipitation-river-shallow groundwater" in the study area. The implementation of soil and water conservation measures has had some influence on the conversion of different water bodies in small watersheds. The results provide a basis for the establishment of water cycle models for hilly and gully regions of the Loess Plateau.

[Size Distribution Characteristics of Water-Soluble Inorganic Ions During Summer and Autumn in Zhengzhou]

To study the compositional characteristics of atmospheric particulates with different particle sizes in the central city of Zhengzhou, China, a Tisch graded impact sampler was used to sample atmospheric particulates in summer and autumn. The mass concentrations of water-soluble inorganic ions, including anions (Cl^-, F^-, NO₃^-, and SO₄^2-) and cations (Na⁺, Ca²⁺, NH₄⁺, K⁺, and Mg²⁺) were measured by ion chromatography, and the online ion chromatography-based analyzer MARGA monitored the real-time concentration of particulate nitrate. The results showed that the average concentration of water-soluble ions in Zhengzhou City was (70.9±52.1) μg·m^-3 during the sampling period, and the order of water-soluble ion mass concentrations was NO₃^- > SO₄^2- > NH₄⁺ > Ca²⁺ > Na⁺ > Cl^- > Mg²⁺ > K⁺ > F^-; NO₃^-, SO₄^2-, and NH₄⁺ accounted for 79.9% of total water-soluble ions. The NO₃^- concentration was mainly concentrated in the 0.65-3.3 μm particle size segment, despite the SO₄^2- concentration being concentrated in the ≤ 1.1 μm particle size segment in autumn or summer. Both NO₃^- and SO₄^2- had a bimodal distribution in summer and autumn and were mainly distributed as fine particles. NH₄⁺ showed seasonal variation with a bimodal distribution in summer and a unimodal distribution in autumn. Zhengzhou City had serious ozone pollution in summer, and O₃ and NO₃^- showed the "staggered peak" phenomenon, indicating photochemical reactions in the atmosphere. In autumn, water-soluble inorganic ion concentration in particulate matter was high, and the ratio of[NO₃^-]/[SO₄^2-] was higher than 0.5. The mobile source is an important source of particles. NOR and SOR peaks were on the 1.1-2.1 μm particle size segment in summer, whereas those in the 0.65-1.1 μm particle size segment occurred in autumn. The sulfur gas-to-grain conversion in summer was larger than that of nitrogen, contrary to the result in autumn.

The Conversion Ratio From Intravenous Hydromorphone to Oral Opioids in Cancer Patients

CONTEXT

The lack of knowledge of the accurate conversion ratio (CR) between intravenous (IV) and oral hydromorphone and opioid rotation ratio (ORR) between IV hydromorphone and oral morphine equivalent daily dose (MEDD) may lead to poorly controlled pain or overdosing in cancer inpatients.

OBJECTIVES

We aimed to determine the CR and ORR from IV hydromorphone to oral hydromorphone and MEDD (obtained from oral morphine and oxycodone).

METHODS

A total of 4745 consecutive inpatient palliative care consults during 2010-14 were reviewed for conversions from IV hydromorphone to oral hydromorphone, morphine or oxycodone. Patient characteristics, symptoms, and opioid doses were determined in patients successfully discharged on oral opioids without readmission within one week. Linear regression analysis was used to estimate the CR or ORR between the 24 hour IV hydromorphone mg dose before conversion and the oral opioid mg dose used before discharge.

RESULTS

Among 394 patients on IV hydromorphone, 147 underwent conversion to oral hydromorphone and 247 underwent rotation to oral morphine (163) or oxycodone (84). The median (interquartile range) CR from IV to PO hydromorphone was 2.5 (2.14-2.75) with correlation of 0.95 (P < 0.0001). The median ORR (interquartile range) from IV hydromorphone to MEDD was 11.46 (9.84-13.00) with correlation of 0.93(P < 0.0001). The median ORR was 11.54 in patients receiving <30 mg of IV hydromorphone/day and 9.86 in patients receiving ≥30 mg (P = 0.0004).

CONCLUSION

Our study found that 1 mg of IV hydromorphone is equivalent to 2.5 mg of oral hydromorphone and 11.46 mg of MEDD. Hydromorphone at doses ≥30 mg/day may require a lower ORR to other opioids.

The Opioid Rotation Ratio From Transdermal Fentanyl to "Strong" Opioids in Patients With Cancer Pain

CONTEXT

One-third of cancer patients require opioid rotation (OR) to treat uncontrolled pain or opioid-induced neurotoxicity. Although fentanyl is the most frequently rotated opioid in cancer patients, the accurate opioid rotation ratio (ORR) from transdermal fentanyl (TDF) to other so-called "strong" opioids is unknown.

OBJECTIVES

We aimed to determine the ORR of TDF to strong opioids, as measured by morphine equivalent daily dose (MEDD).

METHODS

We reviewed 2471 consecutive patient visits (938 patients) to our supportive care center for an OR from TDF to strong opioids. Information regarding demographics, symptoms, and MEDD was collected in patients who followed up within six weeks. Linear regression analysis was used to estimate the ORR between TDF dose and net MEDD (MEDD after OR minus MEDD of the breakthrough opioid used along with TDF before OR).

RESULTS

Among 47 eligible patients, the median age was 54 years, 53% were male, and 77% had advanced cancer. The median time to follow-up was 14 days. Uncontrolled pain (83%) was the most common reason for OR. In patients with OR and no worsening of pain at follow-up (n = 41), the median ORR (range) from TDF mg/day to net MEDD mg/day was 100 (12.5-217) and from TDF mcg/hour to net MEDD was 2.4 (0.3-5.2); the correlation of TDF dose to net MEDD was 0.60 (P < 0.0001).

CONCLUSION

The median ORR from TDF mg/day to MEDD is 100 and from TDF mcg/hour to MEDD is 2.4, suggesting that TDF 100 mcg/hour is equivalent to an MEDD of 240 mg.

Indication of Adequate Transdermal Fentanyl Dose in Opioid Switching From Oral Oxycodone in Patients With Cancer

OBJECTIVE

The present study aimed to examine affecting factors for conversion ratio and to predict adequate fentanyl dose for patients with cancer pain in opioid switching from oral oxycodone.

METHODS

Patient characteristics, biochemical parameters, daily oxycodone dose, and reasons for opioid switching were retrospectively collected. The effect of variables on the conversion ratio was analyzed by multiple regression analysis.

RESULTS

Regression analysis for the data from 122 patients suggested that the typical conversion ratio was 95:1; however, this ratio was significantly reduced in patients taking a daily oral morphine-equivalent dose of <45 mg/d and in patients with poor pain control to 52:1 and 64:1, respectively.

CONCLUSION

We should carefully and rapidly control pain in opioid switching based on the adequate dose indicated in this study.