Breakthrough pain in patients with multiple myeloma: a secondary analysis of IOPS MS study

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.

Breakthrough cancer pain: The importance of the right treatment at the right time

BACKGROUND

Confusion remains over the definition of breakthrough cancer pain (BTcP) potentially leading to delayed diagnosis and treatment.

METHODS

An on-line survey was conducted in four EU countries among relevant healthcare professionals and cancer patients diagnosed with BTcP. The roles of healthcare professionals (HCPs) were examined and their knowledge and use of available medications recorded. Patients were questioned on how BTcP affected their lives and on the medications they had received/were receiving.

RESULTS

There was a 'time lag' of 58 and 13 weeks in Germany and Spain respectively between the initial diagnosis of BTcP and its treatment. Four in ten oncologists across the four countries considered themselves not fully confident in their choice of the appropriate therapy. A quarter of patients in Germany, Italy and Spain and four in ten in France were treated only with increased dosages of the therapy already prescribed for their background pain - often morphine. Almost another quarter received morphine in addition to their treatment for background pain. Oncologists indicated a need for faster-acting treatments revealing a potential lack of awareness of rapid onset oral opioids and patients expressed a desire for more effective pain relief and better psychological support.

CONCLUSIONS

There is a need for a universal definition of BTcP to facilitate earlier and more accurate diagnosis. It is essential that BTcP is treated immediately on diagnosis with therapies that more closely mirror its temporal characteristics to ensure that patients' desire for more effective pain relief is fulfilled.

SIGNIFICANCE

Many cancer patients suffered episodes of BTcP needlessly over many months due to missed diagnosis. Even after diagnosis, many physicians were not fully confident in their choice of 'rescue' therapy which perhaps is not surprising given the very low level of awareness of treatment guidelines, both national and international.

The evidence of neuraxial administration of analgesics for cancer-related pain: a systematic review

BACKGROUND

The present systematic review analysed the existing evidence of analgesic efficacy and side effects of opioids without and with adjuvant analgesics delivered by neuraxial route (epidural and subarachnoid) in adult patients with cancer.

METHODS

Search strategy was elaborated with words related to cancer, pain, neuraxial route, analgesic and side effects. The search was performed in PubMed, EMBASE, and Cochrane for the period until February 2014. Studies were analysed according to methods, results, quality of evidence, and strength of recommendation.

RESULTS

The number of abstracts retrieved was 2147, and 84 articles were selected for full reading. The final selection comprised nine articles regarding randomised controlled trials (RCTs) divided in four groups: neuraxial combinations of opioid and adjuvant analgesic compared with neuraxial administration of opioid alone (n = 4); single neuraxial drug in bolus compared with continuous administration (n = 2); single neuraxial drug compared with neuraxial placebo (n = 1); and neuraxial opioid combined with or without adjuvant analgesic compared with other comprehensive medical management than neuraxial analgesics (n = 2). The RCTs presented clinical and methodological diversity that precluded a meta-analysis. They also presented several limitations, which reduced study internal validity. However, they demonstrated better pain control for all interventions analysed. Side effects were described, but there were few significant differences in favour of the tested interventions.

CONCLUSION

Heterogeneous characteristics and several methodological limitations of the studies resulted in evidence of low quality and a weak recommendation for neuraxial administration of opioids with or without adjuvant analgesics in adult patients with cancer.

Evidence of peripheral nerve blocks for cancer-related pain: a systematic review

The European Association for Palliative Care has initiated a comprehensive program to achieve an over-all review of the evidence of multiple cancer pain management strategies in order to extend the current guideline for treatment of cancer pain. The present systematic review analyzed the existing evidence of analgesic efficacy for peripheral nerve blocks in adult patients with cancer. A search strategy was elaborated with words related to cancer, pain, peripheral nerve and block. The search was performed in PubMed, EMBASE, and Cochrane for the period until February 2014. The number of abstracts retrieved was 155. No controlled studies were identified. Sixteen papers presented a total of 79 cases. The blocks applied were paravertebral blocks (10 cases), blocks in the head region (2 cases), plexus blocks (13 cases), intercostal blocks (43 cases) and others (11 cases). In general, most cases reported good pain relief and no side effects. The use of peripheral blocks is based upon anecdotal evidence. However, this review only demonstrates the lack of studies, which does not equal a lack of effectiveness.

Efficacy, tolerability and virological consequences of long-term use of unboosted atazanavir plus 2 NRTIs in HIV-infected patients

PURPOSE

Switch to unboosted atazanavir (ATV) is an attractive option due to convenience and tolerability in HIV-positive patients. With limited available data we investigated the determinants of long-term efficacy and the consequences of virological failure of unboosted atazanavir-based regimens.

METHODS

Retrospective analysis in two Italian large outpatient clinics including demographic, immunovirological, resistance and pharmacokinetic data.

RESULTS

249 patients receiving atazanavir (400 mg once-daily) plus 2 NRTIs were included; 163 were males (65.5%) and median age was 47 years (42-51.5). Median CD4+ T-cell count was 396/uL (261-583); 146 (58.6%) presented a viral load < 50 copies/mL. Over a median follow up of 157 weeks (106-203) 193 patients (77.5%) were still on treatment with 10 (4%) and 2 (0.8%) stopping for virological failure or toxicity, respectively. Ten patients with virological failure presented newly selected resistance associated mutations (RAMs) for NRTIs (2/10) or ATV (4/10, one I50L). Total cholesterol and triglycerides showed significant decreases at 48 [-4 mg/dL and -41 mg/dL] and 96 weeks [-14 mg/dL and -54 mg/dL] as compared to baseline. At multivariate analysis a genotypic sensitivity score ≤ 1, atazanavir RAMs > 1 and suboptimal adherence were independently associated with virological failure; in lamivudine/emtricitabine-treated patients the presence of M184V (without other NRTI RAMs) was not associated with virological failure.

CONCLUSION

Unboosted-atazanavir containing regimens were efficacious (with uncommon virological failures) and well-tolerated (with improvements in lipid profile over time) treatments in HIV-positive patients. Isolated M184V in lamivudine/emtricitabine recipients was not associated with higher failure rates supporting the use of functional ATV-based dual therapies as maintenance strategies.

Methadone in cancer pain

Methadone is often considered as a second-choice drug alternative to morphine in cancer pain treatment. A lack of information regarding methadone's pharmacokinetic/pharmacodynamic relationships has contributed to limitation in its use in analgesic treatments. However, it has been recently re-evaluated in light of better knowledge of its pharmacological characteristics and wider experience. Concern about the safety of methadone therapy arising because of its long and unpredictable half-life should not deter clinicians from its appropriate use. Methadone is a very useful drug in cancer pain because of its low cost, lack of known metabolites, high oral bioavailability, rapid onset and time to peak analgesic effect, and the long duration of activity which allows for longer intervals between doses. Moreover, methadone has been demonstrated to have a high receptor reserve and to exert some NMDA receptor antagonist effect. A shift from one opioid to methadone is recommended when the side-effect/analgesic balance is unfavourable, as symmetrical patterns of cross-tolerance of opioid agonists have been demonstrated. Different approaches, including the oral PCA, have been proposed to circumvent problems related to its pharmacokinetic properties.

Palliative care in Italy: problem areas emerging from the literature

The aim of this study was to review the Italian literature regarding attitudes toward palliative care in cancer patients, as well as cultural, educational and organizational problems in Italy with respect to palliative care services. The Italian literature published in the last ten years on PUBMED was reviewed. Clinical trials were excluded from this analysis, as their focus was beyond the scope of this study. Non-cancer studies were also excluded. Thirty-nine papers were retrieved. Several weaknesses were recognized in the studies, including a lack of knowledge and negative attitudes regarding cancer pain management and the use of alternative treatments. Communication with patients and family was also inadequate. In general, poor organization of palliative care services was also shown. An appropriate place to die was often not guaranteed and was dependent on the availability of local resources. However, the most striking finding was that there were geographical differences in the distribution of palliative care resources. The development of a range of palliative care programs integrating primary territorial care and specialized palliative services may constitute the ideal synthesis to respond to patients' needs.

Conversion of spinal anesthesia into general anesthesia: an evaluation of more than 35,000 spinal anesthetics

BACKGROUND

The aim of this study was to evaluate the number of conversions from spinal anesthesia (SA) into general anesthesia (GA) in a large number of patients who underwent surgery over a period of twenty-one years.

METHODS

From the hospital's database, all surgical procedures performed under SA between January 1, 1988 and December 31, 2008 were retrieved. From this file, all SA cases converted into GA cases requiring endotracheal intubation were selected. Patients were divided in four groups, according to the reason for GA: IMPOSS (SA impossible to perform), FAIL (SA non profound enough for allowing surgery, even with light sedation), INSUFF (SA inadequate for unexpected prolonged duration of surgery), and COMPL (occurrence of complications associated with SA and requiring rapid control of ventilation). Anesthesiologists who performed SA were divided according their experience. The outcomes of patients converted to GA were compared with a matched sample of patients who received planned GA.

RESULTS

A total of 35,960 SA cases were performed from 1988 to 2008; 29,220 and 6,740 SA cases were for elective and emergency surgery, respectively. Two hundred seventeen (0.6%) SA cases were converted into GA cases; 80.2% and 19.8% of the conversions were recorded in elective and emergency operations, respectively, with obstetric operations being the most prevalent (82/217). The primary reasons for the conversions, in a rank order, were INSUFF 107 (49.3%), FAIL 84 (38.7%), IMPOSS 13 (5.9%), and COMPL 13 (5.9%). Complications more frequently occurred in the aged population (P<0.05). Anesthesiologists with less experience had higher percentages of FAIL, IMPOSS, INSUFF, and COMPL SA cases in comparison with experienced anesthesiologists (odd ratios being 4.7, 3.0, 2.4, and 4.4, respectively). There was no difference in the frequency of complications compared to a matched sample of 1,000 patients who underwent GA (P=0.65).

CONCLUSION

SA has been found to be a safe and highly effective technique. Failure of SA was infrequent in a large number of patients surveyed and most often occurred with less experienced anesthesiologists. Conversion to GA did not produced different outcomes in comparison with planned GA. Prospective studies with a definite protocol for recording data performed on a large number of patients may help in determining the factors associated with conversion from SA into GA and how to avoid these unexpected situations.

A comparison of intranasal fentanyl spray with oral transmucosal fentanyl citrate for the treatment of breakthrough cancer pain: an open-label, randomised, crossover trial

OBJECTIVE

The efficacy of intranasal fentanyl spray (INFS) was compared with that of oral transmucosal fentanyl citrate (OTFC) for the relief of cancer-related breakthrough pain (BTP) in an open-label, crossover trial.

METHODS

Adult cancer patients receiving stable background opioid treatment and experiencing BTP episodes were recruited from 44 study centres in seven European countries (Austria, France, Germany, Italy, Poland, Spain and the United Kingdom); of the 196 patients enrolled, 139 were randomised to receive INFS followed by OTFC, or vice versa. Patients were titrated to an effective dose of one agent (50, 100 or 200 microg INFS; 200, 400, 600, 800, 1200 or 1600 microg OTFC) to treat six BTP episodes, then titration and treatment were repeated with the other agent. The primary outcome was patient-recorded time to onset of 'meaningful' pain relief. Secondary outcomes included pain intensity difference (PID) at 10 and 30 minutes (PID(10), PID(30)), sum of PID at 15 and 60 minutes (SPID(0-15), SPID(0-60)), ease of administration, treatment preference and relationship between background opioid dose and effective INFS dose. Additional outcome measures included proportions of episodes with > or =33% and > or =50% pain intensity (PI) reduction, and PID at additional time points.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00496392.

RESULTS

Among the intention-to-treat population (n = 139), median time to onset of 'meaningful' pain relief was 11 minutes with INFS versus 16 minutes with OTFC; 65.7% of patients attained faster time to 'meaningful' pain-relief onset with INFS (p < 0.001). PID was statistically significantly greater for INFS than OTFC from 5 minutes post-dosing. Significantly more INFS-treated breakthrough pain episodes achieved clinically important pain relief (> or =33% and > or =50% PI reduction) up to 30 minutes post-dosing. The proportions of episodes treated with INFS and OTFC achieving a PI reduction of > or =33% at 5 minutes were 25.3% versus 6.8% (p < 0.001), and at 10 minutes were 51.0% versus 23.6% (p < 0.001), respectively; the proportions of episodes treated with INFS and OTFC achieving a > or =50% PI reduction at 5 minutes were 12.8% versus 2.1% (p < 0.001), and at 10 minutes were 36.9% versus 9.7% (p < 0.001), respectively. Higher SPID(0-15) and SPID(0-60) scores were achieved with INFS (p < 0.001). More patients preferred INFS than OTFC (p < 0.001) and more patients found it very easy/easy to use. Both treatments were well tolerated. In the safety population (n = 139), 56.8% (n = 79) of patients experienced > or =1 AE during the trial. The only AE that occurred in > or =5% of patients in either treatment group was nausea. Among those patients who experienced serious AEs (13.7%, n = 19), none were considered to be related to either study medication. There was a weak correlation between effective INFS doses and background opioid doses.

CONCLUSION

In this open-label, randomised, crossover trial, significantly more patients attained faster 'meaningful' pain relief with INFS than OTFC, and more patients preferred INFS to OTFC.

Clinical and financial analysis of an acute palliative care unit in an oncological department

The aim of this article is to describe the clinical activity and medical intervention of an acute model of palliative care unit (APC), as well as the reimbursement procedures and economic viability. A sample of 504 patients admitted at an APC in 1 year was surveyed. Indications for admission, pain and symptom intensity, analgesic treatments, procedures, instrumental examinations and modalities of discharge were recorded. For each patient, tariff for reimbursement was calculated according to the existent disease related grouping (DRG) system. The mean age was 62 years, and 246 patients were males. The mean hospital stay was 5.4 days. Pain control was the most frequent indication for admission. All patients had laboratory tests and several instrumental examinations. Almost all patients were prescribed one or more opioids at significant doses, and different routes of administration, as well as medication as needed. 59 patients received blood cell transfusions and 34 interventional procedures. Only 40 patients died in the unit, 11 of them being sedated at the end of life. Treatment efficacy was considered optimal and mild in 264 and 226 patients respectively. A mean of 3019 euros for admission was reimbursed by the Health Care System. APCs are of paramount importance within an oncological department, as they provide effective and intensive treatments during the entire course of disease, providing a simultaneous and integrated approach. Our findings also suggest both a cost and quality incentive for oncological departments to develop APC.

Transmucosal fentanyl vs intravenous morphine in doses proportional to basal opioid regimen for episodic-breakthrough pain

The use of supplemental doses of opioids is commonly suggested to manage breakthrough pain. A comparative study of intravenous morphine (IV-MO) and oral transmucosal fentanyl citrate (OTFC) given in doses proportional to the basal opioid regimen was performed in 25 cancer patients receiving stable opioid doses. For each episode, when it occurred and 15 and 30 min after the treatment, pain intensity and opioid-related symptoms were recorded. Fifty-three couples of breakthrough events, each treated with IV-MO and OTFC, were recorded. In episodes treated with IV-MO, pain intensity decreased from a mean of 6.9 to 3.3 and to 1.7 at T1 and T2, respectively. In episodes treated with OTFC, pain intensity decreased from a mean of 6.9 to 4.1 and to 2.4 at T1 and T2, respectively. Statistical differences between the two treatments were found at T1 (P=0.013), but not at T2 (P=0.059). Adverse effects were comparable and were not significantly related with the IV-MO and OTFC doses. Intravenous morphine and OTFC in doses proportional to the scheduled daily dose of opioids were both safe and effective, IV-MO having a shorter onset than OTFC. Future comparative studies with appropriate design should compare titration methods and proportional methods of OTFC dosing.

Use of antiepileptics and tricyclic antidepressants in cancer patients with neuropathic pain

Using a large US health insurance claims database, we identified all persons aged > or =18 years with > or =2 medical encounters with diagnoses of cancer and > or =2 medical encounters with diagnoses of painful neuropathies in calendar year (CY) 2000; persons with seizure disorders or depression were excluded. We then examined the use of antiepileptics (AEDs), tricyclic antidepressants (TCAs) and other pain-related pharmacotherapy among these selected persons, as proxied by pharmacy dispenses. A total of 956 persons were identified who met all entry criteria; 17% received AEDs in CY2000 and 14% received TCAs. Gabapentin was the most widely used AED (92% of all AED patients); amitriptyline was the most widely used TCA (79% of all TCA patients). Patients who received AEDs and/or TCAs were similar in age, gender and the presence of metastases to those who had not received these medications; they were more likely to have received other pain-related therapies, however, including short-acting opioids (73% vs. 53%; P < 0.01) and long-acting opioids (23% vs. 8%; P < 0.01). Use of AEDs and TCAs appears to be relatively low among cancer patients with painful neuropathies. Further research is needed to better understand reasons for this finding, as well as its potential implications for pain management in this patient population.

Morphine but not fentanyl and methadone affects mitochondrial membrane potential by inducing nitric oxide release in glioma cells

We have observed that treatment of human glioma cells with morphine in the nanomolar range of concentration affects the mitochondrial membrane potential. The effect is specific to morphine and is mediated by naloxone-sensitive receptors, and is thus better observed on glioma cells treated with desipramine; moreover, the mitochondrial impairment is not inducible by fentanyl or methadone treatment and is prevented by the nitric oxide (NO) synthase inhibitor L-NAME. We conclude that in cultured glioma cells, the morphine-induced NO release decreases the mitochondrial membrane potential, as one might expect based on the rapid inhibition of the respiratory chain by NO. The identification of new intra-cellular pathways involved in the mechanism of action of morphine opens additional hypotheses, providing a novel rationale relevant to the therapy and toxicology of opioids.

Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey

Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.

Local anesthetic switching for intrathecal tachyphylaxis in cancer patients with pain

IMPLICATIONS

Switching from bupivacaine to lidocaine may improve intrathecal morphine analgesia in advanced cancer patients, possibly because of different spinal mechanisms limiting the hyperalgesic processes.

Opioid plasma concentration during switching from morphine to methadone: preliminary data

Opioid switching is often used to improve the opioid response in cancer patients experiencing poor analgesia or adverse effects. However, no data are available on plasmatic changes of opioids and their metabolites during these phases, and whether there exists a relationship with the clinical events. In a prospective study of 10 consecutive cancer patients on oral morphine but with uncontrolled pain (greater >4 on a numerical scale of 0 to 10) and/or moderate to severe opioid adverse effects (on a level of 2 and 3 of a verbal scale) and not responsive to adjuvant medications, switching to oral methadone was performed using a fixed ratio of 5:1, leaving extra-doses of 1/5 of the daily dose of methadone calculated as needed. Blood samples were obtained at the same hour for four days, before the switching, and then on day 1, 2, and 3. The intensity of pain and the adverse effects were assessed daily to calculate the switching score before and after switching. Completed blood samples were obtained in 9 patients. One patient was separately considered, because of his renal impairment. Significant improvements in pain intensity as well as adverse effects within an average period of 1-2 days were observed. Morphine, morphine-6-glucuronide, and morphine-3-glucuronide were progressively cleared from plasma to almost disappear within three days. Methadone rapidly achieved a stable concentration in 1-2 days. The doses of methadone were changed, but not significantly, and tended to decrease in the following days, according to the clinical situation. The results of this study confirm the need to stop rapidly morphine, and to use a priming dose of methadone, rather than using progressive decrements and increments of morphine and methadone, respectively, during opioid switching. This method allows for a rapid clearance of morphine and its metabolites are rapidly cleared, except in patients with renal failure. Opioid plasma changes substantially overlap the clinical changes observed in these patients, in terms of benefit between analgesia and adverse effects.

A randomised controlled study on the use of anti-inflammatory drugs in patients with cancer pain on morphine therapy: effects on dose-escalation and a pharmacoeconomic analysis

The role of non-steroidal anti-inflammatory drugs (NSAIDs) in cancer pain has been well established in the treatment of mild pain and in association with opioids in the treatment of moderate to severe pain. The aim of this study was to verify the effects of NSAIDs on morphine escalation in advanced cancer patients with pain followed-up at home and to assess the pharmacoeconomic implications. A prospective randomised controlled study was carried out in 156 consecutive advanced cancer patients with pain followed-up at home in the period December 1999-December 2000. In this group of patients, 47 were selected with pain progression after 1 week of opioid stabilisation. Patients were randomly assigned to one of two groups: group 'O' patients were treated with continuing opioid escalation according to their clinical needs; group 'OK' received ketorolac 60 mg/daily orally (p.o.) in three doses and then continued opioid escalation according to their clinical situation. Performance status, doses of morphine before and after starting treatment, mean weekly pain intensity (assessed by means of a numerical scale from 0 to 10), mean weekly symptoms intensity, adverse effects and pain mechanisms were recorded. Moreover, drug costs per day in both groups were calculated. Patients who received ketorolac in addition to morphine showed a better analgesia after a week in comparison to the group treated with morphine only (P=0.005). Thereafter, morphine escalation was slower and the maximum morphine dose was lower in the group treated with ketorolac. The incidence and the severity of gastric discomfort was more evident in patients treated with ketorolac, while constipation was significantly increased in patients who received morphine only. Drug costs per day were similar in both groups; statistical differences were observed in patients who started on lower morphine doses (<100 mg/daily) in the two groups (4.3 in the ketorolac-morphine group versus 3.4 in the morphine group; P=0.012). The use of NSAIDs reduces the need for an opioid dose escalation or allows the use of lower doses. Their use is associated with a more intense gastric discomfort, but results in less opioid-related constipation. The eventual additive cost for NSAIDs therapy is negligible, especially in patients taking high doses of morphine.

Pharmacotherapy of anaemia in cancer patients

Anaemia is a common complication of cancer. The incidence is variable and depends on several factors. A linear correlation between haemoglobin levels and quality of life (QOL) parameters has been found. Erythropoiesis is a finely regulated responsive process and erythropoietin (EPO) is the most important factor influencing progenitor cell proliferation. Impaired EPO production is mediated by inflammatory cytokines liberated in cancer patients. For this reason, EPO has been proposed as an alternative to blood transfusions, which involve many hazards. EPO treatment has been found to be effective in preventing anaemia and reducing the need for blood transfusions, although it would be useful to identify high-risk patient subgroups who would benefit most from this expensive treatment.

Recent progress in the pharmacotherapy of cancer pain

Cancer pain can be relatively well managed with primary therapies, according to the WHO ladder. However, different conditions may limit the response to the analgesic drug used, which are mainly oploids. Specifically, adverse effects may prevail against the analgesic activity in the clinical setting. New pharmacological strategies may enable a more satisfactory response to be obtained, in terms of balance between analgesia and adverse effects. The change of route of administration or the use of alternative opioids is a first-line option. The use of adjuvant drugs may also improve analgesia with different mechanisms. Recent studies have demonstrated the value of these alternative approaches. However, most of them require definite confirmation in specific well-designed studies.

Rifampicin in opioid-induced itching

Pruritus is prevalent in 5-12% of palliative care patients. Rifampicin has been shown to be useful both as initial treatment and as salvage treatment after failure of other agents to control the pruritus associated with the cholestatic jaundice of malignancy. We report the case of a 65-year-old woman who complained of severe pruritus after morphine treatment. The use of rifampicin 300 mg twice a day by the i.v. route was successful, and after opioid switching it was no longer necessary to maintain rifampicin in the therapeutic regimen. Controlled clinical trials are warranted to confirm this preliminary observation.

The use of corticosteroids in home palliative care

Evidence for the effectiveness of corticosteroids in palliative care is anecdotal, and more information is required. From January to December 1999 a total of 376 consecutive patients admitted to a home palliative care program were longitudinally surveyed. Patients who started a corticosteroid treatment after admission on the basis of common indications prescribed by their home care physicians were selected. Fifty patients were enrolled in the study. Dexamethasone, in doses ranging from 4 to 16 mg, was the drug of choice. Corticosteroids were found to be effective in anorexia, weakness, headache, and nausea and vomiting. The reduction of symptom intensity was achieved in less than 3 days on average. However, no great advantages were found in terms of controlling drowsiness or confusional states associated with advanced illness because of cerebral involvement. It can be concluded from this study that: (a) corticosteroids may be effective in controlling anorexia, weakness, headache, and nausea and vomiting associated with cerebral involvement or bowel obstruction; (b) they should be stopped if no therapeutic effect has become evident within 3-5 days; (c) the treatment is not useful when given in the presence of severe neurological impairment resulting from the advanced stage of disease; (d) the range of adverse effects was acceptable for limited periods and in the circumstances in which the preparations were used in this study; and (e) corticosteroids may have an adjuvant role in potentiation of analgesic drugs. These findings will be very useful in the planning of future controlled studies designed to yield evidence-based data on the role of corticosteroids in the relief of specific symptoms.

Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer

The paper highlights a series of questions that doctors need to consider when faced with end-stage cancer patients with bowel obstruction: Is the patient fit for surgery? Is there a place for stenting? Is it necessary to use a venting nasogastric tube (NGT) in inoperable patients? What drugs are indicated for symptom control, what is the proper route for their administration and which can be administered in association? When should a venting gastrostomy be considered? What is the role of total parenteral nutrition (TPN) and parenteral hydration (PH)? A working group was established to review issues relating to bowel obstruction in end-stage cancer and to make recommendations for management. A steering group was established by the (multidisciplinary) Board of Directors of the European Association for Palliative Care (EAPC) to select members of the expert panel, who were required to have specific clinical and research interests relating to the topic and to have published significant papers on advanced cancer patients in the last 5 years, or to have particular clinical expertise that is recognised internationally. The final constitution of this group was approved by the Board of the EAPC. This Working Group was made up of English, French and Italian physicians involved in the field of palliative care for advanced and terminal cancer patients; and of English, American and Italian surgeons who also specialized in artificial nutrition (Dr. Bozzetti) and a professor of health economics. We applied a systematic review methodology that showed the relative lack of RCTs in this area and the importance of retrospective and clinical reports from different authors in different countries. The brief was to review published data but also to provide clinical opinion where data were lacking. The recommendations reflect specialist clinical practice in the countries represented. Each member of the group was allocated a specific question and briefed to review the literature and produce a position paper on the indications, advantages and disadvantages of each symptomatic treatment. The position papers were circulated and then debated at a meeting held in Athens and attended by all panel members. The group reviewed all the available data, discussed the evidence and discussed what practical recommendations could be derived from it. An initial outline of the results of the review and recommendations was produced. Where there were gaps in the evidence, consensus was achieved by debate. Only unanimous conclusions have been incorporated. Subsequently the recommendations were drawn together by Carla Ripamonti (Chairperson) and Robert Twycross (Co-Chair) and refined with input from all panel members. The recommendations have been endorsed by the Board of Directors of the EAPC. It was concluded that surgery should not be undertaken routinely in patients with poor prognostic criteria, such as intra-abdominal carcinomatosis, poor performance status and massive ascites. A nasogastric tube should be used only as a temporary measure. Medical measures such as analgesics, anti-secretory drugs and anti-emetics should be used alone or in combination to relieve symptoms. A venting gastrostomy should be considered if drugs fail to reduce vomiting to an acceptable level. TPN should be considered only for patients who may die of starvation rather than from tumour spread. PH is sometimes indicated to correct nausea, whereas regular mouth care is the treatment of choice for dry mouth. A collaborative approach involving both surgeons and physicians can offer patients an individualized and appropriate symptom management plan.

Switching from morphine to methadone to improve analgesia and tolerability in cancer patients: a prospective study

PURPOSE

To evaluate the clinical benefits of switching from morphine to oral methadone in patients who experience poor analgesia or adverse effects from morphine.

PATIENTS AND METHODS

Fifty-two consecutive cancer patients receiving oral morphine but with uncontrolled pain and/or moderate to severe opioid adverse effects were switched to oral methadone administered every 8 hours using different dose ratios. Intensity of pain and adverse effects were assessed daily, and the symptom distress score (DS) was calculated before and after switching.

RESULTS

Data were analyzed for 50 patients. Switching was considered effective in 80% of the patients; results were achieved in an average of 3.65 days. In the 10 patients who switched to methadone because of uncontrolled pain, a significant reduction in pain intensity (P <.005) and an average of a 33% increase in methadone doses necessary (P <.01) were found after an average of 3.5 days. DS significantly decreased from an average of 8.4 to 4.5 (P <.0005). In the 32 patients switching because of uncontrolled pain and morphine-related adverse effects, significant improvement was found in pain intensity (P <.0005), nausea and vomiting (P <.03), constipation (P <.001), and drowsiness (P <.01), but a significant increase in the methadone dose of an average of 20% (P <.004) was required.

CONCLUSION

In most patients with cancer pain referred for poor pain control and/or adverse effects, switching to oral methadone is a valid therapeutic option. In the clinical setting of poor pain control, higher doses of methadone are necessary with respect to the equianalgesic calculated dose ratios previously published.

Pattern of drug use by advanced cancer patients followed at home

The aim of this study was to document the drugs most commonly prescribed to control symptoms in advanced cancer patients being followed at home. We analyzed data for 128 patients admitted to a home palliative care program from January 1993 to January 1995. All patients were followed at home until death by a team consisting of doctors and nurses, and were given two or three medical examinations a week. The most frequently prescribed drugs were analgesics and drugs commonly used to prevent NSAID-induced gastric toxicity. Slow-release morphine was the analgesic used most often. Most patients received more than four drugs. Younger people received morphine more often than did older patients.

CONCLUSIONS

Drug monitoring is a useful audit tool for verifying the quality and quantity of drugs prescribed for advanced cancer patients being followed at home. Pharmacological usage should be reviewed periodically and should reflect evidence-based practice.

Gabapentin for opiod-related myoclonus in cancer patients

Chronic opioid medication has been found to cause myoclonus in patients taking it for cancer pain. Gabapentin seemed a likely candidate for the treatment of this myoclonus and has indeed proved useful, as illustrated in this paper by two case histories.

Strategies to manage the adverse effects of oral morphine: an evidence-based report

Successful pain management with opioids requires that adequate analgesia be achieved without excessive adverse effects. By these criteria, a substantial minority of patients treated with oral morphine (10% to 30%) do not have a successful outcome because of (1) excessive adverse effects, (2) inadequate analgesia, or (3) a combination of both excessive adverse effects along with inadequate analgesia. The management of excessive adverse effects remains a major clinical challenge. Multiple approaches have been described to address this problem. The clinical challenge of selecting the best option is enhanced by the lack of definitive, evidence-based comparative data. Indeed, this aspect of opioid therapeutics has become a focus of substantial controversy. This study presents evidence-based recommendations for clinical-practice formulated by an Expert Working Group of the European Association of Palliative Care (EAPC) Research NETWORK: These recommendations highlight the need for careful evaluation to distinguish between morphine adverse effects from comorbidity, dehydration, or drug interactions, and initial consideration of dose reduction (possibly by the addition of a co analgesic). If side effects persist, the clinician should consider options of symptomatic management of the adverse effect, opioid rotation, or switching route of systemic administration. The approaches are described and guidelines are provided to aid in selecting between therapeutic options.

Effects of caffeine as an adjuvant to morphine in advanced cancer patients. A randomized, double-blind, placebo-controlled, crossover study

Psychomotor abnormalities are one of the complications of opioid therapy in advanced cancer patients. Caffeine has potential properties to counteract the central effects of morphine. Twelve patients receiving stable doses of slow release morphine with adequate pain relief were scheduled for this double-blind placebo-controlled crossover trial. The treatment consisted of an intravenous dose of 1/6 of the daily morphine dose, using an intravenous/oral conversion ratio of 1:3. The dose calculated was administered in 5 minutes. Patients were randomly divided to received in a double-blind manner an infusion of 200 mg of caffeine or saline solution intravenously over one hour. A crossover took place after 2-3 days. Patients were assessed immediately before the infusion and once at the end (one hour after). Each assessment included pain, nausea, confusion, and drowsiness intensity. Psychomotor tests, including tapping speed with 10-30 seconds trials, arithmetic tests, memory for digits, and visual memory were also performed. Caffeine infusion induced a significant decrease in pain intensity (from 25.3 to 16.3, p =0.003), but this was no different from the placebo. Caffeine increased both tapping speed tests (p = 0.041 and 0.010, respectively) in comparison with placebo treatment. No other significant differences were found in the other parameters examined. Caffeine showed a partial effect on the cognitive performance of advanced cancer patients on chronic morphine treatment who received a bolus of intravenous morphine. Further studies are necessary to evaluate whether higher doses of caffeine may be more effective and to establish the role of tolerance to caffeine in this group of patients.

Opioid poorly-responsive cancer pain. Part 3. Clinical strategies to improve opioid responsiveness

Some pain syndromes may be difficult to treat due to a poor response to opioids. This situation demands a range of alternative measures, including the use of adjuvant drugs with independent effects, such as antidepressants, sodium channel-blocking agents, steroids and anti-inflammatory drugs (NSAIDs); drugs that reduce opioid side effects; and drugs that enhance analgesia produced by opioids, such as N-methyl-D-aspartate (NMDA) antagonists, calcium channel antagonists, and clonidine. Other approaches, including opioid trials, neural blockade when necessary, and psychological interventions, also may be useful.

Opioid poorly-responsive cancer pain. Part 2: basic mechanisms that could shift dose response for analgesia

Basic research in experimental pain models may illuminate the phenomenon of cancer pain that is poorly responsive to opioid drugs. Research findings can be valuable in formulating new strategies in clinical practice. This review evaluated experimental observations in terms of the events that occur in cancer patients receiving opioid therapy for pain.

Morphine and alternative opioids in cancer pain: the EAPC recommendations

An expert working group of the European Association for Palliative Care has revised and updated its guidelines on the use of morphine in the management of cancer pain. The revised recommendations presented here give guidance on the use of morphine and the alternative strong opioid analgesics which have been introduced in many parts of the world in recent years. Practical strategies for dealing with difficult situations are described presenting a consensus view where supporting evidence is lacking. The strength of the evidence on which each recommendation is based is indicated.

Methadone in treatment of tenesmus not responding to morphine escalation

Tenesmus is a painful sensation of incomplete evacuation of the bowel and is often associated with poorly localized perineal pain. We describe a 68-year-old man with locally advanced rectal carcinoma metastatic to lung and with unbearable rectal-perineal pain unresponsive to morphine and ketorolac. Treatment with oral methadone was successful and pain improved considerably. Methadone has been reported to improve pain relief in patients with morphine resistance, and it is lipophilic and exerts a lesser activity on opioid receptors in the gastrointestinal tract.

The use of anti-inflammatory drugs in cancer pain

The role of non-steroidal anti-inflammatory drugs (NSAIDs) in cancer pain has been well established in the treatment of mild pain and also alone or in association with opioids for the treatment of moderate to severe pain. Acutely, NSAIDs may be more than mild analgesics, and may provide additional analgesia when combined with opioids. However, NSAIDs have ceiling effects and there is no therapeutic gain from increasing dosages beyond those recommended. As there is no clearly superior NSAID, the choice should be based on experience and the toxicity profile that probably relates to the COX-1:COX-2 ratio. Among the older drugs, ibuprofen seems to have these properties.Non-steroidal anti-inflammatory drugs have been shown to have an opioid-sparing effect. Although the value of a simple narcotic-sparing effect may be questioned in cancer pain treatment, the use of NSAIDs may be useful when the increase in opioid dosage determine the occurrence of opioid toxicity. Like opioids, NSAIDs should not be considered analgesics for a specific type or cause of pain. There is a lack of evidence for any difference between different routes of NSAIDs administration. The long-term toxicity of NSAIDs in cancer pain is poorly defined due to a lack of studies. A variety of strategies have been used in an attempt to reduce the risks associated with NSAID therapy. Those NSAIDs that are weak COX-1 inhibitors may be preferred. In addition, concomitant administration of misoprostol is recommended in patients at increased risk for upper gastrointestinal complications.

Opioid poorly-responsive cancer pain. Part 1: clinical considerations

Pain that is poorly responsive to opioid analgesics is challenging for physicians who deal with cancer patients. Numerous factors may influence analgesic response during the course of the illness. These include changing nociception associated with disease progression, the appearance of intractable side effects, the development of tolerance, the presence of neuropathic pain, the temporal pattern, the effects produced by the production of opioid metabolites, and many others. These factors influence the delicate balance between pain relief and opioid toxicity that must be achieved in cancer patients with pain.