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Mercadante S. An overview of the current drug treatment strategies for moderate to severe, chronic malignant tumor-related pain. Expert Opin Pharmacother 2024; 25:171-179. [PMID: 37016731 DOI: 10.1080/14656566.2023.2200137] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/04/2023] [Indexed: 04/06/2023]
Abstract
INTRODUCTION The pharmacological management of cancer pain is a complex issue that requires knowledge and experience in the use of analgesics. The aim of this expert review is to provide a panorama of the pharmacological strategies in cancer pain management. AREAS COVERED Opioid dose titration is a delicate process regarding the start of opioid treatment in different clinical conditions. How to improve the opioid response is a fundamental step, which includes different strategies when an initial treatment with opioids fails. The use of adjuvants is another relevant issue that should be considered in some specific circumstances to optimize the management of cancer pain management. Some clinical conditions, such as neuropathic pain and breakthrough pain, deserve a special attention. Relevant literature was selected to provide an overview of cancer pain management strategies. EXPERT OPINION Opioid therapy still remains the cornerstone of pharmacological management of cancer pain. Opioids should be used according to the level of tolerance, also personalizing the treatment (route, drug, and dosing). Adjuvant drugs may help in specific conditions, although their use should be balanced with the adverse effects. Breakthrough pain requires expertise in tailoring a treatment according to patient's profile and characteristics of episodes.
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Affiliation(s)
- Sebastiano Mercadante
- Main regional center of pain relief and supportive/palliative care, La Maddalena Cancer Center, Palermo, Italy
- Home palliative care program, Regional Home care program, SAMOT, Palermo, Italy
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Mercadante S, Adamoli L, Bellavia G, Castellana L, Favara T, Insalaco L, Mauceri M, Scibilia C, Lo Mauro M, Lo Cascio A, Casuccio A. Opioids in advanced cancer: use, storage and disposal in the home. BMJ Support Palliat Care 2024; 13:e855-e858. [PMID: 36175123 DOI: 10.1136/spcare-2022-003964] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/15/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine the patterns of storing, using and disposing of opioids among patients with advanced cancer followed at home. METHODS Patients who were prescribed opioids were selected. Prescribed opioids and their doses used for background pain and breakthrough pain were collected, as well as CAGE (cut down, annoyed, guilty and eye opener) for alcohol and drugs, smoking and history of illicit substance use. Questions regarding the opioid use, storage and disposal were posed. RESULTS 100 patients were surveyed. Fifty-one patients had unused opioids at home, 25 patients did not throw away the drugs, 40 patients saved opioids for future use and 35 patients were unaware of proper opioid disposal methods. A total of 28 patients reported unsafe use by sharing or losing their opioids; 12 patients were unaware that their opioid could be fatal when taken by others. Most patients acknowledged that pain medications could be dangerous when taken by others. Patients with a partner and who were married were more likely to keep their opioids locked (p=0.028 and p=0.025, respectively). CONCLUSION A large number of patients with advanced cancer followed at home do not store, use and dispose of opioids safely. Patient education programmes should be incorporated to decrease the availability of opioids at home for abuse, diversion, and accidental poisoning.
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Affiliation(s)
| | - Lucia Adamoli
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | | | | | - Tommaso Favara
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | | | - Marco Mauceri
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | - Carla Scibilia
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | - Mario Lo Mauro
- Società Assistenza Malato Oncologico Terminale, Palermo, Italy
| | | | - Alessandra Casuccio
- Università degli Studi di Palermo Scuola di Medicina e Chirurgia, Palermo, Italy
- Hygiene, Università degli Studi di Palermo Facoltà di Medicina e Chirurgia, Palermo, Italy
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Gastine S, Morse JD, Leung MT, Wong ICK, Howard RF, Harrop E, Liossi C, Standing JF, Jassal SS, Hain RD, Skene S, Oulton K, Law SL, Quek WT, Anderson BJ. Diamorphine pharmacokinetics and conversion factor estimates for intranasal diamorphine in paediatric breakthrough pain:systematic review. BMJ Support Palliat Care 2024; 13:e485-e493. [PMID: 35184039 DOI: 10.1136/bmjspcare-2021-003461] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/26/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Intranasal diamorphine is a potential treatment for breakthrough pain but few paediatric data are available to assist dose estimation. AIM To determine an intranasal diamorphine dose in children through an understanding of pharmacokinetics. DESIGN A systematic review of the literature was undertaken to seek diamorphine pharmacokinetic parameters in neonates, children and adults. Parenteral and enteral diamorphine bioavailability were reviewed with respect to formation of the major metabolite, morphine. Clinical data quantifying equianalgesic effects of diamorphine and morphine were reviewed. REVIEW SOURCES PubMed (1960-2020); EMBASE (1980-2020); IPA (1973-2020) and original human research studies that reported diacetylmorphine and metabolite after any dose or route of administration. RESULTS The systematic review identified 19 studies: 16 in adults and 1 in children and 2 neonatal reports. Details of study participants were extracted. Age ranged from premature neonates to 67 years and weight 1.4-88 kg. Intranasal diamorphine bioavailability was predicted as 50%. The equianalgesic intravenous conversion ratio of morphine:diamorphine was 2:1. There was heterogeneity between pharmacokinetic parameter estimates attributed to routes of administration, lack of size standardisation, methodology and pharmacokinetic analysis. Estimates of the pharmacokinetic parameters clearance and volume of distribution were reduced in neonates. There were insufficient paediatric data to characterise clearance or volume maturation of either diamorphine or its metabolites. CONCLUSIONS We estimate equianalgesic ratios of intravenous morphine:diamorphine 2:1, intravenous morphine:intranasal diamorphine 1:1 and oral morphine:intranasal diamorphine of 1:3. These ratios are based on adult literature, but are reasonable for deciding on an initial dose of 0.1 mg/kg in children 4-13 years.
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Affiliation(s)
- Silke Gastine
- Great Ormond St Institute of Child Health, University College London, London, UK
| | - James D Morse
- Department of Pharmacology & Clinical Pharmacology, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Miriam Ty Leung
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, Hong Kong
| | - Ian Chi Kei Wong
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Christina Liossi
- School of Psychology, University of Southampton, Southampton, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Immunity and Inflammation, University College London, London, UK
| | - Satbir Singh Jassal
- Palliative Care, Rainbows Hospice for Children and Young Adults, Loughborough, UK
| | - Richard D Hain
- All-Wales Managed Clinical Network in Paediatric Palliative Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Simon Skene
- Faculty of Arts and Human Sciences, Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
| | - Kate Oulton
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Siew L Law
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Wan T Quek
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Brian J Anderson
- Department of Anaesthesiology, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
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Harrop E, Liossi C, Jamieson L, Gastine S, Oulton K, Skene SS, Howard RF, Johnson M, Boyce K, Mitchell L, Jassal S, Anderson AK, Hain RDW, Hills M, Bayliss J, Soman A, Laddie J, Vickers D, Mellor C, Warlow T, Wong IC. Oral morphine versus transmucosal diamorphine for breakthrough pain in children: methods and outcomes: UK (DIPPER study) consensus. BMJ Support Palliat Care 2024; 13:e1019-e1028. [PMID: 34903585 PMCID: PMC10850727 DOI: 10.1136/bmjspcare-2021-003278] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/04/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES No randomised controlled trials have been conducted for breakthrough pain in paediatric palliative care and there are currently no standardised outcome measures. The DIPPER study aims to establish the feasibility of conducting a prospective randomised controlled trial comparing oral and transmucosal administration of opioids for breakthrough pain. The aim of the current study was to achieve consensus on design aspects for a small-scale prospective study to inform a future randomised controlled trial of oral morphine, the current first-line treatment, versus transmucosal diamorphine. METHODS The nominal group technique was used to achieve consensus on best practice for mode of administration, dose regimen and a range of suitable pain intensity outcome measures for transmucosal diamorphine in children and young people with breakthrough pain. An expert panel of ten clinicians in paediatric palliative care and three parent representatives participated. Consensus was achieved when agreement was reached and no further comments from participants were forthcoming. RESULTS The panel favoured the buccal route of administration, with dosing according to the recommendations in the Association for Paediatric Palliative Medicine formulary (fifth Edition, 2020). The verbal Numerical Rating Scale was selected to measure pain in children 8 years old and older, the Faces Pain Scale-Revised for children between 4 and 8 years old, and Face, Legs, Activity, Cry and Consolability (FLACC)/FLACC-Revised as the observational tools. CONCLUSIONS The nominal group technique allowed consensus to be reached for a small-scale, prospective, cohort study and provided information to inform the design of a randomised controlled trial.
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Affiliation(s)
- Emily Harrop
- Helen and Douglas House Hospice, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Christina Liossi
- School of Psychology, University of Southampton, Southampton, UK
- Department of Psychology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Liz Jamieson
- Research Dept of Practice & Policy, University College London School of Pharmacy, London, UK
- UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
| | - Silke Gastine
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Kate Oulton
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Guildford, UK
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Richard F Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Margaret Johnson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Katherine Boyce
- Helen and Douglas House Hospice, Oxford, UK
- Flexicare Oxford & Abingdon, Oxford, UK
| | | | - Satbir Jassal
- Rainbows Hospice for Children and Young People, Loughborough, UK
| | - Anna-Karenia Anderson
- Paediatrics, Royal Marsden Hospital, Sutton, UK
- Shooting Star Children's Hospice, Guildford, UK
| | - Richard D W Hain
- All-Wales Managed Clinical Network in Paediatric Palliative Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Michelle Hills
- Martin House Hospice for Children and Young People, Boston Spa, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Julie Bayliss
- The Louis Dundas Centre, Oncology Outreach and Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Archana Soman
- Sheffield Children's Hospital, Sheffield, UK
- Bluebell Wood Children's Hospice, North Anston, UK
| | | | - David Vickers
- Medical Director, Cambridgeshire Community Services NHS Trust, St Ives, UK
- East Anglia's Children's Hospices, Cambridgeshire, UK
| | | | - Tim Warlow
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Naomi House and Jacksplace, Winchester, UK
| | - Ian Ck Wong
- Research Dept of Practice & Policy, University College London School of Pharmacy, London, UK
- UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Pok Fu Lam, Hong Kong
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Crawford GB, Lakhani A, Palmer L, Sebalj M, Rolan P. A systematic review of qualitative research exploring patient and health professional perspectives of breakthrough cancer pain. Support Care Cancer 2023; 31:619. [PMID: 37812248 PMCID: PMC10562491 DOI: 10.1007/s00520-023-08076-9] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Breakthrough cancer pain (BtCP) is a prevalent health issue which is difficult to manage. A plethora of quantitative research in this area exists. There is a paucity of research on the perspectives of health professionals and patients surrounding domains impacting effective treatment, including definitions of BtCP, treatment, and education opportunities. This review aims to identify and synthesize the extent of qualitative research exploring health professional and patient perspectives of BtCP. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach was undertaken. The approach was registered with Prospero. MEDLINE, EMBASE, and Web of Science were searched for peer-reviewed literature published any date prior to May 19, 2022. Eligible sources must have considered health professional and/or patient perspectives of BtCP. A narrative synthesis approach was utilized. RESULTS Three sources met the review criteria. One source explored nurse perspectives, while two sources explored patient perspectives. Study quality was moderate to high. Overlapping themes across the three studies included communication, defining BtCP, impact of BtCP, management of BtCP, perceptions of BtCP, analgesia and pain relief, and training and professional development. CONCLUSION Given limited research investigating clinician and patient perspectives of BtCP, a rich understanding informed by exploratory qualitative methods around identification, best management strategies, professional development, and factors promoting and inhibiting best practice remains unclear. Further qualitative inquiry is warranted, and it is expected such research will inform BtCP clinical guidelines.
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Affiliation(s)
- G B Crawford
- Faculty of Health & Medical Sciences, University of Adelaide, Adelaide Medical School, North Terrace, Adelaide, SA, 5000, Australia.
- Northern Adelaide Palliative Service, Northern Adelaide Local Health Network, Modbury Hospital, 41-69 Smart Road, Modbury, SA, 5092, Australia.
| | - A Lakhani
- The School of Psychology and Public Health, La Trobe University, 360 Collins St, Melbourne, VIC, 3000, Australia
- The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, University Drive, Logan CampusMeadowbrook, QLD, 4131, Australia
- Palliative Care Department, Eastern Health, 251 Mountain Highway, Wantirna, VIC, 3152, Australia
| | - L Palmer
- Faculty of Health & Medical Sciences, University of Adelaide, Adelaide Medical School, North Terrace, Adelaide, SA, 5000, Australia
- Northern Adelaide Palliative Service, Northern Adelaide Local Health Network, Modbury Hospital, 41-69 Smart Road, Modbury, SA, 5092, Australia
| | - M Sebalj
- The School of Psychology and Public Health, La Trobe University, 360 Collins St, Melbourne, VIC, 3000, Australia
| | - P Rolan
- Faculty of Health & Medical Sciences, University of Adelaide, Adelaide Medical School, North Terrace, Adelaide, SA, 5000, Australia
- Northern Adelaide Pain Service, Northern Adelaide Local Health Network, Modbury Hospital, 41-69 Smart Road, Modbury, SA, 5092, Australia
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Yu Y, Zhang P, Chen D, Jiang SF. Knowledge and practice of the management of breakthrough cancer pain among general practitioners providing palliative care in Shanghai, China: a cross-sectional survey. BMJ Open 2023; 13:e073670. [PMID: 37770268 PMCID: PMC10546098 DOI: 10.1136/bmjopen-2023-073670] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/01/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE This study examined knowledge and practice of breakthrough cancer pain (BTcP) management among general practitioners (GPs) providing palliative care in Shanghai. DESIGN Cross-sectional study using a self-administered questionnaire. SETTING AND PARTICIPANTS A total of 393 GPs providing palliative care in 32 community health service centres in Shanghai were recruited by stratified cluster random sampling between 1 May and 30 June 2022. OUTCOME MEASURES Knowledge and practice concerning BTcP management. RESULTS A total of 375 questionnaires were collected and declared valid. The median knowledge score was 11 out of 21 points. Only 36.3% (n=136) of the participating GPs scored 11 points or more, which was categorised as good knowledge. Only 24.8% (n=93) of the GPs used Davies' adapted diagnostic algorithm as the gold standard for diagnosis. All of the GPs assessed the intensity of BTcP; however, less than a quarter of the GPs evaluated the relationship between background pain and BTcP (22.1%, n=83), the impact of BTcP on activities of daily living (24.0%, n=90), the impact of BTcP on social relationships (14.4%, n=54) and the impact of BTcP on mood (10.1%, n=38). 56.5% (n=212) of the GPs reported that they used pain tools in the assessment of BTcP. All of the GPs prescribed immediate-release morphine as rescue medication for relieving BTcP; however, 60.5% (n=227) prescribed the dose based on their personal experiences, irrespective of the basal opioid dose, and 57.3% (n=215) did not conduct dose titration after providing the initial dose. No GPs reported that they ever administered interventional treatment to their patients. CONCLUSIONS Insufficient knowledge and inappropriate behaviours in BTcP diagnosis, assessment and treatment were identified. There is an urgent need to improve BTcP management among GPs providing palliative care in Shanghai.
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Affiliation(s)
- Ying Yu
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
| | - Panpan Zhang
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
| | - Danxia Chen
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
| | - Sun Fang Jiang
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
- Department of Health Management Center, Zhongshan Hospital Fudan University, Shanghai, China
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Kwon MY, Lee MY, Han YJ, Lee SH, Kim EJ, Park S, Lee Y, Koo DH. Predicting tolerability of high-dose fentanyl buccal tablets in cancer patients. PLoS One 2023; 18:e0280212. [PMID: 36608031 PMCID: PMC9821425 DOI: 10.1371/journal.pone.0280212] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 12/22/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND & AIMS Fentanyl buccal tablets (FBTs) are a rapid-onset opioid indicated for breakthrough cancer pain (BTcP) and FBT titration is needed to optimize BTcP management. We aimed to predict which patients could tolerate a high dose of FBT (400 μg or more at a time). METHODS A retrospective analysis was performed to assess the final FBT dose. The final FBT doses were compared according to the clinical features. The prediction accuracy of patients tolerant of 400 μg or higher FBT was compared using the area under the receiver operating characteristic (ROC) curves. A risk scoring model based on the odds ratio (OR) was developed from the final multivariable model, and patients were assigned into two groups: low tolerance (0-1 point) and high tolerance (2-3 points). RESULTS Among 131 patients, the most frequently effective dose of FBT was 200 μg (54%), followed by 100 μg (30%). The median value of morphine equivalent daily doses (MEDD) was 60 mg/day, and the most common daily use was 3-4 times/day. In multivariable analysis, male sex, younger age, and use of FBTs three or more times per day were independently associated with high-dose FBT. According to the risk scoring model, the patients with a final FBT of 400 μg or higher were significantly more in the high tolerance group (17%) compared to the low tolerance group (3%; p = 0.023). CONCLUSIONS According to the dose relationship between the final FBT dose and the clinical features, three factors (sex, age, daily use of FBT) were independently associated with the final dose of FBT. Our risk score model could help predict tolerance to high-dose FBT and guide the titration plan for BTcP.
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Affiliation(s)
- Mi-Young Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Mi-Yeon Lee
- Division of Biostatistics, Department of R&D Management, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Jae Han
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Sung Hyun Lee
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eo Jin Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Songyi Park
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun‑Gyoo Lee
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Hoe Koo
- Division of Hematology/Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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Do U, El-Kefraoui C, Pook M, Balvardi S, Barone N, Nguyen-Powanda P, Lee L, Baldini G, Feldman LS, Fiore JF. Feasibility of Prospectively Comparing Opioid Analgesia With Opioid-Free Analgesia After Outpatient General Surgery: A Pilot Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2221430. [PMID: 35849399 PMCID: PMC9294998 DOI: 10.1001/jamanetworkopen.2022.21430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain. OBJECTIVE To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery. DESIGN, SETTING, AND PARTICIPANTS This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization. INTERVENTIONS Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge. MAIN OUTCOMES AND MEASURES Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle. RESULTS A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled. CONCLUSIONS AND RELEVANCE The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04254679.
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Affiliation(s)
- Uyen Do
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Charbel El-Kefraoui
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Makena Pook
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Saba Balvardi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Philip Nguyen-Powanda
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Gabriele Baldini
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Liane S. Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Julio F. Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Cascella M, Monaco F, Nocerino D, Chinè E, Carpenedo R, Picerno P, Migliaccio L, Armignacco A, Franceschini G, Coluccia S, Gennaro PD, Tracey MC, Forte CA, Tafuri M, Crispo A, Cutugno F, Vittori A, Natoli S, Cuomo A. Bibliometric Network Analysis on Rapid-Onset Opioids for Breakthrough Cancer Pain Treatment. J Pain Symptom Manage 2022; 63:1041-1050. [PMID: 35151801 DOI: 10.1016/j.jpainsymman.2022.01.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 01/10/2022] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Proper breakthrough cancer pain (BTcP) management is of pivotal importance. Although rapid-acting, oral and nasal transmucosal, fentanyl formulations (rapid-onset opioids, ROOs) are licensed for BTcP treatment, not all guidelines recommend their use. Presumably, some research gaps need to be bridged to produce solid evidence. We present a bibliometric network analysis on ROOs for BTcP treatment. METHODS Documents were retrieved from the Web of Science (WOS) online database. The string was "rapid onset opioids" or "transmucosal fentanyl" and "breakthrough cancer pain". Year of publication, journal metrics (impact factor and quartile), title, document type, topic, and clinical setting (in-patients, outpatients, and palliative care) were extracted. The software tool VOSviewer (version 1.6.17) was used to analyze the semantic network analyzes, bibliographic coupling, journals analysis, and research networks. RESULTS 502 articles were found in WOS. A declining trend in published articles from 2014 to 2021 was observed. Approximately 50% of documents regard top quartile (Q1) journals. Most articles focused on ROOs efficacy, but abuse and misuse issues are poorly addressed. With respect to article type, we calculated 132 clinical investigations. The semantic network analysis found interconnections between the terms "breakthrough cancer pain," "opioids," and "cancers." The top co-cited article was published in 2000 and addressed pain assessment. The largest number of partnerships regarded the United States, Italy, and England. CONCLUSION In this research area, most articles are published in top-ranked journals. Nevertheless, paramount topics should be better addressed, and the implementation of research networks is needed.
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Affiliation(s)
- Marco Cascella
- Division of Anesthesia and Pain Medicine (M.C., F.M., D.N., M.C.T., C.A.F., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G, Pascale, 80100 Naples, Italy; Department of Electrical Engineering and Information Technologies (M.C., F.C.), Università di Napoli "Federico II", 80100 Napoli, Italy.
| | - Federica Monaco
- Division of Anesthesia and Pain Medicine (M.C., F.M., D.N., M.C.T., C.A.F., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G, Pascale, 80100 Naples, Italy
| | - Davide Nocerino
- Division of Anesthesia and Pain Medicine (M.C., F.M., D.N., M.C.T., C.A.F., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G, Pascale, 80100 Naples, Italy
| | - Elisabetta Chinè
- Unit of Pain Therapy (E.C., R.C., S.N.), Polyclinic of Tor Vergata, Rome, Italy
| | - Roberta Carpenedo
- Unit of Pain Therapy (E.C., R.C., S.N.), Polyclinic of Tor Vergata, Rome, Italy
| | - Paola Picerno
- Residency Programme of Anaesthesiology (P.P., L.M., A. A., G.F.), Intensive Care and Pain Therapy. University of Rome Tor Vergata, Italy
| | - Laura Migliaccio
- Residency Programme of Anaesthesiology (P.P., L.M., A. A., G.F.), Intensive Care and Pain Therapy. University of Rome Tor Vergata, Italy
| | - Angela Armignacco
- Residency Programme of Anaesthesiology (P.P., L.M., A. A., G.F.), Intensive Care and Pain Therapy. University of Rome Tor Vergata, Italy
| | - Giulia Franceschini
- Residency Programme of Anaesthesiology (P.P., L.M., A. A., G.F.), Intensive Care and Pain Therapy. University of Rome Tor Vergata, Italy
| | - Sergio Coluccia
- Epidemiology and Biostatistics Unit (S.C., P.D.G., M.T., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80100 Naples, Italy
| | - Piergiacomo Di Gennaro
- Epidemiology and Biostatistics Unit (S.C., P.D.G., M.T., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80100 Naples, Italy
| | - Maura C Tracey
- Division of Anesthesia and Pain Medicine (M.C., F.M., D.N., M.C.T., C.A.F., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G, Pascale, 80100 Naples, Italy
| | - Cira A Forte
- Division of Anesthesia and Pain Medicine (M.C., F.M., D.N., M.C.T., C.A.F., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G, Pascale, 80100 Naples, Italy
| | - Mariangela Tafuri
- Epidemiology and Biostatistics Unit (S.C., P.D.G., M.T., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80100 Naples, Italy
| | - Anna Crispo
- Epidemiology and Biostatistics Unit (S.C., P.D.G., M.T., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80100 Naples, Italy
| | - Francesco Cutugno
- Department of Electrical Engineering and Information Technologies (M.C., F.C.), Università di Napoli "Federico II", 80100 Napoli, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care (A.V.), ARCO Roma, Ospedale Pediatrico Bambino Gesù IRCCS, Rome, Italy
| | - Silvia Natoli
- Unit of Pain Therapy (E.C., R.C., S.N.), Polyclinic of Tor Vergata, Rome, Italy; Department of Clinical Science and Translational Medicine University of Rome (S.N.), Tor Vergata, Rome, Italy
| | - Arturo Cuomo
- Division of Anesthesia and Pain Medicine (M.C., F.M., D.N., M.C.T., C.A.F., A.C.), Istituto Nazionale Tumori, IRCCS Fondazione G, Pascale, 80100 Naples, Italy
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Amezcua V, Doello K, González-Callejas D. Pseudo-addiction in cancer patients and rapid-release fentanyl for breakthrough pain: An increasingly common concern. Med Clin (Barc) 2021; 157:e287. [PMID: 32819770 DOI: 10.1016/j.medcli.2020.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/04/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Víctor Amezcua
- Medical Oncology Department, Virgen de las Nieves University Hospital, Granada, Spain.
| | - Kevin Doello
- Medical Oncology Department, Virgen de las Nieves University Hospital, Granada, Spain
| | - Desirée González-Callejas
- Pharmacy Department, Virgen de las Nieves University Hospital, Granada, Spain; Opioids Prescription Program, Andalusian Government, Spain
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11
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Satomi M, Kono T. [A Case Report of Impaired Consciousness in a Patient after Receiving the Fourth Dose of Fentanyl Sublingual Tablet]. Gan To Kagaku Ryoho 2020; 47:1521-1523. [PMID: 33130755] [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: 06/11/2023]
Abstract
Oral transmucosal fentanyl has been indicated for the management of breakthrough pain in patients with cancer. Fentanyl sublingual tablets(FST)have been approved for use in Japan since 2013. However, the optimal use of FSTs has not been well-elucidated. In this case, a 73-year-old man with rectal cancer and third lumbar vertebral metastasis was treated with 100 μg FST and 12.5 μg/h fentanyl patch every day for the management of cancer-related breakthrough pain. After receiving the fourth dose of FST, the patient was unconscious for 2 days. However, his respiration was stable. This case shows that due care should be taken while administering FSTs to patients, specifically geriatric patients with bone metastasis and hypoalbuminemia.
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12
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Villegas Estévez F, López Alarcón MD, Alonso Babarro A, Olay Gayoso L, de Castro J, Lería-Gelabert M, Melogno-Klinkas M. Breakthrough cancer pain treatment in Spain: physicians' perception of current opioids utilization and prescription. Curr Med Res Opin 2020; 36:1383-1391. [PMID: 32453602 DOI: 10.1080/03007995.2020.1775073] [Citation(s) in RCA: 3] [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] [Indexed: 10/24/2022]
Abstract
Objectives: Multiple reasons for suboptimal treatment of breakthrough cancer pain (BTcP) have been reported in the literature. We aimed to ascertain the perception of physicians on the potential inappropriate use and prescription of rapid-onset opioids (ROOs) for breakthrough cancer pain (BTcP) and the causes thereof.Methods: Observational study based on an online survey addressed to doctors from different specialties (radiation oncology, medical oncology, anesthesia, palliative care and general practitioners) with experience in the management of BTcP in the Spanish public health setting.Results: A total of 114 eligible specialists mainly from radiation oncology (37.7%), medical oncology (24.6%) and pain units (18.4%) participated in the study. Most agreed on important aspects of BTcP management, such as their preference for ROOs or the need for early follow-up after treatment initiation. However, their answers revealed a lack of standardization of BTcP diagnosis. Half of respondents believed that their BTcP patients might misuse ROOs. Physicians polled believed that lack of training in pain management (71.9%) and inadequate BTcP diagnosis and evaluation (66.7%) were the greatest obstacles for prescribing opioids. Specialists also thought that they do not provide the necessary information to patients (51.8%) and caregivers (57.9%) to guarantee the correct use of these drugs.Conclusions: These results are of utmost importance as they highlight the need to increase physicians' awareness of BTcP and its management and the need to improve communication with patients and their caregivers. Our findings also indicate the need for future research on the possible misuse of opioids in BTcP patients and its causes.
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Affiliation(s)
| | | | | | - Luis Olay Gayoso
- Radiation Oncology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Javier de Castro
- Medical Oncology Department, Hospital Universitario la Paz, Madrid, Spain
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13
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Arrieta Loitegui M, Caro Teller JM, Rosas Espinoza C, Ferrari Piquero JM. [Comparison of hospital consumption of immediate-release fentanyl: use or abuse?]. Rev Esp Salud Publica 2020; 94:e202007071. [PMID: 32719309] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 06/12/2020] [Indexed: 06/11/2023] Open
Abstract
OBJECTIVE Immediate-release fentanyl is indicated in the treatment of breakthrough pain in cancer patients who already receive opioids as background chronic analgesia. According to an alert issued by the Spanish Agency of Medicines, its consumption under non-authorized conditions has alarmingly increased in recent years, with a greater risk of abuse and dependence. The main objective of this study is to compare the off-label use of immediate-release fentanyl in our hospital during 2014 and 2017. METHODS Retrospective cross-sectional descriptive study in which immediate-release fentanyl prescriptions were compared in adult patients admitted during 2014 and 2017 in a group 5 hospital. Variables were collected by the electronic medical record. The association study between qualitative variables was calculated using the χ2 test, and quantitative variables with the t-student test. RESULTS In 2014, 0.43 immediate-release fentanyl prescriptions were made in our center for every 100 admissions, and in 2017 0.54/100 admissions. 22.1% (n=34) prescriptions were off-label in 2014, while in 2017 31.8% (n=76) (p=0.034). Both years, the most frequent off-label indications were healing of ulcers and wounds and non-cancer chronic pain. CONCLUSIONS The use of immediate-release fentanyl in the hospital setting has considerably increased in comparison to 2014, as well as its off-label use.
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Affiliation(s)
- David C Currow
- IMPACCT, Faculty of Health, University of Technology, Sydney, Ultimo, New South Wales, Australia
- Australian National Palliative Care Clinical Studies Collaborative, University of Technology, Sydney, Ultimo, New South Wales, Sydney, Australia
| | - Katherine Clark
- Australian National Palliative Care Clinical Studies Collaborative, University of Technology, Sydney, Ultimo, New South Wales, Sydney, Australia
- University of Sydney, Northern Clinical School, Royal North Shore Hospital, St Leonard's, New South Wales, Australia
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15
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Oldenmenger WH, Lucas A, van der Werff GFH, Webber K, Visser D, van der Velden AWG, van der Rijt CCD. Validation of the Dutch Version of the Breakthrough Pain Assessment Tool in Patients With Cancer. J Pain Symptom Manage 2020; 59:709-716.e2. [PMID: 31877346 DOI: 10.1016/j.jpainsymman.2019.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 09/25/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Essential for adequate management of breakthrough cancer pain is a combination of accurate (re-)assessment and a personalized treatment plan. The Breakthrough Pain Assessment Tool (BAT) has been proven to be a brief, multidimensional, reliable, and valid questionnaire for the assessment of breakthrough cancer pain. OBJECTIVES The aim of this study was to examine the validity and reliability of the Dutch Language version of the BAT (BAT-DL) in patients with cancer. METHODS The BAT was forward-backward translated into the Dutch language. Thereafter, the psychometric properties of the BAT-DL were tested, that is factor structure, reliability (internal consistency and test-retest reliability), validity (content validity and construct validity), and the responsiveness to change. RESULTS The BAT-DL confirmed the two-factor structure in 170 patients with cancer: pain severity/impact factor and pain duration/medication efficacy factor. The Cronbach's alpha coefficient was 0.72, and the intraclass correlation for the test-retest reliability was 0.81. The BAT-DL showed to be able to differentiate between different group of patients and correlated significantly with the Brief Pain Inventory. In addition, the BAT-DL was capable to detect clinically important changes over time. CONCLUSION The BAT-DL is a valid and reliable questionnaire to assess breakthrough pain in Dutch patients with cancer and is a relevant questionnaire for daily practice.
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Affiliation(s)
- Wendy H Oldenmenger
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands.
| | - Anne Lucas
- Department of Anesthesiology, Intensive Care and Pain Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Katherine Webber
- Department of Supportive and Palliative Care, Royal Surrey County Hospital, Guidford, United Kingdom
| | - Dick Visser
- Department of Anesthesiology, Intensive Care and Pain Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands; Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
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16
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Mercadante S, Caraceni A, Masedu F, Scipioni T, Aielli F. Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain. Oncologist 2020; 25:156-160. [PMID: 31862860 PMCID: PMC7011660 DOI: 10.1634/theoncologist.2019-0542] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/09/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study aimed to assess the characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain in comparison with patients receiving at least 60 mg of oral morphine equivalents (OME). MATERIALS AND METHODS Patients with advanced cancer receiving less than 60 mg/day of OME with episodes of BTcP were included in the analysis (group L). Data were compared with patients receiving doses of opioids ≥60 mg of OME (group H). Pain intensity, current analgesic therapy, number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, and time to meaningful pain relief were collected. Adverse effects imputable to a BTcP medication were recorded. RESULTS A total of 1,418 and 2,474 patients were included in groups L and H, respectively. A lower number of BTcP episodes (p = .005), a lower BTcP intensity (p = .0001), a faster BTcP onset (p = .024), and a longer time to meaningful pain relief after taking a BTcP medication (p = .009) were found in group L as compared with group H. In group L, BTcP interference on daily activity was less than in group H (p = .009). Patients in group L were less likely to be prescribed an opioid as BTcP medication in comparison with patients in group H (p = .0001). Opioid doses used for BTcP were significantly higher in group H. Patients in group L were more likely to be less satisfied (p = .003) than patients in group H. No adverse effects of severe intensity were reported in both groups. CONCLUSION Patients receiving lower doses of opioids exhibit some differences in BTcP presentation: fewer episodes with lower intensity and a faster onset, a longer time to meaningful pain relief, and less satisfaction with BTcP medication. A relevant percentage of patients was receiving fentanyl preparations normally reserved for patients receiving higher doses of opioids. IMPLICATIONS FOR PRACTICE Breakthrough pain is present in patients receiving low doses of opioids. It has its own peculiarities: less frequent, lower intensity, faster onset, longer time to meaningful pain relief, and less satisfaction with medication. Many patients were prescribed fentanyl preparations, which are normally reserved for patients receiving higher doses of opioids.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer CenterPalermoItaly
- Supportive/Palliative Care, MD Anderson Cancer CenterHoustonTexasUSA
| | | | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'AquilaL'AquilaItaly
| | - Teresa Scipioni
- Medical Oncology Department, Hospital “Giuseppe Mazzini”TeramoItaly
| | - Federica Aielli
- Medical Oncology Department, Hospital “Giuseppe Mazzini”TeramoItaly
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17
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Henche Ruiz AI. [Transmucosal fentanyl and breakthrough pain: The other side of the coin]. Rev Esp Geriatr Gerontol 2020; 55:56-57. [PMID: 31307779 DOI: 10.1016/j.regg.2019.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/02/2019] [Accepted: 02/08/2019] [Indexed: 06/10/2023]
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18
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Kaplan S, Bergamasco A, Sergerie M, Castilloux AM, Moride Y. Effectiveness of Risk Minimization Measures for Fentanyl Buccal Tablet (FENTORA) in Canada: A Mixed-Methods Evaluation Using Surveys, Medical Chart Records and Web Surveillance. Drug Saf 2019; 43:163-177. [PMID: 31691255 DOI: 10.1007/s40264-019-00882-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fentanyl buccal tablet (FBT), a potent opioid, was approved in Canada in 2013 for breakthrough pain in opioid-tolerant adult cancer patients. Additional risk minimization measures (aRMMs), consisting of communications to patients and healthcare providers (HCPs), were implemented from November 2014 through September 2015. OBJECTIVES The aim of this study was to assess the effectiveness of FBT aRMMs as measured by prescriber knowledge, understanding, and behavior regarding key safety concerns (off-label use, use in non-opioid-tolerant patients, misuse/abuse/diversion, and drug-drug interaction) and to evaluate illicit FBT use. METHODS The study included three components: (1) a knowledge and understanding (KAU) survey of FBT prescribers conducted in two waves: November 2016-February 2017 and April-September 2018; (2) a retrospective prescription study of medical records of patients treated with FBT by a subgroup of prescribers from the KAU survey; and (3) Web surveillance of illicit FBT use in Canada using the search term FENTORA (May 2014-September 2018). The aRMMs were considered effective if the lower bound of the 95% confidence interval indicated that at least 65% of respondents met or partly met the knowledge objective for each key safety concern. RESULTS KAU survey: Of 46 eligible HCPs, 97.8% met or partly met the knowledge objective on use in breakthrough pain cancer patients, 97.8% on use in opioid-tolerant patients, 89.1% on dose and titration, 100% on abuse/addiction, and 58.7% on drug-drug interaction. Retrospective prescription study: Of 22 FBT-treated patients identified from 14 HCPs, 45.5% had cancer, 50.0% recorded a breakthrough pain indication, and 36.4% reported opioid tolerance; however, only 13.6% of patients were prescribed FBT according to the approved indication. Web surveillance: Of 932 FBT posts in Canada, only 40 (4.3%) mentioned illicit use. CONCLUSIONS The aRMMs as measured by the prescriber KAU were effective for most key safety messages; however, not all key messages of the aRMMs were stringently followed in routine practice.
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Affiliation(s)
- Sigal Kaplan
- Teva Pharmaceutical Industries Ltd, Netanya, Israel.
| | | | | | | | - Yola Moride
- YOLARX Consultants, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
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Guitart J, Vargas MI, De Sanctis V, Folch J, Salazar R, Fuentes J, Coma J, Ferreras J, Moya J, Tomás A, Estivill P, Rodelas F, Jiménez AJ, Sanz A. Effects of Age Among Elderly Cancer Patients on Breakthrough Pain Management with Sublingual Fentanyl Tablets. Drugs R D 2019; 19:247-254. [PMID: 31177479 PMCID: PMC6738361 DOI: 10.1007/s40268-019-0276-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Sublingual fentanyl tablets (SFTs) have been shown to be a safe and effective option in controlling breakthrough cancer pain (BTcP). However, further examination is required to investigate the use of SFTs among the elderly. The aim of this study was to examine the influence of age in BTcP management with SFTs in the elderly population. Methods We performed subgroup analyses of a recently completed trial in two subsets of individuals: patients aged 65–74 years (low age group) and patients ≥ 75 years (high age group). Pain intensity (PI), onset of pain relief, frequency and duration of BTcP episodes, and adverse events (AEs) were assessed at 3, 7, 15, and 30 days. Health status instruments used were the Hospital Anxiety and Depression Scale (HADS-A and HADS-D) and the Short Form 12, version 2 (SF-12v2) questionnaire. Results Levels of PI at the end of the study improved significantly as compared with baseline in both the low and the high age groups (30.0% and 27.7% reduction, respectively). The onset of analgesia at the end of the study began in < 10 min in 85.0% of young–old subjects and in 62.5% of patients ≥ 75 years, but no significant differences were found. BTcP episodes lasted < 15 min in 75.0% of patients in the low age group and 58.3% in the high age group (p = 0.24). Most of patients in both groups experienced one to five BTcP daily episodes, at all assessment points. HADS-D decreased from 10.78 (± 4.33) to 8.21 (± 3.57) in the low age group, and from 10.96 (± 4.26) to 9.36 (± 3.35) in the high age group (p = 0.02). Significant differences in HADS-A scores from baseline to the end of the study were also observed in both subgroups (p < 0.05). Patients in the low age group had less favorable mental component summary (MCS) and physical component summary (PCS) scores than patients in the high age group. At the end of the study, 10.0% of young–old patients and 29.2% of patients aged ≥ 75 years reported AEs related to their treatment. The most commonly reported AEs included nausea, vomiting, constipation, somnolence, and skin disorders and they were generally mild to moderate in severity. Conclusions The results of this study showed that SFTs provided safe and clinically meaningful pain relief in both elderly subgroups. Clinical implications of these findings await validation in large, confirmatory studies to identify age subgroup divergences among elderly cancer patients treated with SFTs.
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Affiliation(s)
- Jordi Guitart
- Department of Anesthesiology, Hospital Plató, C/Plató 21, 08006, Barcelona, Spain.
| | - María Isabel Vargas
- Department of Anesthesiology, Parc Sanitari Sant Joan de Deu, Barcelona, Spain
| | - Vicente De Sanctis
- Pain Unit, Department of Anesthesiology, Hospital Universitari Sagrat Cor, Barcelona, Spain
| | - Jordi Folch
- Department of Anesthesiology, Hospital Plató, C/Plató 21, 08006, Barcelona, Spain
| | - Rafael Salazar
- Department of Anesthesiology, Hospital Comarcal d'Inca, Palma de Mallorca, Spain
| | - José Fuentes
- Department of Anesthesiology, Pius Hospital de Valls, Tarragona, Spain
| | - Joan Coma
- Department of Anesthesiology, Hospital General de l'Hospitalet, Barcelona, Spain
| | - Julia Ferreras
- Pain Unit, Department of Anesthesiology, Hospital Residència Sant Camil, Barcelona, Spain
| | - Jordi Moya
- Pain Unit, Department of Anesthesiology, Hospital Mateu Orfila, Minorca, Spain
| | - Albert Tomás
- Pain Unit, Department of Anesthesiology, Fundació Hospital Sant Bernabé, Barcelona, Spain
| | - Pere Estivill
- Department of Anesthesiology, Parc Sanitari Sant Joan de Deu, Barcelona, Spain
| | - Francisco Rodelas
- Department of Anesthesiology, Hospital Comarcal d'Inca, Palma de Mallorca, Spain
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Hallway A, Vu J, Lee J, Palazzolo W, Waljee J, Brummett C, Englesbe M, Howard R. Patient Satisfaction and Pain Control Using an Opioid-Sparing Postoperative Pathway. J Am Coll Surg 2019; 229:316-322. [PMID: 31154092 DOI: 10.1016/j.jamcollsurg.2019.04.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Opioids are overprescribed after surgical procedures, leading to dependence and diversion into the community. This can be mitigated by evidence-based prescribing practices. We investigated the feasibility of an opioid-sparing pain management strategy after surgical procedures. STUDY DESIGN Patients undergoing 6 procedures were offered the opportunity to participate in an opioid-sparing pain management pathway. Patients were advised to use acetaminophen and ibuprofen, and were provided with a small "rescue" opioid prescription for breakthrough pain. They were then surveyed postoperatively about opioid use and patient-reported outcomes measures. Overall cohort characteristics and differences between opioid users and non-users were analyzed. RESULTS A total of 190 patients were analyzed. Median prescription size was 5 (interquartile range [IQR] 4 to 6) pills and opioid use was 0 (IQR 0 to 4) pills. Fifty-two percent of patients used no opioids after procedures. Median number of leftover pills was 2 (IQR 0 to 5). Median pain score was 1 (IQR 1 to 2) and satisfaction score was 10 (IQR 8 to 10). Almost all (91%) patients agreed that their pain was manageable. Patients who used opioids were younger (52 ± 14 vs 59 ± 13 years; p = 0.001), reported higher pain scores (2 [IQR 1 to 2] vs 1 [1 to 2]; p = 0.014), received larger rescue prescriptions (6 ± 3 vs 4 ± 4 pills; p = 0.003), and were less likely to agree that their pain was manageable (82% vs 98%; p = 0.001). There were no other significant differences between opioid users and non-users. CONCLUSIONS Patients reported minimal or no opioid use after implementation of an opioid-sparing pathway, and still reported high satisfaction and pain control. These results demonstrate the effectiveness and acceptability of major reduction and even elimination of opioids after discharge from minor surgical procedures.
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Affiliation(s)
- Alexander Hallway
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI; Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Joceline Vu
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI; Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Jay Lee
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI; Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - William Palazzolo
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Jennifer Waljee
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI; Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Chad Brummett
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI; Department of Anesthesia, University of Michigan Health System, Ann Arbor, MI
| | - Michael Englesbe
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI; Section of Transplant Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI.
| | - Ryan Howard
- Michigan Opioid Prescribing and Engagement Network, Ann Arbor, MI; Department of Surgery, University of Michigan Health System, Ann Arbor, MI
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Mercadante S, Adile C, Masedu F, Valenti M, Aielli F. Breakthrough Cancer Pain in Patients With Abdominal Visceral Cancer Pain. J Pain Symptom Manage 2019; 57:966-970. [PMID: 30822530 DOI: 10.1016/j.jpainsymman.2019.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 12/18/2018] [Revised: 02/08/2019] [Accepted: 02/10/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of this study was to assess the characteristics of breakthrough cancer pain (BTcP) in patients with abdominal cancer pain, and the eventual factors associated with its presentation. METHODS Patients with abdominal visceral cancer presenting BTcP were included in the analysis. Pain intensity, current analgesic therapy, number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset (≤10 minutes or >10 minutes), duration, interference with daily activities, medications and doses currently used for BTcP, and time to meaningful pain relief were collected. Adverse effects imputable to a BTcP medication were recorded. RESULTS Four hundred fourteen patients were included in the study. The mean background pain was 2.7 (SD 1.19) and most patients (97.6%) were receiving opioids. The mean number of BTcP episodes/day was 2.2 (SD 1.51). The mean intensity of BTcP was 7.3 (SD 1.32). BTcP onset was ≤10 minutes and >10 minutes in 271 (65.5%) and 143 patients (35.5%), respectively, and the mean duration was 52.6 minutes (SD 38.1). Interference of BTcP with daily activity was relevant for 340 patients (82%). In 122 patients (29.5%), BTcP was predictable and ingestion of food (n = 63, 51.6%) was the most frequent trigger. In comparison with unpredictable BTcP, postprandial BTcP had a lower intensity (P = 0.039), had a faster onset (P = 0.042), and was associated with the use of oxycodone/naloxone (P = 0.003), and less use of nonsteroidal anti-inflammatory drugs (P = 0.006). CONCLUSION Patients with abdominal visceral BTcP represent a subgroup with specific features of BTcP, particularly those with predictable BTcP. Ingestion of food was the prominent trigger for BTcP, having a faster onset and a lower intensity. This group of patients more frequently used oxycodone/naloxone or no anti-inflammatory drugs. These findings suggest consequential therapeutic decisions.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy.
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Marco Valenti
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Federica Aielli
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
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Rollman JE, Heyward J, Olson L, Lurie P, Sharfstein J, Alexander GC. Assessment of the FDA Risk Evaluation and Mitigation Strategy for Transmucosal Immediate-Release Fentanyl Products. JAMA 2019; 321:676-685. [PMID: 30778596 PMCID: PMC6439622 DOI: 10.1001/jama.2019.0235] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Transmucosal immediate-release fentanyls (TIRFs), indicated solely for breakthrough cancer pain in opioid-tolerant patients, are subject to a US Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy (REMS) to prevent them from being prescribed inappropriately. OBJECTIVES To evaluate knowledge assessments of pharmacists, prescribers, and patients regarding appropriate TIRF use; to describe sponsor assessments, based on claims data, of whether the REMS program was meeting its goals; and to characterize how the FDA responded to REMS assessments. DESIGN, SETTING, AND PARTICIPANTS Qualitative analysis of 4877 pages of FDA documents obtained through a Freedom of Information Act request, including 6 annual REMS assessment reports (2012-2017), FDA evaluations of these reports, and FDA-sponsor correspondence about safety issues. EXPOSURE A REMS program to reduce the risk of adverse outcomes, including misuse, abuse, addiction, and overdose, arising from use of TIRFs. MAIN OUTCOMES AND MEASURES (1) Knowledge assessments of pharmacists, prescribers, and patients; (2) survey and claims-based prescribing assessments; (3) FDA and TIRF sponsor communications; (4) modifications to the REMS program; and (5) disenrollment of noncompliant prescribers. RESULTS Twelve months after initiation of the program, 24 of 302 pharmacists (7.9%), 35 of 302 prescribers (11.6%), and 5 of 192 patients (2.6%) incorrectly reported that TIRFs can be prescribed to opioid-nontolerant patients, with similar levels of misunderstanding maintained in the subsequent reports. At 60 months, product-specific analyses of claims data indicated that between 34.6% and 55.4% of patients prescribed TIRFs were opioid-nontolerant. In the 48-month survey, 106 of 310 prescribers (34.2%) reported prescribing TIRFs for opioid-tolerant patients with chronic, noncancer pain; at 60 months, 54 of 302 prescribers (18.4%) and 148 of 310 patients (47.7%) erroneously reported that TIRFs were FDA-approved for such use. Over the 60-month period examined, there were few substantive changes made to the REMS to address evidence of high rates of off-label TIRF use, and, although the REMS program had a noncompliance plan, there was no report of prescribers being disenrolled for inappropriate prescribing. CONCLUSIONS AND RELEVANCE In this review of FDA documents pertaining to the TIRF REMS, surveys of pharmacists, prescribers, and patients reflected generally high levels of knowledge regarding proper TIRF prescribing, yet some survey items as well as claims-based analyses indicated substantial rates of inappropriate TIRF use. Despite these findings, the FDA did not require substantive changes to the program.
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Affiliation(s)
- Jeffrey Eric Rollman
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - James Heyward
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lily Olson
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Peter Lurie
- Center for Science in the Public Interest, Washington, DC
| | - Joshua Sharfstein
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Office of Public Health Practice and Training, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland
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Barbato M, Barclay G, Potter J, Yeo W. Breakthrough Medication in Unresponsive Palliative Care Patients: Indications, Practice, and Efficacy. J Pain Symptom Manage 2018; 56:944-950. [PMID: 30201486 DOI: 10.1016/j.jpainsymman.2018.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 07/27/2018] [Revised: 08/26/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT An unresponsive patient's need and their response to breakthrough medication is determined by clinical assessment and/or observational measures. How closely these methods match the patient's experience is unknown. OBJECTIVES Determine the efficacy and effectiveness of breakthrough medication in unresponsive patients and the perception of patient comfort made by nurses and family. METHODS A prospective study of breakthrough medication in unresponsive patients. The Richmond Agitation-Sedation Scale (RASS) and Patient Comfort Score (PCS) were compared with time-matched Bispectral Index (BIS) Scores. The effects of opioid vs. opioid + benzodiazepine breakthroughs and the relation between synchronous nurse and family measurements of the PCS were evaluated. Analysis of variance and paired t-tests were used for BIS analyses and nonparametric Mann-Whitney tests for RASS and PCS. RESULTS Significant reductions at 30 and 60 minutes after breakthrough medication were noted for BIS (P < 0.0004), RASS (P = 0.043 and 0.004, respectively), and PCS (P < 0.0004). A direct comparison of the effect of opioid breakthrough medication vs. opioid plus benzodiazepine revealed no significant difference (BIS, P = 0.512; RASS, P = 0.195; PCS, P = 0.119). Of the 157 synchronous nurse and family measures of patient comfort, families rated patient discomfort significantly higher than nurses (P < 0.0004). CONCLUSION This study provides additional evidence for the efficacy and effectiveness of breakthrough medication and the merit of observational measures in determining a patient's response. The onset of action is evident at 30 minutes after injection. Family assessment of patient comfort may be more nuanced than that of nurses, and they not uncommonly rate patient discomfort higher than nurses.
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Affiliation(s)
- Michael Barbato
- Palliative Care Services, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia.
| | - Greg Barclay
- Palliative Care Services, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia; School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Jan Potter
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
| | - Wilf Yeo
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
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24
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Yen TY, Chiou JF, Chiang WY, Su WH, Huang MY, Hu MH, Wu SC, Lai YL. Proportional dose of rapid-onset opioid in breakthrough cancer pain management: An open-label, multicenter study. Medicine (Baltimore) 2018; 97:e11593. [PMID: 30045291 PMCID: PMC6078661 DOI: 10.1097/md.0000000000011593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The management of breakthrough pain (BTP) in cancer patients is a challenge. It is clinically useful to evaluate the effectiveness of rapid-onset opioid at a starting dose in proportional to the background opioid regimen. This open-label, multicenter, noncomparative study aimed to assess the efficacy and safety of proportional doses of fentanyl buccal soluble film (FBSF) in patients with breakthrough cancer pain. METHODS Thirty patients aged 20 to 70, experiencing 1 to 3 BTP per day, receiving regimens equivalent to 60 to 360 mg/day of oral morphine or 25 to 150 μg/h of transdermal fentanyl ≥1 week, were prospectively recruited. FBSF was administered proportionally based on their current opioid regimen for baseline pain. The percentage of patients requiring dose titration was evaluated. For each BTP episode, changes in pain intensity at 30 minutes (PID30) after dosing, patient's satisfaction, the percentage of episodes requiring rescue medication, and adverse events (AEs) were recorded. RESULTS The percentage of patients who required dose titration was 21.4% (6/28) and 12.0% (3/25) in the full analysis set and per-protocol populations, respectively. The average PID30 was 3.9, and a pain score ≤3 was achieved in 95.1% of the events. Eight out of 367 (2.2%) BTP episodes needed rescue medication. The majority of subjects (75.8%) rated their experience of pain management as good to excellent. A total of 6 drug-related AEs were reported by 3 (10.7%) patients in the safety population. CONCLUSIONS FBSF dose in proportional to the regimen of opioid for baseline pain management is efficacious and well tolerated for the treatment of cancer patients with BTP.
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Affiliation(s)
- Tsung-Yu Yen
- Department of Radiation Oncology
- Hospice and Palliative Care Center, MacKay Memorial Hospital
| | - Jeng-Fong Chiou
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University
- Department of Radiation Oncology, Taipei Medical University Hospital
- Taipei Cancer Center, Taipei Medical University
- Cancer Center, Taipei Medical University Hospital, Taipei
| | | | - Wen-Hao Su
- Hospice and Palliative Care Center, MacKay Memorial Hospital
| | - Ming-Yuan Huang
- Hospice and Palliative Care Center, MacKay Memorial Hospital
| | - Ming-Hung Hu
- Division of Hematology and Oncology, Department of Medicine, Cardinal Tien Hospital
- School of Medicine, Fu Jen Catholic University, New Taipei
| | - Shen-Chi Wu
- Cancer Center, Taipei Medical University Hospital, Taipei
- Department of Hospice and Palliative Care, Taipei
| | - Yuen-Liang Lai
- Department of Radiation Oncology
- Hospice and Palliative Care Center, MacKay Memorial Hospital
- MacKay Medical College, New Taipei, Taiwan
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25
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Bangash AA, Durrani Z. Effectiveness of acetaminophen in control of breakthrough pain: Randomized controlled trial. J PAK MED ASSOC 2018; 68:994-1001. [PMID: 30317290] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To reduce postoperative pain by using additional analgesic agent in between the usual parenteral analgesia that is used in the postoperative period in surgical patients. METHODS The double-blind, randomised control intervention was conducted from June to November 2015 at Rehman Medical Institute, Peshawar, Pakistan, and comprised postoperative surgical patients of either gender aged 18 or more who had undergone uneventful elective surgery The subjects were divided into test and placebo groups. In the test group, 1gm acetaminophen was additionally prescribed, while in the control group placebo (starch) was administered. Demographics were noted and pain score was recorded using three internationally validated pain scales; Verbal pain intensity scale, Visual analogue scale, and Numeric pain scale. SPSS version 15.0 is used for calculation. Data was collected twice over 48 hours. RESULTS Out of 220 patients, 165(75 %) were male with mean age 31.5±1.93 years and 55(25%) were female with mean age 31.5±1.48 years. There were 118(53.6%) patients in the test group and 102(43.4%) in the control group. In the first 24 hours the cumulative pain score, from numeric pain scale and visual analogue scale, for the control group showed 5(4.90%) patients had no pain, 39(38.24%) had mild pain, 52(50.98%) moderate pain and 6(5.80%) had severe pain. In the test group, 13(11.02%) reported no pain, 83(70.34%) had mild pain, 19(16%) had moderate pain while 3(2.54%) complained of severe pain. In the next 48 hours cumulative pain score in the test group showed 44(37.29%)subjects had no pain, 67(56.78%) had mild pain, 6(5.08%) had moderate pain, 1(0.85%) had severe pain, while in the control group 10(10%) had no pain, 56(55%) had mild pain, 33(32%) had moderate pain and 3(3%) had severe pain. . CONCLUSIONS Additional acetaminophen reduced mild to moderate pain between two doses of parenteral analgesia.
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Kwon MY, Cho HN, Koo DH, Lee YG, Oh S, Lee SS. Initial titration with 200 μg fentanyl buccal tablets: a retrospective safety analysis in Korean cancer patients. Korean J Intern Med 2018; 33:577-584. [PMID: 28111431 PMCID: PMC5943645 DOI: 10.3904/kjim.2016.044] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/AIMS Managing breakthrough pain (BTP) is important for many cancer patients because of the rapid onset and unpredictable nature of the pain episodes. Fentanyl buccal tablets (FBTs) are a rapid-onset opioid indicated for BTP management. However, FBT titration is needed to optimize BTP management. In this study, we aimed to evaluate the safety and efficacy of initiating 200 μg FBTs in Korean cancer patients. METHODS A retrospective analysis of medical records was performed on all advanced cancer patients treated with FBTs for BTP between October 2014 and July 2015. Patients who received initial doses of 200 μg FBTs for at least 3 days and cases in which FBT was available at doses of 200, 400, and 800 μg were included. RESULTS A total of 56 patients with a median age of 62 years (range, 32 to 80) were analyzed, 61% of whom were male. The median and mean values of morphine equivalent daily doses were 60 mg/day (range, 15 to 540) and 114.8 ± 124.8 mg/day, respectively. The most frequent effective doses of FBT were 200 μg (41 patients, 74%) and 400 μg (12 patients, 21%). Three patients (5%) could not tolerate 200 μg of FBT and discontinued treatment. Nausea, vomiting, somnolence, and dizziness were the most frequent treatment-related adverse events (AEs), and all AEs were grade 1 (mild) or 2 (moderate). CONCLUSIONS FBT at the initial 200 μg dosage was well-tolerated and effective as a BTP management strategy in Korean cancer patients. Further prospective studies are needed to determine appropriate initiating doses of FBT in Korean patients with opioid tolerance.
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Affiliation(s)
- Mi-Young Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Ha-Na Cho
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Dong-Hoe Koo
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence to Dong-Hoe Koo, M.D. Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Korea Tel: +82-2-2001-8330 Fax: +82-2-2001-8360 E-mail:
| | - Yun-Gyoo Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sukjoong Oh
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Sei Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Phan J, Pollard C, Brown PD, Guha-Thakurta N, Garden AS, Rosenthal DI, Fuller CD, Frank SJ, Gunn GB, Morrison WH, Ho JC, Li J, Ghia AJ, Yang JN, Luo D, Wang HC, Su SY, Raza SM, Gidley PW, Hanna EY, DeMonte F. Stereotactic radiosurgery for trigeminal pain secondary to recurrent malignant skull base tumors. J Neurosurg 2018; 130:812-821. [PMID: 29701557 DOI: 10.3171/2017.11.jns172084] [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] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/10/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to assess outcomes after Gamma Knife radiosurgery (GKRS) re-irradiation for palliation of patients with trigeminal pain secondary to recurrent malignant skull base tumors. METHODS From 2009 to 2016, 26 patients who had previously undergone radiation treatment to the head and neck received GKRS for palliation of trigeminal neuropathic pain secondary to recurrence of malignant skull base tumors. Twenty-two patients received single-fraction GKRS to a median dose of 17 Gy (range 15-20 Gy) prescribed to the 50% isodose line (range 43%-55%). Four patients received fractionated Gamma Knife Extend therapy to a median dose of 24 Gy in 3 fractions (range 21-27 Gy) prescribed to the 50% isodose line (range 45%-50%). Those with at least a 3-month follow-up were assessed for symptom palliation. Self-reported pain was evaluated by the numeric rating scale (NRS) and MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) pain score. Frequency of as-needed (PRN) analgesic use and opioid requirement were also assessed. Baseline opioid dose was reported as a fentanyl-equivalent dose (FED) and PRN for breakthrough pain use as oral morphine-equivalent dose (OMED). The chi-square and Student t-tests were used to determine differences before and after GKRS. RESULTS Seven patients (29%) were excluded due to local disease progression. Two experienced progression at the first follow-up, and 5 had local recurrence from disease outside the GKRS volume. Nineteen patients were assessed for symptom palliation with a median follow-up duration of 10.4 months (range 3.0-34.4 months). At 3 months after GKRS, the NRS scores (n = 19) decreased from 4.65 ± 3.45 to 1.47 ± 2.11 (p < 0.001); MDASI-HN pain scores (n = 13) decreased from 5.02 ± 1.68 to 2.02 ± 1.54 (p < 0.01); scheduled FED (n = 19) decreased from 62.4 ± 102.1 to 27.9 ± 45.5 mcg/hr (p < 0.01); PRN OMED (n = 19) decreased from 43.9 ± 77.5 to 10.9 ± 20.8 mg/day (p = 0.02); and frequency of any PRN analgesic use (n = 19) decreased from 0.49 ± 0.55 to 1.33 ± 0.90 per day (p = 0.08). At 6 months after GKRS, 9 (56%) of 16 patients reported being pain free (NRS score 0), with 6 (67%) of the 9 being both pain free and not requiring analgesic medications. One patient treated early in our experience developed a temporary increase in trigeminal pain 3-4 days after GKRS requiring hospitalization. All subsequently treated patients were given a single dose of intravenous steroids immediately after GKRS followed by a 2-3-week oral steroid taper. No further cases of increased or new pain after treatment were observed after this intervention. CONCLUSIONS GKRS for palliation of trigeminal pain secondary to recurrent malignant skull base tumors demonstrated a significant decrease in patient-reported pain and opioid requirement. Additional patients and a longer follow-up duration are needed to assess durability of symptom relief and local control.
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Affiliation(s)
| | | | - Paul D Brown
- 6Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Nandita Guha-Thakurta
- 5Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | | | | | | | | | | | | | | | - Jing Li
- Departments of1Radiation Oncology
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Rodríguez MJ, de la Torre R, Ortega JL, Trinidad JM, Benítez D, Jiménez AJ, Sanz-Yagüe A, Soler B, Torres LM. Evaluation of the quality of care of elderly patients with chronic and breakthrough pain treated with opioids: SAND study. Curr Med Res Opin 2018; 34:701-709. [PMID: 28914555 DOI: 10.1080/03007995.2017.1380618] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the quality of care of elderly patients with treatment for chronic pain (CP) and breakthrough pain (BTP). METHODS A cross-sectional observational study was conducted in 20 pain units, selecting patients aged 70 years or older with baseline controlled CP in treatment with opioids and a diagnosis of BTP. Patients were classified as first episode of BTP or patient in follow-up. The patients completed the SF-12 quality of life questionnaire, Brief Pain Inventory, Lattinen Index, and Edmonton Symptoms Assessment Scale. The patient's satisfaction with the treatment was evaluated through a visual analogue scale (VAS). RESULTS A total of 199 patients were included with 67.7% women (132). There were 28.5% (55) attending the first visit for BTP and 71.5% (138) were on follow-up visits. On the physical component of the SF-12, 95% had a score below the mean for the Spanish general population and 44% had a score below the mean on the mental component. Worse scores were observed for women in the bodily pain dimension (p = .032) and in the overall physical component (p = .045). There were 62.9% (112) patients satisfied with the treatment for BTP. In the multivariate analysis, SF-12 physical component scores (p = .017) and patient's satisfaction with BTP treatment was better in follow-up visits (p = .031). CONCLUSIONS All clinical parameters compared between first visit for the treatment of BTP and follow-up visits were improved, so the quality of care was also considered improved. Elderly women and non-oncologic patients were observed to be the population with worse symptom control.
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Affiliation(s)
| | | | | | | | - Diego Benítez
- b Fundación Andaluza para el Tratamiento del Dolor , Sevilla , Spain
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Mercadante S. Non pharmacological interventions and non-fentanyl pharmacological treatments for breakthrough cancer pain: A systematic and critical review. Crit Rev Oncol Hematol 2017; 122:60-63. [PMID: 29458790 DOI: 10.1016/j.critrevonc.2017.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/21/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oral opioids or other pharmacological or non-pharmacological interventions are often suggested in the management of breakthrough cancer pain (BTcP). The aim of this systematic and critical review was to analyse and critically comment the evidence of any non-fentanyl therapies proposed for BTcP. METHODS A systematic literature search was carried out to find studies providing clinical data on any treatment excluding fentanyl products. RESULTS No data exist about the use of oral opioids. Some information is available on parenteral morphine in a large sample of patients and episodes of BTcP. For other treatments, including methadone, nitrous oxide, anti-inflammatory drugs, samarium, and gabapentin the existing data, observational and obtained in a small number of patients do not provide useful information to be generalized. Only ketamine, a drug difficult to use for many physicians, particularly in determined setting, provided some evidence according a randomized controlled double-blind study. CONCLUSIONS Recommendations suggesting the use of oral opioids or other pharmacological and non-pharmacologic interventions for BTcP, are not based on any, even minimal evidence. These treatments are worthwhile of further investigation, particularly in determined conditions that should fit the pharmacokinetics of oral opioids.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia & Intensive Care and Pain relief & Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90145, Italy; SAMO, Palermo, Italy; University of Texas, USA; University of Palermo, Italy.
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Überall MA. [Transmucosal fentanyl administration: sublingual, buccal, nasal - all the same? Treatment of breakthrough cancer pain]. MMW Fortschr Med 2017; 159:15-22. [PMID: 29557092 DOI: 10.1007/s15006-017-0081-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/02/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND Transient exacerbation of pain in cancer patients (breakthrough cancer pain, BTCP) despite adequately controlled background pain should be regarded as an independent disease and receive targeted treatment. The opioid of choice is fentanyl, a rapid onset and highly potent WHO category III analgesic. Fentanyl has a strong first pass effect when administered orally and resorbed enterally, however it is well suited for transmucosal administration, e.g. on the oral or nasal mucosa. Seven different preparations of rapid onset fentanyl for transmucosal administration via various administration pathways are currently available in Germany. SCIENTIFIC PROBLEM AND METHOD The aim of this review article was to determine which patient can benefit most from which forms of administration. Since there are hardly any direct comparisons of administration forms among each other, meta-analyses and reviews were included in the assessment. RESULTS AND CONCLUSION Tablets with an applicator (lozenge), sublingual and buccal tablets, as well as a buccal film are available for the oral transmucosal administration of fentanyl; there is an aqueous fentanyl nasal spray and a pectin-rich nasal spray for nasal transmucosal administration. The individual preparations differ considerably with regard to their pharmacological (e.g. bioavailability, cmax and tmax) and patient-relevant parameters (e.g. onset of action, potency and duration of effect). Fentanyl nasal spray is superior to the other forms of administration in terms of rapid onset of action and clinically relevant pain reduction and can thus be recommended as a treatment option for rapidly evolving and/or spontaneously occurring breakthrough cancer pain.
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Affiliation(s)
- Michael A Überall
- IFNAP - Institut für Neurowissenschaften, Algesiologie & Pädiatrie, Nordostpark 51, 90411, Nürnberg, Deutschland.
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Guitart J, Vargas MI, De Sanctis V, Folch J, Salazar R, Fuentes J, Coma J, Ferreras J, Moya J, Tomás A, Estivill P, Rodelas F, Jiménez AJ, Sanz A. Breakthrough Pain Management with Sublingual Fentanyl Tablets in Patients with Cancer: Age Subgroup Analysis of a Multicenter Prospective Study. Drugs R D 2017; 17:419-425. [PMID: 28744772 PMCID: PMC5629138 DOI: 10.1007/s40268-017-0198-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Breakthrough pain (BTP) management in patients with cancer is challenging, especially in the elderly. However, no studies examining the influence of age on BTP medication have been conducted. The aim of this work was to investigate the effect of sublingual fentanyl tablets (SFTs) in terms of efficacy, safety, and quality of life in two age categories. METHODS We performed age subgroup analyses (<65 and ≥65 years) from a recently completed study conducted in Spain. Pain intensity (PI), onset of pain relief, frequency and duration of BTP episodes, and adverse events (AEs) were assessed at 3, 7, 15, and 30 days. Health-status instruments used were the Short Form 12, version 2 (SF-12v2) questionnaire, and the Hospital Anxiety and Depression Scale (HADS-A and HADS-D). RESULTS Twenty-six patients were aged <65 years and 54 were aged ≥65 years. SF-12v2 scores did not enhance significantly from baseline. HADS scores and PI decreased significantly at the end of the study, particularly in younger patients (HADS-A: 19.05 vs. 14.41%; HADS-D: 21.35 vs. 18.57%; PI: 67.23 vs. 56.30%). Onset of analgesia began in 2-5 min in 63.3% of subjects aged <65 years and in 36.4% of subjects aged >65 years. Most patients experienced one to five daily episodes after 30 days, and <5% needed a treatment change. AEs were less frequently reported in older individuals (20.5 vs. 36.4%). CONCLUSION Age subgroup analyses suggest that SFTs are an effective and safe treatment for the management of BTP in cancer patients of all ages. SFTs may offer a well-tolerated and efficient option to control cancer BTP in the elderly.
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Affiliation(s)
- Jordi Guitart
- Department of Anesthesiology, Hospital Plató, C/Plató 21, 08006, Barcelona, Spain.
| | - María Isabel Vargas
- Department of Anesthesiology, Parc Sanitari Sant Joan de Deu, Barcelona, Spain
| | - Vicente De Sanctis
- Pain Unit, Department of Anesthesiology, Hospital Universitari Sagrat Cor, Barcelona, Spain
| | - Jordi Folch
- Department of Anesthesiology, Hospital Plató, C/Plató 21, 08006, Barcelona, Spain
| | - Rafael Salazar
- Department of Anesthesiology, Hospital Comarcal d'Inca, Palma de Mallorca, Spain
| | - José Fuentes
- Department of Anesthesiology, Pius Hospital de Valls, Tarragona, Spain
| | - Joan Coma
- Department of Anesthesiology, Hospital General de l'Hospitalet, Barcelona, Spain
| | - Julia Ferreras
- Pain Unit, Department of Anesthesiology, Hospital Residència Sant Camil, Barcelona, Spain
| | - Jordi Moya
- Pain Unit, Department of Anesthesiology, Hospital Mateu Orfila, Menorca, Spain
| | - Albert Tomás
- Pain Unit, Department of Anesthesiology, Fundació Hospital Sant Bernabé, Barcelona, Spain
| | - Pere Estivill
- Department of Anesthesiology, Parc Sanitari Sant Joan de Deu, Barcelona, Spain
| | - Francisco Rodelas
- Department of Anesthesiology, Hospital Comarcal d'Inca, Palma de Mallorca, Spain
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Abstract
INTRODUCTION This research was to follow characteristics of breakthrough pain caused by cancer (BTcP) and other most common sympthoms (ESAS) at patients in advanced stage of cancer disease in palliative care. PATIENTS AND METHODS Prospective study included 433 patients which were treated in Palliative Care Centre in UKC Tuzla, Bosnia and Herzegovina. Group 1 was consisted of 353 patients whose basal cancer pain of intensity 4-7 NRS was treated weak opiates (basal analgetic- fixed combination of tramadol/paracetamol (37.5 mg/325 mg) in initial dose 3x1tbl for pain intensity 4, to 4x2tbl (for pain intensity 7). In Group 2 (80 patients) basal pain of intensity 8-10 was treated strong opiates as basal analgetic (oral morphine and transdermal fentanil). If the previous day were 2 or more breakthrough pain that required ''rescue dose'' of analgetics (tramadol 50-100 mg orally in group 1 ie. Oral morphine 8-12 mg in the group 2), the dose of basal analgetic was increased. RESULTS The total number of reported breakthrough pain in all 433 patients for 10 days of treatment was 3 369 (0.78 BTcP /per patient/day), where at Group 1 patients showed significantly lower BTcP (0.56 BTcP/patient/day). The average intensity of BTcP was 5.91 where in the Group1 was 4.51 while in the Group 2 8.04. 582 (17.28%) was rated grade 7, of which 539 were successfully coupled by strong and 43 (7.39%) successfully coupled by weak opiates. From 556 BTcP who were rated with 8, 540 of them were coupled strong and only 16 successfully coupled by weak opiates. 1967 (58.39 %) of breakthrough pain has occured in the evening hours (18-06 h), while 1402 (41.62%) BTCP occured during day hours (06-18h). Most (1290 or 38.29%) of breakthrough pain lasted less than 10 minutes, 882 (26.18%) between 16 and 20 minutes, 752 (22.32%) between 11 and 15 minutes, 407 (12.8%) between 21 and 30 minutes and 38 (1.13%) lasted longer than 20 minutes. CONCLUSION Duriong our study, we noted a relatively large number of breakthrough pain with lower intensity (3-6) in patients treated with weak opiates, which are also adversely affected patients satisfaction with pain treatment and required additional doses of analgetics. In the small percentage is possible the breakthrough pain of stronger intensity (7-8) treat by maximum doses of weak opiates.
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Affiliation(s)
- Samir Husic
- Center for Palliative Care, Univerzity Clinical Center Tuzla, Bosnia and Herzegovina
| | - Semir Imamovic
- Clinic for anesthesia and reanimation, Univerzity Clinical Center Tuzla, Bosnia and Herzegovina
| | - Srecko Matic
- Public Health Institution, Primary Health Care Center Ljubuski, Bosnia and Herzegovina
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Yomiya K, Kaneshima M, Kyosaka B, Warita E, Hosonuma R, Osato S. [A New Therapeutic Approach for Cancer-Related Breakthrough Pain - Focused on Oral Transmucosal Fentanyl]. Gan To Kagaku Ryoho 2017; 44:289-293. [PMID: 28428506] [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: 06/07/2023]
Abstract
In 2013, oral transmucosal fentanyl was first approved in Japan for reducing breakthrough pain(BTP). The development of BTP may contribute to less-effective analgesia, a reduced satisfaction with analgesia therapy, obstacles in daily life, mood disorders, and an increased use of healthcare resources. In most BTP, both the duration from BTP onset to its maximum intensity and the overall duration of BTP episodes are relatively short. The need for improved rapid pain relief for BTP in this setting has led to the development of rapid-onset opioids(ROOs), including oral transmucosal fentanyl citrate(OTFC). OTFC is characterized by a rapid onset and short duration of action. Therefore, the drug is optimally indicated for BTP in patients whose pain cannot be sufficiently controlled by the rapid-release preparation, and whose sleepiness due to the carry-over effect of analgesic action interferes with daily living. In addition, the drug can be used for patients who find it difficult to use oral preparations. Furthermore, since fentanyl is the main active ingredient, less severe side effects, such as constipation, are expected. OTFC may also be safely used for patients with renal dysfunction. Since the drug has many characteristics that differ from conventional rapid-release preparations, it is important to become familiar with the use of OTFC. In order to address improving the QOL of cancer patients, a comprehensive assessment of the patient, including the risk of BTP being inadequately controlled by conventional rescue preparations is necessary.
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Liu Q, Wang Y, Luo XJ, Wang NJ, Chen P, Jin X, Mu GX, Chai XM, Zhang YJ, Li YX, Yu JQ. A fixed inhaled nitrous oxide/oxygen mixture as an analgesic for adult cancer patients with breakthrough pain: study protocol for a randomized controlled trial. Trials 2017; 18:13. [PMID: 28077162 PMCID: PMC5225628 DOI: 10.1186/s13063-016-1739-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 12/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The management of breakthrough pain in cancer patients is always a challenge for medical professions. Occurring in 80% of cancer patients with advanced disease, breakthrough pain significantly decreases both patient's and caregiver's quality of life. The aim of this study is to assess the analgesic efficacy of a fixed inhaled nitrous oxide/oxygen mixture for adult cancer patients with breakthrough pain. METHODS/DESIGN This is a randomized, placebo-controlled, double-blind study; it will be conducted in the General Hospital of Ningxia Medical University. The target study subjects are at least 18 years old, and are hospitalized cancer patients who are receiving routine opioids to control cancer-related pain but still experience breakthrough pain. A total of 240 patients will be recruited and randomly allocated between three treatment groups (A, B, C) and a control group (group D) in a ratio of 3:1. All treatment groups (A, B, C) will receive standard pain treatment (oral immediate-release morphine) plus a pre-prepared nitrous oxide/oxygen mixture, and the control group (D) will receive the standard pain treatment plus oxygen. Patients, doctors, nurses, and data collectors are all blind to the experiment. Assessments will be taken before treatment (T0), at 5 min (T1) and 15 min (T2) during treatment, and at 5 min after treatment (T3). The primary endpoint measures will be the percentage of patients whose pain is relieved at T1, T2, and T3. Secondary outcome measures will include the safety of treatment, adverse events, and satisfaction from both health professionals and patients. DISCUSSION This study aims to provide an effective and practical intervention for a fast breakthrough pain relief and to improve cancer patients' quality of life significantly. The Evidence-Based Medicine Working Group claim that a randomized, double-blind, placebo-controlled experimental intervention is the most appropriate design to demonstrate its efficacy, so this study could give a new approach to controlling breakthrough pain episodes. TRIAL REGISTRATION ChiCTR-INC-16008075 . Registered on 8 March 2016.
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Affiliation(s)
- Qiang Liu
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
- Yinchuan Guolong Hospital, 536 Chang Cheng Road, Xing Qing Area, Yinchuan, 750004 China
| | - Yu Wang
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
| | - Xiang-Jiang Luo
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Ning-Ju Wang
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Ping Chen
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Xin Jin
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
- Department of Nursing, Ningxia People’s Hospital, 301 Zheng Yuan Street, Yinchuan, 750004 China
| | - Guo-Xia Mu
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
| | - Xiao-Min Chai
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
| | - Yue-Juan Zhang
- Department of Medical Oncology, General Hospital of Ningxia Medical University, Yinchuan, 750004 China
| | - Yu-Xiang Li
- School of Nursing, Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
| | - Jian-Qiang Yu
- Department of Pharmacology, Pharmaceutical Institute of Ningxia Medical University, 1160 Sheng Li Street, Yinchuan, 750004 China
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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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Rogríguez D, Urrutia G, Escobar Y, Moya J, Murillo M. Efficacy and Safety of Oral or Nasal Fentanyl for Treatment of Breakthrough Pain in Cancer Patients: A Systematic Review. J Pain Palliat Care Pharmacother 2016; 29:228-46. [PMID: 26458018 DOI: 10.3109/15360288.2015.1047554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Formulations of fentanyl that use buccal, sublingual, or nasal transmucosal routes of administration have been developed for the treatment of BTP in opioid-tolerant patients with cancer. The purposes of this analysis were to identify and review published data describing the efficacy and safety of different oral or nasal transmucosal fentanyl formulations for treatment of cancer-related BTP, based on a critical analysis of scientific literature. Oral transmucosal or intranasal fentanyl is an effective treatment for management of BTP episodes due to a potent analgesic effect, rapid onset of action, and sustained effect. Furthermore, it is a reasonably safe treatment, causing generally mild adverse events not leading to treatment discontinuation. Nevertheless, further progress in standardizing methodology, definitions, and criteria used both in research and in clinical practice is needed in order to generate quality information allowing a better understanding of the comparable efficacy of available formulations of fentanyl. A more rigorous assessment of long-term safety is also needed to establish a balance between benefits and risks of the available options.
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Abstract
The term "breakthrough cancer pain" (BTcP) was introduced about 25 years ago. Peaks of pain intensity reported in patients with cancer had been invariably examined in the past years, providing relevant information for a better knowledge of this phenomenon and its treatment. The aim of this critical review was to provide the golden rules, namely, the 10 commandments, for a correct diagnostic pathway of BTcP and a consequent personalized pharmacological treatment. These are as follows: 1) assessment of background analgesia, 2) drugs used for background analgesia, 3) BTcP is a frequent phenomenon, 4) characteristics of BTcP, 5) diagnosis of BTcP, 6) continuous assessment, 7) tailored pharmacological treatment of BTcP, 8) selection of BTcP medication, 9) dosing BTcP medications, and 10) education. These steps may help clinicians to recognize and treat BTcP adequately.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Arturo Cuomo
- Anesthesia, Intensive care and Pain Therapy, National Cancer Institute, "Pascale", Naples, Italy
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Mercadante S, Aielli F, Adile C, Costanzi A, Casuccio A. Fentanyl Pectin Nasal Spray Versus Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Comparative Study. J Pain Symptom Manage 2016; 52:27-34. [PMID: 27208863 DOI: 10.1016/j.jpainsymman.2016.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 12/22/2015] [Revised: 01/14/2016] [Accepted: 02/13/2016] [Indexed: 11/21/2022]
Abstract
CONTEXT Fentanyl products have shown superiority over oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use an appropriate patient selection, and drugs have been compared using a different rationale. OBJECTIVES The aim of this randomized, crossover, controlled study was to compare the efficacy and safety of fentanyl pectin nasal spray (FPNS) and oral morphine (OM), given in doses proportional to opioid daily doses. METHODS Cancer patients with pain receiving ≥60 mg of OM equivalents/day and presenting with ≤3 episodes of BTcP/day were included. Patients received, in a randomized, crossover manner, FPNS or OM at doses proportional to the daily opioid regimen in four consecutive episodes of BTcP. Pain intensity was measured before (T0), 15 (T15), and 30 minutes (T30) after study drugs. RESULTS A total of 167 episodes were treated, 82 with FNPS and 85 with OM. A statistical difference in pain intensity between the two groups was observed at T15, but not at T30 (P = 0.018 and P = 0.204, respectively). In a greater number of episodes treated with FPNS, there was a pain decrease of ≥33% in comparison with OM after 15 and 30 minutes (76.5% vs. 32.8%, and 89% vs. 54.9%, respectively). Similar differences were found in the decrease in pain intensity of ≥50% after 15 and 30 minutes (52.3% vs. 11.4%, and 75% vs. 45.8%, respectively). The difference was highly significant at T15 (P < 0.0005). The mean (SD) pain difference at T15 of FPNS and OM were 3.24 (1.7) and 2.70 (1.2), respectively, whereas the mean (SD) SPIDs30 of FPNS and OM were 4.87 (1.7) and 4.54 (1.5), respectively. The difference was highly significant at T15 (P = 0.019). No severe adverse effects after study drug administration were observed. CONCLUSION When used in doses proportional to the basal opioid regimen, FPNS showed a superior analgesic effect over OM for the management of BTcP. Only minor adverse effects were found with both medications.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Andrea Costanzi
- Department of Oncology, Hospital Sant'Andrea, University of Rome, Rome, Italy
| | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
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Guitart J, Vargas MI, De Sanctis V, Folch J, Salazar R, Fuentes J, Coma J, Ferreras J, Moya J, Tomás A, Estivill P, Rodelas F, Jiménez AJ. Sublingual Fentanyl Tablets for Relief of Breakthrough Pain in Cancer Patients and Association with Quality-of-Life Outcomes. Clin Drug Investig 2016; 35:815-22. [PMID: 26507617 DOI: 10.1007/s40261-015-0344-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Breakthrough pain (BTP) is highly prevalent in patients with cancer and is strongly associated with adverse outcomes related to health status, mood, anxiety and depression. However, studies on the effect of BTP medication on quality of life (QOL) are lacking. The purpose of this study was to provide a qualitative evaluation of the effect of sublingual fentanyl tablets (SFT), a therapy specifically developed for BTP, on the QOL of cancer pain patients. METHODS We conducted a multicentre, prospective observation post-authorisation, open-label study between March and December 2013. The study consisted of a screening visit and four assessment points at 3, 7, 15 and 30 days. Pain intensity (PI), frequency of BTP, onset of pain relief and adverse events (AEs) were assessed at each visit. Anxiety and depression were evaluated using the validated Hospital Anxiety and Depression Scale (HADS) and health status using the Short Form 12, version 2 (SF-12v2) Health Survey. RESULTS Of the 102 patients considered eligible, 81 (79.4 %) were enrolled; of these, 69 (85.1 %) completed the study. Significant pain reduction was achieved for average PI (p < 0.001) compared with baseline. At the end of the observational period, HADS scores showed significant improvement in the depression subscale (p = 0.005) and the anxiety subscale (p < 0.001). Similarly, SF-12 scores showed significant improvement, both in the mental component score (p < 0.001) and the physical component score (p = 0.002). SFT was well-tolerated and only one patient withdrew from the study due to drug-related AEs. CONCLUSION SFT represents an effective, well-tolerated treatment for cancer BTP. Results provide consistent evidence for the positive impact of SFT on health-related QOL and physical functioning as well as other co-morbidities of cancer BTP such as anxiety and depression.
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Affiliation(s)
- Jordi Guitart
- Department of Anesthesiology, Hospital Plató, c/ Plató 21., 08006, Barcelona, Spain.
| | - María Isabel Vargas
- Department of Anesthesiology, Parc Sanitari Sant Joan de Deu, Barcelona, Spain
| | - Vicente De Sanctis
- Pain Unit, Department of Anesthesiology, Hospital Universitari Sagrat Cor, Barcelona, Spain
| | - Jordi Folch
- Department of Anesthesiology, Hospital Plató, c/ Plató 21., 08006, Barcelona, Spain
| | - Rafael Salazar
- Department of Anesthesiology, Hospital Comarcal d'Inca, Palma de Mallorca, Spain
| | - José Fuentes
- Department of Anesthesiology, Pius Hospital de Valls, Tarragona, Spain
| | - Jordi Coma
- Department of Anesthesiology, Hospital General de l'Hospitalet, Barcelona, Spain
| | - Julia Ferreras
- Pain Unit, Department of Anesthesiology, Hospital Residència Sant Camil, Barcelona, Spain
| | - Jordi Moya
- Pain Unit, Department of Anesthesiology, Hospital Mateu Orfila, Minorca, Spain
| | - Albert Tomás
- Pain Unit, Department of Anesthesiology, Fundació Hospital Sant Bernabé, Barcelona, Spain
| | - Pere Estivill
- Department of Anesthesiology, Parc Sanitari Sant Joan de Deu, Barcelona, Spain
| | - Francisco Rodelas
- Department of Anesthesiology, Hospital Comarcal d'Inca, Palma de Mallorca, Spain
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Prasoon P, Gupta S, Kumar R, Gautam M, Kaler S, Ray SB. Role of fosaprepitant, a neurokinin Type 1 receptor antagonist, in morphine-induced antinociception in rats. Indian J Pharmacol 2016; 48:394-398. [PMID: 27756950 PMCID: PMC4980927 DOI: 10.4103/0253-7613.186198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 06/08/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Opioids such as morphine form the cornerstone in the treatment of moderate to severe pain. However, opioids also produce serious side effects such as tolerance. Fosaprepitant is a substance P (SP) receptor antagonist, which is used for treating chemotherapy-induced nausea and vomiting. SP is an important neuropeptide mediating transmission of pain at the spinal level. Thus, it was hypothesized that combining morphine with fosaprepitant would increase the antinociceptive effect of morphine. The objectives were to evaluate the effect of fosaprepitant on morphine-induced antinociception in rats and to investigate its mechanism of action. METHODS Sprague-Dawley rats were injected with morphine (10 mg/kg twice daily) and/or fosaprepitant (30 mg/kg once daily) for 7 days. Pain threshold was assessed by the hot plate test. Expression of SP and calcitonin gene-related peptide (CGRP) in the spinal cords of these rats was evaluated by immunohistochemistry. RESULTS Morphine administration resulted in an antinociceptive effect compared to the control group (day 1 and to a lesser extent on day 4). The decreased antinociception despite continued morphine treatment indicated development of tolerance. Co-administration of fosaprepitant attenuated tolerance to morphine (days 1 and 3) and increased the antinociceptive effect compared to control group (days 1-4). Expression of SP was increased in the morphine + fosaprepitant group. CONCLUSIONS The results show that fosaprepitant attenuates the development of tolerance to morphine and thereby, increases the antinociceptive effect. This is likely linked to decreased release of SP from presynaptic terminals.
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Affiliation(s)
- Pranav Prasoon
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Shivani Gupta
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Kumar
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Mayank Gautam
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Saroj Kaler
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Subrata Basu Ray
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
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Webber K, Davies AN, Cowie MR. Disparities Between Clinician and Patient Perception of Breakthrough Pain Control. J Pain Symptom Manage 2016; 51:933-937.e2. [PMID: 26740387 DOI: 10.1016/j.jpainsymman.2015.12.309] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 11/20/2014] [Revised: 12/07/2015] [Accepted: 12/15/2015] [Indexed: 11/30/2022]
Abstract
CONTEXT There are disparities in the level of symptom severity as perceived by patients and health professionals. There is limited information about patients' and clinicians' global assessment of breakthrough pain control, the need to change analgesics, and change in breakthrough pain over time. OBJECTIVES To establish whether patients and clinicians independently agree on adequacy of breakthrough pain control, management strategy, and impression of change over time. METHODS One hundred patients with breakthrough cancer pain were assessed and followed up one week later by a palliative medicine specialist. The patient and clinician independently answered the same questions about the adequacy of the patient's breakthrough pain control and breakthrough pain management. The results were compared with items on the Breakthrough Pain Assessment Tool (BAT). RESULTS At initial consultation, 35% of patients rated their breakthrough cancer pain as inadequately controlled compared with 72% of clinicians. Breakthrough pain analgesics were changed in 68% of cases. At one-week follow-up consultation, 62% of patients considered their breakthrough cancer pain to be better, and in 57% of cases, the clinicians also categorized the pain this way. CONCLUSION There are significant differences in global impressions of breakthrough pain between patients and pain clinicians that become less disparate as a therapeutic relationship evolves. Therapeutic decisions were based on clinical rather than patient perceptions.
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Affiliation(s)
- Katherine Webber
- Supportive and Palliative Care, St. Luke's Cancer Centre, Royal Surrey County Hospital, Surrey, United Kingdom.
| | - Andrew N Davies
- Supportive and Palliative Care, St. Luke's Cancer Centre, Royal Surrey County Hospital, Surrey, United Kingdom
| | - Martin R Cowie
- National Heart & Lung Institute, Imperial College, London, United Kingdom
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Romualdi P, Candeletti S. Fentanyl citrate sublingual formulation (Vellofent®) for quick BTcP hindering. Minerva Med 2016; 107:114-122. [PMID: 27064584] [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: 06/05/2023]
Abstract
The management of cancer pain presents manifold challenges: even though background pain is adequately controlled, patients frequently experience episodes of acute pain exacerbation known as breakthrough cancer pain (BTcP). The characteristics of BTcP are a rapid onset, a short duration, and a severe intensity. An innovative sublingual fentanyl citrate formulation (Vellofent®) has been developed to target BTcP. The new formulation allows to increase the solubility of fentanyl and to provide optimal oromucosal conditions for rapid drug absorption, thus featuring a shorter time to onset of pain relief (from 6 minutes post-administration).
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Affiliation(s)
- Patrizia Romualdi
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum, University of Bologna, Bologna, Italy -
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Davies A, Mundin G, Vriens J, Webber K, Buchanan A, Waghorn M. The Influence of Low Salivary Flow Rates on the Absorption of a Sublingual Fentanyl Citrate Formulation for Breakthrough Cancer Pain. J Pain Symptom Manage 2016; 51:538-45. [PMID: 26706627 DOI: 10.1016/j.jpainsymman.2015.11.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 06/09/2015] [Revised: 11/08/2015] [Accepted: 11/09/2015] [Indexed: 11/15/2022]
Abstract
CONTEXT Salivary gland hypofunction may affect the absorption of drugs through the oral mucosa, which in turn may affect their clinical efficacy (e.g., onset of action). OBJECTIVES The aim of this study was to assess the pharmacokinetics of a sublingual fentanyl orally disintegrating tablet (Abstral, Prostrakan Inc.) in a group of cancer patients with salivary gland hypofunction. METHODS Nine cancer patients with salivary gland hypofunction underwent a series of three pharmacokinetic studies with the sublingual fentanyl orally disintegrating tablet. In the first phase, the patients received no pretreatment; in the second phase, the patients were allowed to moisten the oral cavity before dosing; in the third phase, the patients were given pilocarpine hydrochloride (saliva stimulant) before dosing. Fentanyl concentrations were measured using a method of high-performance liquid chromatography with validated tandem mass spectrometric detection. RESULTS The Tmax was longer, the Cmax was lower, the AUC0-30 lower, and the AUClast lower in the phase involving no pretreatment; the Tmax/Cmax/AUC0-30/AUClast were similar in the phase involving moistening of the oral cavity and the phase involving giving pilocarpine hydrochloride. CONCLUSION The pharmacokinetics of the sublingual fentanyl orally disintegrating tablet appear to be negatively affected by the presence of salivary gland hypofunction, although the moistening of the oral cavity before dosing results in a pharmacokinetic profile similar to that seen with the giving of pilocarpine hydrochloride.
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Affiliation(s)
- Andrew Davies
- Royal Surrey County Hospital, Guildford, Surrey, United Kingdom.
| | - Gill Mundin
- Mundipharma Research Ltd., Cambridge, Cambridgeshire, United Kingdom
| | - Joanna Vriens
- Princess Alice Hospice, Esher, Surrey, United Kingdom
| | - Kath Webber
- Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
| | - Alison Buchanan
- Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
| | - Melanie Waghorn
- Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
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Mercadante S, Adile C, Cuomo A, Aielli F, Cortegiani A, Casuccio A, Porzio G. Fentanyl Buccal Tablet vs. Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Randomized, Crossover, Comparison Study. J Pain Symptom Manage 2015; 50:579-86. [PMID: 26303188 DOI: 10.1016/j.jpainsymman.2015.05.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [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: 03/25/2015] [Revised: 05/28/2015] [Accepted: 05/31/2015] [Indexed: 11/16/2022]
Abstract
CONTEXT Fentanyl products have shown superiority to oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use appropriate patient selection, and drugs have been compared by using different rationales. OBJECTIVES The aim of this randomized, crossover, controlled study was to compare efficacy and safety of fentanyl buccal tablets (FBTs) and oral morphine (OM), given in doses proportional to opioid daily doses. METHODS Cancer patients with pain receiving ≥60 mg or more of oral morphine equivalents per day and presenting with ≤3 episodes of BTcP per day were included. In a randomized, crossover manner, patients received FBT or OM at doses proportional to the daily opioid regimen in four consecutive episodes of BTcP. Pain intensity was measured before (T0) and 15 (T15) and 30 minutes (T30), after study drugs. RESULTS In total, 263 episodes of BTcP were treated. A statistical difference in changes in pain intensity-decrease of ≥33% and ≥50%-between the two groups was observed at T15 and T30 (P < 0.0005). No severe adverse effects after study drug administration were observed. CONCLUSION When used in doses proportional to the basal opioid regimen, FBT showed a clear superiority and was well tolerated when compared with OM during the first 30 minutes, which is the approximate target for a timely intervention required for a BTcP medication.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Arturo Cuomo
- Anesthesia and Pain Therapy, National Cancer Institute Pascale, Naples, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Andrea Cortegiani
- Section of Anesthesia, Analgesia, Intensive Care and Emergency, Department of Biopathology, Medical and Forensic Biotechnologies, Policlinico P. Giaccone, University of Palermo, Palermo, Italy
| | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
| | - Giampiero Porzio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Chang A, Roeland EJ, Atayee RS, Revta C, Ma JD. Transmucosal Immediate-Release Fentanyl for Breakthrough Cancer Pain: Opportunities and Challenges for Use in Palliative Care. J Pain Palliat Care Pharmacother 2015; 29:247-60. [PMID: 26368648 DOI: 10.3109/15360288.2015.1063560] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Opioids are used to treat breakthrough cancer pain (BTCP) and can be classified by relative duration and onset of action. Regulatory approvals of numerous transmucosal immediate-release fentanyl (TIRF) formulations provide alternative options to palliative care-trained providers in the management of BTCP. TIRFs have been formulated as a sublingual tablet, sublingual spray, intranasal spray, pectin-based nasal spray, buccal tablet, and buccal soluble film. Differences exist between TIRFs regarding formulation design and dosing to treat BTCP. Opportunities for use include palliation of BTCP in head and neck cancer and/or radiation-induced mucositis. The purpose of this review is to discuss TIRF formulation and dosing, pharmacokinetics, clinical efficacy, patient acceptability, and safety/tolerability. In addition, barriers to TIRF utilization will be discussed.
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Ingram C, Deming J, Bock A. The A, B, C, Ds of Opioid Prescribing for People Living with Cancer. Minn Med 2015; 98:44-46. [PMID: 26442356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This articles reviews guidelines for safe and effective opioid prescribing by primary care physicians for people living with cancer-related pain. It also offers tips for community clinicians on initiating, titrating and managing opioids for pain management.
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Abstract
At August 2015, this review has been withdrawn. It is correct at the date of publication, and previous versions can be accessed in the ‘Other versions’ tab on the Cochrane Library. The Cochrane Editorial Unit (CEU) agreed with the authors of the feedback that the review was misleading, and because the original author team was unavailable to update the review, the CEU advised that it should be withdrawn. See below for full details. PaPaS is seeking a new author team to develop a new review which will serve to update the original. Feedback 1, received 15 February 2015 Dr Vicente Ruiz Garcia
vicenteruizgarcia@gmail.com With colleagues Xavier Bonfill Cosp, Eduardo Lopez Briz, Rafa Carbonell, Jose Luis Gonzalvez Perales, Sylvia Bort Martí, and Marta Roque Figuls. Comment: Dear editor: We have read the update of Zeppetella and Davies about management of breakthrough pain in cancer patients (1). We think that this review is very important to help clinicians and patients to decide whether the new treatments for the breakthrough pain in cancer could be a useful alternative to morphine. In this update, some comments that we made to the previous review (the letter was not published) (2) were considered by the authors; in particular, not pooling the results obtained for oral transmucosal fentanyl citrate (OTFC) versus placebo, with those of OTFC versus morphine, and those of two trials that were titration of doses of fentanyl. However, we do not agree with the authors’ results when they state: “When compared with placebo or oral morphine, participants gave lower pain intensity and higher pain relief scores for transmucosal fentanyl formulations at all time points”. First, the outcomes at 15 min (the most important to obtain a quick relief of pain), Pain intensity Difference (Comparison 2. Transmucosal opioid versus oral morphine) and Comparison 4. OTFC versus intravenous morphine), failed to show statistically significant differences with oral morphine (mean difference 0.37 CI 95% 0.00‐0.73) and with morphine iv (mean difference 0.80 CI 95% 0.00‐1,60). In any case the results had no clinical relevance. Moreover the authors state “at all time points”, whereas they do not provide any data for longer times (i.e. 30, 45, 60 min). In addition, authors state “transmucosal fentanyl citrate are safe (..) (compared with both placebo and morphine) in relieving breakthrough pain”. Surprisingly no analysis of adverse events have been done that were only described in each study. Seven out 15 were crossover trials and it was impossible to draw conclusions about it. As reviewers we know that multiple comparisons could be made, but the most clinical interesting comparison is the gold standard, morphine. The review only shows in SOF, comparisons of fentanyl with placebo and concludes, that it is effective. Surprisingly, there is no mention of morphine comparison, which we consider a key point, because no patient will take placebo if he has a breakthrough pain, but morphine for obvious reasons. In our opinion, traversing the authors’ conclusions, this review did not show that the use of oral and nasal transmucosal fentanyl is an effective alternative to morphine for patients with breakthrough cancer pain. Reply The authors of the review were contacted but chose not to provide a response to the feedback. Contributors Kate Seers, PaPaS Feedback Editor, and Anna Hobson, PaPaS Managing Editor. Additional feedback 2, received May 2015 On 15 February 2015, Dr Vicente Ruiz Garcia (University Hospital La Fe, Spain), and his colleagues Xavier Bonfill Cosp, Eduardo Lopez Briz, Rafa Carbonell, Jose Luis Gonzalvez Perales, Sylvia Bort Martí, and Marta Roque Figuls submitted feedback via the Cochrane Library. The main complaint is available above. On 23 February, 16 March and 15 April, Kate Seers (Feedback Editor, PaPaS) contacted the authors and invited them to respond. On 21 March, John Zeppetella (lead author) declined to provide a formal response. No response was received from Andrew Davies (second author). On 31 March, PaPaS sought advice from the Cochrane Editorial Unit (CEU) on how to manage the issue; advised to publish without a response, depending on nature of feedback. On 11 May 2015, review re‐published with feedback incorporated. On 20 May 2015, Marta Roqué Figuls (Statistician, Iberoamerican Cochrane Centre) wrote to the CEU repeating the initial claim. They did not agree with the approach decided upon by the Co‐Ed, which was supported by the EiC. They stated “The CCIb assessment is that the review presents methodological shortcomings, and the conclusions are skewed in favor of fentanyl. Consequently, we support Vicente and colleagues’ petition to re‐assess the publication status of the review.” Reply On 9 June, Christopher Eccleston (Co‐ordinating Editor, PaPaS) advised that the review remain unchanged until it was ready for updating in September 2015. On 25 June 2015 David Tovey (Editor in Chief, Cochrane) responded to say “We have now had a chance to appraise this review and also obtain a report from our screening team… In summary we agree with almost all of the criticisms made of the review, and are concerned that the flaws may mean that the findings are misleading as currently presented. We note that the authors have declined to respond to the useful comments provided by Vicente. Having considered this and discussed it internally, we agree with our colleagues at the IbCC that the review should be withdrawn temporarily until the errors have been fixed and the review updated. We would like to re‐screen the review before any update or amendment is published.” On 2 July and 23 July, Anna Hobson (Managing Editor, PaPaS) again invited the authors to respond to the initial feedback and subsequent reviews by 23 July. No response was forthcoming. At August 2015, the review was withdrawn. Contributors Kate Seers (Feedback Editor, PaPaS), Cochrane Editorial Unit (CEU), Christopher Eccleston (Co‐ordinating Editor, PaPaS), David Tovey (Editor in Chief, Cochrane), Anna Hobson (Managing Editor, PaPaS). The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
| | - Andrew N Davies
- Royal Surrey County HospitalDepartment of Palliative MedicineGuildfordUK
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Setiabudy R, Irawan C, Sudoyo AW. Opioid Use in Cancer Pain Management in Indonesia: a Call For Attention. Acta Med Indones 2015; 47:244-250. [PMID: 26586391] [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] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Severe pain is a major problem for cancer patients, and pain management often requires the use of opioids. Indonesia is one of the countries where the use of opioids for cancer patients is extremely low, and this calls for attention, as many cancer patients in the country undergo unnecessary suffering as the consequence of this opioid underuse. The inability to assess pain correctly, failure to determine the correct dose, fear of addiction, overly tight regulation, all contribute to the failure to implement rational use of opioids for cancer patients. Breakthrough pain, a problem which requires special attention not only because it is commonly found but also requires proper knowledge to handle them. These hurdles are discussed in the present review, in order to bring a better understanding about the correct use of opioids in severe cancer pain. Some examples where opiods are used inappropriately in cancer pain management are also discussed.
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Affiliation(s)
- Rianto Setiabudy
- Department of Pharmacology and Therapeutics, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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Granata R, Bossi P, Bertulli R, Saita L. Rapid-onset opioids for the treatment of breakthrough cancer pain: two cases of drug abuse. Pain Med 2015; 15:758-61. [PMID: 24967472 DOI: 10.1111/pme.12382] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
SETTING In the last few years, the use of opioids for cancer pain has rapidly increased and new molecules have been developed. Currently, rapid-onset opioids are widely used in clinical practice for breakthrough cancer pain (BTcP). However, the tolerability of these molecules is still a matter of debate. PATIENTS We describe two cases of rapid-onset opioids misuse that have been recently observed at our palliative care unit. DISCUSSION The reported cases are explicative as they occurred in patients suffering from different types of cancer and with different causes of BTcP. Further investigations are needed to identify factors predicting addiction to this new class of molecules.
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