Guidelines for the Management of Breakthrough Pain in Patients With Cancer

Abstract

The moral imperative to adequately manage pain is being increasingly recognized worldwide. A comprehensive pain management approach that addresses the various presentations of pain in patients with cancer is required, including appropriate management of breakthrough pain. Breakthrough pain commonly occurs in patients with advanced cancer and is disabling to the individual and burdensome to society, yet it is often inadequately managed. Because pain is heterogeneous, the best management of an individual's pain, including breakthrough pain in cancer, requires a thorough assessment to tailor the treatment strategies. Recently developed guidelines support this approach and recommend treating breakthrough pain using rapid- or short-acting opioids with pharmacodynamics that mirror the rapid onset and short duration of the presenting pain. This approach should be part of a comprehensive strategy to treat pain within the context of the primary disease trajectory, offering continuity of care and access to specialized palliative care when appropriate.

Breakthrough cancer pain (BTcP) management: a review of international and national guidelines

“…The search revealed a number of generic cancer pain guidelines that included recommendations about the management of BTcP, but relatively few specific BTcP guidelines; the latter included one Canadian,14 one German,15 two Italian,16 17 one Spanish,18 the European Oncology Nursing Society guidelines11 12 and an international pharmaceutical company-sponsored review of BTcP guidelines 19. The search also revealed French guidelines that discuss the use of the so-called rapid-onset opioids (ROOs) for BTcP, rather than the general management of BTcP 20 21.…”

Pain management of the cancer patient

“…In addition, guidelines recommend application of non-pharmacological methods such as radiotherapy, surgical interventions and regional techniques [78].…”

“…Guidelines recommend comprehensive assessment followed by individualized plan for the pain management [45,78]. IR opioid preparations are recommended as the first-line therapy for breakthrough pain.…”

Treatment of breakthrough cancer pain: to titrate or to proportionate?

“…For a long time, only immediate-release formulations such as morphine, oxycodone, or hydromorphone were available, which start to act within about half an hour. According to current evidence-based treatment recommendations, these substances are indicated when BTcP is expected to occur, e.g., as incident pain is triggered by movement, or when a single episode lasts for more than an hour (which is rather unusual) 9,10 . Traditional recommendations (such as to use 1/6th of total daily morphine dose) are hereby based on strategies developed when only immediate-release morphine was available on the market and has -due to its pharmacokinetic properties -to be given six times per day.…”