Opioid rotation in patients with cancer pain: A retrospective comparison of dose ratios between methadone, hydromorphone, and morphine

Bruera, Éduardo; Pereira, João Pablo Fortes; Watanabe, Sharon; Belzile, Michelle; Kuehn, Norma; Hanson, John

doi:10.1002/(sici)1097-0142(19960815)78:4<852::aid-cncr23>3.0.co;2-t

Cited by 286 publications

(164 citation statements)

References 15 publications

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“…It has been estimated that 20-30% of Americans use an NSAID each year and 1-2% use NSAIDs every day. [24] The generally accepted mechanism of action of NSAIDs is that they attenuate prostaglandin synthesis by inhibiting cyclooxygenase (COX) enzymes [25] , although some central action has been reported. [26] NSAID side-effects, however, are often related to COX inhibition, which greatly limits their use.…”

Section: Analgesic Classes Traditional Nonsteroidal Anti-inflammatorycontrasting

confidence: 79%

Molecular Aspects of Toxicity of Centrally Acting Analgesics: A Mini Review

Samie¹

2017

WJPR

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Pain of multiple etiologies remains a significant problem for many patients presenting in the clinical setting. Improved pain relief can be maximized and adverse effects minimized, by multimodal analgesic combinations as the method to improve pain treatment. Significant suggestion supports the use of combination analgesics for the management of pain and in some cases, they have a heterogeneous pharmacologic sparing effect. Fixed-dose combination analgesics having significant efficacy and safety are extensively suitable for pain management and are usually recommended. However, further exploration is required for the best combination that which analgesics at which doses can be pooled with a co-analgesic in a patient-specific manner to attain additive, if not synergistic, multimodal pain relief with the least possible adverse values.Unsupervised intake of over-the-counter drugs offers clinical challenges to both the patient and health care providers. Couple this often unrevealed over-the-counter medication consumption event with prescription medications, which many have similar combination constituents and the potential for a therapeutic misadventure may precipitate. Patient-specific cautions are presented for opiate/opioid combinations, codeine, hydrocodone, oxycodone and propoxyphene and there is a discussion of COX I/COX II agents. This review article address the safety and efficacy of different analgesics individually and in combination with currently available prescription dosage forms with a focus on pharmacology, pharmacotherapeutics, pharmacodynamics, and pharmacokinetics, including drug interactions and toxicity profile.

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Section: Analgesic Classes Traditional Nonsteroidal Anti-inflammatorycontrasting

confidence: 79%

Molecular Aspects of Toxicity of Centrally Acting Analgesics: A Mini Review

Samie¹

2017

WJPR

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“…1,2 The strategy of opioid rotation, that is switching from one opioid drug to another, is substantiated by the medical literature and is commonly used in clinical practice to manage opioid side effects or inadequate analgesia. [3][4][5] The use of equianalgesic dose ratios provides a method to determine equivalent and safe analgesic doses for opioids that differ in potency. 2,6 Many studies have addressed the equianalgesic dose ratios for switching between morphine and hydromorphone, morphine and oxycodone, and when switching from morphine to methadone.…”

mentioning

confidence: 56%

“…The use of opioid consumption rather than analgesic reporting has been established as an alternate viable method of establishing equianalgesic dose ratios. 3,7,8 Multiple studies support the validity of the MEDD conversion ratios used in the methods section this study and in clinical practice.…”

Section: Fig 4 Linear Regression: Oral Methadone To Oral Morphine Ementioning

confidence: 99%

Switching from Methadone to a Different Opioid: What Is the Equianalgesic Dose Ratio?

Walker

Palla

Pei

et al. 2008

Journal of Palliative Medicine

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Introduction: Methadone (ME) is a highly effective opioid agonist used for difficult pain syndromes. However, in the management of cancer pain with strong opioids, rotation to a different opioid (opioid rotation) may be required because of side effects or poor pain control. Rotation from methadone to another opioid has received limited study and therefore may be difficult because of the absence of a uniformly accepted dose conversion ratio. Methods: Retrospectively reviewed consecutive medical records of patients undergoing an opioid rotation from methadone to an alternative opioid were evaluated. For inclusion, patients were required to have received methadone for at least 3 days and have reached stable dose of the alternative opioid(s) during the 7 days following. Stable dose was defined as a 30% or less change in opioid dose from one day to the next. Results: Records of 39 patients met inclusion criteria. Excluded from analysis were 5 patients who were restarted on methadone within 7 days, 2 with irregular opioid use resulting in negligible regular opioid doses postswitch, and 3 due to concerns about reliability of multiple routes used for fentanyl. Data from 29 patients, 10 female, mean age 48 Ϯ 14.4 years, were evaluable. The mean dose ratio for oral methadone to oral morphine equivalent daily dose (MEDD) was 1:4.7 (95% confidence interval [CI], 3.0-6.5; n ϭ 16), and for intravenous (IV) methadone to MEDD was 1:13.5 (95% CI, 6.6-20.5; n ϭ 13), p ϭ 0.06. Methadone dose was significantly correlated to stable MEDD after switching opioids for both methadone IV and oral (Spearman ϭ 0.86, p ϭ 0.0001 and Spearman ϭ 0.72, p ϭ 0.0024), respectively. Mean day of achieving stable dose was day 2.5 Ϯ 0.2 for IV methadone and day 2.6 Ϯ 0.3 for oral methadone. Conclusion: These dose ratios are new findings that may assist in switching patients more safely to alternative opioids when side effects or pain problems occur when patients are receiving methadone. An important difference in analgesic potency appears to exist between IV and oral ME. Future research with prospective studies is required.

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“…In this previous survey, an approximate ratio of 3.3 was found. These data were confirmed in this selective study on opioid switching from oxycodone to methadone, differently from studies of morphine-methadone switching, where there was a correlation between the previous dose of morphine and the final ratio, particularly in patients receiving high doses of morphine [2,6,13]. In this study, the doses of oxycodone were in the medium range of clinical dosages (extremes 20-960 mg/day), so that this approach should be better assessed in patients receiving very high doses of oxycodone.…”

Section: Discussionmentioning

confidence: 99%

Switching from oxycodone to methadone in advanced cancer patients

Mercadante¹,

Ferrera

Villari

et al. 2011

Support Care Cancer

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Purpose The aim of this study was to prospectively evaluate the outcomes and the conversion ratio of switching from oxycodone to methadone in advanced cancer patients admitted to an acute palliative care unit. Patients and methods A prospective study was carried out on a cohort of consecutive sample of patients receiving oxycodone, who were switched for different reasons mainly because of an inconvenient balance between analgesia and adverse effects. An initial conversion ratio between oxycodone and methadone was 3.3:1. Intensity of pain and symptoms associated with opioid therapy were recorded, and a distress score (DS) was also calculated as a sum of symptom intensity. A successful switching was considered when the intensity of pain and/or DS or the principal symptom requiring switching decreased at least of 33% of the value recorded before switching. Results Nineteen out of 542 patients admitted to the unit in 1 year underwent a switching from oxycodone to methadone.Almost all substitutions were successful. The prevalent indication for opioid switching was uncontrolled pain and adverse effects (12 patients). No significant changes between the initial conversion ratio and final conversion ratio between the two opioids were found. Conclusion Switching from oxycodone to methadone is a reliable method to improve the opioid response in advanced cancer patients. A ratio of 3.3 appears to be reliable, even at high doses. Further studies should be performed to confirm these results in other settings and with very high doses of oxycodone.

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Opioid rotation in patients with cancer pain: A retrospective comparison of dose ratios between methadone, hydromorphone, and morphine

Abstract: BACKGROUND.When a change of opioid is considered, equianalgesic dose tables

Cited by 286 publications

References 15 publications

Molecular Aspects of Toxicity of Centrally Acting Analgesics: A Mini Review

Molecular Aspects of Toxicity of Centrally Acting Analgesics: A Mini Review

Switching from Methadone to a Different Opioid: What Is the Equianalgesic Dose Ratio?

Switching from oxycodone to methadone in advanced cancer patients

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