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

Aielli

Journal of Pain and Symptom Management

et al. 2016

Section: Discussionmentioning

confidence: 99%

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

Aielli

Journal of Pain and Symptom Management

et al. 2016

“…Dosing proportional to basic opioid regimen has been proposed as an alternative to dose titration. 10 A simulation of a calculation of doses of opioids used for background analgesia and those achieved after individual titration showed mean values of proportional doses very close to those found after titration. 20 In a ''real world'' study reproducing a clinical scenario of patients receiving opioids for BTP, although the dose of oral opioids used as rescue medication was 18% of the around-the-clock opioid dose, for oral transmucosal fentanyl titrated to determine the effective dose, the rescue dose was about 35% of the around-the-clock dose, 30 suggesting that the titration process may provide even higher doses than those expected by using doses proportional to the basal regimen.…”

Section: Discussionmentioning

confidence: 99%

Intranasal Fentanyl Versus Fentanyl Pectin Nasal Spray for the Management of Breakthrough Cancer Pain in Doses Proportional to Basal Opioid Regimen

Prestia

et al. 2014

The Journal of Pain

The aim of this randomized, crossover, comparison study was to assess the analgesic and adverse effects of 2 nasal preparations, intranasal fentanyl (INFS) and fentanyl pectin nasal spray (FPNS), for breakthrough pain, given in doses proportional to opioid basal regimen. Each patient randomly received INFS or FPNS in doses proportional to opioid dosages used for background analgesia for 2 pairs of episodes. For each episode of breakthrough pain, pain intensity and adverse effects intensity were recorded just before starting the INFS or FPNS (T0) and 5 minutes (T5), 10 minutes (T10), and 20 minutes (T20) after the administration of the nasal drugs. Sixty-nine patients were studied. The mean age was 63.4 years, and 37 patients were males. For the present analysis, 188 episodes were considered. A statistical decrease in pain intensity was observed with both nasal drugs after 5, 10, and 20 minutes. A decrease in pain intensity of >33% was observed in 16, 102, and 159 treated episodes at T5, T10, and T20, respectively. Adverse effects were of mild nature in most cases or were preexistent because of basal opioid therapy. No differences were found in summed pain intensity difference 20 minutes after dosing. Most of patients did not find substantial preferences. INFS and FPNS were effective and well-tolerated treatments for breakthrough pain management. Both delivery systems, in doses proportional to the basal opioid regimen, provided significant analgesia within 10 minutes, without producing relevant adverse effects.Perspective: This article showed that INFS and FPNS in doses proportional to basal opioid regimen are equally safe and effective for the management of breakthrough pain in cancer patients. These data provide new insights on the use of nasal preparations of fentanyl.

“…A series of weaknesses of these studies, designed for regulatory issues (Mercadante et al, , Mercadante, ), has been invariably reported. On the other hand, the titration process may be time‐consuming and could reduce patients’ compliance (Hans, ).…”

Section: Introductionmentioning

confidence: 99%

Factors influencing the use of opioids for breakthrough cancer pain: A secondary analysis of the IOPS‐MS study

European Journal of Pain

Masedu

et al. 2018

Background Controversies exist about the choice and the doses of opioid medication in breakthrough cancer pain (BTcP). Methods The aim was to assess factors influencing the use and the doses of opioids prescribed for BTcP. There was performed a secondary analysis of a national, multicentre study that involving 32 centres performed in patients having BTcP. Diagnosis of BTcP was based on a definite algorithm. Patients using opioids for background pain and for BTcP were selected. Average pain intensity and opioids used for background pain and BTcP, and adverse effects were assessed, as well as patient’s satisfaction and the grade of mucositis. Results The analysis was performed in 2,771 patients. Opioid doses given for BTcP were significantly associated with those given for background pain. No relationship between adverse effects and the use and the doses of opioids used for BTcP was found. Drugs and doses were not correlated to the grade of oral mucositis. Nasal fentanyl preparations provided the fastest meaningful pain relief in comparison with other fentanyl transmucosal preparations or morphine preparations (P = 0.000). The majority of patients were satisfied with opioid medications given for BTcP. Only 2.8% of patients reported adverse effects related to opioid medication used for BTcP. Age and gender were independently associated with dosages of some fentanyl products. Conclusions Opioids for BTcP were effective and safe in a large sample of cancer patients with different stages of disease. Doses of opioids proportional to doses used for background pain seem to guarantee both efficacy and safety. Significance The use of opioids for breakthough cancer pain was effective and safe in a large sample of advanced cancer patients recruited in different stages of disease and settings. Doses of opioids proportional to opioid doses used for background analgesia, seem to guarantee both effectiveness and safety.