First-line methadone for cancer pain: titration time analysis.

BACKGROUND: Methadone is a low-cost, strong opioid that is increasingly used as a first-line treatment for pain in palliative care (PC). Its long and unpredictable half-life and slow elimination phase can make titration challenging. Evidence for titration modalities is scarce. OBJECTIVE: To describe the titration phase of the treatment with low-dose first-line methadone and the use of methadone for breakthrough pain. METHODS: Prospective study with strong opioid-naïve patients with moderate to severe cancer pain followed at a tertiary PC unit in Argentina. Starting methadone dose was 2.5-5 mg/day every 8, 12, or 24 h. Titration allowed daily dose increases from day 1, and prescription of oral methadone 2.5 mg every 2 h with a maximum of 3 rescue doses/day for breakthrough pain. Pain control, methadone stabilization dose, and adverse effects, among other variables, were daily assessed over the first 7 days (T0-T7). RESULTS: Sixty-two patients were included. Initial median (IQR) methadone dose was 5 (2.5) mg/day. Pain intensity decreased from a median (IQR) of 8 (2.3) at T0 to 4 (2.3) at T1 and remained ≤ 4 until T7 (all p < 0.0001 compared to T0). Similar results were obtained through the categorical and tolerability scales for pain. Fifty patients (81%) reached pain control, 66% in the first 48 h. Methadone daily doses at T2 and T7 were higher than that at T0: 7.5 (3) and 6.7 (5.5) versus 5 (2.5), respectively (all p < 0.05). The opioid escalation index at T7 was 1.7%. The median (IQR) number of rescues, stabilization dose, and time for stabilization was 0 (1), 5(4.5) mg, and 3(2) days, respectively. Two patients were discontinued due to delirium. All other side effects were mild. CONCLUSIONS: First-line, low-dose methadone using rescue methadone resulted in a pronounced and rapid decrease in pain, with minimal need for titration and for breakthrough doses, and no evidence of accumulation or sedation by the end of the week.

Methadone as first-line opioid treatment for cancer pain in a developing country palliative care unit.

PURPOSE: The use of methadone for cancer pain is limited by the need of expertise and close titration due to variable half-life. Yet, it is a helpful palliative strategy in low-resources countries given its long-acting effect at low cost and worth additional study. Our aim was to describe the prescription and outcomes of methadone as a first-line treatment for cancer pain in a tertiary palliative care unit (PCU) in Argentina. METHODS: Retrospective review of medical records of patients with moderate to severe cancer pain seen at the PCU in 1-year period, who initiated strong opioids at the first consultation. Data collected during the first month of treatment included disease and pain characteristics, initial and final opioid type and dose and need for opioid rotation. RESULTS: Methadone was the most frequent opioid both at the initial and last assessment (71 and 66 % of the prescriptions). In all, treatment with strong opioids provided considerable decrease in pain intensity (p < 0.001) with low and stable opioid dose. Median and interquartile range (IR) of oral morphine equivalent daily dose (OMEDD) was 26 (16-32) and 39 (32-55) mg for initial and final assessments, respectively (p = 0.3). In patients initiated with methadone, the median (IR) daily methadone dose was 5 (4-6) mg at first and 7.5 (6-10) mg at final assessment, and the median (IR) index of opioid escalation was 0 (0-4) mg; (p < 0.05). Patients on methadone underwent less percentage of opioid rotation (15 versus 50 %; p < 0.001) and longer time to rotation (20.6 ± 4.4 versus 9.0 ± 2.7 days; p < 0.001) than patients on other opioids. CONCLUSIONS: Results indicate the preference of methadone as first-line strong opioid treatment in a PCU, providing good pain relief at low doses with low need for rotation. Several considerations about the costs of strong opioids in the region are given.

Symmetrical activity of the chewing muscles and its relationship with skeletal class and body posture.

OBJECTIVE: To describe the role of body posture and skeletal class in the symmetrical activity of chewing muscles. METHODS: Descriptive study with association. Skeletal class measured by the Steiner method. Postural analysis through APECS mobile application for forward head posture and shoulder discrepancy, and surface electromyography with Biopac® device. RESULTS: The skeletal class, forward head posture, and shoulder discrepancy presented statistical association with the symmetrical electromyographic response of digastric muscles and masseter muscles during swallowing. DISCUSSION: This study exhibited a positive relationship between digastric muscle symmetry and skeletal class during swallowing. The compensation of the hyoid system explains these results, showing that skeletal Class III has better electromyographic balance. In contrast, masseter muscle symmetry during swallowing presented a negative relationship with skeletal class. The stabilization role that this muscle plays during swallowing explains these findings, caused by the different lengths and direction of this muscle in skeletal Class III.

[Interconsultation on palliative care for patients with cancer in a general hospital. Features and opportunity]. / Interconsultas de cuidados paliativos para pacientes con cáncer en un hospital general. Características y oportunidad.

The international recommendations point to the early integration of palliative care (PC) in cancer through simultaneous care and training of primary teams. The PC Unit of the Hospital General de Agudos E. Tornú conducts interconsultations for hospitalized patients in the hospital and provides training to the treatment teams. The profile of the interconsultations carried out could provide important information about the characteristics of the PC intervention within the institution. The objective of this study was to retrospectively analyze the first-time interconsultations of cancer patients carried out over 2 years, focusing on temporality, identification of problems by the treating team and the PC interconsultation team, the promptness of response and the prognostic capacity of the latter. In the period, 168 interconsultations were carried out. Most patients had advanced disease, poor performance status, no possibility of oncological treatment and recent diagnosis. In approximately 25% of the cases, evidence of early intervention and participation of the pc team in decision making was found. The opportunity of PC intervention is discussed and areas needing improvement are indicated, such as the identification of non-physical symptoms and prognosis, to be considered in future care and educational activities.

Las recomendaciones internacionales apuntan a la integración temprana de cuidados paliativos (CP) en cáncer a través de la atención simultánea y del entrenamiento de los equipos primarios. La Unidad de CP del Hospital General de Agudos E. Tornú realiza interconsultas para pacientes internados en el hospital y brinda capacitación a los equipos tratantes. El perfil de las interconsultas realizadas podría brindar información importante sobre las características de la intervención de CP dentro de la institución. El objetivo de este estudio fue analizar retrospectivamente las interconsultas de primera vez de pacientes con cáncer realizadas a lo largo de 2 años, con foco en la temporalidad, la identificación de problemas por parte del equipo tratante y del equipo de interconsulta de CP, y la prontitud de respuesta y capacidad pronóstica de este último. La población atendida en interconsulta (168 casos) estuvo constituida principalmente por pacientes con enfermedad avanzada, deterioro del estado general, sin posibilidad de tratamiento oncológico y diagnóstico reciente. En aproximadamente 25% de los casos se encontraron indicios de intervención temprana y participación del equipo de CP en la toma de decisiones. Se discute la oportunidad de la intervención de CP y se señalan áreas con necesidad de mejora, como la identificación de síntomas no físicos y el pronóstico, a ser tenidas cuenta en las futuras actividades asistenciales y educativas.

Interconsultas de cuidados paliativos para pacientes con cáncer en un hospital general: Características y oportunidad / Interconsultation on palliative care for patients with cancer in a general hospital. Features and opportunity

Las recomendaciones internacionales apuntan a la integración temprana de cuidados paliativos (CP) en cáncer a través de la atención simultánea y del entrenamiento de los equipos primarios. La Unidad de CP del Hospital General de Agudos E. Tornú realiza interconsultas para pacientes internados en el hospital y brinda capacitación a los equipos tratantes. El perfil de las interconsultas realizadas podría brindar información importante sobre las características de la intervención de CP dentro de la institución. El objetivo de este estudio fue analizar retrospectivamente las interconsultas de primera vez de pacientes con cáncer realizadas a lo largo de 2 años, con foco en la temporalidad, la identificación de problemas por parte del equipo tratante y del equipo de interconsulta de CP, y la prontitud de respuesta y capacidad pronóstica de este último. La población atendida en interconsulta (168 casos) estuvo constituida principalmente por pacientes con enfermedad avanzada, deterioro del estado general, sin posibilidad de tratamiento oncológico y diagnóstico reciente. En aproximadamente 25% de los casos se encontraron indicios de intervención temprana y participación del equipo de CP en la toma de decisiones. Se discute la oportunidad de la intervención de CP y se señalan áreas con necesidad de mejora, como la identificación de síntomas no físicos y el pronóstico, a ser tenidas cuenta en las futuras actividades asistenciales y educativas.

The international recommendations point to the early integration of palliative care (PC) in cancer through simultaneous care and training of primary teams. The PC Unit of the Hospital General de Agudos E. Tornú conducts interconsultations for hospitalized patients in the hospital and provides training to the treatment teams. The profile of the interconsultations carried out could provide important information about the characteristics of the PC intervention within the institution. The objective of this study was to retrospectively analyze the first-time interconsultations of cancer patients carried out over 2 years, focusing on temporality, identification of problems by the treating team and the PC interconsultation team, the promptness of response and the prognostic capacity of the latter. In the period, 168 interconsultations were carried out. Most patients had advanced disease, poor performance status, no possibility of oncological treatment and recent diagnosis. In approximately 25% of the cases, evidence of early intervention and participation of the pc team in decision making was found. The opportunity of PC intervention is discussed and areas needing improvement are indicated, such as the identification of non-physical symptoms and prognosis, to be considered in future care and educational activities.