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.

Transcription factor Yin-Yang 2 alters neuronal outgrowth in vitro.

The Yin-Yang 2 (YY2) protein is the most recently described member of the family of YY transcription factors. Despite its high structural and functional homology with the well-characterized YY1, less is known about its role in biological processes. In previous studies, we have found differential yy2 mRNA expression levels in various cell types of the murine brain. To investigate the functional implication of yy2 in neurons, we have examined the influence of altered cellular yy2 concentrations during neuronal differentiation. Our results indicate that both the up- and down-regulation of yy2 significantly impairs the outgrowth of the major neurite of primary hippocampal neurons and the numbers of neuronal processes in proximate extensions. Moreover, enhanced expression of wild-type yy2 results in increased cell death, whereas elevated expression levels of a yy2 DNA-binding mutant have no effect on cell viability. Therefore, stringent regulation of the cellular yy2 content might be needed to ensure proper neurite outgrowth and cell vitality.