Transition from intravenous to subcutaneous biological therapies in inflammatory bowel disease: An online survey of patients.

BACKGROUND: The transition from in-hospital intravenous administration to subcutaneous therapies to treat inflammatory bowel disease (IBD) can raise some concerns among patients due to the self-administration concerns, the management of potential side effects and the overall worries related to a change of treatment. This study aimed at evaluating patients' opinion about the switch from intravenous to subcutaneous formulations and their knowledge on new available therapeutic options. METHODS: We conducted a survey using a questionnaire prepared by a team of gastroenterologists and nurses working at the IBD unit. It consists of 31 items and has been divided into four sections: descriptive, commitment, knowledge and passage mode opinion. The questions were formulated in Italian and conceived according to daily consultations with patients in everyday practice, without any previous piloting or specific medical literature reference. The survey was administered to consecutive IBD patients in intravenous biological treatment; patients currently or previously treated with subcutaneous therapy were excluded. RESULTS: Four hundred questionnaires were distributed to participants. As many as 311 patients (77.7%) completed the survey, while the remaining were excluded from the analysis; 155 (49.8%) patients were favorable to switch from intravenous to subcutaneous therapy, while only 78 (25.1%) disagreed. In univariate and multi-variate analysis, the approval rate for home therapy was significantly associated with the distance from the IBD center and work/family/personal commitments. Surprisingly, only a quarter of the IBD patients knew that almost all available therapeutic agents have a subcutaneous administration route. Regarding patients' opinion on the efficacy of subcutaneous administration of biological agents compared to intravenous drugs, 194 (63%) had no definite idea, while 44 (14%) believed that the effectiveness could be reduced. CONCLUSION: The transition from in-hospital to subcutaneous therapeutic management of biological therapy at home was generally viewed favorably by patients, especially if they have commitments or were residents far from the IBD center.

Switching to Intravenous Methadone in Advanced Cancer Patients: A Retrospective Analysis.

CONTEXT: Information about opioid switching to intravenous methadone is lacking. OBJECTIVES: The aim of this study was to assess the outcome of opioid switching to intravenous methadone (IV-ME) in patients admitted to an acute supportive/palliative care unit (ASPCU). The secondary outcome was to assess the conversion ratio from IV-ME to oral methadone at time of hospital discharge. METHODS: We retrieved from the pharmacy registry the list of patients who were prescribed IV-ME during their ASPCU admission for a period of 47 months. Poor analgesia with previous opioids and/or adverse effects were the main indications for opioid switching. IV-ME was titrated until acceptable analgesia was achieved. The effective dose was multiplied by three to establish the intravenous daily dose, given as a continuous infusion. Doses were then changed according to the clinical needs. Once the patient was stabilized, IV-ME dose was converted to oral methadone, by using an initial ratio of 1:1.2. Further dose changes were made according to clinical needs until stabilization, before patients' discharge. Information about patients' characteristics, pain scores on the Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Cut-down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire, previous opioids and their doses, expressed as oral morphine equivalents (OME), were recorded. The effective bolus of IV-ME, initial daily infusion rate, and oral methadone doses were assessed, and conversion ratios calculated. RESULTS: Forty-one patients were taken into consideration for the study. The mean effective bolus of IV-ME titrated for achieving acceptable analgesia was 9 mg (range 5-15 mg). The mean daily continuous infusion rate of IV-ME was 27.6 mg/day (SD 21). The mean daily dose of oral methadone at time of discharge was 46.8 mg/day (SD 43). Discharge occurred within a median of seven days (range 6-9) after admission. Previous opioid (OME)/IV-ME, oral-IV-ME, and previous opioid (OME)/oral methadone were 6.25, 1.7, and 3.7, respectively. CONCLUSION: IV-ME dose titration followed by intravenous infusion allowed a rapid pain control in few minutes in patients with severe pain intensity, not responsive to previous opioids. Conversion to oral route was successful and facilitated home discharge. Further studies should be performed to confirm these preliminary results.

Characteristics of Untreated Cancer Patients Admitted to an Acute Supportive/Palliative Care Unit.

BACKGRUND: The characteristics of patients who had never received anticancer treatments at admission of an acute supportive palliative care unit (ASPCU) have never been explored. MEASURES: From a consecutive sample of 422 advanced cancer patients, 62 patients with no previous anticancer therapy were selected and compared with a random sample of patients who had received anticancer treatments. Age, gender, primary tumor, Karnofsky status, characteristics of admission, the level of education, economic status, awareness of disease, the presence of cachexia, and comorbidities and palliative prognostic score, symptom intensity, opioid drugs used at admission, reasons for admission to APSCU were recorded in both groups. At time of discharge, ESAS and analgesic drugs used were recorded again. Discharge modalities were also recorded. One month after the end of recruitment period (the last patient enrollment), a follow-up was performed by phone contacts with relatives to assess survival at three months after discharge. OUTCOMES: Patients without previous anticancer therapy (14.7%) were mainly admitted to ASPCU for a low Karnofsky level and high symptom burden, often waiting for or needing a histological diagnosis to make a decision for the next therapeutic steps. This group of patients were older (P<0.0005), more frequently males (P=0.007), and had more comorbidities (P<0.0005) in comparison with treated patients. Twenty-four per cent of these patients started chemotherapy subsequently. Treatment-naive patients had a higher level of symptom burden, which was less responsive to a comprehensive palliative and more frequently died within three months in comparison with treated patients. DISCUSSION: Treatment-naive patients showed a higher level of symptom burden, which was less responsive to a comprehensive palliative treatment. In addition they more frequently died within three months in comparison with treated patients.

Conversion ratios for opioid switching: a pragmatic study.

BACKGROUND: The final conversion ratios among opioids used for successful switching are unknown. The aim of this study was to determine the initial and final conversion ratios used for a successful opioid switching in cancer patients, and eventual associated factors. METHODS: Ninety-five patients who were successfully switched were evaluated. The following data were collected: age, gender, Karnofsky performance score, primary cancer, cognitive function, the presence of neuropathic, and incident pain. Opioids, route of administration, and their doses expressed in oral morphine equivalents used before OS were recorded as well as opioids use for starting opioid switching, and at time of stabilization. Physical and psychological symptoms were routinely evaluated by Edmonton Symptom Assessment Scale. RESULTS: No statistical changes were observed between the initial conversion ratios and those achieved at time of stabilization for all the sequences of opioid switching. When considering patients switched to methadone, there was no association between factors taken into considerations. CONCLUSION: Opioid switching is a highly effective and safe technique, improving analgesia and reducing the opioid-related symptom burden. The final conversion ratios were not different from those used for starting opioid switching. Patients receiving higher doses of opioids should be carefully monitored for individual and unexpected responses in an experienced palliative care unit, particularly those switched to methadone. Future studies should provide data regarding the profile of patients with difficult pain to be hospitalized.

Rapid Titration With Intravenous Oxycodone for Severe Cancer Pain and Oral Conversion Ratio.

CONTEXT: to assess a dose titration with intravenous oxycodone to achieve rapid pain relief of cancer pain of severe intensity. The second objective was to provide a conversion ratio with the oral route. METHODS: Cancer patients admitted for severe pain were prospectively assessed. At admission (T0) previous opioid doses were recorded. Edmonton symptom assessment scale (ESAS) was collected from T0 until the conclusion of the observation. Intravenous boluses of oxycodone were given until the initial signs of significant analgesia were detected. The effective dose was multiplied for six and given as intravenous continuous infusion. When the patient was considered stabilized the intravenous daily dose was converted to oral oxycodone using an initial ratio of 1:2. Subsequently, doses of oral oxycodone were changed according to the clinical situation. RESULTS: Twenty-nine patients were examined. A mean effective bolus dose of oxycodone was 9.5 mg (SD 8.0) allowed to achieve a meaningful pain relief in a mean of 10.4 minutes (SD 3.3). The mean initial and the final infusion doses were 51.0 mg/day (standard deviation 40.9) and 69.7 mg/day ( standard deviation76.6), respectively. A significant change in pain intensity was observed at the different time intervals (P<0.0005). Conversion to oral route occurred after a mean of 2.7 days (standard deviation1.2) of intravenous oxycodone. The final mean conversion ratio was 1:2,12 ( standard deviation0.36). CONCLUSION: Rapid intravenous oxycodone dose titration resulted in rapid pain relief. The intravenous-oral conversion ratio of 1:2 is reliable. Further studies are necessary to confirm this preliminary observation.

The use of complementary alternative medicines in advanced cancer patients followed at home.

OBJECTIVES: To assess the use of complementary alternative medicines (CAM) in advanced cancer patients followed at home. METHODS: A consecutive sample of advanced cancer patients admitted to a home palliative care program was invited to participate in the study in a period of two months. Demographic characteristics, religious belief, education level, diagnosis, and socio-economic condition were recorded. Patients were asked about the use of CAM, considered to be a health-related treatment practiced outside the established health services. Information about CAM indications and those who prescribed or suggested CAM were also collected. RESULTS: Two hundred and eighty-three advanced cancer patients followed at home were surveyed. Twelve patients (4.2%) were receiving CAM. The indication and type of CAM were variable, as well as the costs. Given the low number of patients taking CAM, no further analysis was performed. CONCLUSION: A limited number of advanced cancer patients followed at home were using CAM. Further multicenter studies with a larger sample should be performed to provide information about such therapies, also including eventual benefits.