RESUMO
To evaluate the effectiveness and safety of a cancer pain information platform combined with semi-implantable intrathecal drug delivery systems among the patients with refractory cancer pain under a "home analgesia" model. This was a retrospective study. A total of 49 patients underwent semi-implantable intrathecal drug delivery systems with patient-controlled analgesia in conjunction with the establishment of a cancer pain information platform. Numeric rating scales (NRS), Bruggrmann comfort scale (BCS), high-quality sleep duration, and opioid-related adverse effects were recorded at various time points and analyzed: the day on admission (T0), the day of discharge (T1), 30 days post-discharge (T2), 60 days post-discharge (T3), 90 days post-discharge (T4), 120 days post-discharge (T5), 150 days post-discharge (T6), 180 days post-discharge (T7), and the day before death (T8). Compared with T0, NRS significantly decreased and BCS significantly increased at T1 to T8 time points (Pâ <â .05). However, NRS and BCS did not show differences at T1 to T8 time points (Pâ >â .05). The duration of high-quality sleep was significantly extended, and the incidence of opioid-related adverse effects was significantly reduced. Postoperative complications included 1 case of cerebrospinal fluid leakage, 3 cases of infection at the butterfly needle insertion site, 6 cases of hospital readmission for equipment malfunction, and no cases of respiratory depression. Eleven patients continued standardized antitreatment after IDDS surgery. The mean survival time for all patients was 135.51â ±â 102.69 days, and the survival rate at T7 was 30.61%. The cancer pain information platform combined with semi-implantable IDDS is beneficial for the pain management of refractory cancer patients under the "home analgesia" model, improving their quality of life.
Assuntos
Analgesia Controlada pelo Paciente , Analgésicos Opioides , Dor do Câncer , Humanos , Estudos Retrospectivos , Feminino , Masculino , Dor do Câncer/tratamento farmacológico , Pessoa de Meia-Idade , Idoso , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Analgesia Controlada pelo Paciente/métodos , Medição da Dor , Adulto , Manejo da Dor/métodos , Injeções Espinhais , Dor Intratável/tratamento farmacológico , Dor Intratável/etiologia , Bombas de Infusão ImplantáveisRESUMO
RATIONALE: Patients with bone metastasis-associated cancer pain often experience a complex mix of pain types. Consequently, the use of multimodal combination therapy is essential. While monitoring for common adverse reactions in pain treatment, it is also crucial to be vigilant for the rare but serious serotonin syndrome. PATIENT CONCERNS: A 53-year-old female with metastatic gastric cancer was hospitalized due to severe, uncontrolled thoracic and cervical pain. During the titration of her cancer pain medication, she developed serotonin syndrome. DIAGNOSES: He was diagnosed with refractory cancer pain and serotonin syndrome. INTERVENTIONS: The complete process of cancer pain medication in a patient with gastric cancer and bone metastasis was analyzed, with a primary focus on the selection of analgesic medications, adjustment of opioid dosages, and prevention and treatment of medication-associated adverse reactions. OUTCOMES: The patient's cancer pain was well controlled, with the prompt management of adverse reactions. Furthermore, by adjusting the medication regimen, intolerable adverse reactions were prevented. LESSONS: In clinical settings, personalized analgesic regimens must be developed for patients with cancer pain to enhance patient compliance with medication, prevent the occurrence of severe adverse reactions, and improve the overall quality of life of patients with cancer. Healthcare professionals should pay increased attention to ADRs associated with opioid medications, whereas pharmacists should assist them in promptly identifying ADRs.
Assuntos
Neoplasias Ósseas , Dor do Câncer , Dor Intratável , Neoplasias Gástricas , Humanos , Neoplasias Gástricas/tratamento farmacológico , Neoplasias Gástricas/patologia , Pessoa de Meia-Idade , Dor do Câncer/tratamento farmacológico , Dor do Câncer/etiologia , Feminino , Neoplasias Ósseas/secundário , Neoplasias Ósseas/tratamento farmacológico , Dor Intratável/etiologia , Dor Intratável/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Analgésicos/uso terapêuticoRESUMO
PURPOSE: Refractory cancer-induced bone pain (CIBP) affects a patient's functional capacity and quality of life, but there is limited evidence to guide opioid choice. We assessed the feasibility, tolerability and possible efficacy of methadone rotation (MR) compared to other opioid rotations (OOR) in this cohort. METHODS: Adults with CIBP and worst pain intensity ≥ 4/10 and/or opioid toxicity graded ≥ 2 on the Common Terminology Criteria for Adverse Events were randomised 1:1 to methadone or another opioid rotation. Standardised assessment tools were used at pre-defined study time points up to 14 days. RESULTS: Of 51 eligible participants, 38 (74.5%) consented, and 29 (76.3%, MR: 14, OOR: 15) completed the fourteen days follow-up post-opioid rotation. Both groups displayed significant reduction in average (MR: d = - 1.2, p = 0.003, OOR: d = - 0.8, p = 0.015) and worst pain (MR: d = - 0.9, p = 0.042, OOR: d = - 0.6, p = 0.048) and total pain interference score (MR: d = - 1.1, p = 0.042, OOR: d = - 0.7, p = 0.007). Oral morphine equivalent daily dose was reduced significantly in MR compared to the OOR group (d = - 0.8, p = 0.05). The incidence of opioid-related adverse events following MR was unchanged but lower in the OOR group (d = 0.9, 95% CI 0.1,1.7, p = 0.022). There were no within-group or between-group differences in satisfaction with analgesia at the end of the study. CONCLUSION: This pilot study demonstrated that MR and OOR in patients with refractory CIBP are feasible, safe and acceptable to patients. Appropriately powered multi-centre randomised controlled studies are needed to confirm the efficacy of MR and OOR in this cohort. TRIAL REGISTRATION: ACTRN12621000141842 registered 11 February 2021.
Assuntos
Analgésicos Opioides , Dor do Câncer , Metadona , Humanos , Projetos Piloto , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Analgésicos Opioides/efeitos adversos , Masculino , Feminino , Metadona/administração & dosagem , Metadona/uso terapêutico , Metadona/efeitos adversos , Pessoa de Meia-Idade , Dor do Câncer/tratamento farmacológico , Idoso , Neoplasias Ósseas/complicações , Medição da Dor , Adulto , Estudos de Viabilidade , Qualidade de Vida , Dor Intratável/tratamento farmacológico , Dor Intratável/etiologiaRESUMO
In the cancer pain setting, ketamine has been typically employed as a co-analgesic for opioid refractory and neuropathic pain. One controversial topic is whether subanesthetic ketamine be considered when managing opioid refractory cancer pain. In this "Controversies in Palliative Care" article, three clinicians independently answer this question. Specifically, each clinician provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. Three independent clinicians reported a divergence of opinion regarding the usefulness of subanesthetic ketamine for managing opioid refractory cancer pain. All investigators acknowledged the lack of high-quality trials. All agreed on the need for adequately powered trials, the development of standardized methodology, and the exploration of any patient sub-populations that may benefit from ketamine for cancer related pain.
Assuntos
Analgésicos Opioides , Analgésicos , Dor do Câncer , Ketamina , Dor Intratável , Humanos , Analgésicos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Dor do Câncer/tratamento farmacológico , Ketamina/uso terapêutico , Dor Intratável/tratamento farmacológico , Cuidados Paliativos/métodosRESUMO
This study examined the effects of intrathecal analgesia (ITA) using an extracorporeal pump with a subcutaneous port system in cancer patients with bone metastasis. Among the patients who died of cancer with bone metastasis at the palliative care unit of our institution, 11 who received ITA were selected. Changes in pain, opioid doses, the palliative prognostic index (PPI), and Eastern Cooperative Oncology Group Performance Scaleãafter ITA were assessed. Pain, opioid doses, and PPI decreased after ITA (P = 0.002, 0.002, and 0.017). ITA for cancer patients with increased PPI due to refractory cancer bone pain decreased pain, opioid doses, and PPI.(100 words).
Assuntos
Analgésicos Opioides , Neoplasias Ósseas , Dor do Câncer , Injeções Espinhais , Dor Intratável , Cuidados Paliativos , Humanos , Neoplasias Ósseas/secundário , Neoplasias Ósseas/complicações , Cuidados Paliativos/métodos , Dor do Câncer/tratamento farmacológico , Masculino , Feminino , Injeções Espinhais/métodos , Pessoa de Meia-Idade , Analgésicos Opioides/administração & dosagem , Idoso , Dor Intratável/tratamento farmacológico , Medição da Dor/métodos , Medição da Dor/efeitos dos fármacos , Analgesia/métodos , Manejo da Dor/métodos , Idoso de 80 Anos ou maisRESUMO
No disponible
Assuntos
Humanos , Animais , Neuralgia/tratamento farmacológico , Analgesia/métodos , Drogas em Investigação/farmacocinética , Dor Intratável/tratamento farmacológico , Manejo da Dor/métodos , Aprovação de DrogasRESUMO
No disponible
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Sevoflurano/uso terapêutico , Pé Diabético/cirurgia , Amputação Cirúrgica/métodos , Dor Intratável/tratamento farmacológico , Dor Pós-Operatória/tratamento farmacológico , Amputação Cirúrgica/efeitos adversos , Dor Irruptiva/tratamento farmacológico , Manejo da Dor/métodosRESUMO
Conclusiones de los autores del estudio: los antidepresivos fueron eficaces para el tratamiento del dolor abdominal funcional, siendo mayor la respuesta a los inhibidores de la recaptación de serotonina que a los antidepresivos tricíclicos, independientemente del componente psiquiátrico asociado. Se valoran poco los síntomas gastrointestinales provocados por el fármaco, frecuente causa de la retirada de la medicación. Comentario de los revisores: los antidepresivos parecen ser eficaces para el tratamiento del dolor abdominal funcional, con una ventaja terapéutica de los inhibidores de la recaptación de serotonina frente a los tricíclicos. Sin embargo, dadas las limitaciones metodológicas del trabajo, la falta de concordancia con otros datos disponibles y el porcentaje alto de efectos adversos, parece prudente esperar a la realización de estudios más amplios y de mayor calidad para poder recomendar su uso en esta patología funcional
Authors' conclusions: patients had more response to serotonin reuptake inhibitors than to tricyclic antidepressants, independently of the associated psychiatric component. They give little importance to the gastrointestinal symptoms caused by the drug that could be the cause of the withdrawal of the medication. Reviewers' commentary: antidepressants appear to be effective for the treatment of functional abdominal pain, with a therapeutic advantage of serotonin reuptake inhibitors over tricyclics. However, given the methodological limitations of the study, the lack of concordance with other available data and the high percentage of adverse effects, it seems prudent to wait for larger and higher quality studies to be able to recommend its use in this functional pathology
Assuntos
Humanos , Masculino , Feminino , Criança , Antidepressivos/uso terapêutico , Dor Abdominal/tratamento farmacológico , Inibidores Seletivos de Recaptação de Serotonina/farmacocinética , Antidepressivos Tricíclicos/farmacocinética , Resultado do Tratamento , Amitriptilina/farmacocinética , Estudos Retrospectivos , Dor Intratável/tratamento farmacológico , Manejo da Dor/métodosRESUMO
No disponible
Assuntos
Humanos , Dor/epidemiologia , Dor Intratável/tratamento farmacológico , Manejo da Dor/métodos , Neoplasias/complicações , Cuidados Paliativos/métodosRESUMO
Introducción. Aunque se dispone de diferentes tratamientos para el dolor neuropático, en muchas ocasiones estos pacientes son refractarios, lo que hace necesario probar tratamientos que, por su utilidad en otras patologías, podrían ser eficaces en el dolor neuropático. Pacientes y métodos. Se recogieron las historias clínicas de pacientes que hubieran sido tratados con lacosamida para el dolor neuropático, en diferentes hospitales de la zona centro peninsular, y que cumplieran unas características similares en cuanto a refractariedad a otros tratamientos estándares, en un seguimiento de al menos seis meses, o que hubiesen tenido que suspender el tratamiento con dicho fármaco por cualquier motivo. Se obtuvo una muestra de 114 pacientes, 61 varones y 53 mujeres, con una edad media de 60,5 años. Resultados. Las causas de dolor neuropático más frecuentes fueron: polineuropatía diabética (31,6%), neuralgia postherpética (22,8%), neuralgia del trigémino (17,5%), neuralgia suboccipital y lumbociatalgia (un 12,3% en ambas). La eficacia fue buena/muy buena en la mayoría de los pacientes, con un descenso medio en la escala analógica visual tras seis meses de 7,7 a 4,8. No se registraron efectos secundarios graves en ningún paciente, pero en 12 y 10 pacientes no hubo registro más allá de seis meses, por ineficacia e intolerancia al tratamiento, respectivamente. Conclusiones. El tratamiento con lacosamida en el dolor neuropático de diferentes causas podría considerarse como una alternativa efectiva y bien tolerada para aquellos pacientes que no respondan a los tratamientos estándares (AU)
Introduction. Although different treatments are available for neuropathic pain, these patients are often refractory, which makes it necessary to test treatments that, as they have proven useful in other pathologies, could be effective in neuropathic pain. Patients and methods. The study made use of the medical records of patients who had been treated with lacosamide for neuropathic pain in different hospitals in the central area of the peninsula and who fulfilled similar characteristics in terms of refractoriness to other standard treatments, in a follow-up that lasted at least six months, or who had had to stop treatment with that drug for some reason or another. A sample of 114 patients (61 males and 53 females) with a mean age of 60.5 years was obtained from the data. Results. The most common causes of neuropathic pain were: diabetic polyneuropathy (31.6%), post-herpes neuralgia (22.8%), trigeminal neuralgia (17.5%), suboccipital and lumbar-radicular neuralgia (both 12.3%). Effectiveness was good/ very good in most patients, with the mean score on the visual analogue scale after six months dropping from 7.7 to 4.8. No serious side effects were reported in any of the patients, but in 12 and 10 patients no recordings were made beyond six months, due to ineffectiveness and intolerance to the treatment, respectively. Conclusions. Treatment with lacosamide in neuropathic pain due to different causes could be considered an effective and well-tolerated alternative for patients who fail to respond to standard treatments (AU)
Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Neuralgia/tratamento farmacológico , Anticonvulsivantes/uso terapêutico , Dor Intratável/tratamento farmacológico , Manejo da Dor/métodos , Neuralgia do Trigêmeo/tratamento farmacológico , Neuralgia Pós-Herpética/tratamento farmacológicoRESUMO
Varios estudios han mostrado que la prevalencia del dolor irruptivo en pacientes oncológicos es elevada y que se trata de un problema no completamente resuelto. El tratamiento del dolor irruptivo oncológico (DIO) requiere un fármaco con características específicas siendo probablemente de elección fentanilo, que se presenta en diversas formulaciones. En este trabajo se ha realizado una revisión de los ensayos clínicos publicados sobre el comprimido bucal de fentanilo para valorar la evidencia disponible en relación a su efectividad en el tratamiento del dolor irruptivo oncológico y aspectos relacionados con su farmacocinética, seguridad y particularmente su empleo en condiciones especiales como la mucositis. La evidencia revisada muestra que el comprimido bucal de fentanilo es eficaz en términos de alivio del dolor en el tratamiento de los episodios de DIO, incluyendo los pacientes con mucositis. Se ha revisado también la bioequivalencia entre la administración bucal (entre la encía y la mejilla) y sublingual (bajo la lengua) del preparado)
Several studies have shown that the prevalence of breakthrough pain in cancer patients is high and it is a problem not fully solved. Treatment of breakthrough cancer pain requires a drug with specific characteristics and probably the most useful drug is fentanyl, that is available in several formulations. This paper presents a review of published clinical trials on fentanyl buccal tablet to assess the evidence available regarding its effectiveness in the treatment of breakthrough cancer pain, issues related to its pharmacokinetics, safety and its use in special conditions such as mucositis. Evidence shows that fentanyl buccal tablet is effective for relieving pain in the treatment of episodes in breakthrough pain, including patients with mucositis. The bioequivalence of buccal (between the gum and cheek) and sublingual (under the tongue) administration has been also reviewed
Assuntos
Humanos , Dor Intratável/tratamento farmacológico , Manejo da Dor/métodos , Fentanila/uso terapêutico , Resultado do Tratamento , Segurança do Paciente , EfetividadeRESUMO
Introducción y objetivos: el dolor irruptivo oncológico (DIO) es una exacerbación aguda del dolor que presenta diferentes criterios diagnósticos y de tratamiento por parte de los distintos especialistas implicados en su manejo. Para facilitar la toma de decisiones en la práctica clínica habitual, ocho especialistas de referencia de cuatro sociedades científicas implicadas en el manejo del paciente oncológico handiseñado este documento. Métodos: tras una búsqueda bibliográfica en las publicaciones más relevantes sobre DIO se establecieron las recomendaciones preliminares. El grupo de expertos realizó una reunión de trabajo siguiendo la metodología Metaplan® en la que se debatieron las recomendaciones que incorporar al documento. Cada una de las afirmaciones y recomendaciones fueron clasificadas según su grado de recomendación, atendiendo a las categorías del sistema SIGN (Scottish Intercollegiate Guidelines Network). Resultados: el manejo del DIO requiere una anamnesis completa tanto del DIO como del dolor basal y una exploración física del paciente asociada a pruebas complementarias cuando sean precisas. Los fármacos de elección para el tratamiento del DIO deben ser aquellos que muestren una analgesia potente, con rápido inicio, de efectos secundarios mínimos y de fácil administración. El fentanilo administrado por vía transmucosa es actualmente el principio activo más adecuado a las necesidades analgésicas del dolor irruptivo, con independencia del opioide mayor utilizado para el control del dolor basal. Conclusión: este consenso puede ser una herramienta útil para la mejora de la calidad de vida del paciente con cáncer, ya que permite un mejor diagnóstico y tratamiento del DIO (AU)
Introduction and objectives: Breakthrough cancer pain (BTcP) is an acute exacerbation of baseline pain. The clinicians involved in its management have different diagnostic and therapeutic criteria. In order to facilitate decision making in usual clinical practice, 8 reference experts from 4 scientific associations involved in the management of patients with cancer pain have developed this Consensus Document. Methods: After an initial search on the most relevant publicationsin BTcP literature, a set of preliminary recommendations were established. A working meeting was subsequently held with the experts, following the Metaplan® methodology -a structured brainstorming technique- that produced a first version of theConsensus Document which, after several review rounds, was validated by all the participants. Every statement and recommendation was sorted according to its degree of recommendation, following the categories in the SIGN (Scottish IntercollegiateGuidelines Network) system. Results: The management of BTcP requires a full anamnesis, both of BTcP itself and of baseline pain, a physical examination and the supplementary tests that are deemed necessary. The drugs of choice for the treatment of BTcP must be those with a potent and rapid analgesic effect a short duration, minimal side effects and easy administration. Transmucosal fentanyl is currently the active ingredient most fitting to the analgesic needs of BTcP, regardless of the major opioid used for control of the baseline pain. Conclusion: This Consensus can be a very useful tool to improve the quality of life in cancer patients, because it guidesthe clinician towards a better diagnose and treatment of BTcP (AU)
Assuntos
Humanos , Dor Intratável/diagnóstico , Dor Intratável/tratamento farmacológico , Manejo da Dor/métodos , Medição da Dor/métodos , Percepção da Dor , Neoplasias/complicações , Padrões de Prática Médica , Fentanila/uso terapêutico , Analgésicos Opioides/uso terapêutico , Qualidade de VidaRESUMO
El dolor irruptivo (DIO) consiste en una exacerbación transitoria sobre un dolor de base persistente, por lo demás controlado. Se trata de un dolor moderado o intenso, que alcanza el pico de intensidad rápidamente y tiene una duración relativamente corta. Estas características hacen del fentanilo una buena opción de tratamiento por su alta lipofilia y capacidad de absorción rápida. Aquí cobra especial importancia la vía intranasal que, por su alta vascularización y permeabilidad, constituye una ruta especialmente rápida. Recientemente se ha desarrollado un espray nasal de fentanilo mezclado con una solución de pectina denominado PecFent®. El objetivo de este estudio es realizar una revisión de los estudios publicados sobre su uso para el tratamiento del DIO. Ensayos aleatorizados, controlados, a doble ciego han demostrado un inicio del alivio del dolor en tan sólo 5 minutos tras su administración, así como el alivio del dolor clínicamente significativo en 10 min. A pesar de ser el sulfato morfina de liberación inmediata el tratamiento estándar actual de los episodios de DIO, estudios comparativos han demostrado la superioridad del fentanilo intranasal para tratar este tipo de episodios porque logra un alivio del dolor clínicamente significativo y más rápido que otros fármacos. La administración por vía nasal del fentanilo ha demostrado ser bien tolerada. En el programa de ensayos clínicos se ha objetivado la presencia de efectos adversos típicos de los medicamentos opioides en esta población. Los más frecuentes fueron vómitos, náuseas, progresión de la enfermedad y estreñimiento, siendo la mayoría de leves a moderados en intensidad. La vía nasal no presentó daños por el uso continuado de fentanilo intranasal (AU)
Breakthrough oncological pain (BOP) consists of a transient exacerbation on a persistent otherwise basal controlled pain. It is a moderate or severe pain that reaches the peak of intensity quickly and has a relatively short duration. These features make fentanyl a good treatment option due its high lipophilicity and quick absorption. Here takes on special importance the intranasally route which, by its high vascularization and permeability, constitutes a particularly quick route. Recently, fentanyl mixed with a solution of pectin called PecFent® nasal spray has been developed. The objective of this study is to conduct a review of published studies on its use for the treatment of BOP. Randomized, controlled, double- blind trials have shown an onset of the pain relief in just 5 minutes after its administration, as well as in 10 min clinically meaningful pain relief. Despite being the current standard treatment of immediate release morphine sulfate, comparative studies have shown the superiority of intranasal fentanyl to treat this type of episodes. Intranasal fentanyl achieves a faster than other drugs and clinically meaningful pain relief. The administration by intranasal fentanyl has proven to be well tolerated. Clinical trials program is has found the presence of typical adverse effects of the drugs opioid in this population. The most common were vomiting, nausea, progression of the disease and constipation, the majority being mild to moderate in intensity. The nasal route did not damage by continued use of intranasal fentanyl (AU)
Assuntos
Humanos , Fentanila/administração & dosagem , Dor Intratável/tratamento farmacológico , Administração Intranasal , Manejo da Dor/métodos , Pectinas/uso terapêutico , Morfina/uso terapêutico , Neoplasias/complicaçõesRESUMO
INTRODUCCIÓN Y OBJETIVOS: El dolor irruptivo oncológico (DIO) es una exacerbación aguda del dolor que presenta diferentes criterios diagnósticos y de tratamiento por parte de los diferentes especialistas implicados en su manejo. Para facilitar la toma de decisiones en la práctica clínica habitual, ocho especialistas de referencia de 4 sociedades científicas implicadas en el manejo del paciente oncológico, han diseñado este documento de consenso. MÉTODOS: Tras una búsqueda bibliográfica en las publicaciones más relevantes sobre DIO, se establecieron las recomendaciones preliminares. El grupo de expertos realizó una reunión de trabajo siguiendo la metodología Metaplan(R), donde se debatieron las recomendaciones a incorporar al documento. Cada una de las afirmaciones y recomendaciones fueron clasificadas según su grado de recomendación, atendiendo a las categorías del sistema SIGN (Scottish Intercollegiate Guidelines Network). RESULTADOS: El manejo del DIO requiere de una anamnesis completa, tanto del DIO como del dolor basal, y una exploración física del paciente asociada a pruebas complementarias cuando sean precisas. Los fármacos de elección para el tratamiento del DIO deben ser aquellos que muestren una analgesia potente, con rápido inicio de acción, efectos secundarios mínimos y de fácil administración. El fentanilo administrado por vía transmucosa es actualmente el principio activo más adecuado a las necesidades analgésicas del dolor irruptivo, con independencia del opioide mayor utilizado para el control del dolor basal. CONCLUSIÓN: Este consenso puede ser una herramienta útil para la mejora de la calidad de vida del paciente con cáncer, ya que permite un mejor diagnóstico y tratamiento del DIO
INTRODUCTION OBJECTIVES: Breakthrough cancer pain (BTcP) is an acute exacerbation of baseline pain. The clinicians involved in its management have different diagnostic and therapeutic criteria. In order to facilitate decision making in usual clinical practice, 8 reference experts from 4 scientific associations involved in the management of patients with cancer pain have developed this Consensus Document. METHODS: After an initial search on the most relevant publications in BTcP literature, a set of preliminary recommendations were established. A working meeting was subsequently held with the experts, following the Metaplan(R) methodology -a structured brainstorming technique- that produced a first version of the Consensus Document which, after several review rounds, was validated by all the participants. Every statement and recommendation was sorted according to its degree of recommendation, following the categories in the SIGN (Scottish Intercollegiate Guidelines Network) system. OUTCOMES: The management of BTcP requires a full anamnesis, both of BTcP itself and of baseline pain, a physical examination and the supplementary tests that are deemed necessary. The drugs of choice for the treatment of BTcP must be those with a potent and rapid analgesic effect a short duration, minimal side effects and easy administration. Transmucosal fentanyl is currently the active ingredient most fitting to the analgesic needs of BTcP, regardless of the major opioid used for control of the baseline pain. CONCLUSION: This Consensus can be a very useful tool to improve the quality of life in cancer patients, because it guides the clinician towards a better diagnose and treatment of BTcP
Assuntos
Humanos , Manejo da Dor/métodos , Dor Intratável/tratamento farmacológico , Neoplasias/complicações , Cuidados Paliativos/métodos , Cuidados Paliativos na Terminalidade da Vida/métodos , Padrões de Prática MédicaRESUMO
Objetivo: ofrecer una revisión de las características farmacológicas de la ketamina, sus propiedades analgésicas y su aplicación en el manejo del dolor oncológico. Material y métodos: revisión de la literatura hasta octubre de 2009 utilizando las palabras clave: ketamina, dolor, neoplasia, cuidados paliativos. Asimismo, se han utilizado posibles fuentes bibliográficas suministradas en las referencias de los artículos, búsquedas vía on-line a través de Google y el uso de textos reconocidos de anestesia general. Resultados: la ketamina es un anestésico disociativo con efecto analgésico a dosis subanestésicas, teniendo como peculiaridades una acción antagonista sobre la sensibilización central y la disminución de la tolerancia del uso crónico de los opioides. Estas propiedades hacen que sea un fármaco co-analgésico útil en el dolor oncológico refractario, Sin embargo no está libre de efectos secundarios, siendo los psicomiméticos los más frecuentes, También se ha descrito su uso para la sedación del paciente oncológico con buenos resultados. Conclusiones: a pesar las propiedades beneficiosas de la ketamina en el manejo del dolor refractario, aún no existe la suficiente evidencia científica para confirmadas, siendo necesarios más ensayos clínicos randomizados bien diseñados. Tras la revisión realizada se proponen unas recomendaciones para su uso como co-analgésico en el tratamiento del dolor de difícil control en el paciente con cáncer avanzado (AU)
Objectives: to review the pharmacologic characters of ketamine, its analgesic properties and its application on cancer pain. Matherial and methods: a review till October 2009 using the key words: ketamine, pain, neoplasm, palliative care. Potencial sources provided by bibliographic references in reviewed articles were used, as well as searches on line in Google and recognized texts of Anaesthesia. Results: ketamine is a dissociative anaesthetic with analgesic effect at sub-anaesthetic doses, where it has an antagonism effect to central sensibilitation and anti-tolerance effect to opioids. These properties make ketamine a useful treatment for refractory cancer pain. Nevertheless, it is not free of side effects being the psychotomimetic the most frequent ones. It has also been described its use as a sedative in oncologic patients with good results. Conclusions: although the beneficial ketamina's properties in the management of refractory pain, there is not yet enough evidence to confirm those characteristics. Thus, more randomized clinical trials are needed. After the review done, some recommendations are given for the use of ketamine as a co-analgesic in the treatment of difficult pain control in advanced cancer patients (AU)
Assuntos
Humanos , Ketamina/farmacocinética , Dor Intratável/tratamento farmacológico , Cuidados Paliativos/métodos , Manejo da Dor/métodos , Neoplasias/complicações , Interações Medicamentosas , Analgésicos/farmacocinéticaRESUMO
Antecedentes: Aproximadamente 6,35 millones de nuevos casos de cáncer se diagnostican anualmente. El 90% de los pacientes con cáncer avanzado presentan dolor. El objetivo en el tratamiento del dolor oncológico es aliviar el dolor, interrumpiendo la transmisión o modulándolo a nivel cerebral o espinal. La Organización Mundial de la Salud (OMS) desarrolló una escala de tres escalones para manejar el dolor oncológico. En el escalón se incluyen analgésicos no opiáceos + coadyuvantes; en el escalón II se incluyen opiáceos leves + coadyuvantes y en el escalón III se incluyen opiáceos potentes + coadyuvantes. Material y métodos: Se revisaron 72 expedientes, en un total de 4 años, de todos los pacientes con dolor crónico oncológico que hayan estado en tratamiento con hidromorfona. En este trabajo obtuvimos la dosis promedio en la que se logró un buen control del dolor (escala analógica visual [EVA] < 4). También reportamos los efectos adversos que más se presentaron, así como si algún paciente abandonó el tratamiento, y sus causas. Se reportó el tipo de cáncer de cada paciente y el tiempo de tratamiento con hidromorfona. Resultados: La dosis promedio que se utilizó fue de 22 mg + 16 mg en 24 h. De estos 72 pacientes, 7 no lograron llegar a un control del dolor y 1 abandonó el tratamiento, ya que no toleró los efectos adversos. Los efectos adversos que más comúnmente se presentaron fueron estreñimiento, náuseas, vómitos y somnolencia. El efecto adverso que más se presentó fue el estreñimiento, con una diferencia estadísticamente significativa respecto de los otros efectos adversos presentados. El estreñimiento es un efecto adverso que, si se controla con un fármaco, es muy tolerable. Conclusiones: El promedio de dosis efectiva de hidromorfona que encontramos es una dosis relativamente baja, a la que los efectos adversos son tolerables ( ) (AU)
Background: Approximately 6.35 million patients are diagnosed with cancer annually. Around 90% of patients with advanced cancer have pain. Treatment of oncologic pain aims to relieve pain by modulating or interrupting transmission in the spine or brain. The World Health Organization (WHO) has developed a three-step ladder for cancer pain management. At step I, non-opioid plus adjuvant drugs are included. Step II includes opioids for mild to moderate pain plus adjuvants, and step III includes opioids for moderate to severe pain plus adjuvants. Material and methods: We reviewed 72 files corresponding to all the patients with chronic cancer pain that had been treated with hydromorphone during the previous 4 years in our hospital and calculated the mean dose at which the patients reported good pain control (Visual Analog Scale [VAS] < 4). We also studied the most common adverse effects, and whether any of the patients discontinued the treatment, and if so, the reasons for discontinuance. The type of cancer in each patient and the length hydromorphone treatment were also noted. Results: The mean dose used was 22 mg + 16 mg in 24 hours. Of the 72 patients, seven did not achieve adequate pain control and one discontinued the treatment due to adverse effects. The most common adverse effects were constipation, nausea, vomiting and drowsiness. Constipation was significantly more frequent than the remaining adverse effects. Constipation is an adverse effect that is highly tolerable when controlled by medication. Conclusions: The mean effective hydromorphone dose is a relatively low dose at which the adverse effects are still tolerable. The most common adverse effect was constipation, which is fairly tolerable with medication. Hydromorphone is a safe and effective drug even for prolonged periods (AU)
Assuntos
Humanos , Hidromorfona/administração & dosagem , Dor Intratável/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Neoplasias/complicações , Constipação Intestinal/induzido quimicamenteRESUMO
Objetivos: describir la evolución del consumo de analgésicos opioides en el Área Sanitaria de Puertollano en el periodo 2001-2005 y evaluar el mismo tras la puesta en marcha en 2006 de un recurso de Cuidados Paliativos como medida de resultado. Método: análisis de los cinco opioides mayores más prescritos. Los datos de consumo se obtuvieron del archivo informático del Servicio de Farmacia. Se evaluaron las prescripciones realizadas por Atención Primaria, médicos especialistas y en el hospital, expresado en DHD (dosis diaria definida por mil habitantes por día) para los dos primeros niveles y en DDD (dosis diaria definida)/100 estancias para el tercero, entre los años 2001-2006. Resultados: en Atención Primaria se observa un incremento progresivo en el consumo global de opioides, pasando de 0,68 a 2,89 DHD. Por fármacos, destaca la prescripción de opioides de liberación transdérmica, que se incrementa desde 0,51 DHD en 2001 hasta 2,80 DHD en 2006, representando este año el 93% de las DHD totales. Las DHD prescritas por médicos especialistas aumentan de forma más moderada, de 0,02 a 0,06, y en 2006 disminuyen ligeramente. Sólo las de morfina oral se incrementan acusadamente en este último año, pasando de 0,0003 DHD en 2005 a 0,0064 DHD en 2006. También aquí las DHD de fármacos administrados en parches suponen casi la totalidad del grupo(99,2% en 2001), aunque disminuye el porcentaje ligeramente en 2006 (90,2%). En el ámbito hospitalario, no se observa correlación entre las DDD consumidas, ni de manera global ni para cada uno de los fármacos, con el número de estancias hospitalarias. Sin embargo en 2006 existe un incremento importante del consumo global y de morfina en particular (60,8% de las DDD/100 estancias totales), que supera por vez primera al de opioides de liberación transdérmica (31,6%), sin que una variación apreciable del case-mix lo justifique. Conclusiones: se observa un incremento continuado en las DHD prescritas tanto por médicos especialistas como en Atención Primaria. Sin embargo, el consumo en el hospital evoluciona de forma errática. Este comportamiento parece cambiar coincidiendo con el inicio de la actividad del Equipo Hospitalario de Cuidados Paliativos (AU)
Objectives: to describe the trends of use for opioid analgesics in theArea of Puertollano during the period 2001-2005, and to evaluate it as an outcome measure after launching a Palliative Care Program in 2006. Method: an analysis of the five strong opioids most commonly prescribed. Data on use were obtained from the Pharmacy Service computer files. The prescription of opioid analgesics in primary, specialized, and hospital care were assessed and expressed as DHD (Defined Daily Dose per 1,000 inhabitants per day) for the two first sanitary levels, and as DDD (Defined Daily Doses)/100 hospital stays for the third one, from 2001 to 2006. Results: there is a gradual increase in the overall use of opioids that moves from 0.68 to 2.89 DHDs in primary care. The prescription of transdermal release opioids, which increased from 0.51 DHDs in 2001 to 2.80 in 2006, should be highlighted. This represents 93% of total DHDs this year. DHDs prescribed by medical specialists increased in a more moderate way, from 0.02 to 0.06, and decreased slightly in 2006. Only oral morphine DHDs increased sharply in the past year, from 0.0003 DHDs in 2005 to 0.0064 DHDs in 2006. Here, the DHDs for drugs administered in patches account for almost the entire group too (99.2% in 2001), although its share declined slightly in 2006 (90.2%).In the hospital setting no correlation between DDDs used, either overall or for each drug, and number of hospital stays was seen.However, in 2006 there was a significant increase in global consumption, particularly for morphine (60.8% of total DDDs/100 hospital stays), exceeding for the first time those of transdermal release opioids (31.6%) without a significant variation of case-mix warrants. Conclusions: there is continued growth in DHDs prescribed by both specialists and primary care physicians. However, hospital use evolves in an erratic manner. This behavior seems to be changing since palliative care teams were implemented (AU)
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Humanos , Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Cuidados Paliativos/estatística & dados numéricos , Dor Intratável/tratamento farmacológico , Uso de Medicamentos/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricosRESUMO
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Humanos , Masculino , Neoplasias da Próstata/tratamento farmacológico , Difosfonatos/farmacocinética , Antígeno Prostático Específico , Cuidados Paliativos , Dor Intratável/tratamento farmacológicoRESUMO
Los opioides representan la mejor arma terapéutica para el control del dolor en el paciente oncológico. Más de la mitad de los pacientes con dolor oncológico precisarán, a lo largo de su seguimiento, tratamiento con opioides del 3.er escalón de la Organización Mundial de la Salud (OMS) para ser controlados. El tipo de interacción con los receptores opioides determina las distintas acciones farmacológicas y sus efectos adversos. Pero además las sustancias opioides pueden interaccionar sobre otros sistemas de neurotransmisores y otros receptores. La codeína y el tramadol constituyen el segundo nivel de la escala de la OMS, eficaces en dolor moderado. Se caracterizan por tener techo analgésico. Dentro de este grupo se incluye a la buprenorfina. La morfina, la oxicodona, el fentanilo y la metadona son igual de eficaces para el control del dolor. La selección de uno u otro depende de la vía de administración, el coste del fármaco y los efectos secundarios. La morfina es el opioide mayor de elección aunque no existen estudios concluyentes. El tratamiento del dolor oncológico debe incluir siempre dosis de opioides de rescate para control del dolor irruptivo. Debemos de tener siempre en cuenta los efectos secundarios de los opioides y prevenirlos. La rotación o el cambio de opiáceos es una alternativa terapéutica para mejorar la relación entre la eficacia analgésica y la aparición de efectos secundarios de tratamiento opi
Opioids are the best therapeutic armamentarium for the control of pain in the oncology patient. More than half of the cancer patients with pain will need treatment with opioid treatment (WHO step 3) during their follow-up to be controlled. The type of interaction with the opioid receptors determines the different drug actions and their adverse effects. However, opioid substances can also interact on other neurotransmitter systems and other receptors. Codeine and tramadol make up the second level on the WHO scale, and are effective in moderate pain. They are characterized by having an analgesic ceiling effect. Buprenorphine are included within this group. Morphine, oxycodone, phentanyl and methadone are as effective to control pain. Choosing one or the other depends on the administration route, drug cost, side effects. Morphine is the opioid of choice, although there are no conclusive studies. Treatment of cancer pain should always include rescue opioid dose to control irruptive pain. We should always keep the side effects of opioids in mind and prevent them. Rotation or change of opiates is a therapeutic alternative to improve the relationship between analgesic efficacy and appearance of side effects of opiate treatment
Assuntos
Humanos , Dor Intratável/tratamento farmacológico , Analgésicos Opioides/farmacocinética , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Interações Medicamentosas , Analgésicos Opioides/classificaçãoRESUMO
El dolor crónico intenso es un problema de salud de primer orden, ya que presenta un prevalenciaelevada (5-10%), una etiología multifactorial y un abordaje en muchas ocasiones realmente complejo. El tratamiento en los casos graves precisa, en ocasiones, abordajes intervencionistas, como los opioides vía intratecal en infusión continua. Casoclínico. Mujer de 38 años de edad, con dolor neuropático intenso en la zona lumbar y los miembros inferiores secundario a tres intervenciones en el segmento lumbar L5-S1. Tras diversos esquemas farmacológicos orales y mediante sistemas implantados(estimulador de cordones posteriores y bomba de infusión subaracnoidea con diferentes combinaciones farmacológicas) sin obtener mejoría clínica, se incluyó en el protocolo de infusión intratecal con ziconotide. Conclusiones. El ziconotide es el primer bloqueador neuronal específico que actúa sobre el canal de calcio, bloqueando los canales tipo N del calcio dependientesde voltaje. Es un nuevo analgésico no opioide con indicación aprobada en el tratamiento del dolor crónico intenso, en aquellos pacientes que requieren de analgesia intratecal, refractario a otros tratamientos analgésicos. Por lo tanto, deberemosconsiderar este fármaco como una alternativa de terapia en aquellos pacientes que con la farmacopea y los mediosdisponibles actualmente no encuentran alivio suficiente
Intense chronic pain is a very important health problem, as it has a high prevalence (5-10%), amultifactorial aetiology and its management is very often a very complex affair. Treatment of severe cases sometimes requires interventional approaches, such as continuous intrathecal infusion of opioids. Case report.We report the case of a 38-year-oldfemale with intense neuropathic pain in the lower back and the lower limbs secondary to three operations on the L5-S1 lumbar segment. After implementing several different pharmacological regimes involving both oral and implanted systems (spinal cord stimulation and subarachnoid infusion pump with different pharmacological combinations) with no clinicalimprovement, intrathecal infusion with ziconotide was included in the protocol. Conclusions. Ziconotide is the first specific neuronal blocker that acts on the calcium channel by blocking the N-type voltage-dependent calcium channels. It is a new nonopioidanalgesic with approved indication in the treatment of intense chronic pain, in patients who require intrathecalanalgesics and are refractory to other analgesic treatments. Therefore, we shall have to consider this drug as a therapeutic alternative in patients do not experience sufficient relief with the pharmacological agents and means currently available to treat them