Journal of Pain & Palliative Care Pharmacotherapy最新文献

To develop consensus recommendations for improving the diagnosis and treatment of breakthrough cancer pain (BTcP), including procedural BTcP, the opinions of 107 medical experts in managing patients with cancer in Spain were collected using a two-round Delphi method. Consensus was assessed for 76 items using a Likert scale (1-9). Agreement was reached when the median (MED) score was ≥ 7 and the interquartile range (IQR) ≤ 3, while disagreement was considered when MED was ≤ 3 and IQR was ≤ 3. Consensus was reached on 90% of the statements. Experts agreed on the main characteristics of BTcP, which may have a variable number of episodes per day and occur in patients with opioid-controlled background pain. There was resounding agreement on the need to evaluate pain severity, both background and breakthrough cancer pain, in patients with cancer, involving adequately trained physicians and nursing staff. Procedural BTcP, a subtype of BTcP, is common in cancer diagnosis and/or treatment procedures. For this, premedication with an appropriate fast-acting, short-duration drug is necessary. These findings highlight the need for standardized protocols and specific training to improve the quality of life of patients suffering from BTcP, including procedural BTcP, and the efficiency of healthcare resource management.

Management of "death rattle" at the end of life typically involves the use of anticholinergic agents to reduce airway secretions. However, in patients with myasthenia gravis - an autoimmune condition affecting acetylcholine receptors, causing fatigability and weakness of the skeletal muscles - the use of such agents poses a challenge. Anticholinergic agents antagonize the effects of acetylcholinesterase inhibitors, which are critical for treating myasthenia gravis, and may exacerbate symptoms. We report the case of a terminal patient with underlying myasthenia gravis who had concomitant death rattle. A trial of hyoscine butylbromide was effective in treating the death rattle, while the myasthenic symptoms remained quiescent. To our knowledge, this has not been reported previously.

Short gut syndrome presents multiple unique challenges in pain management and orally delivered medications. The removal or reduction of gastrointestinal sites of absorption, high-output states, and inability to absorb oral medications often limit pain management strategies. We report our experiences caring for individuals with short gut syndrome and share the challenges and strategies we have utilized to optimize pain control for our patients. Case 1 describes a 49-year-old male with an extensive history of abdominal surgery leading to chronic abdominal pain requiring alternative routes of administration and utilization of unique pharmacology considerations to optimize oral absorption and pain control. Case 2 describes a 68-year-old female with cancer-related pain, which required high opioid requirements and utilization of opioids with unique mechanisms of action for complex pain syndromes. We will include potential management strategies described in the cases and conclude with pharmacokinetic considerations for various drug therapy options in pain management.

Pain management is a critical challenge in healthcare as acute and chronic pain affect millions of individuals globally. Opioid-based therapies that were once considered the traditional treatment methods are facing scrutiny due to their limitations and risks, due to which it is evident that an equally effective alternative pain management approach is necessary. Ketamine is a promising solution. Ketamine acts as an NMDA (N-methyl-D-aspartate) receptor antagonist, and modulates pain pathways at central and peripheral levels, which enables it to address complex pain mechanisms that opioids cannot adequately target. It is a valuable option for patients who are opioid refractory, intolerant, or have insufficient pain relief from standard therapies. While traditionally used in intensive care units (ICUs), ketamine use has been expanded to general inpatient floors at our institution. This article will present a model for implementing a low-dose ketamine protocol for pain management in a community hospital setting, using our experience as a prototype. It will highlight ketamine's pharmacological advantages, safety considerations, and the staff education, logistics, and collaboration necessary for implementation. By pioneering this model in our county, our goal is to provide a model for other community hospitals to adopt.

Dexmedetomidine (DEX) has been proposed as an opioid-sparing adjunct after spinal fusion, but its efficacy across age groups is unclear. We conducted a systematic review and meta-analysis following PRISMA and registered in International Prospective Register of Systematic Reviews (PROSPERO) (CRD42024531252). Twelve studies (RCTs and cohorts; n=1,644) were included. Outcomes were postoperative pain (VAS), opioid consumption, and adverse events. DEX significantly reduced postoperative nausea and vomiting (OR 0.55; 95% CI 0.39-0.77) and respiratory adverse events (OR 0.13; 95% CI 0.04-0.39). Among adults, effects on VAS and opioid consumption were not significant; pediatric cohorts showed a trend toward lower morphine use. Certainty of evidence was appraised with GRADE; risk of bias with RoB 2.0 and MINORS. Heterogeneity for opioid-related outcomes was high (I²=96%). In summary, DEX appears to be a safe adjunct for postoperative analgesia after spinal fusion, with clearer benefits on adverse-effect profiles and potential opioid-sparing effects in pediatric patients. Its impact on adult pain and opioid outcomes is limited. Further adequately powered trials should clarify optimal dosing, timing, and administration routes and explore age-specific effects.

Although the pathogenesis and management of Myofascial Pain Syndrome (MPS) have been discussed in the literature, only a few studies have examined the effects of trigger point injection (TPI) on MPS or opioid dosage in patients with cancer. We evaluated changes in numeric rating scale (NRS) scores and opioid dosage, along with the duration of opioid use, nutritional status, and the types of cancer and metastases in patients with cancer and MPS who received TPI, to evaluate its clinical significance. Data were collected retrospectively from 20 inpatients with cancer and MPS who received TPI for pain management from the palliative care team between April 2018 and January 2020. TPI improved NRS scores in several cases and reduced opioid dosage. Notably, long-term opioid users (up to 336 days) also experienced improvements in NRS scores and discontinued opioids. TPI is an effective intervention for managing MPS in patients with cancer and may help prevent unnecessary escalation of opioid therapy, reducing the associated risks of side effects and dependency.

Adequate analgesia in patients with advanced cancer can pose a significant clinical challenge, particularly when refractory to conventional opioid-based therapies. Refractory cancer pain, characterized by inadequate relief despite optimized opioid regimens or intolerable side effects, often prompts alternative treatments to improve patient's quality of life. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, may represent a useful adjunctive therapy due to its unique analgesic properties and potential to mitigate opioid tolerance and hyperalgesia. While traditionally recognized for its anesthetic and dissociative effects, low-dose, subanesthetic ketamine can be useful in palliative care to manage severe, intractable pain. This article reviews the unique pharmacologic properties of ketamine and describes a case report recounting ketamine use in a patient with refractory cancer pain, highlighting therapeutic potential and clinical implications in the palliative setting.

Patients with lung cancer tend to suffer from cough, which is usually managed with antitussives and opioids. Some of these patients develop cough that do not respond to these first line medications. Nebulized lidocaine can be administered to help relieve this distressing symptom. We describe two patients with lung cancer who developed cough despite use of antitussives, opioids and antibiotics (Patient A) in an inpatient hospice. Both patients responded to the addition of nebulized lidocaine to manage cough. In this paper, we outline clinical considerations for its use in cough.

This pilot study aimed to determine feasibility of a larger definitive study evaluating sublingual ketamine efficacy as first-line breakthrough analgesia for moderate-to-severe pain in advanced cancer. This prospective, double-blind, randomized, placebo-controlled, repeated cross-over trial included patients (≥18 years) with moderate-to-severe pain from advanced cancer requiring opioid analgesia, randomized to weekly-alternating treatment sequences (APAPAP, APAPPA, APPAAP, APPAPA, PAAPAP, PAAPPA, PAPAAP, PAPAPA; A = sublingual ketamine, P = placebo). The primary outcome was attrition rate, measured by completion of two treatment cycles over 12-months. Of 64 patients referred, 29 were randomized, 11 received intervention. The pre-determined criterion of 24 patients completing 2-cycles over 12-months was not met. Most patients perceived receiving active drugs in placebo (0.71) and active (0.67) periods. Ketamine scored higher than placebo for pain reduction, perceived to be more efficacious than usual breakthrough analgesia, and increased quality-of-life scores. This study design will be infeasible for a larger trial due to a high attrition rate. The patients' inability to discriminate between the placebo versus active medication and the minimal adverse effects suggested that the chosen dose was possibly too low. The potential issue of disease progression over the study period suggests that further target population refinement should be considered.