Journal of Pain & Palliative Care Pharmacotherapy最新文献

Serotonin toxicity (ST) is a preventable, life-threatening condition caused by serotonergic agents. It typically arises from combined drug use that affects serotonin's release and metabolism. While often presenting with mild symptoms that may be overlooked or misdiagnosed, severe toxicity is associated with significant mortality. The older population is particularly at risk due to altered drug pharmacokinetics, a tendency for multiple drug use, and symptom overlap with common neurodegenerative conditions. The case study discusses an older patient with prolonged ST developed with the use of several serotonergic drugs for postherpetic neuralgia. It emphasizes the challenges of polypharmacy in older patients, offering insights into the serotoninergic potential of multiple medicines commonly used in older adults, the pathophysiology, proper diagnosis and differential diagnoses, and management strategies of ST. Accurate diagnosis requires heightened vigilance from healthcare professionals regarding potential drug interactions and familiarity with the specific clinical criteria. Regular revision and adjustment of medications in older patients and preference for the non-pharmacological treatment of chronic pain are essential for preventing ST. This case report is a convenient way for many healthcare professionals to update their knowledge about ST, its diagnosis and management.

Buprenorphine can be an effective and safe option for patients with chronic pain. We describe a case in which a patient on long-term full opioid agonists for chronic non-cancer pain was safely transitioned from methadone to buprenorphine in the outpatient setting using a low dose buprenorphine initiation protocol. One month after the opioid rotation, the patient reported adequate analgesic effect from the buprenorphine regimen. Further studies are warranted to better guide prescribing of buprenorphine for chronic nonmalignant pain.

IgE-mediated opioid hypersensitivities, or true allergies, are rare and most adverse reactions to opioids can be attributed to side effects or to pseudo-allergies. Given that immune-mediated allergies to opioids are uncommon, literature regarding cross-reactivity among opioid classes are limited. This retrospective study aimed to determine the rates of cross-reactivity and tolerance among patients with previously documented opioid allergy or adverse drug reaction (ADR) across three opioid drug classes (natural, semisynthetic, and synthetic opioids). Patients with documented allergy(s) and/or ADR(s) to opioids were assessed for outcomes of subsequent opioid exposure during any hospital admission at a Veterans Affairs hospital over a 10-year time-period. Veterans were sorted into three cohorts based on the opioid class of the previously documented allergy or ADR. Each cohort had three study arms, one for each class of subsequent opioid exposure. A total of 1507 patients were identified with previously documented allergy or ADR to at least one opioid and at least one subsequent opioid drug exposure. No cross-reactivity among any of the opioid drug classes were found resulting in 100% re-exposure tolerance rates with all study arms. These findings could increase confidence in utilizing opioids in patients with historically documented opioid allergies or ADRs.

Numerous opioid-induced respiratory depression (OIRD), oversedation, and overdose prediction models exist to quantify a probability or estimate risk severity for a future event. The primary aim was to determine OIRD, oversedation, and overdose risk severity (i.e., low, moderate, and high) and agreement of risk severity between three previously published prediction models. This single-center, retrospective analysis evaluated 134 patients with cancer. Sixty-five (49%) patients were Caucasian. Forty-three (32%) patients were diagnosed with gastrointestinal cancer. Predictive factors from prediction models were concurrent sedating medication (n = 119, 89%), female sex (n = 85, 63%), a mental health diagnosis (n = 68, 51%), and antidepressant use (n = 55, 41%). For most patients, risk severity varied between moderate to high risk. Risk class severity was significantly different between prediction models (p ≤ 0.05). Frequencies of risk severity agreement between all three prediction models, between two prediction models, and no agreement was 16% (n = 22), 69% (n = 93), and 14% (n = 19), respectively. Additional research is needed to evaluate model calibration to increase OIRD, oversedation, and overdose prediction model validity and generalizability for future clinical implementation.

Mirtazapine is a selective serotonergic antidepressant that functions by blocking adrenergic alpha2-autoreceptors and heteroreceptors and inhibiting 5-HT2 and 5-HT3 receptors. It is a noradrenergic drug. Mirtazapine has anxiolytic or sleep-quality-improving effects, aggravates appetite-stimulation, and has stomach emptying functions. When treating poly-symptoms such as appetite loss, anxiety, depression, nausea, and sleeplessness off-label, mirtazapine is being used more and more. A not so common side effect of mirtazapine medication is peripheral edema. The ensuing case study will demonstrate how peripheral edema is an uncommon mirtazapine adverse effect. Peripheral edema was observed in a patient with advanced oral cavity cancer three days after starting a daily dose of 15 mg of mirtazapine for polysymptomatology. The peripheral edema completely resolved after stopping mirtazapine. To the best of our knowledge, this is the first instance of a patient with advanced oral cavity cancer experiencing peripheral edema as a result of receiving mirtazapine medication. Our study will assist medical professionals in identifying the potential use of mirtazapine in situations where peripheral edema develops quickly, facilitating its quick clearance.

The purpose of this study was to better characterize morphine equivalent daily dose (MEDD) equivalencies with buccal buprenorphine, and identify real-world efficacy and safety outcomes associated with the use of buccal buprenorphine for chronic pain at a local VA Medical Center. This study was a retrospective chart review of Computerized Patient Record System (CPRS) patient records with outpatient prescriptions for buccal buprenorphine (Belbuca^®). Overall, there was a high discontinuation rate of Belbuca^®: being 60% or greater across all different patient groups. These high attrition rates may potentially be result of failure to titrate to an optimal dose of Belbuca^® needed for adequate analgesia. Those fully rotated fared marginally better than those partially rotated in that those fully rotated discontinued at a lesser rate and less quickly than those who were partially rotated. From the results of this study, a local dosing scheme for Belbuca^® based on baseline MEDD was created for facility level guidance. The exact MEDD conversion ratio, however, for individual buprenorphine products as well as MEDD contributed by these products on a patient's overall opioid related risk compared to other full agonist opioids still remains unclear and further studies are warranted.

Chronic pancreatitis is a globally prevalent progressive disease, with pain affecting up to 90% of patients, significantly impairing quality of life and leading to high rates of disability, hospitalizations, and opioid dependence. Pain management is crucial in treating chronic pancreatitis, with endoscopic ultrasound-guided celiac plexus block (EUS-CPB) recognized as an interventional option. This systematic review and meta-analysis, following PRISMA guidelines, synthesized data from 12 studies (5 randomized control trials and 7 observational) on the efficacy of EUS-CPB in managing chronic pancreatitis pain. The overall analysis revealed a significant pain relief proportion of 0.64 (n=612) with moderate heterogeneity. Subgroup analyses revealed a proportion of 0.72 in RCTs and 0.59 in observational studies. Common complications included diarrhea and exacerbation of abdominal pain, with no reported mortality. Despite variations in efficacy due to study heterogeneity and patient differences, the findings suggest EUS-CPB as a safe and effective option, with effects lasting weeks to months. Recent studies have demonstrated the applicability of EUS-CPB across ethnically diverse and pediatric populations. However, limitations including small sample sizes and study variability highlight the need for personalized treatment approaches. Future larger randomized sham-controlled trials are recommended to better assess the duration of pain relief and impact on opioid use.

Bone pain is the commonest side-effect faced by cancer patients receiving granulocyte colony stimulating factor (G-CSF) therapy for the primary or secondary prevention of febrile neutropenia. We conducted a prospective quasi-experimental study at our setup to see the efficacy of dual histamine blockade (combined H1 and H2 receptor blockers) for preventing G-CSF-induced bone pain. Adult female patients with solid tumors who had received filgrastim for the primary prophylaxis of febrile neutropenia and met our inclusion criteria, were enrolled (n = 119). This population was analyzed for the development of significant bone pain 24 h after the administration of Filgrastim. Significant bone pain in our study was defined as emergence of new onset pain measuring ≥4 on 11-point Numerical rating scale (NRS) or at least ≥ 2-point increase in score when compared to the baseline pain (if any). Those patients who experienced significant bone pain (n = 47) were given Loratadine 10 mg and Famotidine 20 mg orally half an hour before the next filgrastim administration. Pain assessment was done 24 h after Filgrastim administration, using NRS and data was analyzed. The mean NRS score in our patients after administration of filgrastim was 6.87 ± 1.055. Most of these patients (n = 34 i.e 72%) experienced relief in bone pain after dual histamine blockade use. The mean NRS score following the use of dual antihistamines was 4.36 ± 1.870. The NRS score improved by a mean of 2.51 after using dual histamine blockade, which was statistically significant (p-value= 0.0005). We propose that dualhistamine blockade may prove to be an effective option for prophylaxis of G-CSF-induced-bone-pain. Randomized control trials on larger and more diverse patient populations are required to reinforce the findings.

Intravenous (IV) magnesium sulfate, a versatile electrolyte, plays a pivotal role across various medical domains. From cardiac care to obstetrics, gastrointestinal to pulmonary therapies, the impact is far-reaching among acute care services. Notably, in the postoperative phase of care, it shares intriguing similarities with ketamine as an NMDA receptor antagonist. This case series describes the difficulties experienced with postoperative analgesia in three patient cases with complex comorbidities and discusses the beneficial impact observed when magnesium was administered concomitantly with ketamine. Further research is necessary to outline the specific role, ideal population, and recommended bolus and infusion rate for optimal analgesic efficacy.