- Minor contribution of cytochrome P450 3A activity on fentanyl exposure in palliative care cancer patients. [Journal Article]Sci Rep 2019; 9(1):14635SR
- Transdermal fentanyl is widely used to control pain in cancer patients. The high pharmacokinetic variability of fentanyl is assumed to be due to cytochrome P450 3A-mediated (CYP3A) N-dealkylation to norfentanyl in humans. However, recently published clinical studies question the importance of the described metabolic pathway. In this small study in palliative cancer patients under real-life clinic…
Transdermal fentanyl is widely used to control pain in cancer patients. The high pharmacokinetic variability of fentanyl is assumed to be due to cytochrome P450 3A-mediated (CYP3A) N-dealkylation to norfentanyl in humans. However, recently published clinical studies question the importance of the described metabolic pathway. In this small study in palliative cancer patients under real-life clinical conditions, the influence of CYP3A on fentanyl variability was investigated. In addition to the determination of midazolam plasma concentration to reveal CYP3A activity, plasma concentrations of fentanyl and its metabolite, norfentanyl, were measured in identical blood samples of 20 patients who participated in an ongoing trial and had been on transdermal fentanyl. Fentanyl, norfentanyl, midazolam, and 1'-OH-midazolam were quantified by liquid chromatography/tandem mass spectrometry. Plasma concentrations of fentanyl and norfentanyl exhibited a large variability. Mean estimated total clearance of fentanyl and mean metabolic clearance of midazolam (as a marker of CYP3A activity) were 75.5 and 36.3 L/h. Both clearances showed a weak correlation and hence a minimal influence of CYP3A on fentanyl elimination.
- Does transdermal fentanyl work in patients with low BMI? Patient-reported outcomes of pain and percent pain relief in cancer patients on transdermal fentanyl. [Journal Article]Cancer Med 2019CM
- CONCLUSIONS: When predicting percent pain relief, we conclude that there is no basis for avoiding TDF or modifying its dose in cancer patients with low BMI and cachexia.
- Transdermal fentanyl to parenteral morphine route switch and drug rotation in refractory cancer cachexia. [Journal Article]BMJ Support Palliat Care 2019BS
- It is recommended not to use transdermal fentanyl (Fe) patches (TFP) in cancer cachexia but TFP may be the only available option for pain. Limited evidence suggests lower Fe absorption from TFP in cachexia. We describe a case of metastatic breast cancer with refractory cachexia. Her pain was uncontrolled on TFP and was route switched and drug rotated to intravenous morphine (M). We were conservat…
It is recommended not to use transdermal fentanyl (Fe) patches (TFP) in cancer cachexia but TFP may be the only available option for pain. Limited evidence suggests lower Fe absorption from TFP in cachexia. We describe a case of metastatic breast cancer with refractory cachexia. Her pain was uncontrolled on TFP and was route switched and drug rotated to intravenous morphine (M). We were conservative and did not use the 1:100 TFP to oral M conversion ratio. Assuming opioid needs were similar before and after switch/rotation, the suitable conversion ratio in this case was about 1:25. Absent clear guidelines on converting from TFP in cachexia, it is better to avoid TFP. When essential to use TFP in cachexia, caution should be taken when switching from TFP to avoid overdose.
- Percutaneous Vertebroplasty versus Conservative Treatment Using a Transdermal Fentanyl Patch for Osteoporotic Vertebral Compression Fractures. [Journal Article]J Korean Neurosurg Soc 2019; 62(5):594-602JK
- CONCLUSIONS: We compared clinical and radiological outcomes between the TFP and PVP groups. The immediate pain reduction effect was superior in the PVP group, but the final clinical outcome was similar. Although the PVP group had a better-preserved compression rate than the TFP group for 1 year, the development of adjacent fractures was significantly higher. Although TFPs seemed to be beneficial in reducing the failure rate of conservative treatment, the possibility of side effects (22.6%, 17 out of 75 patients, in this study) should be carefully monitored.
- Buprenorphine for Opioid Use Disorders during Pregnancy: A Review of Comparative Clinical Effectiveness, Safety, Cost-Effectiveness, and Guidelines [BOOK]Canadian Agency for Drugs and Technologies in Health: Ottawa (ON)BOOK
- Opioid use disorders (OUD) refer to non-medical uses of opioids, a class of compounds that includes heroin and opium but also includes prescribed medications such as morphine, codeine, fentanyl, oxycodone, and hydrocodone.1 OUD rates in the US are approximately 4.2% and evidence suggests that rates are similar in Canada.2 OUD during pregnancy has escalated in parallel with the epidemic observed i…
Opioid use disorders (OUD) refer to non-medical uses of opioids, a class of compounds that includes heroin and opium but also includes prescribed medications such as morphine, codeine, fentanyl, oxycodone, and hydrocodone.1 OUD rates in the US are approximately 4.2% and evidence suggests that rates are similar in Canada.2 OUD during pregnancy has escalated in parallel with the epidemic observed in the general population.1 In addition to the risks associated with withdrawal and relapse, pregnant women with OUD are more likely to seek prenatal care late in pregnancy, miss appointments, acquire infection, and experience poor weight gain.3,4 OUD during pregnancy also presents significant risks to the developing fetus including fetal growth restriction, fetal demise, and neonatal opioid withdrawal.4 Treatment goals for this population therefore aims to reduce these maternal and infant risks. Opioid agonist therapy is the standard of care for OUD during pregnancy as opioid detoxification has been associated with a high rate of relapse.5 As an opioid agonist, methadone has long been prescribed to pregnant women to treat OUD. More recently, buprenorphine has demonstrated similar maternal outcomes and superior neonatal outcomes in comparison to methadone.5 Buprenorphine is available as a monoproduct in different formulations, or as a combined formulation with naloxone, an opioid antagonist. The buprenorphine monoproducts include extended-release subcutaneous injection, sublingual, implant, transdermal, and intramuscular formulations. The buprenorhpine-naloxone combination is available as a sublingual formulation taken under the tongue in which the naloxone portion of the combination is not orally active. The combination of the opioid agonist (buprenorphine) and non-orally active antagonist (naloxone) in this formulation discourages injection use or diversion since naloxone causes severe withdrawal symptoms if the combination is injected.1 Buprenorphine monoproducts have been recommended during pregnancy to avoid prenatal exposure to naloxone.4 The purpose of this report is to review and appraise the evidence for the clinical effectiveness, safety, and cost-effectiveness of various buprenorphine monoproducts and buprenorphine-naloxone combination formulations for UOD during pregnancy. Additionally, this report aims to review current evidence-based guidelines regarding appropriate buprenorphine formulation use for this population.
- Fast increase of postmortem fentanyl blood concentrations after transdermal application: A call to careful interpretation. [Journal Article]Forensic Sci Int 2019; 302:109896FS
- CONCLUSIONS: Postmortem fentanyl concentrations increased quickly. As early as 6-8h after death, postmortem concentrations differ significantly from antemortem ones. Our results strongly indicate that postmortem blood concentrations of fentanyl after transdermal application should be interpreted carefully.
- Patch Problems? Characteristics of Transdermal Drug Delivery System Exposures Reported to the National Poison Data System. [Journal Article]J Med Toxicol 2019JM
- CONCLUSIONS: Overall, single-substance TDDS exposures decreased over the duration of this study and typically resulted in no or mild effects. However, exposures involving fentanyl resulted in higher rates of major or moderate medical outcomes and were associated with multiple deaths.
- Comparison of Analgesic Effects of Nebulized Morphine with Fentanyl Transdermal Patch and Oral Methadone for Cancer Patients in Terminal Stages; a Double-blind Randomized Controlled Study. [Journal Article]Adv J Emerg Med 2019; 3(3):e23AJ
- CONCLUSIONS: Our study showed that nebulized morphine, just like oral methadone and transdermal fentanyl, is effective, safe, and well-tolerated for pain management in patients with cancer.
- Impact of a pharmacist-directed pain management service on inpatient opioid use, pain control, and patient safety. [Journal Article]Am J Health Syst Pharm 2019; 76(1):17-25AJ
- CONCLUSIONS: Our data highlights the impact of a pharmacy directed pain management service on institutional opioid use with available data suggesting improved patient satisfaction scores and indirect cost savings. Despite decreased opioid use, available patient satisfaction data suggested ongoing improvement in associated HCAHPS survey pain management domains.
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- Breakthrough pain in patients with head & neck cancer. A secondary analysis of IOPS MS study. [Journal Article]Oral Oncol 2019; 95:87-90OO
- CONCLUSIONS: BTcP in patients with H&N cancer is characterized by a larger number of episodes/day and the predictability, particularly with ingestion of food. The use of drugs for background analgesia and BTcP were conditioned by the possible interference with swallowing or local mucosal damage.