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      Journal of Pain Research (submit here)

      This international, peer-reviewed Open Access journal by Dove Medical Press focuses on reporting of high-quality laboratory and clinical findings in all fields of pain research and the prevention and management of pain. Sign up for email alerts here.

      52,235 Monthly downloads/views I 2.832 Impact Factor I 4.5 CiteScore I 1.2 Source Normalized Impact per Paper (SNIP) I 0.655 Scimago Journal & Country Rank (SJR)

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      The use of rotation to fentanyl in cancer-related pain

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          Abstract

          Pain is commonly diagnosed with respect to cancer and heart diseases, being a major symptom in most neoplastic diseases. Uncontrolled pain leads to a decrease in the quality of life and an increase in the morbidity of the patient. Opioids represent the best analgetic supportive therapy and are frequently used in patients suffering from cancer and experiencing a high level of pain. Opioid treatment starts with a gradual titration of the dose until the minimum effective dose and the maximum tolerated dose are determined. Opioid rotation refers to the switch from one opioid to another in order to get a better response to analgetic therapy and reduce side effects. Fentanyl therapy is recommended to be continued during chemotherapy, radiotherapy, or in the case of surgical intervention. Rotation to fentanyl patches is an efficient and elegant solution for cancer patients, with reduced side effects. Opioid rotation, especially to fentanyl, was shown to increase the quality of life in patients with malignant disease. Finally, rotation to fentanyl is also advantageous from an economic point of view.

          Most cited references51

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          Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review.

          Ewan D. McNicol, Nathalie Horowicz-Mehler, Ruth A Fisk … (2003)
          Side effects can limit opioid dosage and reduce quality of life. The purpose of this systematic review was to assess the management of opioid side effects in the context of cancer pain management or, in the event that no evidence was available for cancer pain, for chronic noncancer pain. The side effects studied were constipation, pruritus, nausea and vomiting, myoclonus, sedation, respiratory depression, and delirium. Opioid rotation to manage side effects was also studied. For each side effect, we searched MEDLINE and the Cochrane Controlled Trials Register and identified 657 possible titles for inclusion. Of these, 67 studies met inclusion criteria for analysis. The lack of well-designed, randomized controlled trials and the heterogeneity of populations and study designs made the drawing of firm conclusions difficult and precluded performance of meta-analysis. The type, strength, and consistency of evidence for available interventions to manage opioid side effects vary from strong (eg, on the use of naloxone to reverse respiratory depression or constipation) to weak (eg, changing from the oral to epidural route of morphine administration to manage sedation). Well-designed trials in the specified populations are required to furnish clinicians with secure evidence on managing opioid side effects successfully.
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            Opioid rotation: the science and the limitations of the equianalgesic dose table.

            Helena Knotkova, Perry Fine, Russell Portenoy (2009)
            Opioid rotation refers to a switch from one opioid to another in an effort to improve the response to analgesic therapy or reduce adverse effects. It is a common method to address the problem of poor opioid responsiveness despite optimal dose titration. Guidelines for opioid rotation are empirical and begin with the selection of a safe and reasonably effective starting dose for the new opioid, followed by dose adjustment to optimize the balance between analgesia and side effects. The selection of a starting dose must be based on an estimate of the relative potency between the existing opioid and the new one. Potency, which is defined as the dose required to produce a given effect, differs widely among opioids, and among individuals under varying conditions. To effectively rotate from one opioid to another, the new opioid must be started at a dose that will cause neither toxicity nor abstinence, and will be sufficiently efficacious in that pain is no worse than before the change. The estimate of relative potency used in calculating this starting dose has been codified on "equianalgesic dose tables," which historically have been based on the best science available and have been used with little modification for more than 40 years. These tables, and the clinical protocols used to apply them to opioid rotation, may need revision, however, as the science underlying relative potency evolves. Review of these issues informs the use of opioid rotation in the clinical setting and defines key areas for future research.
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              Opioid equianalgesic tables: are they all equally dangerous?

              Philip Shaheen, Declan Walsh, Wael Lasheen … (2009)
              Pain is one of the most common symptoms in cancer patients. Opioids are widely prescribed for this and other purposes. Properly used, they are safe, but they have serious and potentially lethal side effects. Successful use of opioids to manage cancer pain requires adequate knowledge about opioid pharmacology and equianalgesia for the purpose of both drug rotation and route conversion. The aim of this study was to demonstrate variations in equianalgesic ratios, as quoted in equianalgesic tables and various educational materials widely available to practicing physicians. We surveyed commercially available educational materials in package inserts, teaching materials provided by pharmaceutical companies, and the Physicians' Desk Reference for equianalgesic tables of commonly used opioids. We found inconsistent and variable equianalgesic ratios recommended for both opioid rotation and conversion. Multiple factors like inter- and intraindividual differences in opioid pharmacology may influence the accuracy of dose calculations, as does the heterogeneity of study design used to derive equianalgesic ratios. Equianalgesic tables should only serve as a general guideline to estimate equivalent opioid doses. Clinical judgment should be used and individual patient characteristics considered when applying any table. Professional organizations and regulators should establish a rotation and conversion consensus concerning opioid equianalgesic ratios. Systematic research on equianalgesic opioid dose calculation is recommended to avoid adverse public health consequences of incorrect or inappropriate dosing. Current information in equianalgesic tables is confusing for physicians, and dangerous to the public.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Pain Res
                Journal ID (iso-abbrev): J Pain Res
                Journal ID (publisher-id): Journal of Pain Research
                Title: Journal of Pain Research
                Publisher: Dove Medical Press
                ISSN (Electronic): 1178-7090
                Publication date Collection: 2017
                Publication date (Electronic): 09 February 2017
                Volume: 10
                Pages: 341-348
                Affiliations
                [1 ]Department of Hematology, Ion Chiricuta Oncology Institute
                [2 ]Faculty of Medicine, Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Iuliu Hatieganu
                [3 ]Department of Functional Genomics, The Oncology Institute Ion Chiricuta
                [4 ]Medfuture Research Center for Advanced Medicine, University of Medicine and Pharmacy, Iuliu Hatieganu
                [5 ]Department of Surgery, Ion Chiricuta Oncology Institute
                [6 ]Department of Oncology, University of Medicine and Pharmacy, Iuliu Hatieganu
                [7 ]Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
                Author notes
                Correspondence: Ciprian Tomuleasa, Department of Hematology, Ion Chiricuta Oncology Institute/Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Strada Gheorghe Marinescu No 23, Cluj Napoca 400124, Romania, Tel +40 264 74133 7480, Email ciprian.tomuleasa@ 123456umfcluj.ro
                Article
                Publisher ID: jpr-10-341
                DOI: 10.2147/JPR.S121920
                PMC ID: 5310636
                SO-VID: 128f901d-b919-4f00-a502-23af3732b1d8
                Copyright © © 2017 Dima et al. This work is published and licensed by Dove Medical Press Limited
                License:

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                History
                Categories
                Subject: Perspectives

                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: opioid rotation,cancer-related pain,fentanyl
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: opioid rotation, cancer-related pain, fentanyl

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