Sharon Watanabe

Opioid rotation in patients with cancer pain: A retrospective comparison of dose ratios between methadone, hydromorphone, and morphine

When a change of opioid is considered, equianalgesic dose tables are used. These tables generally propose a dose ratio of 5:1 between morphine and hydromorphone. In the case of a change from subcutaneous hydromorphone to methadone, dose ratios ranging from 1:6 to 1:10 are proposed. The purpose of this study was to review the analgesic dose ratios for methadone compared with hydromorphone.

Changing pattern of agitated impaired mental status in patients with advanced cancer: Association with cognitive monitoring, hydration, and opioid rotation

In late 1990, it became standard practice at the palliative care unit of the Edmonton General Hospital to regularly administer the Mini-Mental State Questionnaire (MMSQ) and to undertake opioid rotation and hydration upon detection of cognitive failure. We retrospectively reviewed the charts of 117 and 162 patients admitted in 1988-1989 and 1991-1992, respectively, to assess the impact of these maneuvers on the prevalence of agitated impaired mental status (IMS). All patients underwent regular cognitive assessment in 1991-1992 versus none in 1988-1989. Seventy-three percent of patients received hydration in the second period versus 32% in the first (P < 0.01). The frequency of opioid rotation was also greater in the second period (41% versus 21%, P < 0.001). The incidence of agitated IMS decreased from 26% in 1988-1989 to 10% in 1991-1992 (P < 0.001). This was reflected by a lower mean dose of the major drug used to treat this condition, haloperidol (3.6 +/- 2.4 versus 5.6 +/- 3.8 mg/day, P < 0.01), and less frequent use of other neuroleptics and benzodiazepines (0.12 versus 0.38 prescriptions per patient, P < 0.01) in the second period. Our data suggest that routine cognitive monitoring, opioid rotation, and hydration may reduce the incidence of agitated IMS in terminal cancer patients.

The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991–2006)

Introduction: The purpose of this review was to identify and critique validation studies focusing on the Edmonton Symptom Assessment System (ESAS), a commonly used symptom assessment tool for advanced cancer and palliative patients. Methods: Using a comprehensive literature search, the authors identified and screened 87 publications. Thirteen articles were selected for in-depth review, based on the following inclusion criteria: psychometric studies with a primary focus on the ESAS, 1991–2006 publication dates and peer-reviewed English language publications. Results: Most studies involved cancer patients (n = 11). The ESAS format varied across studies, in terms of scale format, item number, item selection and language. Studies focused on gathering reliability estimates (n = 8), content validity evidence (n = 1), concurrent validity evidence (n = 5), predictive validity evidence (n = 1), and sensitivity and/or specificity (n = 3). None of these studies involved patients’ perspectives as a source of validity evidence. Discussion: The use of varying instrument formats and limited psychometric evidence support the need for further ESAS validation studies, including the involvement of patients.

Corticosteroids as adjuvant analgesics

Corticosteroids have multiple effects as adjuvant drugs in pain management. Their pharmacologic characteristics will be described. Studies documenting the efficacy of corticosteroids for different pain syndromes and other cancer-related symptoms will be reviewed. Practical guidelines will be given and directions for future research suggested.

Custom-made capsules and suppositories of methadone for patients on high-dose opioids for cancer pain

&NA; In a prospective, open study, 37 advanced cancer patients in poor pain control receiving high doses of subcutaneous hydromorphone (mean daily dose: 276 ± 163 mg) were switched to methadone by use of custom‐made capsules (21 patients) or suppositories (16 patients). The change in opioid took place over 6.5 ± 3.6 days (oral) and 3.2 ± 2.7 days (rectal). The methadone/ hydromorphone dose ratios were 1.2 ± 1.3 and 3 ± 2 for the oral and rectal routes, respectively (P = 0.03) as compared to an expected ratio of 5–7, based on single dose available data. Pain intensity (VAS 0–100 mm) and the number of extra doses of analgesic per day were 51 ± 22 and 3.2 ± 2.7 with hydromorphone, versus 34 ± 21 (P < 0.001) and 2.1 ± 1.9 (P = 0.03) with methadone, respectively. The total cost of treatment was Canadian

The Edmonton Symptom Assessment System, a proposed tool for distress screening in cancer patients: development and refinement

148 ± 202 with methadone as compared to Canadian

Chronic nausea in advanced cancer patients: A retrospective assessment of a metoclopramide-based antiemetic regimen

2135 ± 472 with hydromorphone (P < 0.001). Toxicity was limited to mild sedation in all patients and proctitis in 2 patients on suppositories (one of whom required discontinuation of methadone). Plasma levels obtained in 6 patients on suppositories revealed large inter‐individual variation in methadone level (ng/ ml) to dose (mg/ day) ratio (range: 0.8–8.5). Within individuals, the ratio remained constant over a range of doses. We conclude that a slow switch‐over to methadone is a safe, effective and low cost alternative in selected cancer patients receiving high doses of opioids for poor prognostic pain syndromes.

Prognostic Factors in Patients With Advanced Cancer: Use of the Patient-Generated Subjective Global Assessment in Survival Prediction

The Edmonton Symptom Assessment System (ESAS) has been proposed as one element of a distress screening strategy in cancer patients. It consists of 11‐point numerical rating scales for self‐report of nine common symptoms of cancer, with a 10th scale for a patient‐specific symptom. The ESAS has undergone widespread adoption internationally for clinical, research and administrative purposes. Despite its rapid uptake, validity evidence has lagged behind, and concerns have been raised about feasibility and usefulness. The objective of this paper is to provide a synthesis of a program of research focusing on the psychometric properties of the ESAS.

Volume of hydration in terminal cancer patients

The purpose of this retrospective study is to assess the frequency and intensity of chronic nausea in patients admitted to the Palliative Care Unit and the results of a metoclopramide-based treatment regimen. We reviewed the medical records of 100 consecutive patients admitted to the Palliative Care Unit at the Edmonton General Hospital until death during 1992-1993. All patients had terminal cancer and normal cognitive function. All patients completed the Functional Analogue Scale for appetite, nausea, pain, activity, shortness of breath, and sensation of well-being at 1000 and 1600 hours every day. Patients who complained of nausea initially received metoclopramide 10 mg every 4 hr orally or subcutaneously (Step 1). If nausea persisted, dexamethasone 10 mg twice daily was added (Step 2). Step 3 consisted of a continuous subcutaneous infusion of metoclopramide of 60-120 mg/day plus dexamethasone. If no response was observed, other antiemetics were administered (Step 4). Upon admission to the unit, 32 patients (32%) presented with nausea. During the average admission of 25 +/- 13 days, 98 patients (98%) developed nausea. Twenty-five patients (25%) required other antiemetics because of bowel obstruction (18), extrapyramidal side effects (3), or other reasons (4). Most patients without bowel obstruction achieved excellent control of nausea using the metoclopramide-based regimen. During the first 5 days and last 5 days of admission, nausea had significantly lower intensity than the rest of the symptoms that were monitored. Our results suggest that, although nausea is very frequent, it can be well controlled in the majority of patients using safe and simple antiemetic regimens.

Sleep disturbances in palliative cancer patients attending a pain and symptom control clinic.

PURPOSE To determine whether elements of a standard nutritional screening assessment are independently prognostic of survival in patients with advanced cancer. PATIENTS AND METHODS A prospective nested cohort of patients with metastatic cancer were accrued from different units of a Regional Palliative Care Program. Patients completed a nutritional screen on admission. Data included age, sex, cancer site, height, weight history, dietary intake, 13 nutrition impact symptoms, and patient- and physician-reported performance status (PS). Univariate and multivariate survival analyses were conducted. Concordance statistics (c-statistics) were used to test the predictive accuracy of models based on training and validation sets; a c-statistic of 0.5 indicates the model predicts the outcome as well as chance; perfect prediction has a c-statistic of 1.0. RESULTS A training set of patients in palliative home care (n = 1,164) was used to identify prognostic variables. Primary disease site, PS, short-term weight change (either gain or loss), dietary intake, and dysphagia predicted survival in multivariate analysis (P < .05). A model including only patients separated by disease site and PS with high c-statistics between predicted and observed responses for survival in the training set (0.90) and validation set (0.88; n = 603). The addition of weight change, dietary intake, and dysphagia did not further improve the c-statistic of the model. The c-statistic was also not altered by substituting physician-rated palliative PS for patient-reported PS. CONCLUSION We demonstrate a high probability of concordance between predicted and observed survival for patients in distinct palliative care settings (home care, tertiary inpatient, ambulatory outpatient) based on patient-reported information.