A German model for methadone conversion

Nauck, Friedemann; Ostgathe, Christoph; Dickerson, E. Duke

doi:10.1177/104990910101800312

Cited by 49 publications

(20 citation statements)

References 6 publications

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“…There are several protocols for opioid rotation to methadone levomethadone [170][171][172][173][174] that use two fundamentally different approaches, which are not evidence based in pediatrics. Side effects other than constipation or hyperexcitability in patients with controlled pain (change from morphine to hydromorphone).…”

Section: Opioid Rotationmentioning

confidence: 99%

“…Side effects other than constipation or hyperexcitability in patients with controlled pain (change from morphine to hydromorphone). [173] The other approach incorporates a transition period where the dose of the former opioid is reduced and partially replaced by methadone. Side effects (hyperexcitability) in patients with controlled pain (change from morphine to buprenorphine, methadone).…”

Section: Opioid Rotationmentioning

confidence: 99%

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Pediatric Palliative Care

et al. 2009

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Pediatric palliative care (PPC) is provided to children experiencing life-limiting diseases (LLD) or life-threatening diseases (LTD). Sixty to 90% of children with LLD/LTD undergoing PPC receive opioids at the end of life. Analgesia is often insufficient. Reasons include a lack of knowledge concerning opioid prescribing and adjustment of opioid dose to changing requirements. The choice of first-line opioid is based on scientific evidence, pain pathophysiology, and available administration modes. Doses are calculated on a bodyweight basis up to a maximum absolute starting dose. Morphine remains the gold standard starting opioid in PPC. Long-term opioid choice and dose administration is determined by the pathology, analgesic effectiveness, and adverse effect profile. Slow-release oral morphine remains the dominant formulation for long-term use in PPC with hydromorphone slow-release preparations being the first rotation opioid when morphine shows severe adverse effects. The recently introduced fentanyl transdermal therapeutic system with a drug-release rate of 12.5 microg/hour matches the lower dose requirements of pediatric cancer pain control. Its use may be associated with less constipation compared with morphine use. Though oral transmucosal fentanyl citrate has reduced bioavailability (25%), it inherits potential for breakthrough pain management. However, the gold standard breakthrough opioid remains immediate-release morphine. Buprenorphine is of special clinical interest as a result of its different administration routes, long duration of action, and metabolism largely independent of renal function. Antihyperalgesic effects, induced through antagonism at the kappa-receptor, may contribute to its effectiveness in neuropathic pain. Methadone also has a long elimination half-life (19 [SD 14] hours) and NMDA receptor activity although dose administration is complicated by highly variable morphine equianalgesic equivalence (1 : 2.5-20). Opioid rotation to methadone requires special protocols that take this into account. Strategies to minimize adverse effects of long-term opioid treatment include dose reduction, symptomatic therapy, opioid rotation, and administration route change. Patient- or nurse-controlled analgesia devices are useful when pain is rapidly changing, or in terminal care where analgesic requirements may escalate. In this article, we present detailed pediatric pharmacokinetic and pharmacodynamic data for opioids, their indications and contraindications, as well as dose-administration regimens that include practical strategies for opioid switching and dose reduction. Additionally, we discuss the problem of hyperalgesia and the use of adjuvant drugs to support opioid therapy.

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Section: Opioid Rotationmentioning

confidence: 99%

Section: Opioid Rotationmentioning

confidence: 99%

Pediatric Palliative Care

et al. 2009

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“…Nach 72 Stunden wird auf eine 8-stündliche Gabe gewechselt. Schmerzspitzen werden durch ergänzende Bedarfsmedikation abgefangen [14]. Dieses Titrationsschema wurde bei über 30 Patienten mit sehr unterschiedlichen Opioiddosierungen in der Vorbehandlung für den Opioidwechsel auf Levomethadon angewendet.…”

Section: Indikation Und Anwendung Von Methadon/levomethadonunclassified

Methadon/Levomethadon - Ein altes Medikament mit neuen Möglichkeiten

2003

Palliativmedizin

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ZusammenfassungDie meisten Patienten mit Tumorschmerzen lassen sich durch die Gabe von starken Opioiden ausreichend analgetisch behandeln. Aufgrund von anhaltenden Nebenwirkungen oder unzureichender analgetischer Wirkung trotz Dosissteigerung ist bei etwa 10 % der Patienten ein Opioidwechsel erforderlich. Methadon/Levomethadon stellt aufgrund starker analgetischer Wirksamkeit, fehlender toxischer Metabolite, guter oraler und rektaler Bioverfügbarkeit, hoher Lipidlöslichkeit und niedriger Kosten für diese Patienten eine wichtige Alternative in der Schmerztherapie dar. In den vergangenen Jahren führte ein besseres Verständnis der Pharmakodynamik und Pharmakokinetik sowie der Problematik der äquianalgetischen Dosierung von Methadon/Levomethadon zu einer Zunahme der Verwendung dieser Substanz als Medikament ¹zweiter Wahlª in der Behandlung von Patienten mit Tumorschmerzen, obwohl es durch eine unvorhersehbare variable Halbwertszeit und aufgrund seiner höheren äquianalgetischen Potenz als früher angenommen, bei einigen Patienten zu Kumulation und Toxizität kommen kann. Auûerdem ist ein Wechsel auf Methadon/Levomethadon aufgrund der erhöhten analgetischen Potenz bei den Patienten, die eine Opioidtoleranz aufweisen bzw. bei Patienten, die bereits hohe Opioiddosierungen erhalten, schwieriger als auf andere starke Opioide. In diesem Artikel werden unterschiedliche Strategien der Dosistitration und ein eigenes Titrationsschema dargestellt. In Zukunft muss die Anwendung von Methadon/Levomethadon bei Patienten mit neuropathischen Schmerzen und Patienten, die eine rasche Toleranz auf andere Opioide entwickeln, ein Forschungsschwerpunkt sein. AbstractMost cancer pain patients can be treated adequately with strong opioids. Because of continuous side effects or insufficient pain control in spite of dose escalation about 10 % of patients need an opioid rotation. Methadone/levomethadone may be an excellent alternative option for pain treatment because of its high analgesic effect, due to its lack of known active metabolites, high lipid solubility, high oral and rectal bioavailability, as well as the advantage of very low cost. In recent years a better understanding of the pharmacologic and pharmacokinetic properties of methadone, including equianalgesic ratios has led to its increased use as a second-line opioid for the treatment of pain in patients with cancer. However, it has a long, unpredictable half-life and a greater potency than previously assumed, which can result in accumulation and toxicity in some patients. In addition, rotation to methadone is more complex than to other opioids because of its increased potency in those patients who are opioid-tolerant, particularly those who have been on higher doses of other opioids. In the article different conversion strategies for dose titration and our own levomethadone conversion regime will be presented. Future research should address the use of methadone in patients with neuropathic pain, and in those who develop rapid tolerance to other opioids.

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“…Application is limited by its long plasma half life which can be a cause of cumulation. For that reason, titration of methadone/levomethadone should be performed in an in-patient setting [20]. Invasive non-destructive procedures like epidural application of opioids as well as invasivedestructive procedures are rarely necessary.…”

Section: Neuropathic Pain and Co-analgesicsmentioning

confidence: 99%

Pain Management and Symptom-Oriented Drug Therapy in Palliative Care

Klein

Lang²,

Bükki³

et al. 2011

Breast Care

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Patients with advanced lifelimiting disease often suffer from symptoms that considerably impair their quality of life and that of their families. Palliative care aims to alleviate these symptoms by a multidimensional approach. Pharmacotherapy is an essential component. The objective of this review is to give an overview of symptomoriented drug therapy for the most important symptoms in palliative care. Leading symptoms that affect quality of life include pain, dyspnea, nausea and emesis, weakness and disorientation. Careful examination and history taking help to understand the individual mechanisms underlying these symptoms. Specific pharmacotherapy provides an efficient way to achieve symptom control in the context of palliative care.

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A German model for methadone conversion

Cited by 49 publications

References 6 publications

Pediatric Palliative Care

Pediatric Palliative Care

Methadon/Levomethadon - Ein altes Medikament mit neuen Möglichkeiten

Pain Management and Symptom-Oriented Drug Therapy in Palliative Care

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