Characteristics and Treatment of Breakthrought Pain (BTcP) in Palliative Care

Abstract

Introduction:This research was to follow characteristics of breakthrough pain caused by cancer (BTcP) and other most common sympthoms (ESAS) at patients in advanced stage of cancer disease in palliative care.Patients and methods:Prospective study included 433 patients which were treated in Palliative Care Centre in UKC Tuzla, Bosnia and Herzegovina. Group 1 was consisted of 353 patients whose basal cancer pain of intensity 4-7 NRS was treated weak opiates (basal analgetic- fixed combination of tramadol/paracetamol (37.5 mg/325 mg) in initial dose 3x1tbl for pain intensity 4, to 4x2tbl (for pain intensity 7). In Group 2 (80 patients) basal pain of intensity 8-10 was treated strong opiates as basal analgetic (oral morphine and transdermal fentanil). If the previous day were 2 or more breakthrough pain that required ‘’rescue dose’’ of analgetics (tramadol 50-100 mg orally in group 1 ie. Oral morphine 8-12 mg in the group 2), the dose of basal analgetic was increased.Results:The total number of reported breakthrough pain in all 433 patients for 10 days of treatment was 3 369 (0.78 BTcP /per patient/day), where at Group 1 patients showed significantly lower BTcP (0.56 BTcP/patient/day). The average intensity of BTcP was 5.91 where in the Group1 was 4.51 while in the Group 2 8.04. 582 (17.28%) was rated grade 7, of which 539 were successfully coupled by strong and 43 (7.39%) successfully coupled by weak opiates. From 556 BTcP who were rated with 8, 540 of them were coupled strong and only 16 successfully coupled by weak opiates. 1967 (58.39 %) of breakthrough pain has occured in the evening hours (18-06 h), while 1402 (41.62%) BTCP occured during day hours (06-18h). Most (1290 or 38.29%) of breakthrough pain lasted less than 10 minutes, 882 (26.18%) between 16 and 20 minutes, 752 (22.32%) between 11 and 15 minutes, 407 (12.8%) between 21 and 30 minutes and 38 (1.13%) lasted longer than 20 minutes.Conclusion:Duriong our study, we noted a relatively large number of breakthrough pain with lower intensity (3-6) in patients treated with weak opiates, which are also adversely affected patients satisfaction with pain treatment and required additional doses of analgetics. In the small percentage is possible the breakthrough pain of stronger intensity (7-8) treat by maximum doses of weak opiates.

High-rate breakthrough cancer pain and tumour characteristics – literature review and case series

“…62 The most common sites of metastases are the vertebrae, pelvis, long bones, and ribs 63 and innocuous movement, bumps or falls may result in painful pathological fractures, 1 which might reduce mobility and increase anxiety, significantly worsening QoL. 64 Many breakthrough pain episodes of greater intensity in the advanced stages of cancer are due to bone pain caused by metastasis 17 and require additional proper therapy. Albiach et al 76 collected data from patients with metastatic bone disease and BTcP and demonstrated that primary cancer was mainly localized in the lungs and prostate (85 out of 386 patients or 22%), and BTcP occurred spontaneously and suddenly with high pain intensity in 70.6% of cases.…”

“…Most BTcP episodes peak in intensity within a few minutes and last for 30-60 minutes. 12,[15][16][17] Idiopathic or spontaneous BTcP occurs in the absence of a relationship to any specific, recognizable cause, whereas incident pain can be volitional if triggered by a voluntary act (e.g. walking, weightbearing, food/liquid ingestion, and changes in sleeping position) or non-volitional if related to an involuntary act (e.g.…”

Multidisciplinary approach, continuous care and opioid management in cancer pain: case series and review of the literature

“…This is responsible for both incident and movement-induced BTcP. 134 Correct management of BTcP allows for significant improvement in the QoL of these patients. [135][136][137] TIRF is the treatment of choice for BTcP due to its pharmacological properties, including rapid onset, increased potency and short half-life.…”

Optimization of opioid utility in cancer pain populations

“…The selection of an appropriate on-demand IR opioid depends on a number of factors: the patient's physical condition and dexterity (which affect administration and tolerance) and likelihood of adherence/abuse; and the medication's onset and duration of action and route of administration (38,75). For example, oral tramadol may be efficacious in cancer patients experiencing breakthrough pain of mild to moderate intensity (76); fentanyl may provide a greater level of pain relief in a shorter time frame (77). Because of a lack of bioequivalence between different fentanyl formulations, individualized dose-titration may be needed for balancing efficacy with tolerability and avoiding overdose (75).…”