Management of Acute Cancer Pain in Asia: An Expert Opinion on the Role of Tramadol/Dexketoprofen Fixed-Dose Combination

Abstract

Most patients experience acute cancer pain at some stage throughout their cancer journey. When inadequately managed, cancer pain has devastating consequences for the patient's quality of life.The suboptimal management of cancer pain in Asia is mainly driven by over-regulation and limited access to opioids. Concerns about adverse events and addiction have resulted in a negative perception of this group of drugs among physicians, as well as patients. There is a need to optimize the management of cancer pain across the region, through the provision of an alternative treatment option that is simple to prescribe, convenient to administer and well tolerated by patients, which will increase patients' compliance and good results.As recommended in many international guidelines, starting by the WHO analgesic ladder, cancer pain can be effectively managed with multimodal analgesia. Fixed-dose combinations (FDCs), in which two or more analgesic agents act synergistically to deliver a broad spectrum of pain relief, represent an effective and convenient option for delivering multimodal analgesia to patients with cancer pain. This is extremely well accepted by patients for several reasons. Any multimodal pharmacological approach to pain management should be based on the potentiality to block pain at different levels and to reduce the dosages of single analgesics, reducing their side effects. Hence, the use of NSAIDs, combined with other analgesics, is the general basis of multimodal pain management. If NSAIDs are combined with tramadol, a weak opioid that has per se a multimodal analgesic efficacy, it may be ideal. The tramadol/dexketoprofen FDC combines the centrally acting weak opioid with a peripherally acting NSAID to deliver rapid-onset, long-lasting analgesia, which has been proven efficacious and safe in the management of moderate-to-severe acute pain in the postoperative setting. This expert opinion explores the role of tramadol/dexketoprofen FDC in the management of patients with moderate-to-severe acute cancer pain. It is essentially based on the incredibly high amount of existing data on the use of the drug, and on the long-lasting experience of the experts in pain management of cancer patients participating in the advisory panel.

Challenges and Opportunities in Developing Tailored Pain Management Strategies for Liver Patients

“…In cases of compromised liver function, as seen in CLDs, the risk of hepatotoxicity escalates. The narrow therapeutic window of acetaminophen poses a challenge, requiring meticulous dosing and close monitoring to avert potential harm [ 13 ]. NSAIDs, with their potent anti-inflammatory and analgesic properties, are commonly utilized for pain relief.…”

“…However, their use in liver patients is riddled with complexities. The risk of gastrointestinal bleeding, coupled with the potential to exacerbate renal dysfunction and induce hepatorenal syndrome, necessitates caution [ 13 ]. In particular, individuals with cirrhosis face an elevated risk of complications associated with NSAID use, emphasizing the need for vigilant risk-benefit assessments.…”

“…The liver, a hub for drug metabolism, plays a pivotal role in opioid processing. In the context of CLDs, alterations in drug metabolism may lead to opioid accumulation, raising concerns about respiratory depression and other opioid-related adverse effects [ 13 ]. Furthermore, the opioid epidemic underscores the imperative to approach opioid use judiciously, considering the risk of addiction and the potential for unintended consequences.…”

Looking Back, Moving Forward in Pain Medicine

“…Opioid monotherapy is discouraged today, because although it can be effective in the short and even long term, it needs to be done in a way that reduces harm and can still be associated with side effects, tolerance, and abuse potential. Equivalent analgesia with fewer adverse consequences may be obtained by using additive or synergistic combinations of smaller amounts of opioids and nonopioid analgesics, where nonopioids are reducing the dosages of opioids [ 86 ].…”