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Biomedical subjects

S Mercadante

Publications and source records attributed to S Mercadante.

At least 55 records · Page 3Linked to original sources
PubMed2000

Analgesic effect of intravenous ketamine in cancer patients on morphine therapy: a randomized, controlled, double-blind, crossover, double-dose study.

Pain not responsive to morphine is often problematic. Animal and clinical studies have suggested that N-methyl-D-aspartate (NMDA) antagonists, such as ketamine, may be effective in improving opioid analgesia in difficult pain syndromes, such as neuropathic pain. A slow bolus of subhypnotic doses of ketamine (0.25 mg/kg or 0.50 mg/kg) was given to 10 cancer patients whose pain was unrelieved by morphine in a randomized, double-blind, crossover, double-dose study. Pain intensity on a 0 to 10 numerical scale; nausea and vomiting, drowsiness, confusion, and dry mouth, using a scale from 0 to 3 (not at all, slight, a lot, awful); Mini-Mental State Examination (MMSE) (0-30); and arterial pressure were recorded before administration of drugs (T0) and after 30 minutes (T30), 60 minutes (T60), 120 minutes (T120), and 180 minutes (T180). Ketamine, but not saline solution, significantly reduced the pain intensity in almost all the patients at both doses. This effect was more relevant in patients treated with higher doses. Hallucinations occurred in 4 patients, and an unpleasant sensation ("empty head") was also reported by 2 patients. These episodes reversed after the administration of diazepam 1 mg intravenously. Significant increases in drowsiness were reported in patients treated with ketamine in both groups and were more marked with ketamine 0.50 mg/kg. A significant difference in MMSE was observed at T30 in patients who received 0.50 mg/kg of ketamine. Ketamine can improve morphine analgesia in difficult pain syndromes, such as neuropathic pain. However, the occurrence of central adverse effects should be taken into account, especially when using higher doses. This observation should be tested in studies of prolonged ketamine administration.

Adult↗
PubMed2000

Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial.

Bowel obstruction may be an inoperable complication in patients with end-stage cancer. Scopolamine butylbromide (SB) and octreotide (OCT) have been successfully used with the aim of reducing gastrointestinal (GI) secretions to avoid placement of a nasogastric tube (NGT); however, there have been no comparative studies concerning the efficacy of these drugs. Furthermore, there is little information about the role played by parenteral hydration in symptom control of these patients. In a prospective trial that involved all 17 inoperable bowel-obstructed patients presenting to our services with a decompressive NGT, patients were randomized to OCT 0.3 mg/day or SB 60 mg/day for 3 days through a continuous subcutaneous infusion. Clinical data, survival time, and the time interval from the first diagnosis of cancer to the onset of inoperable bowel obstruction were noted. The intensity of pain, nausea, dry mouth, thirst, dyspnea, feeling of abdominal distension, and drowsiness were assessed by means of a verbal scale before starting treatment with the drugs under study (T0) and then daily for 3 days (T1, T2, T3). Moreover, daily information was collected regarding the quantity of GI secretions through the NGT, the oral intake of fluids, the quantity of parenteral hydration, and the analgesic therapy used. The NGT could be removed in all 10 home care and in 3 hospitalized patients without changing the dosage of the drugs. OCT significantly reduced the amount of GI secretions at T2 (P = 0.016) and T3 (P = 0.020). Compared to the home care patients, the hospitalized patients received significantly more parenteral hydration (P = 0.0005) and drank more fluids (P = 0.025). There was no difference in the daily thirst and dry mouth intensity in relation to the amount of parenteral hydration or the treatment provided (OCT or SB). Independent of antisecretory treatment, the patients receiving less parenteral hydration presented significantly more nausea (T0 P = 0.002; T1 P = 0.001; T2 P = 0.003; T3 P = 0.001) and drowsiness at T3 (P < 0.5). Pain relief was obtained in all 17 patients and only two patients required an increase in morphine dose at T1. All patients with inoperable malignant bowel obstruction should undergo treatment with antisecretory drugs so as to evaluate the possibility of removing the NGT. When a more rapid reduction in GI secretions is desired, OCT should be considered as the first choice drug. Parenteral hydration over 500 ml/day may reduce nausea and drowsiness.

Aged↗
PubMed2000

Anaemia in cancer: pathophysiology and treatment.

Anaemia in cancer patients is multifactorial and may occur as a either a direct effect of the cancer, as a result of the cancer treatment itself, or due to chemical factors produced by the cancer. The clinical symptoms of anaemia vary according to the individual's capacity to respond to blood loss or reduced red cell production. The haematological features in anaemic patients depend on the different types of malignant disease. Clinical and laboratory evaluation, and examination of the bone marrow can provide important diagnostic clues in many cases. Decisions are commonly made based on subjective consideration rather than on objective data. Blood transfusion involves many hazards, some of which may be reduced or avoided. Erythropoietin (EPO) treatment has been found to be effective in preventing anaemia and in reducing the need for blood transfusions, although it would be useful to identify high-risk patient subgroups who would benefit most from this expensive treatment. In advanced cancer patients the use of blood transfusion should be evaluated on an individual basis, according to the presence of distressing symptoms and life expectancy. These measures are unlikely to have an effect in irreversible and progressive bleeding states.

Anemia↗
PubMed1999

Opioid rotation for cancer pain: rationale and clinical aspects.

BACKGROUND: Some patients with cancer pain may develop uncontrolled adverse effects, including generalized myoclonus, delirium, nausea and emesis, or severe sedation before achieving adequate analgesia during opioid dose titration. Sequential therapeutic trials should be considered to determine the most favorable drug. METHODS: Recent literature was taken into account when reviewing the rationale and potential of opioid rotation. RESULTS: When aggressive attempts to prevent adverse effects fail, drug rotation should be considered, because sequential therapeutic trials can be useful in identifying the most favorable drug. Different mechanisms, including receptor activity, the asymmetry in cross-tolerance among different opioids, different opioid efficacies, and accumulation of toxic metabolites can explain the differences in analgesic or adverse effect responses among opioids in a clinical setting. CONCLUSIONS: When pain is relieved inadequately by opioid analgesics given in a dose that causes intolerable side effects despite routine measures to control them, treatment with the same opioid by an alternative route or with an alternative opioid administered by the same route should be considered. Opioid rotation may be useful in opening the therapeutic window and for establishing a more advantageous analgesia/toxicity relationship. By substituting opioids and using lower doses than expected according to the equivalency conversion tables, it is possible in the majority of cases to reduce or relieve the symptoms of opioid toxicity in those patients who were highly tolerant to previous opioids while improving analgesia and, as a consequence, the opioid responsiveness.

Analgesics, Opioid↗
PubMed1999

Pain treatment and outcomes for patients with advanced cancer who receive follow-up care at home.

BACKGROUND: A small sample size, a high rate of exclusions, inadequate follow-up in different settings, and a lack of comparison with previous levels of analgesia have recently been reported to be the principal limitations of the World Health Organization (WHO) guidelines regarding cancer pain. METHODS: A total of 3678 consecutive patients with advanced cancer referred to a home palliative care program were enrolled in an open prospective study over a 9-year period, from June 1988 to June 1997, to determine the effectiveness, safety, and feasibility of implementing the WHO guidelines. Age, gender, Eastern Cooperative Oncology Group performance status, pain mechanism at referral, pain and symptom intensity, and doses and days of drug administration during the course of the treatment were recorded at regular intervals. RESULTS: Therapy was required for 70.3% of patients for a mean duration of 64 days. The mean duration periods of the 3 steps were 18, 27, and 19 days, respectively. At referral, most patients received inadequate treatment. In the last week of life, 16%, 49%, and 35% of patients were taking nonopioid drugs, moderate opioids, and strong opioids, respectively. A significant improvement in pain and symptom intensity was achieved after referral. Symptom intensity worsened in the last week of life. A minority of patients (2.65%) underwent invasive procedures. CONCLUSIONS: This study demonstrates that a managed home care system enables patients to receive adequate pain treatment, according to WHO guidelines, in the comfort of their own homes.

Adolescent↗
PubMed1999

When all else fails: stepwise multiple solutions for a complex cancer pain syndrome.

In the presence of insufficient pain relief and substantial adverse effects, application of alternative routes of administration and a change of opioid are the main methods used to improve the analgesic response. When all else fails, the result may further be optimized using adjuvant drugs by an alternative route, namely the intrathecal route. A stepwise approach with multiple drugs and routes of administration is described. This was implemented to resolve a complex pain syndrome otherwise considered uncontrollable. We found it possible to manage a very difficult pain situation by intrathecal home infusion through the efforts of a well-trained family and GP and a continuous exchange of information and advice with the pain relief team about changes in therapy to adapt to the clinical situation. A stepwise and a meaningful approach to clinical problems with use of advanced techniques and alternative drugs in the patient's home may be helpful in the treatment of conditions otherwise considered intractable.

Aged↗
PubMed1999

Analgesic effects of nonsteroidal anti-inflammatory drugs in cancer pain due to somatic or visceral mechanisms.

The role of nonsteroidal anti-inflammatory drugs (NSAIDs) is well established in the treatment of cancer pain. This class of drugs is considered particularly effective in pain due to somatic mechanisms, although proof of this observation is lacking. To ascertain whether NSAIDs are more effective in specific nociceptive forms of cancer pain, they were administered alone or added to opioids in 32 patients with a sole pain mechanism, somatic pain due to bone metastases (17 patients) or visceral pain (15 patients), respectively. Pain intensity, mean doses of opioids used, and symptoms were recorded after starting NSAID. A significant reduction in pain intensity was found at 3, 7, and 14 days. No differences in pain intensity between the two groups were observed. However, patients with a visceral mechanism required higher opioid doses after a week of treatment. No differences in adverse effects were reported. NSAIDs may be useful drugs in the management of cancer pain, regardless of the mechanism of pain involved. The incidence of adverse effects during prolonged administration should be assessed in future studies.

Adult↗
PubMed1999

Methadone response in advanced cancer patients with pain followed at home.

Concerns about the safety of therapy with methadone, which may arise because of its pharmacokinetic characteristics and inappropriate dosing, may deter clinicians from using this drug, especially in elderly patients. Experience is accumulating that the drug may be used safely and successfully if low doses are given initially and care is taken in the titration of the dose against the pain. A prospective study was carried out in a consecutive sample of 45 advanced cancer patients followed at home, who had never received other strong opioids for their pain. Patients were treated with an oral liquid preparation of methadone, which was administered 2-3 times daily, according to need. Doses were kept as low as possible and were titrated to achieve acceptable analgesia with minimal adverse effects. The methadone starting dose (MSD) at referral, the maximum dose of methadone (MMD), the days of methadone treatment, the use of other nonopioid analgesics, symptoms associated with methadone therapy, pain intensity, and pain mechanism were recorded. Methadone escalation index percentage (MEI%) and methadone escalation index in mg (MEI mg) were calculated from these parameters. No correlations between age and gender, and MSD, MMD, days on methadone, VAS and symptoms were found. No significant differences were found in pain mechanisms, age, and other parameters, including methadone-related symptoms. Treatment of pain with methadone provides important support to patients with cancer followed at home and the risks are low with individually titrated doses, even in older patients or in the presence of a neuropathic pain mechanism.

Analgesics, Opioid↗
PubMed1999

Investigation of an opioid response categorization in advanced cancer patients.

The aim of this study was to investigate a possible distinction in three categories of opioid response and to identify possible factors associated with a poor response. A prospective survey was carried out in 105 consecutive patients requiring morphine for at least 4 weeks before death. Mean pain intensity, opioid doses and symptom intensity at weekly intervals, pain syndromes, and the presence of psychological distress were assessed. Opioid escalation index (OEI%) was calculated from the parameters recorded. Three categories were considered, including (1) patients with slow increments of opioid dose and a mean analgesic 10-cm visual analogue scale (VAS) less than 4 (responders), (2) patients with an OEI% more than 5 but a mean VAS less than 4 (partial responders), and (3) patients with a mean VAS more than 4 (poor responders). Treating physicians were asked to make a judgment on the pain treatment difficulties on a numerical scale (0-10). Significant differences in opioid starting dose (OSD), opioid dose at--4 weeks, nausea and vomiting at--1 week, opioid maximum doses, mean VAS, and OEI were found in the three categories of response. Significant correlations with the physician judgment were found for opioid maximum dose, mean VAS, VAS at the different time intervals, the doses used at the different intervals, OEI, and confusion. Neuropathic pain was significantly associated with a judgment of poor pain outcome. The correlation between the physician judgment and the categories of opioid response was highly significant. Seven of the 12 patients in the third category (poor response) were considered as having a relevant psychological distress. The categorization of the opioid response used in this study could be used in clinical research and as an audit tool, and could be tested in other settings to compare different treatments.

Aged↗
PubMed1999

The role of morphine glucuronides in cancer pain.

Morphine metabolites are involved in various ways in determining the complex effects of morphine, both favourable and adverse, and may complicate the clinical use of morphine in the treatment of cancer pain. The production and effects of the principal morphine metabolites, morphine-3-glucuronide and morphine-6-glucuronide, in both normal and pathological states have been reviewed in the current literature. Therapeutic implications are also reviewed on the basis of experimental and clinical reports. The presence of these metabolites should be recognized in the chronic treatment of cancer pain with morphine, especially in the presence of renal impairment, and should be considered to have an important influence on opioid responsiveness, defined as a balance between the achievement of an optimal analgesia and the occurrence of adverse effects.

Analgesics, Opioid↗
PubMed1999

Rapid switching from morphine to methadone in cancer patients with poor response to morphine.

PURPOSE: The aim of this study was to evidence the clinical effects of an abrupt substitution of morphine with methadone using a fixed ratio of 1:5 in patients for whom limiting adverse effects occurred before adequate analgesia was achieved with oral morphine. PATIENTS AND METHODS: A cross-sectional prospective study was carried out on 24 consecutive patients who were switched from oral morphine to oral methadone because they experienced substantial adverse effects that limited further increase in morphine dose. A fixed conversion morphine-to-methadone ratio of 5:1 was chosen. Subsequently, doses were changed according to clinical need, with frequent visits or phone contacts. Pain and symptom intensity, preswitching doses of morphine, initial and subsequent doses of methadone, and survival were recorded. RESULTS: A significant decrease in pain and symptom intensity was found within 24 hours after the substitution took place. The switching was effective in most patients (19 of 24), although five patients required alternative treatments. No significant changes in methadone dose were reported in the 3 days after switching. Methadone dose was significantly higher in patients who had lower preswitching doses of morphine and vice versa. No relevant complications were reported. CONCLUSION: A rapid substitution of morphine with methadone using an initial fixed ratio of 5:1 is a safe and effective method for improving the balance between analgesia and adverse effects in cancer patients with poor morphine response. An appropriate system of patient monitoring is necessary, because further changes in dose may be required according to clinical needs.

Aged↗