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Biomedical subjects

S Mercadante

Publications and source records attributed to S Mercadante.

At least 73 records · Page 4Linked to original sources
PubMed1999

Alternatives to oral opioids for cancer pain.

Although the optimal route of administration of opioids is by mouth, some patients may require alternative routes during the course of their illnesses for several reasons. These include bowel obstruction, severe emesis, or severe dysphagia. In these cases, the alternatives include the subcutaneous or rectal route. The transdermal route also provides a simple, comfortable method that produces stable blood drug concentrations. The high potency and lipid solubility of fentanyl make it suitable for this route of administration. Iontophoresis can provide a rapid drug delivery rate, but no clinical studies exist to document the long-term effectiveness of this method in controlling pain. The transmucosal route is recommended only for those opioids with high solubility, such as buprenorphine, the fentanyl series, and methadone. Oral transmucosal fentanyl (Actiq) provides a rapid onset of pain relief and is appropriate for treating episodes of breakthrough pain.

Administration, Oral↗
PubMed1998

Parenteral versus enteral nutrition in cancer patients: indications and practice.

Prospective randomly controlled trials have failed to demonstrate the clinical efficacy of providing nutritional support to most cancer patients in terms of morbidity, mortality, and duration of hospitalization. Serious shortcomings in study design have limited the possibility of drawing definitive conclusions from the data. Thus, nutritional intervention needs to be seen as a method of support, with the aim of maintaining nutritional and functional status during the stress of the oncology treatment to prevent or attenuate cachexia. There is no disease during which the patient benefits from prolonged wasting. Pretreatment weight loss is quoted as a major indicator of poor survival and response to therapy of cancer patients. As a consequence, an early and serial assessment of nutritional status, perhaps followed by an immediate intervention with nutritional support is strongly recommended. There are other specific reasons for using the gut rather than the intravenous route for nutrient administration besides the often reported disadvantage of significant cost. Local intestinal stimulation prevents the mucosal atrophy and bacterial translocation that can be triggered by several precipitating factors, as frequently seen in oncologic patients. These include endotoxin, radiation therapy, cytotoxic and immunosuppressive drugs, cytokines, bowel and biliary obstruction, broad-spectrum antibiotics, and the tumour itself, as well as parenteral nutrition (PN). As the enteral route of nutritional support has been found to be as good as or preferable to PN in terms of maintenance of nutritional status or immune function, prevention of bacterial translocation, maintenance of normal gut flora, transit and histology, and prevention of hypercatabolic responses to stressful events, it is always preferable in terms of physiological response, local and systemic competence, quality of life and cost, and should be the method of choice for the nutritional support of cancer patients. Although retrospective studies of PN suggest a benefit for patients with cancer who are undergoing surgery, radiation, or chemotherapy, carefully designed, prospective studies report less conclusive findings. The failure of conventional PN to improve clinical outcomes in patients with cancer may be related to the fact that standard formulations do not address or reverse abnormalities of intermediate metabolism that result in cancer cachexia. Supplemental substances have been proposed in an attempt to improve the efficacy of PN, including insulin, growth hormone and branched chain amino acids. The difficult task is to identify those patients who are at risk for malnutrition and at the same time identify the subset of patients who will benefit clinically from parenteral nutritional repletion. Severe malnutrition in patients requiring surgery, bone marrow transplantation in patients unable to tolerate enteral supplementation and postoperative complications necessitating nutritional support are specific indications. Routine use of PN should be discouraged.

Cachexia↗
PubMed1998

Opioid responsiveness in patients with advanced head and neck cancer.

The degree of opioid responsiveness in patients with different pain syndromes associated with advanced head and neck cancer was studied with the aid of various indices that have proved to be easy to compare and capable of eliciting individual profiles of opioid responsiveness in cancer patients with pain. Thirty-seven patients requiring opioid therapy for more than 6 weeks were reviewed. The opioid escalation index (OEI) was lower in aged patients, albeit not significantly. Significant differences in OEI were found among patients belonging to the different categories of responses proposed. Although higher doses were needed than reported in the general population, pain was considered acceptable and most patients were classified as partially responsive. Neuropathic pain was associated with higher OEIs. The indices applied will be useful in clinical research to demonstrate individual profiles of opioid responsiveness, from cases of easy and immediate pain control to unresponsiveness to opioid treatment, which can be difficult to evaluate in the clinical setting.

Age Factors↗
PubMed1998

Controversies over spinal treatment in advanced cancer patients.

About 10% of patients with cancer pain do not obtain pain relief or experience unacceptable side effects with systemic opioids. In some cases a change of the route of administration can improve the balance of analgesia and adverse effects. In this paper the use of spinal opioids in such patients is discussed from various aspects: patient selection, epidural vs intrathecal administration, dosage, association with local anaesthetic agents, dosage conversion systems (for the change from systemic administration) and home use. The main problems involved are dealt with an attempt to find how to use the drugs and techniques involved to the best possible advantage.

Analgesics, Opioid↗
PubMed1998

Temporary drainage of symptomatic malignant ascites by a catheter inserted under computerized tomography.

The development of malignant ascites is an unfavorable prognostic sign in patients with advanced cancer. Interventions may be justified when discomfort and overall compromise in well-being are due to diaphragmatic spinting and abdominal compression of viscera. A patient with symptomatic ascites was admitted to hospital for temporary drainage using a catheter inserted under computerized tomography. Over 12 liters of fluids were removed in 3 days, without complications. A minimal ascitic leakage occurred after removing the cannula. Dyspnea and gastrointestinal symptoms improved and the patient died with good symptom control 15 days later. This approach should be considered in advanced cancer patients with symptomatic ascites that is not responsive to diuretics.

Aged↗
PubMed1998

Ondansetron in nausea and vomiting induced by spinal morphine.

Nausea and vomiting induced by opioids are relatively frequent in advanced cancer patients, although other factors may play a role. These effects, which tend to disappear after repeated dosing, can usually be controlled with antiemetic drugs, including metoclopramide, haloperidol, and phenothiazines. Occasionally, nausea and vomiting persist, in spite of the prolonged administration of the antiemetic treatment. We report a patient who had nausea and vomiting that was resistant to common antiemetic treatments, change in opioid drugs, and change in route of administration, and who had a complete and immediate response to parenteral or oral ondansetron.

Analgesics, Opioid↗
PubMed1998

Predictive factors and opioid responsiveness in cancer pain.

The management of cancer pain not readily responsive to morphine is often problematic. Several factors can interfere with an appropriate analgesic opioid response in the course of the illness, including the progression of the disease and tolerance, the appearance of intractable side-effects, type and temporal pattern of pain, morphine metabolites, pharmacokinetic and pharmacodynamic factors, as well as individual factors. Different methodologies capable of accurately predicting or monitoring opioid response have been proposed in an attempt to allow researchers to 'speak a common language'. Tolerance is a component of the concept of opioid responsiveness. However, the assessment of analgesic tolerance in cancer patients is constrained by numerous difficulties because of the changes in the noxious stimuli with increasing activity in nociceptive pathways.

Drug Administration Routes↗
PubMed1998

Morphine versus methadone in the pain treatment of advanced-cancer patients followed up at home.

PURPOSE: The aim of this study was to evaluate the analgesic and adverse effects and the doses of methadone in comparison to morphine. PATIENTS AND METHODS: A prospective randomized study was performed in a sample of 40 patients with advanced cancer who required strong opioids for their pain management. Patients were treated with sustained-release morphine or methadone in doses titrated against the effect administered two or three times daily according to clinical need. Opioid doses, adjuvant medications, symptoms associated with opioid therapy, pain intensity, and pain mechanisms were recorded. The opioid escalation indices in percentage (OEI%) and milligrams (OEImg) were calculated. The effective analgesic score (EAS) that monitors the analgesic consumption-pain ratio was also calculated at fixed weekly intervals. RESULTS: differences in pain intensity were found. Patients treated with methadone reported values of OEI significantly less than those observed in patients treated with morphine. Seven patients in the methadone group maintained the same initial dosage until death, whereas only one patient in the morphine group did not require opioid dose escalation. A more stable analgesia in time in patients treated with methadone was shown by the low number of gaps in EASs reported. Symptom frequencies and intensities were similar in the two groups. CONCLUSION: Methadone is a drug of indisputable value in the treatment of cancer pain, and an unbalanced focus on the risks of inappropriate use rather than the benefits should not compromise the use of a relevant alternative to morphine in the management of cancer pain.

Adult↗
PubMed1998

Dextropropoxyphene versus morphine in opioid-naive cancer patients with pain.

The role of opioids for moderate pain (so-called "weak" opioids) in the second step of the World Health Organization's analgesic ladder has been investigated in a prospective randomized study. Sixteen patients were administered dextropropoxyphene (DPP) in a dosage ranging from 120 mg to 240 mg daily (group 1), and 16 patients were administered the lowest doses (20 mg daily) of commercially available controlled-release morphine (group 2). Equianalgesic doses of oral morphine, pain relief, and symptoms during the first 10 days of therapy and during the last 4 weeks before death were assessed. Three of 16 patients maintained DPP until death, whereas three patients in group 2 were switched to DPP due to the occurrence of intolerable side effects. Intensity and frequency of nausea and vomiting, drowsiness, and dry mouth were higher in group 2 than in group 1 during the initial treatment. These results stress the role of "weak" opioids during the induction of opioid therapy in opioid-naive cancer patients.

Aged↗
PubMed1998

Pathophysiology and treatment of opioid-related myoclonus in cancer patients.

Myoclonus occasionally occurs in the perioperative setting and in patients on chronic opioid therapy. It appears to be dose-related in a unpredictable manner. Different mechanisms have been proposed to explain the occurrence of a series of neuromuscular disturbances probably sharing final common pathways. A neuroexcitatory opioid metabolite accumulation has been proposed to have a relevant role in determining myoclonus in patients treated with chronic opioid therapy for cancer pain, especially in the presence of renal impairment. The neurological status, previous oncologic treatment and concomitant therapy with neuroleptic drugs, the metabolic and hydration status should also have been considered. Adjuvant drugs, such as benzodiazepines or dantrolene may avoid the reduction of the opioid dose while maintaining an acceptable analgesia. Current practice suggests a change in opioid when pain control is not obtained at opioid doses resulting in unacceptable adverse effects, including myoclonus and hyperalgesia. A change in the type of opioid may be useful in patients who develop severe central adverse effects, even if these patients appear to have normal renal function or hydration status.

Analgesics, Opioid↗
PubMed1998

Oral Morphine Consumption in Italy and Sicily.

The trend in morphine consumption in Italy and in Sicily was investigated, using sales of sustained-release formulations as an indicator. A slight increase in morphine consumption has been observed in the last few years. This trend was more evident in Sicily. Formulations with the lowest dose (10-30 mg) were more frequently used. Italian laws and restrictions concerning the medical use of opioids are the most sever in Europe. Although some countries have a high level of opioid consumption, the assertion that morphine consumption is an indicator of progress in cancer pain management is only valid in countries in which opioids are not generally used for other purposes, like in Italy. Continual medical education, postgraduate training courses, and the development of pilot programs of pain relief and palliative care may improve the knowledge of cancer pain.

Administration, Oral↗