The Opioid Rotation Ratio (ORR) to transdermal fentanyl (TDF) in cancer patients.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 181-181
Author(s):  
Akhila Sunkepally Reddy ◽  
Ali Haider ◽  
Supakarn Tayjasanant ◽  
Jimin Wu ◽  
Diane D Liu ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Care Center ◽  
Linear Regression Analysis ◽  
Symptom Assessment ◽  
Transdermal Fentanyl ◽  
Opioid Rotation ◽  
Edmonton Symptom Assessment Scale ◽  
Symptom Assessment Scale ◽  
Frequent Reason

181 Background: Cancer patients frequently undergo opioid rotation (OR) for uncontrolled pain or opioid induced neurotoxicity. TDF is one of the most common opioids prescribed to cancer patients. However, the accurate ORR from other opioids to TDF is unknown and various currently used methods result in a wide variation of ORRs. Our aim was to determine the ORR of morphine equivalent daily dose (MEDD) to TDF when correcting for MEDD of breakthrough opioids (net MEDD) in cancer outpatients. Methods: We reviewed records of 22,532 consecutive patient visits at our Supportive Care Center in 2010-13 for OR from to TDF by a palliative medicine specialist. Data regarding Edmonton Symptom Assessment Scale (ESAS) and MEDD were collected in patients who returned for follow up within 5 weeks. Linear regression analysis was used to estimate the ORR between TDF dose and net MEDD (MEDD prior to OR minus MEDD of breakthrough opioid used along with TDF after OR). Successful OR was defined as 2-point or 30% reduction in pain score and continuation of the new opioid at follow up. Results: 129 patients underwent OR to TDF from other opioids. The mean age was 56 years, 59% male, and 88% had advanced cancer. The median time between OR and follow up was 14 days. Uncontrolled pain (80%) was the most frequent reason for OR and 59% had a successful OR with significant improvement in ESAS pain, constipation, and symptom distress scores. In 101 patients with OR and no worsening of pain at follow up, the median ORR (range) from net MEDD to TDF mg/day was .01 (-0.02-0.04) and correlation of TDF dose to net MEDD was .77 (P < .0001). The ORR was not significantly impacted by variables such as mucositis, serum albumin, and body mass index (BMI). The ORR of .01 suggests that MEDD of 100mg is equivalent to 1mg TDF/day or 40mcg/hour TDF patch (1000mcg/24hours). Conclusions: The median ORR from MEDD to TDF mg/day is .01 and the ORR from MEDD to TDF mcg/hour patch is 0.4. Further validation studies are needed. [Table: see text]

The conversion ratio for opioid rotation from hydrocodone to other strong opioids in cancer patients.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 164-164
Author(s):  
Akhila Sunkepally Reddy ◽  
Sriram Yennu ◽  
Jimin Wu ◽  
Diane Liu ◽  
Suresh K. Reddy ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Care Center ◽  
Linear Regression Analysis ◽  
Symptom Assessment ◽  
Conversion Ratio ◽  
Opioid Rotation ◽  
Edmonton Symptom Assessment Scale ◽  
Symptom Assessment Scale ◽  
Strong Opioids

164 Background: Cancer pain is initially treated with intermediate strength analgesics such as hydrocodone and subsequently escalated to stronger opioids. There are no studies on the process of opioid rotation (OR) from hydrocodone to strong opioids in cancer patients. Our aim was to determine the conversion ratio (CR) for OR from hydrocodone to morphine equivalent daily dose (MEDD) in cancer outpatients. Methods: We reviewed records of 3,144 consecutive patient visits at our Supportive Care Center in 2011-12 for OR from hydrocodone to stronger opioids. Data regarding demographics, Edmonton Symptom Assessment Scale (ESAS), and MEDD were collected in patients who returned for follow up within 6 weeks. Linear regression analysis was used to estimate the CR between hydrocodone and MEDD. Successful OR was defined as 2-point or 30% reduction in the pain score and continuation of the new opioid at follow up. Results: 170/3,144 patients underwent OR from hydrocodone to stronger opioid. 72% were white, 56% male, and 81% had advanced cancer. The median time between OR and follow up was 21 days. 53% had a successful OR with significant improvement in the ESAS pain and symptom distress scores. In 100 patients with complete OR and no worsening of pain at follow up, the median CR (Q1-Q3) from hydrocodone to MEDD was 1.5 (0.9-2) and hydrocodone dose to MEDD correlation was.52 (P<0.0001). The correlation of CR with hydrocodone dose was -0.52 (P<0.0001). The median CR of hydrocodone to MEDD was 2 in patients receiving < 40mg of hydrocodone/day and 1 in patients receiving ≥ 40mg of hydrocodone/day (P<0.0001). The median conversion ratio of hydrocodone to morphine was 1.5 (n=44) and hydrocodone to oxycodone was 0.9 (n=24). Conclusions: Hydrocodone is 1.5-fold stronger than Morphine. The median conversion ratio from hydrocodone to MEDD varied according to hydrocodone dose/day. [Table: see text]

The Opioid Rotation Ratio (ORR) from transdermal fentanyl (TDF) to strong opioids in cancer patients.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 182-182
Author(s):  
Akhila Sunkepally Reddy ◽  
Sriram Yennu ◽  
Suresh K. Reddy ◽  
Jimin Wu ◽  
Diane D Liu ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Care Center ◽  
Linear Regression Analysis ◽  
Symptom Assessment ◽  
Cancer Center ◽  
Transdermal Fentanyl ◽  
Opioid Rotation ◽  
Edmonton Symptom Assessment Scale ◽  
Strong Opioids

182 Background: Despite being the most frequently prescribed strong opioid by oncologists, there is a lack of knowledge of the accurate the opioid rotation ratio (ORR) from transdermal fentanyl (TDF) to other strong opioids in cancer patients. Opioid rotation (OR) from TDF to other strong opioids is performed very frequently in cancer patients for uncontrolled pain or opioid induced neurotoxicity (OIN). The aim of our study was to determine the ORR of TDF to other strong opioids, as measured by morphine equivalent daily dose (MEDD). Methods: In this ad hoc analysis, we reviewed 2471 consecutive patient visits to the supportive care center of a tertiary cancer center in 2008 for an OR from TDF to other strong opioids by a palliative medicine specialist. Information regarding demographics, Edmonton Symptom Assessment Scale (ESAS), and MEDD were collected in patients who followed-up within 6 weeks. Linear regression analysis was used to estimate the ORR between TDF dose and net MEDD (MEDD after OR minus MEDD of breakthrough opioid used along with TDF before OR). Successful OR was defined as 2-point or 30% reduction in pain score and continuation of the new opioid at follow up. Results: 47/2471 patients underwent OR from TDF to other opioids and followed-up within 6 weeks. The median age was 54 years, 53% were male, and 77% had advanced cancer. The median time between OR and follow up was 14 days. Uncontrolled pain (83%) followed by OIN (15%) were the most frequent reasons for OR and 77% had a successful OR with significant improvement in ESAS pain and symptom distress scores. In patients with OR and no worsening of pain at follow-up (n = 41), the median ORR (range) from TDF mg/day to net MEDD was 100 (12.5-217), TDF mcg/hour to net MEDD was 2.4 (0.3-5.2), and correlation of TDF dose to net MEDD was .60 (P < 0.0001). Conclusions: The median ORR from TDF mg/day to MEDD is 100 and from TDF mcg/hour to MEDD is 2.4. Further validation studies are needed.

Symptom Management in Palliative Medicine

2012 ◽  
Author(s):  
Kathy J Selvaggi ◽  
Janet L Abrahm
Keyword(s):  
Symptom Management ◽  
Symptom Control ◽  
Hot Flashes ◽  
Symptom Assessment ◽  
Symptomatic Treatment ◽  
Assessment Scale ◽  
Transdermal Fentanyl ◽  
Memorial Symptom Assessment Scale ◽  
Edmonton Symptom Assessment Scale ◽  
Symptom Assessment Scale

Palliative care is an interdisciplinary specialty focused on providing comfort, communication, and support for patients, families, and professional caregivers throughout the course of a life-limiting illness. This chapter discusses assessment and treatment of symptoms and disorders that commonly contribute to patient distress during these illnesses: pain, disorders of the respiratory and gastrointestinal systems, skin disorders, hot flashes, fatigue, pruritis, insomnia, and delirium. This chapter reviews care of the imminently dying patient, discusses methods for assessing patients' symptoms, and provides two examples of valid and reliable symptom measurement systems: the Edmonton Symptom Assessment Scale and the Memorial Symptom Assessment Scale. Achieving symptom control requires the physician to assess patient suffering in all dimensions: physical, psychological, social, and spiritual. The extent of the assessment may be modified, however, based on patients’ prognosis as well as their goals and the burden and benefit of the diagnostic intervention. A 10-step protocol for terminal wean is presented. Signs that patients are entering their final days and symptom management in the last hours of a patient's life are discussed. Tables list the modified Edmonton Symptom Assessment Scale; the Memorial Symptom Assessment Scale; the DOLOPLUS-2 scale (behavioral pain assessment in the elderly); relative potencies of commonly used opioids; conversions between the transdermal fentanyl patch and morphine; symptomatic treatment for dyspnea, cough, and hiccups; pharmacologic treatment of nausea and vomiting; a progressive bowel regimen for patients receiving opioid therapy; treatments for constipation; etiology-based treatment for oral problems; risk factors for pressure ulcers; and applicable medications for physical and psychological sources of distress near the end of life. This review contains 12 tables and 120 references

scholarly journals Patterns of Opioid Prescription, Use, and Costs Among Patients With Advanced Cancer and Inpatient Palliative Care Between 2008 and 2014

2019 ◽  
Vol 15 (1) ◽  
pp. e74-e83 ◽  
Author(s):  
Sriram Yennurajalingam ◽  
Zhanni Lu ◽  
Suresh K. Reddy ◽  
EdenMae C. Rodriguez ◽  
Kristy Nguyen ◽  
...  
Keyword(s):  
Palliative Care ◽  
Advanced Cancer ◽  
Symptom Assessment ◽  
Patient Characteristics ◽  
Opioid Prescription ◽  
Patients With Cancer ◽  
Edmonton Symptom Assessment Scale ◽  
Symptom Assessment Scale ◽  
Symptom Changes

PURPOSE: An understanding of opioid prescription and cost patterns is important to optimize pain management for patients with advanced cancer. This study aimed to determine opioid prescription and cost patterns and to identify opioid prescription predictors in patients with advanced cancer who received inpatient palliative care (IPC). MATERIALS AND METHODS: We reviewed data from 807 consecutive patients with cancer who received IPC in each October from 2008 through 2014. Patient characteristics; opioid types; morphine equivalent daily dose (MEDD) in milligrams per day of scheduled opioids before, during, and after hospitalization; and in-admission opioid cost per patient were assessed. We determined symptom changes between baseline and follow-up palliative care visits and the in-admission opioid prescription predictors. RESULTS: A total of 714 (88%) of the 807 patients were evaluable. The median MEDD per patient decreased from 150 mg/d in 2008 to 83 mg/d in 2014 ( P < .001). The median opioid cost per patient decreased and then increased from $22.97 to $40.35 over the 7 years ( P = .03). The median MEDDs increased from IPC to discharge by 67% ( P < .001). The median Edmonton Symptom Assessment Scale pain improvement at follow-up was 1 ( P < .001). Younger patients with advanced cancer (odds ratio [OR[, 0.95; P < . 001) were prescribed higher preadmission MEDDs (OR, 1.01; P < .001) more often in the earlier study years (2014 v 2009: OR, 0.18 [ P = .004] v 0.30 [ P = .02]) and tended to use high MEDDs (> 75 mg/d) during hospitalization. CONCLUSION: The MEDD per person decreased from 2008 to 2014. The opioid cost per patient decreased from 2008 to 2011 and then increased from 2012 to 2014. Age, prescription year, and preadmission opioid doses were significantly associated with opioid doses prescribed to patients with advanced cancer who received IPC.

The influence of a cachexia clinic on palliative care integration in oncology.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 124-124
Author(s):  
Diane Portman ◽  
Sarah Thirlwell ◽  
Kristine A. Donovan
Keyword(s):  
Palliative Care ◽  
Weight Loss ◽  
Advanced Cancer ◽  
Symptom Burden ◽  
Symptom Assessment ◽  
Cancer Center ◽  
Edmonton Symptom Assessment Scale ◽  
Symptom Assessment Scale ◽  
The Impact

124 Background: Appetite and weight loss are common in patients with advanced cancer and specialized cachexia clinics have been established to address these symptoms. Given the association between anorexia/cachexia and other adverse symptoms, these patients may also benefit from specialty level palliative care (PC). However, referral to outpatient specialty level PC is often delayed or does not occur. We sought to examine the prevalence of other factors associated with appetite and weight loss in patients with advanced cancer and the impact of a specialized cachexia clinic on identification and treatment of other PC needs. Methods: The records of patients referred by their Oncologist to the cachexia clinic of a cancer center from August 2016 to June 2017 were reviewed retrospectively. Subjects who had been referred to PC by their Oncologist were excluded. Patients had been assessed for symptom burden using the Edmonton Symptom Assessment Scale (ESAS-r). Patients identified with PC needs had been referred to the PC clinic for follow-up within 30 days after cachexia clinic consultation. Results: Thirty subjects were evaluated in the cachexia clinic (average age 68 years; 63% female). The predominant diagnosis was lung cancer (70%). An average of 6 symptoms per patient were in the moderate to severe range on ESAS, excluding appetite. Depression, fatigue and pain were most common. The average cachexia clinic total ESAS score was 51.61. Only 17% of patients had completed advance directives. Ninety-three % of patients were referred to PC and 68% were seen. The average number of PC visits was 2.79. Within the PC clinic, advance directive completion increased to 37%, goals of care discussion occurred with 50% and 17% received hospice referrals. At the most recent follow-up in the PC clinic, the average total ESAS score had decreased by 11.44 (22%) and all ESAS item scores were improved on average. Conclusions: The cachexia clinic proved a useful means to identify other PC needs and achieve effective PC referrals. We suggest this is proof of concept that specialty clinics can be a meaningful way to achieve an earlier entry point to comprehensive PC in patients who were not previously referred by their Oncologists.

Patients’ characteristics and outcomes of palliative care inpatient consults at a comprehensive cancer center

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 8524-8524 ◽  
Author(s):  
B. El Osta ◽  
F. S. Braiteh ◽  
S. Reddy ◽  
H. El Osta ◽  
E. Bruera
Keyword(s):  
Palliative Care ◽  
Symptom Assessment ◽  
Disease Diagnosis ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Limited Information ◽  
Opioid Rotation ◽  
Cancer Data ◽  
Edmonton Symptom Assessment Scale ◽  
Symptom Assessment Scale

8524 Background: There is limited information about the characteristics and outcomes of inpatient palliative care consults in cancer centers. Two mobile teams (MT) each with a physician, fellow, and a nurse, provide consultation to hospitalized patients (pts) with complex symptoms. Methods: We analyzed the pts characteristics and outcomes during a two-month period. The charts were reviewed for demographics, cancer data, reason for consultation, symptoms, interventions, and outcomes. Results: Sixty-one pts were analyzed. Pain was the main reason for a consult request in 46 pts (75%), delirium in 10 (16%), anxiety in 4 (7%) and constipation in 5 (8 %). Some pts had more than one reason. 56(92%) pts had metastatic disease, diagnosis for ≤1 year in 26 (42%) and ≤2 years in 44 (72%) (Median =17 months). The Edmonton Symptom Assessment Scale (ESAS), 0–10, is summarized in the table. We uncovered new issues at consultation, such as 20 pts (38%) screened positive for alcoholism with CAGE questionnaire and the 34 pts (56%) had clinical delirium. Features of opioids toxicity such as constipation (N=43;70%), confusion (N=35;57%) (Mean MMSE = 23 ± 5), hallucinations (N=21;34%), myoclonus (N=16;26%) and miosis (N=18;29%) were frequently identified. The MT interventions included imaging studies (23%), enema (43%), laxatives (49%), neuroleptics (54%), metoclopramide (39%), corticosteroids (25%). Half (N=30;50%) of the pts had opioid rotation and/or had counseling (N=27;46%). One out of two pts (N=30;49%) required transfer to the palliative care unit. Conclusions: Most pts had previously undiagnosed opioid toxicity, delirium, and other symptoms. Opioid toxicity occurred secondary to rapid opioid escalation, possibly linked to chemical coping, and psychosocial distress. The outcome of these pts improved by opioid rotation, adding laxatives, metoclopramide, neuroleptics, and steroids. [Table: see text] No significant financial relationships to disclose.

Increased symptom expression among patients (PTS) with delirium admitted to an acute palliative care unit (APCU).

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 56-56
Author(s):  
Maxine Grace De la Cruz ◽  
Sriram Yennu ◽  
Diane D Liu ◽  
Jimin Wu ◽  
Akhila Sunkepally Reddy ◽  
...  
Keyword(s):  
Case Reports ◽  
Symptom Assessment ◽  
Physical Symptoms ◽  
Assessment Scale ◽  
Delirium Assessment ◽  
Wilcoxon Rank Sum Test ◽  
Edmonton Symptom Assessment Scale ◽  
Chi Squared ◽  
Symptom Assessment Scale

56 Background: Previous case reports found that delirium-induced disinhibition may lead to overexpression of symptoms. Our aim was to determine the effect of delirium on the reporting of symptom severity in pts with advanced cancer. Methods: We reviewed 329 consecutive pts admitted to the APCU without a diagnosis of delirium from Jan 2011-Dec 2011. Demographics, Memorial Delirium Assessment Scale (MDAS), ECOG, Edmonton Symptom Assessment Scale (ESAS) on 2 time points were collected. Pts who developed delirium and those who did not develop delirium during the entire course of admission were compared using Chi-Squared test and Wilcoxon rank-sum test. Paired t-test was used to assess if the change of ESAS from baseline to follow-up was associated with delirium. Results: 96/329 (29%) of pts developed delirium during their admission to the APCU. The median time to delirium was 2 days. There was no difference in the length of stay in the APCU for both groups. Table 1 shows the changes in the ESAS scores of the two groups from baseline to follow-up. Pts who did not have delirium expressed improvement in all their symptoms while those who developed delirium during the hospitalization showed no improvement in physical symptoms and worsening in depression, anxiety, appetite and wellbeing. Conclusions: Pts with delirium reported no improvement or worsening symptoms as compared to pts without delirium. Screening for delirium is important in pts who continue to report worsening symptoms despite appropriate management. [Table: see text]

scholarly journals Comfort level of caregivers of cancer patients receiving palliative care

2018 ◽  
Vol 26 (0) ◽  
Author(s):  
Maisa Vitória Gayoso ◽  
Marla Andréia Garcia de Avila ◽  
Thays Antunes da Silva ◽  
Rúbia Aguiar Alencar
Keyword(s):  
Palliative Care ◽  
Functional Status ◽  
Cancer Patients ◽  
Symptom Assessment ◽  
Cross Sectional Study ◽  
Demographic Variables ◽  
Comfort Level ◽  
Cross Sectional ◽  
Edmonton Symptom Assessment Scale ◽  
Symptom Assessment Scale

ABSTRACT Objective: To verify the association between the level of comfort of the caregiver and socio-demographic variables related to caregiving, and the patient’s functional status and symptoms. Method: Cross-sectional study with non-probabilistic intentional sample. The instruments Palliative Performance Scale (score 0 to 100%), Edmonton Symptom Assessment Scale (symptom scores from zero to ten) and Holistic Comfort Questionnaire (total score ranging from 49 to 294 and mean score from 1 to 6) were used. The relationship between comfort scores and independent variables was calculated by multiple linear regression. Results: Fifty informal caregivers participated in the study - 80% were female, 32% were 60 years old or older, 36% were children of the patient, 58% had paid work and 60% did not have help in the care. The mean overall comfort was 4.52 points. A better functional status of the patients was associated with higher levels of comfort of the caregivers. Older caregivers who received helped in the care activities presented higher comfort scores. Conclusion: The level of comfort of caregivers of cancer patients receiving palliative care was associated with socio-demographic variables and patients’ functional status and symptoms.

The Effect of Combined Drug Management and an Exercise Program on Symptoms and the Happiness Level in Elderly Women

2020 ◽  
Vol 33 (1) ◽  
pp. 14-20
Author(s):  
Seçil Gülhan Güner ◽  
Arzu Erden ◽  
Nesrin Nural
Keyword(s):  
Elderly Women ◽  
Short Form ◽  
Exercise Program ◽  
Symptom Assessment ◽  
Well Being ◽  
Drug Management ◽  
Edmonton Symptom Assessment Scale ◽  
Post Test ◽  
Symptom Assessment Scale

The aim of this study was to determine the effect of combined drug management and an exercise program on symptoms and the happiness levels of elderly women people living at home. This interventional study included a total of 35 women, aged 65 to 74 years, who were registered at the Family Healthcare Centre. A 14-week program was combined with exercise and drug management. Pre-test and post-test evaluations results were recorded. The Edmonton Symptom Assessment Scale (ESAS), Oxford Happiness Questionnaire-Short Form (OHQ-SF) and a sociodemographic form and Follow-Up form were used for data collection. The mean ESAS points of the symptoms of pain, tiredness, sadness, and insomnia showed a significant decrease after intervention and the sense of well-being improved ( p < .001). A statistically significant increase was determined in the happiness levels of the participants after intervention. The combined program of drug management and exercise was found to be effective in raising happiness levels and reducing symptoms in elderly women.

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