Break-through pain Break-through pain and it’s management and it’s management

Slavica Lahajnar

Institut of oncology Ljubljana

Break-through pain – patient’s statement

This sudden, strong pain brings me in anger and fear, my heart beats faster, I can not do anything. It takes from me the courage for life.

Patient with breast cancer and bone metastases

Break-through pain – incidence and consequences

a half to two thirds of patients with chronic cancer pain

often unrecognized and untreated

worsens quality of life

economic burden

Portenoy RK et al. Pain 1999;81(1–2):129–134.Caraceni A et al. Palliat Med 2004;18:177–183.Fortner BV et al. J Pain 2002;3:38–44.

Break-through pain - definition

transitory exacerbation of pain with relatively stable and adequately controlled baseline pain

spontaneous or provoked

Davies et all. Eur J Pain 2009;13: 331-338 Zappetella. Curr Opin Support Palliat Care 2009; 3: 1-6

Break-through pain - characteristics

CauseSiteAnticipationOnset speedDurationIntensityFrequency

in 80% same as in baseline pain

in 75% one-sided

in 50 %

~ in 3 min.

~ 30 min

≥ 7 (VAS 0-10)

4x/day

in 80% same as in baseline pain

in 75% one-sided

in 50 %

~ in 3 min.

~ 30 min

≥ 7 (VAS 0-10)

4x/day

Portenoy et all. J Pain 2006; 7: 583-591

Break-through pain - treatment

Treatment of basic illness:

RT, CT ..

Treatment of basic illness:

RT, CT ..

Non-pharmacologic methods

Non-pharmacologic methods

Change of lifestyle

Change of lifestyle

Psyhological support

Psyhological support

Interveningprocedures:

neuroaxilar inf., nevroablation

Interveningprocedures:

neuroaxilar inf., nevroablation

Pharmacotherapy: opioids,

non-opioids, additional drugs

Pharmacotherapy: opioids,

non-opioids, additional drugs

Multimodal treatment

Multimodal treatment

Break-through pain – treatment with opioids

Treating cancer pain - idealTreating cancer pain - ideal

Treating cancer pain - currentTreating cancer pain - current

Break-through pain - treatment

• morphinemorphine

Current treatment is NOT optimal

Davies A. BMJ 2009; in press

Break-through pain - treatment

fentanylfentanyl

• oral transmucosal (lollipop), • buccal (tablet), • sublingual (tablet), • nasal (sprey), • inhaling

Fentanyl – 40 years long history of analgetic activity

1968

intravenous fentanyl

1993

fentanyl patch

1998

oral transmucosal

fentanyl citrate

2006

fentanyl tablets (USA)

2008

fentanyl tablets(EU)

• pure agonist of mu-opioid receptors

• 80-100 x more potent than morphine

• without active metabolites

• very lipophylic: fast membrane crossing into CNS

Abstral® - new innovative drug release technology

Rapid disintegration... Muco-adhesion... Rapid absorption.

Fentanyl sublingual tablet (Abstral®)

rapid absorption into blood, high biologic availability (without first-pass metabolism in liver)

for opioid tolerant patients, already taking ≥ 60 mg of morphine or equivalent dose of other strong opioid

adverse events like in other strong opioids

Abstral® - titration

ABSTRAL - significant improvement in pain intensity after 15 minutes, maximum dose of 800μg per episode of pain, patients should receive no more than 4 doses (8 tbl.)/day

first tablet second tablet

100 µg 100 µg

200 µg 100 µg

300 µg 100 µg

400 µg 200 µg

600 µg 200 µg

800 µg –

Different strengths available, the packaging is colour-coded and the tablets are differently shaped.

Abstral – Prescribing information

Conclusions

multimodal treatment of break-through pain

tretment with opioids, which have rapid onset of action

sublingual fentanyl designed to match the temporal profile of breakthrough pain

effective dose should be titrated

Bredenburg S et al. Eur J Pharm Sci 2003;20:327–334.