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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