Durchbruchschmerzen

Zusammenfassung

Mit der hier vorliegenden CME-zertifizierten Fortbildung soll ein Überblick über die Epidemiologie, die charakteristischen Merkmale und die Therapie der Durchbruchschmerzen gegeben werden. Obwohl Durchbruchschmerzen in den meisten Fällen am selben Ort wie der Dauerschmerz auftreten und ihnen die gleichen pathophysiologischen Abläufe zugrunde liegen, stellt ihre medikamentöse Therapie andere Herausforderungen an die verwendeten Substanzen und deren Applikationsformen. Während die Therapie des Dauerschmerzes im Idealfall auf der regelmäßigen Einnahme eines ausreichend dosierten retardierten Opioidpräparates beruht, bedarf die Behandlung von Durchbruchschmerzen hochwirksamer, rasch wirkender und rasch wieder abflutender Zubereitungen. Daher sind die verschiedenen, teilweise neu entwickelten Applikationsformen der Opioidbedarfsmediaktion ein Schwerpunkt dieser Fortbildung.

Abstract

This CME certified article will review the epidemiological basis, clinical characteristics and therapeutic options of breakthrough pain. Although breakthrough pain refers to the same clinical locations like the underlying chronic pain in most instances and although their pathophysiological processes are comparable, breakthrough pain therapy will require substances with extraordinary pharmacological characteristics and routes of application. Whilst chronic pain therapy consists ideally on a steady intake of prolonged released opioids, aiming at constant, sufficiently high substance levels, breakthrough pain therapy relies on highly potent, rapidly and shortly acting formulations. Therefore, the spectrum of different formulations and modes of application and their recent developments are of special emphasis in this article.

Literatur

• 1 Ferlay J, Autier P, Boniol M. et al . Estimates of the cancer incidence and mortality in Europe in 2006.  Ann Oncol. 2007;  18 581-592
• 2 Bruera E, Portenoy R eds. Oxford Textbook of Palliative Medicine (Oxford Textbook). Geneva; World Health Organization 1998
• 3 Vainio A, Auvinen A. Symptom Prevalence Group. Prevalence of symptoms among patients with advanced cancer: an international collaborative study.  J Pain Symptom Manage. 1996;  12 3-10
• 4 Svendsen K B, Andersen S, Arnason S. et al . Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms.  Eur J Pain. 2005;  9 195-206
• 5 Bruera E, Schoeller T, Wenk R. et al . A prospective multicenter assessment of the Edmonton staging system for cancer pain.  J Pain Symptom Manage. 1995;  10 348-355
• 6 Mercadante S, Radbruch L, Caraceni A. et al . Committee of the European Association for Palliative Care (EAPC) Research Network. Episodic (breakthrough) pain: consensus conference of an expert working group of the European Association for Palliative Care.  Cancer. 2002;  94 832-839
• 7 IASP . International association for the study of pain.  Pain. 1979;  6 249-252
• 8 McCaffery M, Beebe A. Pain: Clinical Manual for Nursing Practice. St Louis; CV Mosby Company 1989
• 9 Portenoy R K, Forbes K, Lussier D. et al . Difficult pain problems: an integrated approach. In: Doyle D, Hanks G, Cherny N, Calman K, eds Oxford Textbook of Palliative Medicine. 3rd. ed. Oxford; Oxford University Press 2004: 438-458
• 10 Wincent A, Lidén Y, Arnér S. Pain questionnaires in the analysis of long lasting (chronic) pain conditions.  Eur J Pain. 2003;  7 311-321
• 11 Ferrell B R, Juarez G, Borneman T. Use of routine and breakthrough analgesia in home care.  Oncol Nurs Forum. 1999;  26 1655-1661
• 12 Caraceni A, Martini C, Zecca E. et al . Working Group of an IASP Task Force on Cancer Pain. Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey.  Palliat Med. 2004;  18 177-183
• 13 Portenoy R K, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain.  Pain. 1999;  81 129-134
• 14 Zeppetella G, Ribeiro M D. Episodic pain in patients with advanced cancer.  Am J Hosp Palliat Care. 2002;  19 267-276
• 15 Fortner B V, Demarco G, Irving G. et al . Description and predictors of direct and indirect costs of pain reported by cancer patients.  J Pain Symptom Manage. 2003;  25 9-18
• 16 Skinner C, Thompson E, Davies A. Clinical features. In: Davies A, ed Cancer related breakthrough pain. Oxford; Oxford University Press 2006: 13-22
• 17 Portenoy R K, Hagen N A. Breakthrough pain: definition, prevalence and characteristics.  Pain. 1990;  41 273-281
• 18 Fine P G, Busch M A. Characterization of breakthrough pain by hospice patients and their caregivers.  J Pain Symptom Manage. 1998;  16 179-183
• 19 Gómez-Batiste X, Madrid F, Moreno F. et al . Breakthrough cancer pain: prevalence and characteristics in patients in Catalonia, Spain.  J Pain Symptom Manage. 2002;  24 45-52
• 20 Hwang S S, Chang V T, Kasimis B. Cancer breakthrough pain characteristics and responses to treatment at a VA medical center.  Pain. 2003;  101 55-64
• 21 Petzke F, Radbruch L, Zech D. et al . Temporal presentation of chronic cancer pain: transitory pains on admission to a multidisciplinary pain clinic.  J Pain Symptom Manage (United States). 1999;  17 391-401
• 22 Melzack R, Wall P D. Pain mechanisms: a new theory.  Science. 1965;  150 971-979
• 23 Bailey F, Farley A. Oral opioid drugs. In: Davies A, ed Cancer related breakthrough pain. Oxford; Oxford University Press 2006: 43-55
• 24 Warren D E. Practical use of rectal medications in palliative care.  J Pain Symptom Manage. 1996;  11 378-387
• 25 Walker G, Wilcock A, Manderson C. et al . The acceptability of different routes of administration of analgesia for breakthrough pain.  Palliat Med. 2003;  17 219-221
• 26 Mercadante S, Villari P, Ferrera P. et al . Safety and effectiveness of intravenous morphine for episodic (breakthrough) pain using a fixed ratio with the oral daily morphine dose.  J Pain Symptom Manage. 2004;  27 352-359
• 27 Moulin D E, Johnson N G, Murray-Parsons N. et al . Subcutaneous narcotic infusions for cancer pain: treatment outcome and guidelines for use.  CMAJ. 1992;  146 891-897
• 28 Swanson G, Smith J, Bulich R. et al . Patient-controlled analgesia for chronic cancer pain in the ambulatory setting: a report of 117 patients.  J Clin Oncol. 1989;  7 1903-1908
• 29 Schiessl C, Bidmon J, Sittl R. et al . Patient-controlled analgesia (PCA) in outpatients with cancer pain: Analysis of 1,692 treatment days.  Schmerz. 2007;  21 35-42
• 30 Dale O. Opioid drugs via other routes. In: Davies A, ed Cancer related breakthrough pain. Oxford; Oxford University Press 2006: 73-82
• 31 Enting R H, Mucchiano C, Oldenmenger W H. et al . The „pain pen” for breakthrough cancer pain: a promising treatment.  J Pain Symptom Manage. 2005;  29 213-217
• 32 Mayes S, Ferrone M. Fentanyl HCl patient-controlled iontophoretic transdermal system for the management of acute postoperative pain.  Ann Pharmacother. 2006;  40 2178-2186
• 33 Minkowitz H S, Rathmell J P, Vallow S. et al . Efficacy and safety of the fentanyl iontophoretic transdermal system (ITS) and intravenous patient-controlled analgesia (IV PCA) with morphine for pain management following abdominal or pelvic surgery.  Pain Med. 2007;  8 657-668
• 34 Lee V H. Mucosal drug delivery.  J Natl Cancer Inst Monogr. 2001;  29 41-44
• 35 Hao J, Heng P W. Buccal delivery systems.  Drug Dev Ind Pharm. 2003;  29 821-832
• 36 Zhang H, Zhang J, Streisand J B. Oral mucosal drug delivery: clinical pharmacokinetics and therapeutic applications.  Clin Pharmacokinet. 2002;  41 661-680
• 37 Coluzzi P H. Sublingual morphine: efficacy reviewed.  J Pain Symptom Manage. 1998;  16 184-192
• 38 Davis T, Miser A W, Loprinzi C L. et al . Comparative morphine pharmacokinetics following sublingual, intramuscular, and oral administration in patients with cancer.  Hosp J. 1993;  9 85-90
• 39 Osborne R, Joel S, Trew D. et al . Morphine and metabolite behavior after different routes of morphine administration: demonstration of the importance of the active metabolite morphine-6-glucuronide.  Clin Pharmacol Ther. 1990;  47 12-19
• 40 Zeppetella G. Oral transmucosal opioid drugs. In: Davies A, ed Cancer related breakthrough pain. Oxford; Oxford University Press 2006: 57-71
• 41 Hanks G W, Nugent M, Higgs C M. et al. OTFC Multicentre Study Group . Oral transmucosal fentanyl citrate in the management of breakthrough pain in cancer: an open, multicentre, dose-titration and long-term use study.  Palliat Med. 2004;  18 698-704
• 42 Portenoy R K, Payne R, Coluzzi P. et al . Oral transmucosal fentanyl citrate (OTFC) for the treatment of breakthrough pain in cancer patients: a controlled dose titration study.  Pain. 1999;  79 303-312
• 43 Slatkin N E, Xie F, Messina J. et al . Fentanyl buccal tablet for relief of breakthrough pain in opioid-tolerant patients with cancer-related chronic pain.  J Support Oncol. 2007;  5 327-334
• 44 Weinberg D S, Inturrisi C E, Reidenberg B. et al . Sublingual absorption of selected opioid analgesics.  Clin Pharmacol Ther. 1988;  44 335-342
• 45 Davis M P. Buprenorphine in cancer pain.  Support Care Cancer. 2005;  13 878-887
• 46 Thompson J W. Clinical pharmacology of opioid agonists and partial agonists. In: Doyle D, ed Opioids in the Treatment of Cancer Pain. London; Royal Society of Medicine Services Ltd 1990: 17-38
• 47 Dale O, Hjortkjaer R, Kharasch E D. Nasal administration of opioids for pain management in adults.  Acta Anaesthesiol Scand. 2002;  46 759-770
• 48 Zeppetella G. An assessment of the safety, efficacy, and acceptability of intranasal fentanyl citrate in the management of cancer-related breakthrough pain: a pilot study.  J Pain Symptom Manage. 2000;  20 253-258
• 49 Kaasa S. A randomised, double-blind, placebo-controlled, cross-over, multi-centre trial to evaluate the efficacy of intranasal fentanyl for breakthrough pain in cancer patients. 5th Research Congress of the European Association for Palliative Care (EAPC), Trondheim (Norway), Mai 2008.  Palliat Med. 2008;  22 411