Survey on the use of buprenorphine patches in the palliative care practice

Transdermal buprenorphine is a new formulation of the old drug available for the treatment of cancer and non-cancer pain. The drug offers number of interesting new features and was found effective in clinical trials in cancer patients with pain. We performed a survey of the use of buprenorphine patches for one year. In the survey we included 58 admitted patients (67 admission periods), whose clinical records and drug charts were subjected to analysis. Opioid naive patients were started either on 5 or 10 μg/hour. Mean buprenorphine dose was 22.3 μg/hour (95% CI: 16–28.6), increased on day 8 to 25.4 μg/hour (95% CI: 18.6–32) and ended up at the dose of 31.3 μg/hour (95% CI: 20.9–41.6) on the last day of treatment; day 19 (95% CI: 14.5–23.5). The overall dose increase was approximately 2% per day. Approximately half of the patients needed beside buprenorphine other opioids either in a slow release or immediate release form, usually morphine or oxycodone. Swapping from morphine, oxycodone and fentanyl to buprenorphine was without problems in all of the cases. The doses of all opioids administered calculated as oral morphine equivalents showed insignificant decreases for morphine and oxycodone to buprenorphine swaps. In case of fentanyl the oral morphine equivalents of opioids were significantly lower after swap (p = 0.0039). No signs of antagonism between the drugs were observed. In conclusion: buprenorphine patches appear to be useful in the treatment of cancer pain, either as monotherapy or in combination with other opioids. Swap from fentanyl to buprenorphine offers perspective of achievement of pain control with much less toxicity and should be investigated in more detail. Adv. Pall. Med. 2010; 9, 2: 39–44Transdermal buprenorphine is a new formulation of the old drug available for the treatment of cancer and non-cancer pain. The drug offers number of interesting new features and was found effective in clinical trials in cancer patients with pain. We performed a survey of the use of buprenorphine patches for one year. In the survey we included 58 admitted patients (67 admission periods), whose clinical records and drug charts were subjected to analysis. Opioid naive patients were started either on 5 or 10 μg/hour. Mean buprenorphine dose was 22.3 μg/hour (95% CI: 16–28.6), increased on day 8 to 25.4 μg/hour (95% CI: 18.6–32) and ended up at the dose of 31.3 μg/hour (95% CI: 20.9–41.6) on the last day of treatment; day 19 (95% CI: 14.5–23.5). The overall dose increase was approximately 2% per day. Approximately half of the patients needed beside buprenorphine other opioids either in a slow release or immediate release form, usually morphine or oxycodone. Swapping from morphine, oxycodone and fentanyl to buprenorphine was without problems in all of the cases. The doses of all opioids administered calculated as oral morphine equivalents showed insignificant decreases for morphine and oxycodone to buprenorphine swaps. In case of fentanyl the oral morphine equivalents of opioids were significantly lower after swap (p = 0.0039). No signs of antagonism between the drugs were observed. In conclusion: buprenorphine patches appear to be useful in the treatment of cancer pain, either as monotherapy or in combination with other opioids. Swap from fentanyl to buprenorphine offers perspective of achievement of pain control with much less toxicity and should be investigated in more detail. Adv. Pall. Med. 2010; 9, 2: 39–4

Badanie dotyczące stosowania buprenorfiny w plastrach w opiece paliatywnej

Przezskórne podawanie buprenorfiny jest nową formą starego leku dostępną w terapii bólu nowotworowego i nienowotworowego. Lek ten ma liczne zachęcające właściwości i okazał się skuteczny w badaniach klinicznych u chorych na nowotwory, cierpiących z powodu bólu. Autorzy niniejszej pracy przeprowadzili badanie dotyczące stosowania buprenorfiny w plastrach przez okres 1 roku. Do badania włączono 58 chorych (67 okresów hospitalizacji), analizowano ich historie chorób i karty leków. Chorzy niestosujący wcześniej opioidów zaczynali od dawki 5 lub 10 μg/h. Średnia dawka buprenorfiny wynosiła 22,3 μg/h [95% CI: 16-28,6], zwiększana w 8. dniu do 25,4 μg/h (95% CI: 18,6-32), aż do ostatecznej dawki 31,3 μg/h (95% CI: 20,9-41,6) w ostatnim, 19. dniu leczenia (95% CI: 14,5-23,5). Łączny wzrost dawki wynosił średnio 2% dziennie. Około połowa chorych wymagała, oprócz stosowania buprenorfiny, podania innych opioidów o powolnym lub natychmiastowym uwalnianiu - zwykle były to morfina lub oksykodon. Zamiana z morfiny, oksykodonu czy fentanylu na buprenorfinę przebiegała bez problemów u wszystkich chorych. Wykazano nieistotny statystycznie spadek zużycia morfiny czy oksykodonu przy zamianie na buprenorfinę, w przeliczeniu na ekwiwalenty doustnej morfiny. W przypadku fentanylu dawka liczona jako ekwiwalenty doustnej morfiny była istotnie mniejsza (p = 0,0039) po zamianie na buprenorfinę. Nie stwierdzono antagonistycznych działań między lekami. Podsumowując, buprenorfina w plastrach wydaje się skuteczna w terapii bólu nowotworowego, zarówno w monoterapii, jak i w leczeniu skojarzonym z innymi opioidami. Zamiana z fentanylu może być alternatywą dla osiągnięcia lepszej kontroli bólu ze znacznie mniejszą toksycznością - zagadnienie to powinno być dokładniej zbadane. Medycyna Paliatywna w Praktyce 2010; 4, 3: 99-10

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification