Continuous Subsutaneous Infusion

1. Watanabe S, Pereira J, Hanson J, Bruera E. Fentanyl by continuous subcutaneous infusion for the management of cancer pain: A retrospective study. Journal of Pain and Symptom Management, 1998; 16(5): 323-326.

Background: Individual variability in analgesic and nonanalgesic response is being increasingly recognized, as is the usefulness of sequential opioid trials to optimize the balance of analgesia and side effects. It is therefore recognized that clinicians treating patients with cancer-related pain need to be proficient in using more than one route of opioid administration and more than one strong opioid. Formulation in a transdermal patch has allowed sustained release of drug for chronic pain management. However, it is not recommended for the rapid titration of patients with unstable pain. If the dose of transdermal fentanyl needs to be increased, it is generally recommended that it should not be increased more frequently than every 3 days. In the context of poorly controlled pain, this time frame may be unacceptable. On the other hand, parenteral administration of Fentanyl by a continuous infusion allows for rapid dose titration.

Summary: We evaluated, retrospectively, twenty-two consecutive patients who received fentanyl by continuous subcutaneous infusion (CSCI). The 2 reasons for these switches to CSCI fentanyl were as follows: i) 17 patients were switched because they developed toxicity to other opioids, and ii) 5 patients were switched from transdermal fentanyl to CSCI of fentanyl because their pain was not well controlled. Of the 17 patients switched to CSCI of fentanyl, 10 achieved stability, with documented improvement in toxicity in 7 of these. Unfortunately, improvement or persistence of toxicity was not documented in the remaining 3 patients and it was therefore not known whether they had improved or not. Of the five patients switched from transdermal fentanyl, three achieved stability accompanied by improvements in visual analogue scores for pain. Altogether 6 patients were switched to transdermal fentanyl once stability was achieved on the CSCI of fentanyl. The median dose ratio of opioid prior to switchover (mg/day) to fentanyl at stabilization (mg/day) was 85.4 (range 65-112.5) for morphine and 23.0 (range 10.7-29.7) for hydromorphone. We conclude that fentanyl by CSCI is a useful alternative for cancer patients who experience uncontrolled pain while receiving transdermal fentanyl or who experience toxicity on other opioids.




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