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Three Part Question

In [patients with poorly controlled chronic pain related to malignancy] does [the switching of transdermal fentanyl from long acting oral opioids] achieve [better pain control, reduced somnolence, constipation, nausea and vomiting]?

Clinical Scenario

A 56 year old palliative care patient with transitional cell urothelial carcinoma presents with excruciating cancer related pain in the Emergency Department (ED). He is no longer responsive to opioids for moderate pain and now requires management of his severe cancer related pain. He has experienced constipation, nausea, vomiting and decreased cognition since being placed on morphine (70 mg/day) previously and would like to avoid significant side effects of his medication and focus on maintaining a good quality of life.

Search Strategy

A Medline clinical queries search was conducted using the MeSH terms “Fentanyl" or “transdermal fentanyl", combined with “administration, cutaneous”. Next, the MeSH terms “Analgesics, Opioids”, “Administration, Oral”, “Palliative Care”, “Terminal Care”, “end stage.tw”, “terminally ill” were combined using “OR”. Lastly, the term “Neoplasms” was combined with the above and the search was limited to English language.
This revealed a total of 33 results, of which 2 articles looked at switching of opioids: specifically oral morphine and transdermal fentanyl. However, the retrospective analysis by Clemens and Klaschick compared switching of opioids from transdermal fentanyl to oral morphine.

Search Outcome

McNarmara, P. 2002. Opioid switching from morphine to transdermal fentanyl for toxicity reduction in palliative care. Palliative Medicine, 16: 425-435.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
McNamara, P 2002 United Kingdom	19 palliative cancer patients with malignancy related pain whom required ≥60 mg/day morphine, had poor sense of well being along with distress as a result of opioid toxicity were included in this study.	Single-center, noncomparative, open-label study.	Pain control	Not significantly different when compared to baseline (p=0.2773)	The study had a small sample size, breakthrough medication doses were unlimited and the study was not a RCT.
			Daytime Somnolence	Significant improvement when compared to baseline (p=0.0012)
			Constipation	No significant improvement when compared to baseline (p=0.1563)
			Vomiting	No significant improvement when compared to baseline (p=1.000)
			Nausea	Slight improvement but not statistically significant (p=0.8828)
			Dizziness	Significant improvement (p=0.0156)
			Cognition	Significant improvement in quality of working memory (p=0.0345) and speed of memory (p=0.0212).
			Overall wellbeing	Significant improvement when compared to baseline (p=0.0031)

Comment(s)

This study is not the highest quality and has some limitations. A more robust randomized control trial with larger sample population is needed to make definite recommendations for palliative care patients. Better control and analysis of breakthrough pain medication is required to assess the true effect of transdermal fentanyl on chronic cancer related pain management in this population.

Clinical Bottom Line

There is a clinical benefit of switching from oral morphine to transdermal fentanyl in terms of greater overall well being in life, improved cognition, decreased daytime somnolence and dizziness related to opioid related adverse effects in chronic cancer patients. However, nausea, constipation and vomiting were not significantly reduced when switching over to transdermal fentanyl according to this study.

References

1. McNamara, P Opioid switching from morphine to transdermal fentanyl for toxicity reduction in palliative care. Palliative Medicine 2002 Sep; 425-435