Page 42 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)
2SLRLG URWDWLRQ
Opioid rotation is a strategy of switching from one opioid to another to
improve pain relief or reduce AEs.

This strategy may be indicated in up to 44% of patients with cancer-
related pain. Improvement in pain as well as reduced AEs after rotation
were seen in 50 - 90% of these patients. Uncontrolled pain was the
main reason for opioid rotation in the outpatient setting while AEs were
the reason in the inpatient setting where patients were often more
debilitated. 47, level III

• Common indications for opioid switching include: 47, level III
{ inadequate pain relief despite appropriate titration
{ intolerable AEs (e.g. sedation, nausea, vomiting, constipation)
{ organ impairment
{ practical considerations (e.g. lack of compliance, inability to swallow)

,Q D ODUJH V\VWHPDWLF UHYLHZ RQ RSLRLG URWDWLRQ WKH ¿QGLQJV ZHUH 48, level I
• all studies showed pain improvement or stable pain relief with
opioid rotation
• dose titration may still be necessary to achieve stable analgesia
• no particular opioid demonstrated superiority to another opioid
‡ D KLJKHU GRVDJH RI WKH ¿UVW OLQH RSLRLG WHQGHG WR UHVXOW LQ ORZHU
success rates of rotation
• reduction of AEs was limited with rotation, but patient’s satisfaction
was generally positive ranging from 60 - 90%

Rotating between opioids remains challenging due to a lack of well-
established evidence to support the dose conversions used in clinical
SUDFWLFH DQG PRUH VR LQ FRPSOH[ FDVHV ZKHQ WKHUH LV D QHHG WR EDODQFH
between pain relief and AEs. To address this, a common suggestion is
to reduce the calculated dose by 25 - 50% when initiating opioid rotation
and titrate upwards accordingly. Because of individual variability, the
9
conversion between opioids should always take into consideration
the patient’s co-morbidities, concomitant medications, pain and AE
LQWHQVLW\ DQG DOVR DQ\ SKDUPDFRNLQHWLF IDFWRUV WKDW FRXOG LQÀXHQFH WKH
effectiveness of the medications.
$ V\VWHPDWLF UHYLHZ WKDW VSHFL¿FDOO\ ORRNHG DW HTXLDQDOJHVLF RSLRLG
doses reported the following conversion ratios: 28
‡ PRUSKLQH R[\FRGRQH RI
• oral morphine-transdermal fentanyl of 100:1
The conversion ratio from different opioids to methadone was highly
variable, ranging from 5:1 to 10:1.

24

e-cpg inside text-Cancer pain-25/5/24.indd 24 09/08/2024 12:09 AM