Palliative medicine
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Palliative medicine · Jul 2011
ReviewThe second step of the analgesic ladder and oral tramadol in the treatment of mild to moderate cancer pain: a systematic review.
To analyse the evidence supporting the widespread use of modified analgesic ladders or oral tramadol as alternatives to codeine/paracetamol for mild to moderate cancer pain. ⋯ Data supporting the role of modified two-step analgesic ladders or oral tramadol as an alternative to codeine/paracetamol are insufficient to recommend their routine use in cancer patients with mild to moderate cancer pain.
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Palliative medicine · Jul 2011
ReviewEvidence-based medicine: what is the evidence that it has made a difference?
Evidence-based medicine (EBM) has, over the past 20 years, made us all more critical in our thinking about the efficacy and safety of interventions. This is evident in the higher standards of our spoken and written work, formal and informal, and in our approach to the subject. The downside has been the coincidence of the squeeze on healthcare funding with the emergence of the EBM ideas - it has been all too easy to misuse the tools of EBM to deny patients access to treatment, and this, together with the off-putting political correctness of the EBM approach in some quarters, has made clinicians uneasy. ⋯ Tom Chalmers, a grandfather of the EBM movement, argued late in his career that the most important function of the EBM approach was to frame the research agenda. This we think is correct. The process of systematic review of a topic throws up the deficits in trial methods and the lacunae in the data, and this then can show the way forward.
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Palliative medicine · Jul 2011
ReviewEuropean Palliative Care Research collaborative pain guidelines. Central side-effects management: what is the evidence to support best practice in the management of sedation, cognitive impairment and myoclonus?
This is a systematic review examining the management of opioid-induced central side effects. It has been conducted as part of a larger European Palliative Care Research collaborative review into the use and role of opioids in cancer pain. The review process identified 26 studies that met the inclusion criteria. ⋯ Overall there is limited evidence for the use of methylphenidate in counteracting opioid-induced sedation and cognitive disturbance. No clear recommendations can be made concerning other individual drugs for the management of any of the central side effects examined. Given the lack of available data from this review there need to be further prospective controlled trials to confirm or refute these findings.
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Palliative medicine · Jul 2011
ReviewStarting step III opioids for moderate to severe pain in cancer patients: dose titration: a systematic review.
The European Association for Palliative Care recommendation for starting morphine for cancer pain is dose titration with immediate release (IR) oral morphine given every 4 h with additionally doses for breakthrough pain. As part of a EU 6th framework programme to revise the guidelines we review the evidence regarding starting treatment and dose titration of opioids in adult patients with moderate to severe cancer pain. Relevant papers were identified though a systematic search in Medline for papers published until the end of 2009. ⋯ All treatment strategies resulted in acceptable pain control and were well tolerated. Two randomized controlled trials were identified. One study compared starting opioid treatment with intravenous morphine versus IR oral morphine and one study compared IR oral morphine versus sustained release oral morphine.
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Palliative medicine · Jul 2011
ReviewIs oral methadone better than placebo or other oral/transdermal opioids in the management of pain?
To address the question: is oral methadone better than placebo, or other oral/transdermal opioids in the management of cancer pain? ⋯ This limited data suggests that (1) methadone may be an equally effective candidate for first-line opioid therapy, (2) that it is possibly less expensive, (3) that there may be a propensity to sedation and dose accumulation unless there is close monitoring and conservative dose selection and (4) that it should be initiated with a calculated dose based on a morphine to methadone dose ratio of not less than 4:1.