Breakthrough Pain An Update Prof. Pesach Shvartzman Pain and Palliative Care Unit, Ben-Gurion University of the Negev, Clalit Health Services, Beer-Sheva,

Breakthrough Pain Breakthrough Pain An UpdateAn Update

Prof. Pesach ShvartzmanProf. Pesach ShvartzmanPain and Palliative Care Unit, Pain and Palliative Care Unit,

Ben-Gurion University of the Negev, Ben-Gurion University of the Negev, Clalit Health Services, Clalit Health Services,

Beer-Sheva, IsraelBeer-Sheva, Israel

Definitions for BTPDefinitions for BTPHistoric DefinitionHistoric Definition11A transient increase in pain to greater A transient increase in pain to greater

than moderate intensity, occurring on a than moderate intensity, occurring on a baseline pain of moderate intensity or baseline pain of moderate intensity or less.less.

Narrow DefinitionNarrow Definition22A transitory flare of pain superimposed A transitory flare of pain superimposed on an otherwise stable pain pattern in on an otherwise stable pain pattern in patients treated with opioids.patients treated with opioids.

Broad DefinitionBroad Definition33Any acute transient pain the flares over Any acute transient pain the flares over baseline.baseline.

Consensus Panel Consensus Panel RecommendationRecommendation44

A transient exacerbation of pain A transient exacerbation of pain occurring in patients with otherwise occurring in patients with otherwise stable, baseline persistent pain.stable, baseline persistent pain.

11Portenoy & Hagen. Pain 1990;41:273. Portenoy & Hagen. Pain 1990;41:273. 22Coluzzi. Am J Hosp Palliat Care 1998;15:13. Coluzzi. Am J Hosp Palliat Care 1998;15:13. 33Hanks et al. Oxford Hanks et al. Oxford Textbook of Palliative Medicine 1998;454. Textbook of Palliative Medicine 1998;454. 44Bennett et al. P&T 2005;30(5):296.Bennett et al. P&T 2005;30(5):296.

EpidemiologyEpidemiology

19% to 95% of patients with pain also 19% to 95% of patients with pain also experience BTP experience BTP – The wide range reflects both the type of The wide range reflects both the type of

patient population sampled, and the definition patient population sampled, and the definition of BTP used of BTP used

Bennett et al. P&T. 2005;30(6):354

PrevalencePrevalence

In cancer patients:In cancer patients:– At diagnosis: 30% to 40%At diagnosis: 30% to 40%– During active treatment: 50% to 70%During active treatment: 50% to 70%– During endstage disease: 70% to 80%During endstage disease: 70% to 80%11

International study data (n=1095) indicate that International study data (n=1095) indicate that around two thirds of cancer patients experience around two thirds of cancer patients experience BTPBTP22..

In non-cancer patients:In non-cancer patients:– Of 43 terminally-ill hospice patients with pain, 27 Of 43 terminally-ill hospice patients with pain, 27

reported BTPreported BTP33..

1Svendsen et al. Eur J Pain 2005;9(2):195. 2Caraceni & Portenoy. Pain 1999;82:263. 3Zeppetella et al. Palliat Med 2001;15:243.

Personal Burden of DiseasePersonal Burden of Disease

BTP has an overall demoralizing effect on BTP has an overall demoralizing effect on patients and their families.patients and their families.

It is strongly associated with:It is strongly associated with:– Impaired daily functioningImpaired daily functioning– Worsening of depression and anxietyWorsening of depression and anxiety– Dissatisfaction with opioid therapyDissatisfaction with opioid therapy– Poor medical outcomes.Poor medical outcomes.

Socioeconomic Burden of DiseaseSocioeconomic Burden of Disease

Patients with BTP are also likely to utilize Patients with BTP are also likely to utilize more healthcare resources than patients more healthcare resources than patients without BTPwithout BTP11

– More pain-related hospitalizationMore pain-related hospitalization1,21,2

– More pain-related emergency department More pain-related emergency department visitsvisits22

– Increased direct and indirect treatment costsIncreased direct and indirect treatment costs33

1Fortner et al. J Pain 2005;3(1):38. 2Grant et al. Nurs Clin North Am. 1995;30(4):674. 3Fortner et al. J Pain Symptom Manage 2003;25(1):9.

Features of BTPFeatures of BTP

The cause and anatomical site of BTP is The cause and anatomical site of BTP is often, but not always, the same as that of often, but not always, the same as that of the chronic baseline pain.the chronic baseline pain.

Clinical features of BTP are similar among Clinical features of BTP are similar among patients with and without malignant patients with and without malignant disease.disease.

1Bennett et al. P&T 2005;30(5):296. 2Svendsen et al. Eur J Pain 2005;9(2):195.

BTP EpisodesBTP Episodes

In some patients, several episodes of BTP In some patients, several episodes of BTP may occur on a daily basis.may occur on a daily basis.

More than 4 episode per day may warrant More than 4 episode per day may warrant reassessment of the cause and approach reassessment of the cause and approach for management of baseline chronic pain.for management of baseline chronic pain.

Bennett et al. P&T. 2005;30(5):296

Treating cancerTreating cancer--related breakthrough related breakthrough painpain: : the oral transmucosal routethe oral transmucosal route

Int J Palliat Nurs 2007 Jul;13Int J Palliat Nurs 2007 Jul;13((77):):326-31326-31

Between 40 and 80% of patients with advanced cancer Between 40 and 80% of patients with advanced cancer experience breakthrough pain experience breakthrough pain ((BTPBTP)). . Patients often have up to four episodes of BTP each Patients often have up to four episodes of BTP each daydayA typical episode reaching its peak intensity in three to A typical episode reaching its peak intensity in three to five minutes and lasting about 30 minutes in totalfive minutes and lasting about 30 minutes in total.. It is essential to provide fast relief.It is essential to provide fast relief.BTP reduces the quality of life of patients and their BTP reduces the quality of life of patients and their families, and increases health care costsfamilies, and increases health care costs. . The usual approach is to treat BTP with a shortThe usual approach is to treat BTP with a short--acting acting opioidsopioidsOral transmucosal fentanyl citrate Oral transmucosal fentanyl citrate ((ActiqActiq) ) is an effective is an effective strong opioid that has a rapid onset and short duration of strong opioid that has a rapid onset and short duration of actionaction

Breakthrough pain in children with Breakthrough pain in children with cancercancer

J Pain Symptom Manage. 2007 Aug;34(2):209-16J Pain Symptom Manage. 2007 Aug;34(2):209-16

A prospective study to determine the A prospective study to determine the prevalence, characteristics, and impact of prevalence, characteristics, and impact of breakthrough pain in children with cancerbreakthrough pain in children with cancer. . TwentyTwenty--seven pediatric inpatients with seven pediatric inpatients with cancer cancer ((aged 7-18 yearsaged 7-18 years) ) who had severe who had severe pain requiring treatment with opioids pain requiring treatment with opioids Structured interview. Structured interview. Measures of pain, anxiety, and depressed Measures of pain, anxiety, and depressed mood were completedmood were completed..

ResultsResultsFiftyFifty--seven percent of the children seven percent of the children experienced one or more episodes of experienced one or more episodes of breakthrough pain during the preceding 24 breakthrough pain during the preceding 24 hours, each episode lasting seconds to hours, each episode lasting seconds to minutes, occurring 3-4 timesminutes, occurring 3-4 times//d, and most d, and most commonly characterized as commonly characterized as ""sharpsharp" " and and ""shootingshooting" " by the childrenby the children.. Younger children Younger children ((7-12 years7-12 years) ) had a had a significantly higher risk significantly higher risk The most effective treatment was a patientThe most effective treatment was a patient--controlled analgesia opioid bolus dosecontrolled analgesia opioid bolus dose. .

Subtypes of BTPSubtypes of BTP

Incident (~50% of BTP episodes)Incident (~50% of BTP episodes)– Predictable:Predictable: consistent, strong, temporal relationship with a consistent, strong, temporal relationship with a

precipitating factor (eg, movement).precipitating factor (eg, movement).– UnpredictableUnpredictable: inconsistent temporal realtionship with motor : inconsistent temporal realtionship with motor

activity (eg, bladder spasm).activity (eg, bladder spasm).

IdiopathicIdiopathic– Not induced by a readily identifiable cause.Not induced by a readily identifiable cause.– Lasts longer than incident pain (>30 minutes).Lasts longer than incident pain (>30 minutes).

End of doseEnd of dose– Presents prior to a scheduled dose of an around-the-clock Presents prior to a scheduled dose of an around-the-clock

analgesic.analgesic.– Gradual in onset and of longer duration than both incident and Gradual in onset and of longer duration than both incident and

idiopathic pain.idiopathic pain.

Bennett et al. P&T 2005:30(5):296.

Treatment OptionsTreatment OptionsThe appropriate intervention is determined by The appropriate intervention is determined by the type, severity and pattern of BTPthe type, severity and pattern of BTPAttempt to find a correctable cause of BTP that Attempt to find a correctable cause of BTP that may be reversedmay be reversed– Radiation or strontium (Radiation or strontium (8989SR) chloride therapy for SR) chloride therapy for

palliation of bone secondariespalliation of bone secondaries– Surgical debulking of solid tumorsSurgical debulking of solid tumors– Vertebroplasty for hitherto undiagnosed compression Vertebroplasty for hitherto undiagnosed compression

fracturefracture

Then consider pharmacologic and Then consider pharmacologic and nonpharmacologic (physical and psychosocial) nonpharmacologic (physical and psychosocial) therapies.therapies.

Bennett et al. P&T 2005:30(6):354.

Nonpharmacologic InterventionNonpharmacologic Intervention

Lifestyle interventionsLifestyle interventions– Self-awareness of physical limitationsSelf-awareness of physical limitations– Pace activities with regular breaksPace activities with regular breaks– Use of ice packs, massage, exercise, repositioning, Use of ice packs, massage, exercise, repositioning,

and immobilization to remove focus from pain and immobilization to remove focus from pain sensation.sensation.

Healthcare system interventionsHealthcare system interventions– Transcutaneous electrical nerve stimulation (TENS) Transcutaneous electrical nerve stimulation (TENS)

and acupunctureand acupuncture– Cognitive-behavioral techniques (hypnosis, relaxation Cognitive-behavioral techniques (hypnosis, relaxation

methods)methods)22

1NCI. Pain (PDQ) www.nci.nih.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional. 2Bennett et al. P&T 2005;30(6):354.

Ideal BTP MedicationIdeal BTP Medication

Potent pain relieverPotent pain reliever

Rapid onset of actionRapid onset of action

Sufficient duration of effect to treat BTP Sufficient duration of effect to treat BTP episodeepisode

Minimal or manageable side effectsMinimal or manageable side effects

Easy to administerEasy to administer

Pharmacologic InterventionPharmacologic Intervention

GoalGoal: reduce the frequency and intensity of BTP: reduce the frequency and intensity of BTP

If BTP regularly occurs at the end of each If BTP regularly occurs at the end of each scheduled dosing interval, then two options are scheduled dosing interval, then two options are available:available:– Increase total daily dose of opioid by 25-50%.Increase total daily dose of opioid by 25-50%.– Shorten the dosage intervalShorten the dosage interval

Approximately one sixth of the total daily Approximately one sixth of the total daily analgesic dose is given as an immediate release analgesic dose is given as an immediate release preparation to control BTPpreparation to control BTP

Bennett et al. P&T 2005:30(6):354.

Management by subtype of Management by subtype of Breakthrough PainBreakthrough Pain

SubtypeSubtypeGeneral Management ApproachGeneral Management Approach

End-of-doseEnd-of-doseCarefully tailor around-the-clock Carefully tailor around-the-clock dosingdosing

Incident, Incident, predictablepredictable

Pre-emptive immediate-release Pre-emptive immediate-release opioid, given 30-60 minutes prior to opioid, given 30-60 minutes prior to activityactivity

Incident, Incident, unpredictableunpredictable

Lipophilic immediate-release opioidLipophilic immediate-release opioid

IdiopathicIdiopathicLipophilic immediate-release opioidLipophilic immediate-release opioid

Bennett et al. P&T. 2005;30(5):297

Current Medications for Current Medications for Breakthrough PainBreakthrough Pain

Oral Immediate-release (IR) opioids Oral Immediate-release (IR) opioids for BTPfor BTP

Hydrocodone, morphine, oxycodone, Hydrocodone, morphine, oxycodone, hydromorphone, combination with hydromorphone, combination with paracetamol/aspirinparacetamol/aspirinOral absorption means slower onset Oral absorption means slower onset analgesia (+/- 30 min)analgesia (+/- 30 min)Duration of effect +/- 4hrsDuration of effect +/- 4hrsUseful for predictable incident painUseful for predictable incident painLess suitable for severe idiopathic or Less suitable for severe idiopathic or unpredictable incident BTPunpredictable incident BTP

Bennett et al. P&T. 2005;30(6):354

Oral IR Opioids for BTP: Oral IR Opioids for BTP: MethadoneMethadone

Rapid onset (10-15 min), excellent oral Rapid onset (10-15 min), excellent oral and rectal absorptionand rectal absorption

Opioid agonist, NMDA antagonism, and Opioid agonist, NMDA antagonism, and monoaminergic effectsmonoaminergic effects

Duration of effect (4-6 hours)Duration of effect (4-6 hours)

Accumulation, toxicity possible with Accumulation, toxicity possible with frequents dosingfrequents dosing

Bennett et al. P&T. 2005;30(6):354; Lynch. Pain Res Manag. 2005;10(3):133.

Opioid Efficacy Studies in BTPOpioid Efficacy Studies in BTP

Oral transmucosal fentanyl citrate (OTFC)Oral transmucosal fentanyl citrate (OTFC)– More effective than IR oral morphine for More effective than IR oral morphine for

cancer-related BTP paincancer-related BTP pain11

– Effective for neuropathic, nonciceptive BTPEffective for neuropathic, nonciceptive BTP22

– Effective in outpatients with sickle-cell painEffective in outpatients with sickle-cell pain33

1 Coluzzi et al. Pain 2001;91:123; 2 Farrar&Thompson. APS annual meeting 2005; 3Shalova et al. J Nati Med Assoc. 2004;96:984.

Opioids for the management of Opioids for the management of breakthrough breakthrough ((episodicepisodic) ) pain in cancer pain in cancer

patientspatients

Cochrane Database Syst Rev Jan 2006 Cochrane Database Syst Rev Jan 2006 25;25;((1)1)

Four studies Four studies ((393 participants393 participants) ) met the inclusion met the inclusion criteriacriteriaAll were concerned with the use of oral All were concerned with the use of oral transmucosal fentanyl citrate transmucosal fentanyl citrate ((OTFCOTFC) ) in the in the management of breakthrough painmanagement of breakthrough pain.. Two studies examined the titration of OTFC, Two studies examined the titration of OTFC, one study compared OTFC to normal release one study compared OTFC to normal release morphine and one study compared OTFC to morphine and one study compared OTFC to placeboplacebo..OTFC was shown to be an effective OTFC was shown to be an effective treatment for breakthrough paintreatment for breakthrough pain. .

Cochrane Database Syst Rev Jan 2006 Cochrane Database Syst Rev Jan 2006 25;25;((1)1)

When compared to placebo and morphine, When compared to placebo and morphine, participants gave lower pain intensity scores and participants gave lower pain intensity scores and higher pain relief scores for OTFC at all time higher pain relief scores for OTFC at all time pointspoints. . Global assessment scores also favoured Global assessment scores also favoured OTFCOTFC. . There is evidence that OTFC is an effective There is evidence that OTFC is an effective treatment in the management of breakthrough treatment in the management of breakthrough painpain. . The randomised trial literature for the The randomised trial literature for the management of breakthrough pain is small and management of breakthrough pain is small and no trials were found for other opioidsno trials were found for other opioids. .

*

(*)

Absorption of Opioids from Absorption of Opioids from Oral MucosaOral Mucosa

Adapted from Weinberg DS, et al. Clin Pharm Ther. 1988;44:337.

0

10

20

30

40

50

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Abs

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Mor

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Oxyco

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Levor

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Hydro

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Naloxo

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Meth

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Bupren

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Opioid (dose in mg)

Commonly Commonly prescribed prescribed opioid opioid medicationsmedications

ACTIQ IndicationACTIQ IndicationACTIQ was FDA approved in April, 1999ACTIQ was FDA approved in April, 1999ACTIQ is indicated in the US for the management ACTIQ is indicated in the US for the management of of breakthrough cancer painbreakthrough cancer pain in patients with in patients with malignanciesmalignancies who are who are already already receivingreceiving and who and who are are toleranttolerant** to opioid to opioid therapy for their therapy for their underlying persistent cancer painunderlying persistent cancer pain ..

** Patients considered opioid tolerant are those who are taking atPatients considered opioid tolerant are those who are taking at least least 60 mg morphine/day, 50 mcg transdermal 60 mg morphine/day, 50 mcg transdermal fentanyl/hour,fentanyl/hour, or equianalgesic or equianalgesic dose of another opioid for a week dose of another opioid for a week or longeror longer

Pharmacodynamics Pharmacodynamics –– Onset Onset of Pain Reliefof Pain Relief

Once in the bloodstream, fentanyl is rapidly Once in the bloodstream, fentanyl is rapidly distributed to the CNS (a process with a 3- to 5-distributed to the CNS (a process with a 3- to 5-minute half-life)minute half-life)

Onset of pain relief may begin while consuming Onset of pain relief may begin while consuming an ACTIQ unit (within 15 minutes)an ACTIQ unit (within 15 minutes)

Full pain relief may not be felt for up to 45 Full pain relief may not be felt for up to 45 minutes after consuming an ACTIQ unitminutes after consuming an ACTIQ unit

Longer or shorter consumption times may Longer or shorter consumption times may produce less efficacy than reported in ACTIQ produce less efficacy than reported in ACTIQ clinical trialsclinical trials

ACTIQ Package Insert. May 2003.

Summary: IR Opioids for BTPSummary: IR Opioids for BTP

Immediate-Immediate-Release OpioidRelease Opioid

Onset of Onset of AnalgesiaAnalgesia

Duration Duration of Effectof Effect

Advantages (A)/ Disadvantages (D)Advantages (A)/ Disadvantages (D)

Morphine (oral)Morphine (oral)30-40 min30-40 min4 hrs4 hrsA- available in multiple dosage forms, liquid A- available in multiple dosage forms, liquid concentrateconcentrate

D- slow onset of analgesia for Idiopathic BTPD- slow onset of analgesia for Idiopathic BTP

Oxycodone (oral)Oxycodone (oral)30 min30 min4 hrs4 hrsSame as morphineSame as morphine

Hydromorphone Hydromorphone (oral)(oral)

30 min30 min4 hrs4 hrsD- no liquid concentrate, slow onset of D- no liquid concentrate, slow onset of analgesic for Idiopathic BTPanalgesic for Idiopathic BTP

Methadone (oral)Methadone (oral)-10-15 min-10-15 min4-6 hrs4-6 hrsA- faster onset of analgesic in one small studyA- faster onset of analgesic in one small study

D- complex pharmacology, pharmacokineticsD- complex pharmacology, pharmacokinetics

Fentanyl Fentanyl

(trans-mucosal)(trans-mucosal)

-5-10 min-5-10 min1-2 hrs1-2 hrsA- fastest onset of analgesiaA- fastest onset of analgesia

D- requires ongoing patient cooperation in useD- requires ongoing patient cooperation in use

Characteristics of Immediate-Release Opioid Useful for Breakthrough Pain (BTP)

Lipophilic

Hydrophilic

Bennett et al. P&T. 2005;30(6):354

Investigational Opioid for BTPInvestigational Opioid for BTP

Sublingual fentanylSublingual fentanyl– Dissolves rapidlyDissolves rapidly– Detectable plasma levels in8-11 minutesDetectable plasma levels in8-11 minutes– Well-tolerated in patients with metastatic Well-tolerated in patients with metastatic

cancercancer

Lennernds et al. Br J Pharmacol. 2005;59:249.

Analgetic Medications for Analgetic Medications for Breakthrough pain in the Breakthrough pain in the

Pipe LinePipe Line

Fentanyl Buccal TabletFentanyl Buccal Tablet::

New sugarNew sugar--free, that uses an effervescent drug delivery free, that uses an effervescent drug delivery system to enhance the rate and extent of fentanyl system to enhance the rate and extent of fentanyl absorption across the buccal mucosaabsorption across the buccal mucosa. . Pain relief is observed within 10Pain relief is observed within 10 - - 15 min of 15 min of administrationadministration. . Generally well tolerated, with the most commonly Generally well tolerated, with the most commonly observed adverse events being typical opioid side observed adverse events being typical opioid side effectseffects. . Represent a convenient and effective treatment for the Represent a convenient and effective treatment for the control of breakthrough paincontrol of breakthrough pain..

Expert Opin PharmacotherExpert Opin Pharmacother.. 2007 Dec;8(17):3043-51 2007 Dec;8(17):3043-51

Fentanyl buccal tablet for relief of Fentanyl buccal tablet for relief of breakthrough pain in opioidbreakthrough pain in opioid--tolerant tolerant

patients with cancerpatients with cancer--related chronic painrelated chronic pain..

In this study of opioidIn this study of opioid--tolerant patients with tolerant patients with chronic cancer pain and BTP, FBT was chronic cancer pain and BTP, FBT was efficacious, well tolerated, demonstrated rapid efficacious, well tolerated, demonstrated rapid onset of analgesia onset of analgesia ((within 10 minuteswithin 10 minutes)), and had , and had a sustained effecta sustained effect..

J Support OncolJ Support Oncol.. 2007 Jul-Aug;5(7):327-34 2007 Jul-Aug;5(7):327-34

Effervescent morphine results in faster Effervescent morphine results in faster relief of breakthrough pain in patients relief of breakthrough pain in patients

compared to immediate release morphine compared to immediate release morphine sulfate tabletsulfate tablet

Effervescent morphine was given to 76 Effervescent morphine was given to 76 chronic cancer pain patients for treatment chronic cancer pain patients for treatment of BTP evaluating time until pain relief, of BTP evaluating time until pain relief, global satisfaction and side effectsglobal satisfaction and side effects. . Results were compared to those obtained Results were compared to those obtained using an IRMS formulation in a preceding using an IRMS formulation in a preceding runrun--in periodin period. .

Effervescent morphine results in faster Effervescent morphine results in faster relief of breakthrough pain in patients relief of breakthrough pain in patients

compared to immediate release morphine compared to immediate release morphine sulfate tabletsulfate tablet

A mean dose of 28 mg of effervescent morphine A mean dose of 28 mg of effervescent morphine ((range range 10-80 mg10-80 mg) ) resulted in a highly significant reduction of resulted in a highly significant reduction of pain score pain score ((mean 7.8 to mean 3.2; P < 0.001mean 7.8 to mean 3.2; P < 0.001).). Efficacy was not different from that observed with IRMSEfficacy was not different from that observed with IRMS. . However, mean time until sufficient pain relief was However, mean time until sufficient pain relief was significantly shorter than with IRMS significantly shorter than with IRMS ((1313 +/- +/- 5.6 vs5.6 vs. . 2727 +/- +/- 4.4 minutes; P < 0.014.4 minutes; P < 0.01).). The incidence of side effects was similar with the new The incidence of side effects was similar with the new morphine formulation and with IRMSmorphine formulation and with IRMS.. There was no relationship between the previous dose of There was no relationship between the previous dose of the daily opioid and the effective dose of effervescent the daily opioid and the effective dose of effervescent morphinemorphine. .

Effervescent morphine results in faster Effervescent morphine results in faster relief of breakthrough pain in patients relief of breakthrough pain in patients

compared to immediate release morphine compared to immediate release morphine sulfate tabletsulfate tablet

Overall satisfaction for effervescent Overall satisfaction for effervescent morphine was rated morphine was rated ""superiorsuperior" " by 16.7%, by 16.7%, and and ""betterbetter" " by 63.2% of patientsby 63.2% of patients..

Pain PractPain Pract.. 2007 Dec;7(4):324-31. Epub 2007 Nov 6. 2007 Dec;7(4):324-31. Epub 2007 Nov 6.

A trial looking at fentanyl nasal spray to A trial looking at fentanyl nasal spray to treat breakthrough cancer paintreat breakthrough cancer pain

Cancer Research UKCancer Research UK

This trial will compare fentanyl citrate nasal This trial will compare fentanyl citrate nasal spray spray ((also called NasalFentalso called NasalFent) ) with other with other painkillers that are already used to treat cancer painkillers that are already used to treat cancer painpain. . StartsStarts 01/05/2007 01/05/2007EndsEnds 01/06/2008 01/06/2008Phase 3Phase 3

Miranda PenhaligonMiranda PenhaligonArchimedes Pharmaceuticals Archimedes Pharmaceuticals

ConclusionConclusion

BTP is a common, disabling feature of malignant BTP is a common, disabling feature of malignant disease and other illnessesdisease and other illnesses– There are 3 subtypes of BTP (incident, idiopathic, and There are 3 subtypes of BTP (incident, idiopathic, and

end-of-dose)end-of-dose)– BTP is assessed and managed separately from BTP is assessed and managed separately from

chronic baseline painchronic baseline pain

Consider pharmacologic and nonConsider pharmacologic and non- - pharmacologic utilitiespharmacologic utilitiesAppropriate assessment , planning, and patient Appropriate assessment , planning, and patient education can reduce the frequency and severity education can reduce the frequency and severity of BTP in most patients of BTP in most patients