Zeppetella, G., Davies, A., Eijgelshoven, I., & Jansen, J.P. (2014). A network meta-analysis of the efficacy of opioid analgesics for the management of breakthrough cancer pain episodes. Journal of Pain and Symptom Management, 47,  772–785.e5. 

DOI Link

Purpose

STUDY PURPOSE: To identify the relative value of current approved medications for breakthrough pain

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

DATABASES USED:  MEDLINE, EMBASE, and BIOSIS; data from a previous systematic review was incorporated into this review
 
KEYWORDS: Detailed search criteria are provided
 
INCLUSION CRITERIA: Randomized, controlled trials of the management of breakthrough pain that would allow the comparison of intranasal and all types of transmucosal opioids as well as short-acting oral opioids; adult patients with cancer treated with opioids for background pain; key outcome variable was pain intensity difference (PID) at the start of a breakthrough episode and a specified time point after taking the medication 
 
EXCLUSION CRITERIA: None specified

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 210
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Used the Jadad scale for risk of bias

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 10
  • TOTAL PATIENTS INCLUDED IN REVIEW = 892
  • SAMPLE RANGE ACROSS STUDIES: 66–139 patients
  • KEY SAMPLE CHARACTERISTICS: None specified

Phase of Care and Clinical Applications

APPLICATIONS: Palliative care

Results

Intranasal fentanyl spray (INFS), fentanyl pectin nasal spray, fentanyl buccal soluble film, fentanyl sublingual tablets, fentanyl buccal tablets, oral transmucosal fentanyl citrate, and immediate-release morphine sulfate were all superior to a placebo. All medications other than morphine sulfate were superior at 15 minutes, and INFS provided the greatest effect in this timeframe. There was evidence that INFS was most effective compared to others at five minutes. However, these data were of lower quality. Overall, the studies were of high quality.

Conclusions

All of the current approved medications for breakthrough pain were effective. Transmucosal agents and INFS were effective more quickly than immediate-release oral morphine.

Limitations

None identified

Nursing Implications

The findings of this meta-analysis suggest that transmucosal and intranasal medication for breakthrough pain are effective more rapidly than immediate-release oral morphine. These should be considered for the management of breakthrough pain, according to patient tolerance and preferences. INFS could be considered the treatment of choice for patients with rapid-onset and short-duration breakthrough pain.

Legacy ID

5182