title: Intravenous versus subcutaneous morphine titration in patients with persisting exacerbation of cancer pain.
abstract: BACKGROUND
  Patients with cancer pain with initially adequate analgesia under oral sustained-release opioid medication may suffer from persisting pain exacerbations. Sometimes even fast help is needed and then optimally performed by intravenous application (IVA) of immediate-release (IR) opioids. This IVA, however, may only be performed by physicians in Germany.
  
  
  OBJECTIVE
  We wanted to find out if subcutaneous application of IR-opioids might be an adequate alternative to IVA in persisting pain exacerbations of patients with cancer pain because this could be performed by the nursing staff in Germany as well.
  
  
  METHODS
  An open randomized controlled trial was used to compare intravenous versus subcutaneous morphine titration in persisting pain exacerbations in patients with cancer pain.
  
  
  METHODS
  Thirty-nine patients with cancer (21 intravenously, 18 subcutaneously) of the pain management department of the university hospital of Cologne, Germany were included into the study.
  
  
  METHODS
  Calculated from preexisting analgesic medication boli of morphine were given every 5 minutes (intravenously) or 30 minutes (subcutaneously) up to adequate analgesia or intolerable side effects. Pain intensity, nausea, sedation, and some vital parameters were documented before the start, after each application and at the end of titration.
  
  
  RESULTS
  Thirty-five patients were pretreated with oral opioids, 4 patients with nonopioid analgesics. Six patients stopped titration because of intolerable side effects (sedation, vomiting). Thirty patients (77%) reported at least sufficient pain reduction, 3 patients were free of pain (intravenously). Mean pain intensity decreased on a visual analogue scale (VAS, 0-100) from 83 to 32 (intravenously) and from 68 to 42 (subcutaneously). Morphine doses ranged from 4 mg to 32 mg (intravenously; mean, 18.5 +/- 9.2 mg) and from 10 mg to 200 mg (subcutaneously mean, 57.9 +/- 59.6 mg). Mean time up to adequate analgesia was 53 (intravenously) 77 min (subcutaneously), respectively. There was no change in vital parameters but an increase of sedation in both groups. The adaptation of the continuous analgesic medication resulted in a stable and lasting pain relief after 4 days in both groups.
  
  
  CONCLUSIONS
  Intravenous and subcutaneous-morphine titration are adequate to antagonize persisting pain exacerbations in cancer pain patients quickly and to adapt the continuous opioid analgesic medication.
authors.affiliation: Department of Palliative Medicine, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany. felsner@ukaachen.de
authors.forename: F
authors.initials: F
authors.lastname: Elsner
authors.forename: L
authors.initials: L
authors.lastname: Radbruch
authors.forename: G
authors.initials: G
authors.lastname: Loick
authors.forename: J
authors.initials: J
authors.lastname: Gaertner
authors.forename: R
authors.initials: R
authors.lastname: Sabatowski
mesh_terms: D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D002908:Chronic Disease; D005260:Female; D005858:Germany; D006801:Humans; D007262:Infusions, Intravenous; D007279:Injections, Subcutaneous; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage*; D009369:Neoplasms / Q000150:complications / Q000503:physiopathology*; D010148:Intractable Pain / Q000188:drug therapy*
chemical_list: D000701:Analgesics, Opioid; D009020:Morphine