title: A network meta-analysis of the efficacy of opioid analgesics for the management of breakthrough cancer pain episodes.
abstract: BACKGROUND
  With many medications available for the management of breakthrough cancer pain (BTCP), physicians may require additional guidance in selecting an appropriate medication to suit an individual patient's needs.
  
  
  OBJECTIVE
  To identify all the evidence and assess the relative clinical value of currently approved BTCP medications.
  
  
  METHODS
  Following a systematic literature search (2007-2010), the results of 10 randomized controlled trials investigating the effects of BTCP medications (intranasal fentanyl spray [INFS], fentanyl pectin nasal spray, fentanyl sublingual tablets, fentanyl buccal soluble film, fentanyl buccal tablets, oral transmucosal fentanyl citrate, and morphine sulfate immediate release) were synthesized using a network meta-analysis. The main outcome was pain intensity difference (PID) relative to placebo up to 60 minutes after the intake of medication.
  
  
  RESULTS
  INFS, fentanyl pectin nasal spray, fentanyl buccal tablet, and oral transmucosal fentanyl citrate showed greater PIDs relative to placebo than other BTCP medications 15 minutes after intake. All other medications showed greater PIDs relative to placebo at 30 minutes, except morphine sulfate immediate release, which did not show efficacy over placebo until 45 minutes. Only INFS produced clinically meaningful pain relief (absolute PID ≥2) at 15 minutes.
  
  
  CONCLUSIONS
  From current evidence, although all BTCP medications provided pain relief within the time frames assessed, transmucosal fentanyl medications achieved a greater level of pain relief in a shorter time frame than placebo or oral morphine.
authors: St. Clare Hospice, Hastingwood, Essex, United Kingdom. Electronic address: john.zeppetella@stclarehospice.org.uk.
authors: Giovambattista
authors: G
authors: Zeppetella
authors: St. Luke's Cancer Centre, The Royal Surrey County Hospital, Guildford, Surrey, United Kingdom.
authors: Andrew
authors: A
authors: Davies
authors: Mapi, Houten, The Netherlands.
authors: Indra
authors: I
authors: Eijgelshoven
authors: Mapi, Boston, Massachusetts, USA; Tufts University School of Medicine, Boston, Massachusetts, USA.
authors: Jeroen P
authors: JP
authors: Jansen
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use*; D059390:Breakthrough Pain / Q000188:drug therapy* / Q000503:physiopathology*; D006801:Humans; D009369:Neoplasms / Q000503:physiopathology*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000701:Analgesics, Opioid
keywords: Analgesia; breakthrough cancer pain; fentanyl; morphine; network meta-analysis; randomized controlled trial