Intravenous methadone for cancer pain unrelieved by morphine and hydromorphone: clinical observations.

Methadone is a very effective second-line opioid for treatment of cancer pain. However, the starting doses of methadone indicated on opioid conversion charts may over-estimate the dose of intravenous (i.v.) methadone needed. In this report, we describe four patients with cancer-related pain treated with continuous i.v. morphine and hydromorphone. Because of persistent pain and opioid side effects limiting increases in opioid dose, each patient was switched to i.v. methadone. All four patients had excellent pain relief without significant side effects at a dose that, according to the available conversion charts, was approximately 3% of the calculated equianalgesic dose of hydromorphone. When converting from continuous i.v. hydromorphone to continuous i.v. methadone, much lower doses than those suggested by the opioid conversion charts should be used as starting doses.

High-dose epidural infusion of opioids for cancer pain: cost issues.

The safety and efficacy of intraspinal opioids as therapy for selected patients with cancer pain are well-established. The choice of the appropriate drug is influenced by many variables that are to date incompletely elucidated. The cost of therapy is an increasingly important component of decision-making. This report describes the management of a patient who achieved excellent pain control with the administration of epidural sufentanil and bupivacaine. Daily Average Wholesale Price for sufentanil was, however, $698. Until the data comparing the efficacy of different epidurally administered opioids in the treatment of cancer pain are available, we suggest that treatment with more costly opioids be reserved for patients for whom analgesia cannot be achieved after maximizing epidural morphine analgesia with aggressive side-effect management.

Combined administration of opioids with selected drugs to manage pain and other cancer symptoms: initial safety screening for compatibility.

Cancer patients suffer multiple symptoms and require numerous drug therapies. Parenteral administration of multiple medications from a single container can simplify drug regimens for patient self-administration. This simplification reduces drug preparation costs and risk of infection. Therapeutic options are limited by the lack of published information on the compatibility of opioids and adjuvant drugs. We report the results of a study evaluating the physical compatibility of injectable opioids with selected drugs for pain and symptom management. Fentanyl citrate, hydromorphone hydrochloride, methadone hydrochloride, and morphine sulfate solutions were physically compatible with 14 of 15 supportive care drugs tested through visual examination using a high intensity light beam and through measured examination using a turbidimeter over a range of times up to 48 hr. Phenytoin sodium was the only drug found to be incompatible with all opioid solutions tested. This compatibility information will assist clinicians in selecting the most efficient, safe, and cost-effective supportive care drug regimen.

Inappropriate use of naloxone in cancer patients with pain.

Opioid overdose is rarely the primary cause of altered mental status in cancer patients receiving opioid therapy. The inappropriate administration of naloxone to reverse an abnormal mental status can cause severe withdrawal symptoms and pain. To illustrate this problem, we report the case of a patient inappropriately treated with naloxone and the results of a retrospective review of the medical records of 15 consecutive patients with cancer treated with naloxone in the emergency department over a 5-month period. We offer guidelines for a more thoughtful approach to the management of patients with cancer who present with encephalopathy.

Treatment of cyclophosphamide-induced hemorrhagic cystitis with prostaglandins.

OBJECTIVE: To report a case of cyclophosphamide-induced hemorrhagic cystitis, discuss prevention, and review treatment options, particularly the use of intravesicular prostaglandins. DATA SOURCES: Literature obtained through a computerized search, with subsequent bibliography scanning. Information on the individual case was obtained from the patient's medical record and the Pharmacy Clinical Research Specialist. CASE SUMMARY: A 29-year-old woman who had a postallogeneic bone marrow transplantation was hospitalized because of graft-versus-host disease. During hospitalization, she developed a cyclophosphamide-induced hematuria that, despite hydration and transfusions of blood products, progressed to refractory hemorrhagic cystitis. A response was prompted ultimately by a regimen consisting of continuous bladder irrigation and intermittent intravesical instillation of carboprost. DISCUSSION: The best treatment for hemorrhagic cystitis remains prevention. Therapies for established cystitis are varied; the choice depends on the degree of hematuria present. Therapies are often temporary or ineffective, and themselves cause significant morbidity. One promising treatment option involves the intravesicular administration of prostaglandins. Reports in the literature discuss a variety of products, dosages, and treatment schedules that have been used with some success. The available data on this technique are presented. CONCLUSIONS: Prostaglandins appear to be effective in resolving established hemorrhagic cystitis; however, their place in therapy remains unclear. Before this class can be employed routinely, several basic issues remain. These include optimal dosage, dosing schedule, duration of treatment, and comparative efficacy with other agents.

Evaluation of air quality in a sterile-drug preparation area with an electronic particle counter.

The air quality in a sterile-drug preparation area was assessed with an electronic particle counter. The numbers of airborne particles of > or = 0.5 and > 5 microns in a hospital i.v. room were determined. Initially, a total of seven sampling sites were designated; the four locations and four times with the highest concentrations of particles were analyzed. To determine the classification of the cleanroom, as described in Federal Standard 209E (FS209E), four equally spaced locations in the room were examined on one day. According to FS209E, the average concentration of particles in samples obtained at each of four locations uniformly spaced in a room must be < or = 100,000 per cubic foot of sampled air for particles of > or = 0.5 micron in order for a room to qualify as a Class 100,000 cleanroom. Throughout the seven-day initial study, all measurements of particles of > or = 0.5 micron except one yielded counts of < 100,000/cu ft. The four highest average particle concentrations were recorded at 1000, 1100, 1400, and 1500. Although measurement of particles of > 5 microns was not necessary, the measurements of these particles showed that their concentrations were highly dependent on staff activity. The average particle concentration at the four equally spaced locations was < 36,000/cu ft. At the four locations, the mean of the average concentrations was 29,664 particles per cubic foot. The upper limit of the 95% confidence interval for particle concentration at the four locations was 35,896/cu ft.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of disk approximation and agar dilution induction tests for demonstration of in vitro antagonism of cefotaxime by cefoxitin in Enterobacter species.

Cefoxitin-resistant clinical isolates of Enterobacter spp. demonstrated inducible beta-lactamase activity in 31 of 47 (65.9%) disk approximation tests and in 32 of 52 (63.5%) agar dilution induction tests. Agreement between the two results was only 72.3%, and 80.9% of the strains were positive in at least one induction test. Lack of valid interpretive criteria preclude their routine use in the clinical laboratory.