Professor and Chair
Dept. of Special Anaesthesia and Pain Therapy
Medical University / AKH Vienna
Vienna, Austria
Since 1993, Hans G. Kress is Professor of Anaesthesiology, Intensive Care and Pain Medicine and Head of the Department of Special Anaesthesia and Pain Therapy at the Medical University/AKH Vienna, Austria. He is certified by the Austrian and the German Board of Physicians, with added qualifications in pain management, critical care medicine, emergency medicine and pre-hospital care.
Professor Kress is President of the European Pain Federation EFIC. He was founding chairman of the Task Force on Pain Management for the Austrian Society of Anaesthesiology, Resuscitation and Intensive Care Medicine, co-founder and executive board member of the Austrian Society for Palliative Care, and Past-President of the Austrian Pain Society, where he is a member of the executive board.
Professor Kress is deputy editor and associate editor of the European Journal of Pain and former co-editor of Acute Pain. He has authored numerous scientific articles, books and book chapters. His multiple clinical and experimental research interests include pharmacological treatment of acute and chronic pain, invasive pain therapy and neuromodulation in cancer and non-cancer patients, as well as neuro- and immunopharmacology of anaesthetics, analgesics and cannabinoids.
New Pharmacological Options for Cancer Pain Management
Abstract
Pain occurs in 50-70% of patients under anticancer therapy and up to 80% with advanced cancer. If unrelieved, it has a disruptive impact on cancer patients. “Cancer pain” is not an entity, but typically presents a complex syndrome of acute and chronic pain types, including breakthrough cancer pain (BTcP). The assessment of individual nature, site and mechanism of these separate pains is essential for their effective treatment with invasive and/or non-invasive options.
Available drugs:
The WHO analgesic ladder using non-opioids, opioids, and adjuvant analgesics remains the mainstay of cancer pain management. Morphine is still considered the gold standard opioid for cancer pain. Newer µ-opioid receptor agonists (MOR) like fentanyl, buprenorphine, hydromorphone, and oxycodone have been developed, targeting an improved efficacy and safety profile compared to morphine. The development of transdermal delivery systems for fentanyl or buprenorphine (opioid patches) for continuous, convenient treatment, and matrix patch technologies have further advanced cancer pain management.
New pharmacological options:
Several new application systems allow oromucosal, intranasal or buccal administration of fentanyl. These rapid-onset formulations provide fast and effective pain relief, and reduce the negative impact of BTcP on daily life.
The innovative centrally-acting analgesic tapentadol (Nucynta®, Palexia®) represents a new class of strong analgesics with 2 simultaneous mechanisms of action in one molecule, μ-opioid receptor agonism (MOR) and noradrenaline reuptake inhibition (NRI). In registration studies of several thousand patients, tapentadol prolonged release (PR=ER in US; 50-250 mg bid) has been shown to be effective and well tolerated for the management of moderate to severe, chronic non-cancer pain, with comparable efficacy but significantly superior gastrointestinal tolerability to oxycodone controlled release (CR) for moderate to severe, chronic osteoarthritis and low back pain. A now completed multicenter, placebo- and active-controlled, double-blind, phase 3 study compared the efficacy and tolerability of the MOR-NRI tapentadol PR (100-250 mg bid) for the management of moderate to severe, chronic cancer pain with placebo and morphine sulfate CR (40-100 mg bid). Based on responder rates at the end of titration, tapentadol PR was non-inferior to morphine CR. During titration, incidences of treatment-emergent adverse events (TEAEs) were 50.0% (169/338) with tapentadol PR and 63.9% (101/158) with morphine CR; incidences of nausea, vomiting, and dry mouth were lower with tapentadol PR than with morphine CR. Results of 4 week maintenance indicate that tapentadol PR is effective compared with placebo for managing moderate to severe, chronic cancer pain. Based on results obtained during titration, tapentadol PR provides comparable efficacy to that of morphine sulfate CR (40-100 mg bid) but is associated with significantly better gastrointestinal tolerability.
