Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942007000100003
Brazilian Journal of Anesthesiology
Scientific Article

Avaliação da S(+) cetamina por via oral associada à morfina no tratamento da dor oncológica

Assessment of oral S(+) ketamine associated with morphine for the treatment of oncologic pain

Pedro Ishizuka; João Batista Santos Garcia; Rioko Kimiko Sakata; Adriana Machado Issy; Sílvia Letícia Mülich

http://dx.doi.org/10.1590/S0034-70942007000100003 Braz J Anesthesiol, vol.57, n1, p.19-31, 2007
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Resumo

JUSTIFICATIVA E OBJETIVOS: A morfina é muito usada para o alívio da dor oncológica. Entretanto, pode ocorrer tolerância com seu uso prolongado. A associação de antagonista de receptores NMDA pode diminuir ou retardar esse fenômeno. A S(+) cetamina parece ser mais potente e com menos efeitos colaterais. O objetivo deste estudo foi avaliar a ação da S(+) cetamina associada à morfina no tratamento da dor oncológica. MÉTODO: Foram avaliados, de forma duplamente encoberta, 30 pacientes divididos em dois grupos. Os do G1 receberam 10 mg de morfina a cada seis horas, associada a 10 mg de S(+) cetamina a cada oito horas, por via oral. Os do G2 receberam 10 mg de morfina a cada seis horas, associada ao placebo a cada oito horas, por via oral. A dose de morfina foi aumentada em 5 mg, quando necessário. A intensidade da dor foi avaliada por meio de escala verbal. RESULTADOS: A porcentagem de dor ausente e leve foi semelhante nos grupos (G1 = 0 e G2 = 0 no M0; G1 = 22,2 e G2 = 53,8 no M1; G1 = 22,2 e G2 = 61,5 no M2; G1 = 44,6 e G2 = 61,5 no M3; e G1 = 44,5 e G2 = 53,8 no M4); teste do Qui-quadrado. Foi observada porcentagem de alívio moderado e completo semelhante nos grupos (G1 = 33,4 e G2 = 53,9 após uma semana; G1 = 44,4 e G2 = 69,2 após duas semanas; G1 = 66,6 e G2 = 69,2 após três semanas; G1 = 55,6 e G2 = 53,9 após quatro semanas); teste do Qui-quadrado. A necessidade de aumento da dose de morfina foi semelhante nos dois grupos (G1 = 2,22 e G2 = 2,15), teste de Mann-Whitney. CONCLUSÕES: Não foi observado aumento do efeito analgésico com 10 mg de S (+) cetamina, administrada a cada oito horas por via oral associada à morfina no tratamento da dor oncológica.

Palavras-chave

ANALGÉSICOS, Opióides, cetamina, DOR, Oncológica

Abstract

BACKGROUND AND OBJECTIVES: Morphine is used frequently to treat oncologic pain. However, tolerance may develop with prolonged use. The association of a NMDA receptor antagonist may reduce or delay the onset of tolerance. S(+) ketamine seems to be more potent and with fewer side effects. The aim of this study was to evaluate the association of S(+) ketamine and morphine in the treatment of oncologic pain. METHODS: Thirty patients, randomly divided in two groups, participated in this double-blind study. Patients in G1 received 10 mg of morphine PO every 6 hours and 10 mg of S(+) ketamine PO every 8 hours. Patients in G2 received 10 mg of morphine PO every 6 hours and placebo PO every 8 hours. The dose of morphine was adjusted by 5 mg increments whenever necessary. Pain severity was evaluated through a verbal scale. RESULTS: The percentage of no pain and mild pain was similar in both groups (G1 = 0 and G2 = 0 at M0; G1 = 22.2 and G2 = 53.8 at M1; G1 = 22.2 and G2 = 61.5 at M2; G1 = 44.6 and G2 = 61.5 at M3; and G1 = 44.5 and G2 = 53.8 at M4); Chi-square test. The percentage of moderate relief and complete relief was similar in both groups (G1 = 33.4 and G2 = 53.9 after one week; G1 = 44.4 and G2 = 69.2 after two weeks; G1 = 66.6 and G2 = 69.2 after three weeks; and G1 = 55.6 and G2 = 53.9 after four weeks); Chi-square test. The need to increase the dose of morphine was also similar in both groups (G1 = 2.22 and G2 = 2.15); Mann-Whitney test. CONCLUSIONS: We did not observe an increase on the analgesic effects of morphine with the association of 10 mg of S(+) ketamine PO in the treatment of oncologic pain.

Keywords

ANALGESICS, Opioids, ketamine, PAIN, oncologic

References

Chiu TY, Hu WY, Chen CY. Prevalence and severity of symptoms in terminal cancer patients: a study in Taiwan. Support Care Cancer. 2000;8:311-313.

Meuser T, Pietruck C, Radbruch L. Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain. 2001;93:247-257.

Vainio A, Auvinen A. Prevalence of symptoms among patients with advanced cancer: an international collaborative study. Symptom Prevalence Group. J Pain Symptom Manage. 1996;12:3-10.

Soares LGL. Dor em Pacientes com Câncer. Dor. 2003:285-297.

Patt RB. A new mandate for the anesthesiologist cancer pain specialist: expertise in prescribing analgesics. .

Portenoy RK. Practical Aspects of Pain Control in the Patient with Cancer. Pain Control in the Patient with Cancer. 1989:7-32.

Grisel JE, Watkins LR, Maier SF. Associative and non-associative mechanisms of morphine analgesic tolerance are neurochemically distinct in the rat spinal cord. Psychopharmacology. 1996;128:248-255.

Guignard B, Bossard AE, Coste C. Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology. 2000;93:409-417.

Mao J, Price DD, Mayer DJ. Mechanisms of hyperalgesia and morphine tolerance: a current view of their possible interactions. Pain. 1995;62:259-274.

Laulin JP, Celerier E, Larcher A. Opiate tolerance to daily heroin administration: an apparent phenomenon associated with enhanced pain sensitivity. Neuroscience. 1999;89:631-636.

Coderre TJ, Katz J, Vaccarino AL. Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence. Pain. 1993;52:259-285.

Millan MJ. The induction of pain: an integrative review. Prog Neurobiol. 1999;57:1-164.

Celerier E, Rivat C, Jun Y. Long-lasting hiperalgesia induced by fentanyl in rats: preventive effect of ketamine. Anesthesiology. 2000;92:465-472.

Hoffmann V, Coppejans H, Vercauteren M. Successful treatment of postherpetic neuralgia with oral ketamine. Clin J Pain. 1994;10:240-242.

Fine PG. Low-dose ketamine in the management of opioid nonresponsive terminal cancer pain. J Pain Symptom Manage. 1999;17:296-300.

Yamakura T, Sakimura K, Shimoji K. The stereoselective effects of ketamine isomers on heteromeric N-methyl-D-aspartate receptor channels. Anesth Analg. 2000;91:225-229.

Yang CY, Wong CS, Chang JY. Intrathecal ketamine reduces morphine requirements in patients with terminal cancer pain. Can J Anaesth. 1996;43:379-383.

Kannan TR, Saxena A, Bhatnagar S. Oral ketamine as an adjuvant to oral morphine for neuropathic pain in cancer patients. J Pain Symptom Manage. 2002;23:60-65.

Longo DL. Distúrbios Neoplásicos. Medicina Interna. 2002:521-528.

I Consenso Nacional de Dor Oncológica. Sociedade Brasileira para Estudo da Dor (SBED). 2002.

Grond S, Zech D, Diefenbach C. Assessment of cancer pain: a prospective evaluation in 2266 cancer patients referred to a pain service. Pain. 1996;64:107-114.

Portenoy RK, Miransky J, Thaler HT. Pain in ambulatory patients with lung or colon cancer. Prevalence, characteristics and effect. Cancer. 1992;70:1616-1624.

Portenoy RK, Lesage . Management of cancer pain. Lancet. 1999;353:1695 -1700.

Cleeland CS, Gonin R, Hatfield AK. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994;330:592-596.

Pimenta CAM, Koizumi MS, Teixeira MJ. Dor no doente com câncer: características e controle. Rev Bras Cancerol. 1997;1:21-44.

Mercadante S. Costs are a further barrier to cancer pain management. J Pain Symptom Manage. 1999;18:3-4.

Savage SR. Long-term opioid therapy: assessment of consequences and risks. J Pain Symptom Manage. 1996;11:274-286.

Vanderah TW, Suenaga NM, Ossipov MH. Tonic descending facilitation from the rostral ventromedial medulla mediates opioid-induced abnormal pain and antinociceptive tolerance. J Neurosci. 2001;21:279-286.

Kissin I, Bright CA, Bradley EL Jr. The effect of ketamine on opioid-induced acute tolerance: can it explain reduction of opioid consumption with ketamine-opioid analgesic combinations?. . 2000;91:1483-1488.

Mercadante S. Ketamine in cancer pain: an update. Palliat Med. 1996;10:225-230.

Grant IS, Nimmo WS, Clements JA. Pharmacokinetics and analgesic effects of i.m. and oral ketamine. Br J Anaesth. 1981;53:805-810.

Enarson MC. Hays H, Woodroffe MA - Clinical experience with oral ketamine. J Pain Symptom Manage. 1999;17:384-386.

Raeder JC, Stenseth LB. Ketamine: a new look to an old drug. Curr Opin Anaesthesiol. 2000;13:463-468.

Fisher K, Hagen NA. Analgesic effect of oral ketamine in chronic neuropathic pain of spinal origin: a case report. J Pain Symptom Manage. 1999;18:61-66.

Kuiken SD, van den Berg SJ, Tytgat GN. Oral S(+)-ketamine does not change visceral perception in health. Dig Dis Sci. 2004;49:1745-1751.

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