Karimian Parisa, Atayee Rabia S, Ajayi Toluwalase A, Edmonds Kyle P
1 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego , La Jolla, California.
2 Doris A. Howell Palliative Care Service, University of California San Diego , La Jolla, California.
J Palliat Med. 2017 Dec;20(12):1385-1388. doi: 10.1089/jpm.2017.0089. Epub 2017 Jun 13.
Many factors make methadone an appealing option for treatment of pain in patients seen by palliative care; however, complex drug-related properties and variable patient response complicate appropriate conversion ratios from other opioids to methadone. Currently, there is no consensus regarding one accepted conversion method.
Current patterns of prescribing for clinicians at a three-hospital academic health system on initial rotation to methadone for the management of pain were compared with a series of consensus recommendations for methadone dose calculation.
Retrospective chart review of 98 hospital patients. Settings/Participants: Adult subjects hospitalized in an academic medical center between January 1, 2013, and January 1, 2015, who were initiated on oral methadone for pain during the same admission.
Final target daily dose of methadone was calculated using End of Life/Palliative Education Resource Center (EPERC) and Friedman conversion methods based on opioids provided in the prior 24 hours. This was then compared with actual dosing as ordered by clinicians and received by the patient.
Average range of final daily methadone dose for new starts was 18.1 ± 16.7 mg. Final methadone dose as received by two-thirds of patients was below the dosing target calculated by EPERC and Friedman guidelines by an average of 35 mg. In addition, more than 80% of patients' final methadone doses fell below the range recommended by these two methods. No patients received opioid reversal agents during their index hospitalization.
These findings may question the best approach to clinical application of EPERC and Friedman methods and call for more research to determine the safest, lowest, and most effective methadone target dosing selection. Final methadone dosing as received by patients compared favorably with a conservative methadone dosing method that recommends starting doses no higher than 30-40 mg per day.
许多因素使美沙酮成为姑息治疗患者疼痛的一个有吸引力的选择；然而，复杂的药物相关特性和患者反应的变异性使从其他阿片类药物到美沙酮的适当转换比率变得复杂。目前，对于一种公认的转换方法尚无共识。
将一个三院学术医疗系统中临床医生在初次轮转使用美沙酮治疗疼痛时的当前处方模式，与一系列美沙酮剂量计算的共识建议进行比较。
对98例住院患者进行回顾性病历审查。设置/参与者：2013年1月1日至2015年1月1日期间在一所学术医疗中心住院的成年受试者，他们在同一住院期间开始口服美沙酮治疗疼痛。
根据生命终末期/姑息治疗教育资源中心（EPERC）和弗里德曼转换方法，基于前24小时提供的阿片类药物计算美沙酮的最终目标每日剂量。然后将其与临床医生开出并由患者接受的实际剂量进行比较。
新开始使用美沙酮的患者最终每日剂量的平均范围为18.1±16.7毫克。三分之二患者接受的美沙酮最终剂量低于EPERC和弗里德曼指南计算的给药目标，平均低35毫克。此外，超过80%患者的美沙酮最终剂量低于这两种方法推荐的范围。在其索引住院期间，没有患者接受阿片类逆转剂。
这些发现可能会质疑EPERC和弗里德曼方法临床应用的最佳方法，并呼吁进行更多研究以确定最安全、最低和最有效的美沙酮目标剂量选择。患者接受的美沙酮最终剂量与推荐起始剂量不高于每天30 - 40毫克的保守美沙酮给药方法相比具有优势。
