Objective of study: A systematic review to develop evidenced based guidelines for severe or crescendo cancer pain. Titration studies reviewed involved planned escalation at fixed or variable dosing intervals and/or titration by loading dose followed by maintenance.
Method: Published studies of opioid dose titration were accessed by Pub Med, Ovid Med and the Cochrane Reviews. Articles were classified as Class A (randomized controlled) Class B (Cohort) Class C (non-randomized) Class D (case series or cross-sectional). A grading scale (Institute for Clinical System) for strength of evidence for guideline development was used. Pretitration opioid, dosing strategy, method assessment schedule, time to analgesia, side effects and patient demographics were obtained.
Results: Nine trials were identified. One was retrospective, 6 single-arm trials (Class D) and 2 randomized (Class A). Patient characteristics, trial design, pain scales, timing of assessment and outcome measures were widely variable. Time to relief were: 10-90 minutes by IV titration, 5-24 hours by PCA, 6 hours by every 2-hour and 24-48 hours by every 4 hour oral dosing. No respiratory depression was reported. Grade III (I -IV) evidence is available to support dosing guidelines.
Conclusions: This systematic review of opioid titration for acute cancer pain failed to find supporting evidence for dose titration guidelines.