TORADOL (ketorolac) linked to Recurrence Prevention
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I was going to delete my doc letter from some time ago and substitute the above post about Falleaves letter. I apparently revised my letter some time ago. Fuzzy memory, but seems to me I did it after rainnyc posted about revising it before her doc visit.
The info in mine is different than the info in Falls. Opting to put the two together. Here's the link for anyone trying to find it.
https://community.breastcancer.org/forum/73/topics/833612?page=7#post_4496841
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Peace, I went and started pulling info on TIVA. Total IV Anesthesia. As I stated in earlier posts. while not familiar with the TIVA term. It's just saying the all meds are delivered through a control device. TIVA while indicated that meds were all delivered by a device versus hand push, total iv use of drugs has been done back to the 1800's. My experience with it has been since the 70's.Think of the way it's used. TIVA---all drugs delivered by device versus tiva-- just means no gas was used. Think of it as Big T--little t.
Basically, it's accomplishable and not sure why the doc would say it's expensive. The drugs used are common to the OR situation. Diprivan( propofol), and Sufentanil(stronger form of fentanyl). Diprivan(1980's) has to have a control device for delivery and always has. But that's been managed for decades. Sufentanil(1970's) has been used for decades as an IV push med, but can be delivered by a device.
http://www.ebme.co.uk/articles/clinical-engineering/95-total-intravenous-anaesthesia-tiva
Remifentanil a opiod as mentioned in the article, I have no familiarity with. But Falleaves may be able to jump in b/c of her extensive work in the opiod area.
Since the focus of the research on opiods is that it may impact recurrence, then it would seem asking for this drug to be limited too makes sense. I'll use remifentanil as a keyword with BC and see what it pulls.
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Tetonic Hi, met you on your thread. Falls did a thread two years ago now almost. I missed hers, but went looking for her when I started this thread. She and 123JustMe have become the trio.
Need to shout out Geewhiz................HOOTIeHOOoooo
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Techtonic, Now their both prophylactic. You have time to study and develop a plan.
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I'm new to this thread and scheduled for UMX with TEs on Jan. 13, so trying to get through all the posts here. I'm confused about some of the terminology - opioids is a general term but then specific drugs are often mentioned and I'm not sure which are opioids to be avoided and which ones are not. Could someone post a list of the drugs and how they are classified? And also what they are used for (postoperative pain, anesthetic used during surgery, etc. Thanks!
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Sorry the table is not very clear. Brand names is in parenthesis.
Morphine (Roxanol, MS Contin, Oramorph, Kadian)
Fetanyl (Sublimaze, Duragesics)
Hydromorphone (Dilaudid)
Oxycodone (Roxicodone, Oxy IR, also found in Percocet, Percodan, Tylox)
Meperidine (Demerol)
Codeine (can be found in Tylenol #2, Tylenol #3, and Tylenol #4)
Tramadol (Ultram)
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List of NSAIDS (non-steroidal anti-inflammatory drugs)
The one mentioned in the studies is ketorolac (Toradol)
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Loverly, well that's nice. Great lists.
Hi Grammy, Falleaves will likely be along. She's the resident expert on the opiod studies and relationship to recurrence. Maybe not tonight LOL. But soon. I'll send her a PM.
Here's her list of threads. She's been a busy woman. More studying. It'll be like you were back in college.
Links to BCO threads that are related to this topic:
Topic: Paravertebral Nerve Block and Propofol Sept. 2015, by Falleaves
https://community.breastcancer.org/forum/73/topic/834546?page=1#idx_15
Topic: Effects of opioids on cancer progression Sept. 2015, by Falleaves
https://community.breastcancer.org/forum/73/topic/835291?page=1#idx_
Topic: ketorolac to reduce recurrence Mar. 2014, by Falleaves
https://community.breastcancer.org/forum/91/topic/818961?page=1#post_3936891
Topic: Anesthesia and recurrence of cancer Sept. 2015, by Fallleaves
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Done......Pm'd Falls.
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Hi Grammy3x, I looked for a comprehensive review of various opioids and their effects on immunity and cancer, but couldn't find anything. Here's a pretty extensive general overview of different opioids, though: ( http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3555047/)
Most of the opioid studies are on morphine, which is still the heavy hitter, used during surgery and for postsurgical and chronic pain management. The studies indicate that morphine is immunosuppressive, but have shown conflicting results regarding morphine's effect on tumor growth and metastasis. Of the many synthetic opioids, fentanyl seems to be the most studied, along with the much stronger sufentanil, both of which are used during surgery and for postsurgical and chronic pain relief. They have also been shown to be immunosuppressive (http://www.ncbi.nlm.nih.gov/pubmed/15249732), although I did find one study that showed fentanyl promoted NK cell cytoxicity (http://journals.lww.com/anesthesia-analgesia/Abstr...). I also ran across this study, which indicated that fentanyl used for postoperative analgesia in mastectomy patients promoted factors associated with metastasis and recurrence, but that the effects were greatly diminished by the addition of a NSAID called flurbiprofen. (http://onlinelibrary.wiley.com/doi/10.1111/papr.12...) (Honestly, every time I read flurbiprofen, I think of flubber....)
The synthetic opioids I have read positive things about are Tramadol and buprenorphine. Tramadol may actually stimulate NK cell activity and prevent metastasis. (Discussed in the opioids section of this paper:http://bja.oxfordjournals.org/content/105/2/106.fu...) In a rat model buprenorphine was able to prevent the surgical stress response (which decreases NK cell activity and promotes tumor metastasis), while fentanyl and morphine did not (http://www.ncbi.nlm.nih.gov/pubmed/17291715).
Happy New Year everybody!
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Hi Solfeo, great to see you on here! Sorry you had an injury, but good on you for doing the yoga (looks like you are working all the angles to stay healthy!) Hope you heal up very soon, and your New Year is wonderful!
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The very first time? Oh nooo...that really sucks!
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SOLFEOOOOOOOOOOOOOoooooooooo. Yay doing good! Except for Yoga. Can empathize. Swimming's my trick. The stroke that works well for my spinal problems is --Backstroke. Every time I get in the routine something interferes. Like two falls a couple a weeks a part on first one shoulder, then the other. Wiped out months. Then decide I want to lengthen the pool year after 22 years of having a pool, I install solar pool heating. ChChing$$$. We have the most cloudy days EVER.
Seriously though Happy New Year.
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Been meaning to write a synopsis of what occurred since the beginning of this thread. Many were involved. The uniqueness can't be compared.
I found Dr Retsky's and Dr Forget's study's as a result of a statement on the Port thread. That statement from another member said NSAIDS should never be used around surgery time. Not faulting the member. I thought 'yes that is the prevailing thought'. When I read words like never or always they trigger a response. Pavlov conditioning. I went on a search. Came across Retsky's & Forget's research. Changed my world. Started the thread.
Fairly soon Stephmom--Stephy, Solfeo, geewhiz, PeaceStrength and Rainnyc joined. I did a search on BCO engine and found Falleaves had done a thread. Went looking for her. Coincident to that time 123Justme joined, energetic and thriving on research. Falls chimed in with her old thread and much new information. Falls, and 123JM have been a researchers dream as compatriots. And in the background, Is Loveroflife(Loverly).
What happened after that was the uniqueness. Solfeo, Rainny, Stephy were going for surgery. It became more than an esoteric discussion. Each was seeking to prevent recurrence. They read everything. Here. Everything that Falls had on the other Toradol thread. Everything Falls had gathered on opiod and block links.
Each tried to do it.
The risk was all the research is not proven. Each felt that they wanted to risk it. Toradol, no opiods, and blocks.
They're was much discussion early on about the risk of a bleed with Toradol as a NSAID. the literature showed that bleeding wasn't an absolute risk. The pediatric studies where bleeding was a critical risk in tonsillectomies showed that bleeding minimal and that an NSAID could be used safely i.e Ibuprofen. They're was a study on Reduction Mammoplasties that showed Toradol risk. Overall it determined there was some risk, but didn't contraindicated it's use.
Stephy was the first to have surgery. Low and behold she has a bleed. The origin of her bleed is undetermined. But it was intense time for all off us.
Two more seeking the same path and the first to go, has a bleed.
Rainnyc and Solfeo followed, but with concern. Each had uncomplicated paths.
If you look at the three's self reports it becomes a microcosm of the macro world of science. They covered the spectrum of the studies. I think all involved understand.
Falls, 123, and I linked all the studies in the topic boxes. Very busy topic boxes. They will be relevant for awhile i.e. a few years. But for anyone wanting to know, they have much to work with, that they don't have to seek on their own.
We were privileged to have Dr. Retsky and Dr Forget come here. Never has that happened on BCO that I know of. Thank you to both of them. Their effort in this area of research is continuing.
I contacted Dr. Retsky at the moment that I felt I had to seek counsel. He came within the hour. Bless him. He then brought Dr Forget here. They only were here briefly, but the door is open and I'm sure they are watching.
Solfeo had a question for Forget. Forget's response to Solfeo's question to me was perfect. But I had worked the OR, his response did cover everything. Solfeo was not convinced. It took me a bit to figure out why she had questions versus my concurrence. Her challenge of his response was perfect b/c she was the patient. She didn't have the insider's knowledge of the OR(operating room/anesthesia). Her questions were excellent, and should be considered by all patients.
Just this week I took a risk and posted on the Jan. 2016 Surgery thread. Have thought long and hard about what do we do with this informationthat we have gathered here. Ethical conundrum. Do we make those that haven't had surgery yet, aware they're may be a better way? Do we let them find their own way? Have felt guilt that time has lapsed and they're surgical groups, that could have been made aware.
Thankful, that all have contributed.
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Sassy - I'm from the Jan. 2016 surgery group and was not aware of any of this until you posted it, so thank you. I have since asked my surgeon for the PVB and she agreed. I also will talk to her by phone this week about non-narcotic alternatives to pain control. I think you should continue to post for every new month. I'm not totally convinced that morphine directly promotes cancer progression, but the side effects of opioates are enough to make me think that they should be used only if necessary for break-through pain.0 -
Sassy, very nice synopsis. I agree, there has been an amazing synergy on this thread. Also agree with Grandma3x that you should continue to post on the surgery group threads for each new month. Anesthesia is an afterthought for probably the majority of people going into surgery. Many people see their anesthesiologist for the first time right before they go into surgery, and then there's no choice offered. I still don't know what anesthesia I got. (All I know is what I asked NOT to get!) I think it is very valuable for people going into surgery to know they DO have choices, so they can discuss them with their doctors ahead of time.
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I agree with what Fallleaves just said. I only knew about this because the thread was so active in the couple of weeks before my surgery. Even armed with that information--and I am not in the medical field and even reading the medical articles was only able to form an imperfect understanding of the issues involved--it was very difficult to bring this to the attention of the surgeon and anesthesiologist, whom I met only minutes before the surgery. It needs to be linked to the first page of that very helpful thread about preparing for surgery. I was very grateful for this thread though I wasn't able to get everything I asked for. With reconstructive surgery coming up (I hope) once I heal from radiation, I know that I have at least one more surgery in my future.
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Sass, I ran across a small study comparing the impacts of IV morphine, tramadol and ketorolac on the immune functioning of mastectomy patients. Ketorolac was the least immunosuppressive (morphine was most immunosuppressive and tramadol was in the middle). http://www.ncbi.nlm.nih.gov/pubmed/26710216 This is just the abstract, I can't access the full text ($)
Should it go on one of the threads?
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Good. Glad you are happy with the summary.
Falls, I think it would be a good to add that abstract to the topic boxes.
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I had my BMX 3 1/2 months ago. I'm having a hip replacement in a month. Much sooner than ideal, but my hip is bone on bone and I can barely walk.
Should I be asking for Torodal during anesthesia? I'm still at risk for post surgical metastasis, and immune system is stressed from the other surgery. I sleep 9-10 hours a night and am often fatigued.
I've also been on Opiates since my cancer dx. I developed an Opioid dependency in the last years of my career, so I could keep going through the Arthritic pain. Back surgery in my early 30's started chronic pain and I used NSAIDS like candy. I developed Diverticulitis 15 years later (10 years ago) and ended up with a bowel resection to remove a bad part of my colon. Also was told to NOT use NSAIDS.
My back and a bad hip kept me from being able to sit, stand or walk very long, so I was miserable the last 5 years I worked. My PCP had me on Opiates so I could keep going. My left hip was botched when replaced in 2010 so I didn't return to work. I've used Buphrenorphine much of the time since to treat chronic pain and reduce opiate dependency. But it isn't nearly as effective to me as regular opiates, and can really block the effectiveness of anesthesia when you have surgery. I've found this out the hard way. Even an Opiate dependency can be problematic, as they don't want to give you the amounts you need for pain control in recovery
So I'm very confused with this info as to how to handle my pain. I don't think asking for Torodal is a problem, as short term use is OK. Should I get back on Buphrenorphine as soon as I can? Having this goofy ILC, where standard chemo doesn't work, but the cancer has to metastasize to receive the right medications is frustrating
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Hi Leslie,
I'm sorry you are having to have another surgery so soon, and sorry you have been dealing with so much pain. I hope this hip surgery goes much better than the last.
Can you schedule a one on one with the anesthesiologist or at least contact that person through email? I think you should try discussing your concerns with the anesthesiologist well ahead of your surgery, because you might have some back and forth.
I'm not at all familiar with hip replacement surgery, but I did find this review of methods of reducing postoperative pain in knee and hip replacement. It has a few things you might want to discuss with the anesthesiologist.
http://www.practicalpainmanagement.com/pain/myofas...
This article mentions:
1) periarticular injections that include the local anesthetic ropivicaine mixed with epinephrine and ketorolac. "the local anesthetic mixture significantly reduced opioid consumption over 48 hours postoperatively (P=0.003). The local anesthetic group also reported lower mean VAS pain scores at rest (P=0.01) and during exercise on POD 1 (P=0.008) and on POD 2 (P=0.02), as well as less postoperative nausea (P=0.011) compared to the control group.13"
2) peripheral femoral block (FNB). "A continuous ropivacaine FNB with a fentanyl PCA (patient controlled analgesia) was compared with PCA alone. The control had a higher total opioid consumption (P<0.001) and required more PCA dose increases compared to the FNB group. Those with an FNB, however, experienced lower ROM in both flexion and extension. Similarly, when levobupivacaine FNB with patient-controlled epidural analgesia (PCEA) was compared with PCEA alone, the FNB group had lower VAS scores from 0 to 24 hours (P<0.001), and 24 to 48 hours (P=0.025). Patients receiving FNB also experienced significantly less nausea (P<0.001), vomiting (P=0.033), and demand for rescue antiemetics."
Nerve blocks (regional anesthesia) may reduce the stress response associated with surgery that suppresses the immune system, and some studies have shown reduced recurrence of breast cancer with the use of paravertebral nerve blocks (this is the thread on that: https://community.breastcancer.org/forum/73/topics...).
3) celecoxib, an anti-inflammatory (COX2 inhibitor/NSAID), reduced the need for postsurgical opioids
Celecoxib is being studied for a beneficial effect on breast cancer, as BC strongly expresses COX2, so definitely won't hurt in that regard.
4) gabapentin and pregabalin, are thought to reduce the need for opioids, and reduce chronic postsurgical pain. But this may be more for knee replacement than hip surgery.
A few other things:
If you are getting spinal anesthesia, this study indicated that unilateral spinal anesthesia was better than conventional bilateral spinal anesthesia in preventing a surgical stress response when undergoing hip replacement. This could be beneficial to you because the stress response is thought to drive cancer progression.
http://www.ncbi.nlm.nih.gov/pubmed/25410068
You might want to ask about having dexmedetimidine added to the mix. It was seen to be cardioprotective in this study of patients with coronary heart disease undergoing hip replacement http://www.ncbi.nlm.nih.gov/pubmed/25132247 (however it does have the effect of lowering blood pressure), and in this study of children with cancer, presurgical administration of dex reduced the stress response and immunosuppression. http://www.ncbi.nlm.nih.gov/pubmed/25932229 Also, this study of breast cancer surgeries showed dex lowered postoperative opioid consumption and nausea and vomiting. http://www.ncbi.nlm.nih.gov/pubmed/26694929
Tramadol is another alternative that may be less immunosuppressive than other opioids, as seen in this study of gastric cancer patients:http://www.ncbi.nlm.nih.gov/pubmed/25885721
If you can use buprenorphine again that would be good too. This study (in rats) showed buprenorphine prevented the surgical stress response on the neuroendocrine and immune systems. http://www.ncbi.nlm.nih.gov/pubmed/17291715
Anyway, I just want to wish you luck with your surgery. Hope you can have a good discussion with your anesthesiologist beforehand!
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Leslie What Falleaves has bought forward is very good. Amazing. But you have to study. You have to read. You have to search. It's so hard. Never depend on just one search or study.
They're is a bigger reason why I say don't depend on what we say or discuss. We are at a crossroads in knowledge. What is exciting based on our research or many, may in a few years be proven false.
You are in a hard situation based on history. But it can be dealt with. Consider genetics. I was thought to be strange on anesthesia. Finally, learned I had a rare metabolism. of drugs. If the Anesthiologists had applied the concepts of my rare metabolism, they wouldn't of raised certain questions.
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Ad a drug checker _-------------Genelex
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bump
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Bump
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Hi, All, received this from Dr. Retsky
Look at this video from my coauthor Vikas Sukhatme. He is academic dean at Beth Israel Deaconess Medical Center at Harvard. A very smart guy. OK to circulate.
Michael
https://www.youtube.com/watch?v=H8zVrYEW8vE&feature=youtu.be
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This is an amazing video presentation. The fella is brilliant and he makes the info so easy.
Every concern that we went through in the summer and into the fall for our small group, is addressed in this video.
What I think anyone trying to digest this info should request of their doc is to review this video. Then give a solid reason why not, if you are willing to take the risk of a bleed.
Folks with the knowledge that we gained last year, by talking it out, and flying by the seat of our pants came to the same conclusions that Dr. Retsky, Dr, Forget, and Dr. Sukhatme, we did good. Our research and conclusions were good. Yes, it needs to be confirmed by a prospective study. I hate the thought of a prospective study when the results mean that recurrence could be avoided by a simple < 10$ IV push pre-op.
Way back when I said that being on the right side of the change when change is occurring is the side we want to be on.
Dr. Forget has a study going in Belgium. Dr. Retsky is working on getting something approved in two other areas.
As Dr. Retsky has said feel free to share the link.
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wow, great ideas. I just donated!
What about an observational study on recurrence rates for women who had mastectomy with and without reconstruction? I wonder if the surgery from reconstruction could put into action the inflamation behind this theory. Thoughts?
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