NanaBis™ an Oro-buccal Administered delta9-Tetrahydrocannabinol (d9-THC) & Cannabidiol (CBD) Medicine for the Management of Bone Pain From Metastatic Cancers
Study Details
Study Description
Brief Summary
This is a multi-centre, long term, double blind, clinical protocol for NanaBis™ as a monotherapy treatment in participants 18-75 years of age with cancer related pain.
Condition or Disease | Intervention/Treatment | Phase |
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Phase 3 |
Detailed Description
This trial uses an alternative method to demonstrate the analgesic efficacy of NanaBis™ as a monotherapy in cancer participants. Proving analgesic efficacy requires demonstrating that (i) the analgesic is significantly better than placebo and (ii) that the magnitude of the improvement is clinically important. The latter is standardly done by measuring the change in pain levels from a baseline (no analgesia) to the end of a treatment period. A 30% decrease in the Numerical Pain Rating Scale (NPRS) has been correlated with participants reporting a moderate improvement in their pain and this was adopted as the standard method of demonstrating a clinically important magnitude of improvement. In this strategy, the measure of analgesic efficacy is the proportion of participants in the treatment group whose pain is adequately treated (responders). A responder is defined as a patient who completes the treatment phase with an acceptable level of pain (NPRS ≤ 5) and without requiring excessive amounts of rescue (breakthrough analgesia) medication. Unlimited breakthrough analgesia (Oxycodone) is allowed throughout the study; however, excessive use will result in discontinuation. Comparison of the proportion of responders in the NanaBis™ arm and placebo arms will determine if NanaBis™ is significantly better than placebo. Demonstrating that the proportion of responders in the NanaBis™ arm is non-inferior to the Oxycodone controlled release (CR) comparator arm will determine if the magnitude of improvement (provided by NanaBis™) is clinically important because Oxycodone CR has been established as the benchmark analgesic that provides a clinically important effect.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Placebo Comparator: Double Placebo Arm Spray Placebo + Tablet Placebo Spray Placebo is a nanoparticle water soluble solution without cannabinoids containing a small amount of hemp seed oil (for fragrance purposes only) as defined by Australian Office of Drug Control (ODC) (https://www.odc.gov.au/hemp-products). One dose is equivalent to 2 actuations of the pump delivering 280 µL volume. Tablet Placebo will be identical to the Oxycontin tablets. |
Drug: Placebo Spray
Placebo comparator used against both NanaBis™ and Oxycodone depending on randomisation of arms.
Other Names:
Drug: Placebo Tablet
Placebo comparator used against both NanaBis™ and Oxycodone depending on randomisation of arms.
Drug: Oxycodone IR
Oxycodone immediate release (IR) tablet or capsule or oral solution used as breakthrough analgesia.
Other Names:
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Experimental: Treatment NanaBis™ Arm NanaBis™ + Tablet Placebo NanaBis™ is a nanoparticle water soluble equimolar solution of d9-THC and CBD. One dose is equivalent to 2 actuations of the pump delivering 280 µL volume containing 2.5 mg d9-THC and 2.5 mg CBD. The dose administered will be 1 - 3.5 doses (2 sprays to 7 sprays) per 4 hours unless asleep. |
Drug: NanaBis™
NanaBis™ is a nanoparticle water soluble equimolar solution of d9-THC & CBD. One dose is equivalent to 2 actuations of the pump delivering 280 µL volume containing 2.5 mg d9-THC and 2.5 mg CBD
Other Names:
Drug: Placebo Tablet
Placebo comparator used against both NanaBis™ and Oxycodone depending on randomisation of arms.
Drug: Oxycodone IR
Oxycodone immediate release (IR) tablet or capsule or oral solution used as breakthrough analgesia.
Other Names:
|
Active Comparator: Comparator (Oxycodone) Arm Spray Placebo + Oxycodone CR Spray Placebo is a nanoparticle water soluble solution without cannabinoids containing a small amount of hemp seed oil (for fragrance purposes only) as defined by Australian ODC (https://www.odc.gov.au/hemp-products). One dose is equivalent to 2 actuations of the pump delivering 280 µL volume. Oxycodone controlled release (CR) used as a comparator will be Oxycontin tablets 10 mg - 70 mg po bd. |
Drug: Oxycodone CR
Oxycodone CR tablet is an opioid agonist supplied in 10 mg, 15 mg, 20 mg, 30 mg,40 mg, 60 mg and 80 mg tablets for oral administration. The tablet strengths describe the amount of oxycodone per tablet as the hydrochloride salt.
Other Names:
Drug: Placebo Spray
Placebo comparator used against both NanaBis™ and Oxycodone depending on randomisation of arms.
Other Names:
Drug: Oxycodone IR
Oxycodone immediate release (IR) tablet or capsule or oral solution used as breakthrough analgesia.
Other Names:
|
Outcome Measures
Primary Outcome Measures
- Significant changes in responders with NanaBis™ spray over placebo (p<0.05) [6 weeks]
To demonstrate that at the end of the 6-week study period the proportion of responders in the NanaBis™ group shows significant change than the proportion of responders in the placebo group. A responder is defined as a participant who completes the maintenance phase with an acceptable level of pain (NPRS is equal to 5) and without requiring excessive amounts of rescue (breakthrough analgesia) medication. NPRS Assessment [Time Frame: Baseline and then twice daily for the duration of the study]. The NPRS questionnaire is completed by the participant to determine their pain intensity. The NPRS is an 11-point scale scored from '0-10'. A score of '0' being no pain and a score of '10' being the most intense pain imaginable. Participants select the value that is most in line with the intensity of pain they have experienced in the last 24 hours.
Secondary Outcome Measures
- Comparable efficacy in proportion of responders from NanaBis™ spray to the proportion of responders to Oxycodone CR [6 weeks]
To demonstrate that at the end of the 6-week study period the proportion of responders in the NanaBis™ group is similar to the proportion of responders in the Oxycodone group determined by pain levels recorded using NPRS. A responder is defined as a participant who completes the maintenance phase with an acceptable level of pain (NPRS is equal to 5) and without requiring excessive amounts of rescue (breakthrough analgesia) medication. NPRS Assessment [Time Frame: Baseline and then twice daily for the duration of the study]. The NPRS questionnaire is completed by the participant to determine their pain intensity. The NPRS is an 11-point scale scored from '0-10'. A score of '0' being no pain and a score of '10' being the most intense pain imaginable. Participants select the value that is most in line with the intensity of pain they have experienced in the last 24 hours.
- Significant change in the Health-Related Quality of Life Scores with NanaBis™ spray over placebo (p<0.05) and comparable to Oxycodone CR [6 weeks]
To demonstrate that at the end of the 6-week study period the Health-Related Quality of Life scores in the NanaBis™ treated group are significantly changed than in the Placebo group and is similar to the Oxycodone CR treated group. Quality of life as assessed by the EORTC-QLQ-C30 validated questionnaire [ Time Frame: Baseline and then weekly during the maintenance phase of the study and at then weeks 7 and 18 of the Open Label Extension]. The EORTC-QLQ-C30 is validated questionnaire answered by participants to assess the quality of life of cancer patients. It assesses important functioning domains (e.g. physical, emotional, role) and common cancer symptoms (e.g. fatigue, pain, nausea/vomiting, appetite loss).
- Significant change in the NPRS score with NanaBis™ spray over placebo (p<0.05) and comparable to Oxycodone CR [18 weeks]
NPRS Assessment [Time Frame: Baseline and then twice daily for the duration of the study]. The NPRS questionnaire is completed by the participant to determine their pain intensity. The NPRS is an 11-point scale scored from '0-10'. A score of '0' being no pain and a score of '10' being the most intense pain imaginable. Participants select the value that is most in line with the intensity of pain they have experienced in the last 24 hours.
- NanaBis™ Adverse Events [18 weeks]
To demonstrate that at the end of the 6-week study period that NanaBis™ is safe and tolerable. Safety and tolerability will be assessed via standardised adverse events, Serious adverse events, Deaths, UKU - Side Effects Rating Scale (UKU), Local Adverse Events Charts and patient medical records. Adverse events, serious adverse events and deaths will be summarised by treatment arm. Does the daily use of NanaBis™ oro-buccal spray reduce the severity of Treatment-Emergent Adverse Events (safety and tolerability). [Time Frame: Baseline and then weekly for the duration of the study]. Changes in validated UKU scale range is 0 to 3 for rating the degree of severity (mild, moderate or severe) and a second scale for the investigator that assigns a casual relationship of improbable, possible or probable.
- Fifty percent or greater of the NanaBis™ treated group request compassionate extension with NanaBis™ spray [12 weeks]
To demonstrate that at the end of the 6-week study period that after unblinding, half or more of the NanaBis™ treated group prefer further treatment with NanaBis™ in the open label extension phase (note that all participants will be all offered open label extension if appropriate).
Eligibility Criteria
Criteria
Inclusion Criteria:
At Screening Phase
Participants must fulfil all of the following criteria:
- Prospective male and female participants that are:
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in the age range 18-65 years or
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65 to 75 years without significant co-morbidities (heart, lung, liver or renal failure, myocardial infarction, cerebral vascular accident, peripheral vascular disease, chronic obstructive pulmonary disease, dementia, connective tissue disease or diabetes mellitus with end-organ damage)
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Metastatic bone pain from a cancer diagnosis is the only major cause of pain.
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Documented proof (imaging) confirming the Metastatic Bone Disease at the current site of pain and that there has no been treatment since diagnosis
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Meet International Classification of Diseases, Tenth Revision (ICD-10) codes for pain management criteria (i.e., bone cancer pain)
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During the screening period, the participant is on stable opioid pain management and pain severity (NPRS) ≤ 8 with a maximum variation of ± 1
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Pain Detect score > 18
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Participant willing and able to provide informed consent and follow study procedures
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including agreeing to not drive or operate heavy machinery; and
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females of child-bearing potential agree to use reliable contraception during the duration of the clinical trial
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Patient deemed tolerable to Oxycodone and NanaBis™ determined by medical history of allergies to cannabinoids or opioids
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Patient must not be a participant in a clinical trial or study.
Exclusion Criteria:
At Screening Phase
Participants will be excluded if they meet any of the following criteria that include:
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History of epilepsy or recurrent seizures
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Moderate to severe medical conditions such as
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Severe hepatic, cardiovascular, pulmonary or renal impairment or
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Psychiatric disorders (i.e., unstable schizophrenia, recent drug-induced psychosis, severe mood disorders), that would be assessed at the medical screen
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If participants have been diagnosed with a current substance abuse disorder
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Women who are pregnant, lactating or planning to become pregnant
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Identified concerns by the nursing / medical team relevant to the safe storage of medications (i.e., NanaBis™ or standard medical therapy)
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Participants who may not be available for follow up (i.e., planned or expected travel or other)
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Participants plan to undergo any treatment that will substantially reduce the burden of disease (and therefore bone pain) during the screening, titration or maintenance phase of the clinical trial such as radiotherapy or cytotoxic chemotherapy
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Participants who are unable to withhold all analgesia (apart from which is part of this trial) during the titration and maintenance phase of the study, including bisphosphonates, or are currently exceeding equivalence of 70mg BD Oxycodone CR. Medications such as bisphosphonates may be coordinated so they are given either side of the excluded period that covers the titration and maintenance phases
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Participants will NOT be excluded if they are being treated with maintenance pharmacotherapy to prevent progression of disease such as steroids and hormone therapy, which may be continued during the trial at a stable dose
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Participant will be excluded if they are participating in any other clinical trial or study.
Contacts and Locations
Locations
No locations specified.Sponsors and Collaborators
- Medlab Clinical
- George Clinical Pty Ltd
- WriteSource Medical Pty Ltd
Investigators
None specified.Study Documents (Full-Text)
None provided.More Information
Additional Information:
- Note for Guidance on Good Clinical Practice (CPMP/ICH/135/95) - annotated with TGA comments. DSEB. 2000.
- Note for Guidance on Clinical Safety Data Management: Definitions and Standards for Expedited Reporting (CPMP/ICH/377/95). Annotated with TGA comments,. 2001.
- VA Evidence-based Synthesis Program Reports. In Benefits and Harms of Cannabis in Chronic Pain or Post-traumatic Stress Disorder: A Systematic Review, Department of Veterans Affairs (US): Washington (DC), 2017.
- Pilot clinical and pharmacokinetic study of a water soluble nanoparticle cannabis-based medicine in advanced cancer with intractable pain. S. Clarke, B. Butcher, A.J McLachlan, J.D Henson, D. Rutolo, S. Hall, L. Vitetta. 2020. Abstract 219
Publications
- Ahmad I, Ahmed MM, Ahsraf MF, Naeem A, Tasleem A, Ahmed M, Farooqi MS. Pain Management in Metastatic Bone Disease: A Literature Review. Cureus. 2018 Sep 11;10(9):e3286. doi: 10.7759/cureus.3286. Review.
- Anderson W. 2007 National Statement on Ethical Conduct in Human Research. Intern Med J. 2011 Jul;41(7):581-2. doi: 10.1111/j.1445-5994.2011.02528.x.
- Blake A, Wan BA, Malek L, DeAngelis C, Diaz P, Lao N, Chow E, O'Hearn S. A selective review of medical cannabis in cancer pain management. Ann Palliat Med. 2017 Dec;6(Suppl 2):S215-S222. doi: 10.21037/apm.2017.08.05. Epub 2017 Aug 23. Review.
- Body JJ, Quinn G, Talbot S, Booth E, Demonty G, Taylor A, Amelio J. Systematic review and meta-analysis on the proportion of patients with breast cancer who develop bone metastases. Crit Rev Oncol Hematol. 2017 Jul;115:67-80. doi: 10.1016/j.critrevonc.2017.04.008. Epub 2017 Apr 23. Review.
- Boland EG, Bennett MI, Allgar V, Boland JW. Cannabinoids for adult cancer-related pain: systematic review and meta-analysis. BMJ Support Palliat Care. 2020 Mar;10(1):14-24. doi: 10.1136/bmjspcare-2019-002032. Epub 2020 Jan 20.
- Bubendorf L, Schöpfer A, Wagner U, Sauter G, Moch H, Willi N, Gasser TC, Mihatsch MJ. Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients. Hum Pathol. 2000 May;31(5):578-83.
- Cavalli E, Mammana S, Nicoletti F, Bramanti P, Mazzon E. The neuropathic pain: An overview of the current treatment and future therapeutic approaches. Int J Immunopathol Pharmacol. 2019 Jan-Dec;33:2058738419838383. doi: 10.1177/2058738419838383. Review.
- Chan AW, Tetzlaff JM, Altman DG, Laupacis A, Gøtzsche PC, Krleža-Jerić K, Hróbjartsson A, Mann H, Dickersin K, Berlin JA, Doré CJ, Parulekar WR, Summerskill WS, Groves T, Schulz KF, Sox HC, Rockhold FW, Rennie D, Moher D. SPIRIT 2013 statement: defining standard protocol items for clinical trials. Ann Intern Med. 2013 Feb 5;158(3):200-7. doi: 10.7326/0003-4819-158-3-201302050-00583.
- Choong PF. The molecular basis of skeletal metastases. Clin Orthop Relat Res. 2003 Oct;(415 Suppl):S19-31. Review.
- Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006 Oct 15;12(20 Pt 2):6243s-6249s. Review.
- Colloca L, Ludman T, Bouhassira D, Baron R, Dickenson AH, Yarnitsky D, Freeman R, Truini A, Attal N, Finnerup NB, Eccleston C, Kalso E, Bennett DL, Dworkin RH, Raja SN. Neuropathic pain. Nat Rev Dis Primers. 2017 Feb 16;3:17002. doi: 10.1038/nrdp.2017.2. Review.
- Deandrea S, Montanari M, Moja L, Apolone G. Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol. 2008 Dec;19(12):1985-91. doi: 10.1093/annonc/mdn419. Epub 2008 Jul 15. Review.
- Deshpande A, Mailis-Gagnon A, Zoheiry N, Lakha SF. Efficacy and adverse effects of medical marijuana for chronic noncancer pain: Systematic review of randomized controlled trials. Can Fam Physician. 2015 Aug;61(8):e372-81. Review.
- Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole MR. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001 Nov;94(2):149-158. doi: 10.1016/S0304-3959(01)00349-9.
- Freynhagen R, Baron R, Gockel U, Tölle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006 Oct;22(10):1911-20.
- Freynhagen R, Baron R, Tölle T, Stemmler E, Gockel U, Stevens M, Maier C. Screening of neuropathic pain components in patients with chronic back pain associated with nerve root compression: a prospective observational pilot study (MIPORT). Curr Med Res Opin. 2006 Mar;22(3):529-37.
- Gregorian RS Jr, Gasik A, Kwong WJ, Voeller S, Kavanagh S. Importance of side effects in opioid treatment: a trade-off analysis with patients and physicians. J Pain. 2010 Nov;11(11):1095-108. doi: 10.1016/j.jpain.2010.02.007. Epub 2010 May 10.
- Handelsman L, Cochrane KJ, Aronson MJ, Ness R, Rubinstein KJ, Kanof PD. Two new rating scales for opiate withdrawal. Am J Drug Alcohol Abuse. 1987;13(3):293-308.
- Imanaka K, Tominaga Y, Etropolski M, Ohashi H, Hirose K, Matsumura T. Ready conversion of patients with well-controlled, moderate to severe, chronic malignant tumor-related pain on other opioids to tapentadol extended release. Clin Drug Investig. 2014 Jul;34(7):501-11. doi: 10.1007/s40261-014-0204-3.
- Kane CM, Hoskin P, Bennett MI. Cancer induced bone pain. BMJ. 2015 Jan 29;350:h315. doi: 10.1136/bmj.h315. Review.
- Kress HG, Koch ED, Kosturski H, Steup A, Karcher K, Lange B, Dogan C, Etropolski MS, Eerdekens M. Tapentadol prolonged release for managing moderate to severe, chronic malignant tumor-related pain. Pain Physician. 2014 Jul-Aug;17(4):329-43.
- Lee SH, Min YS, Park HY, Jung TD. Health-related quality of life in breast cancer patients with lymphedema who survived more than one year after surgery. J Breast Cancer. 2012 Dec;15(4):449-53. doi: 10.4048/jbc.2012.15.4.449. Epub 2012 Dec 31.
- Lee-Kubli CA, Calcutt NA. Painful neuropathy: Mechanisms. Handb Clin Neurol. 2014;126:533-57. doi: 10.1016/B978-0-444-53480-4.00034-5. Review.
- Ligresti A, De Petrocellis L, Di Marzo V. From Phytocannabinoids to Cannabinoid Receptors and Endocannabinoids: Pleiotropic Physiological and Pathological Roles Through Complex Pharmacology. Physiol Rev. 2016 Oct;96(4):1593-659. doi: 10.1152/physrev.00002.2016. Review.
- Macedo F, Ladeira K, Pinho F, Saraiva N, Bonito N, Pinto L, Goncalves F. Bone Metastases: An Overview. Oncol Rev. 2017 May 9;11(1):321. doi: 10.4081/oncol.2017.321. eCollection 2017 Mar 3. Review.
- Mantyh PW. Bone cancer pain: from mechanism to therapy. Curr Opin Support Palliat Care. 2014 Jun;8(2):83-90. doi: 10.1097/SPC.0000000000000048. Review.
- Mao Y, Huang Y, Zhang Y, Wang C, Wu H, Tian X, Liu Y, Hou B, Liang Y, Rong H, Gu X, Ma Z. Cannabinoid receptor 2-selective agonist JWH015 attenuates bone cancer pain through the amelioration of impaired autophagy flux induced by inflammatory mediators in the spinal cord. Mol Med Rep. 2019 Dec;20(6):5100-5110. doi: 10.3892/mmr.2019.10772. Epub 2019 Oct 25.
- Meng H, Johnston B, Englesakis M, Moulin DE, Bhatia A. Selective Cannabinoids for Chronic Neuropathic Pain: A Systematic Review and Meta-analysis. Anesth Analg. 2017 Nov;125(5):1638-1652. doi: 10.1213/ANE.0000000000002110. Review.
- Murnion BP. Neuropathic pain: current definition and review of drug treatment. Aust Prescr. 2018 Jun;41(3):60-63. doi: 10.18773/austprescr.2018.022. Epub 2018 Jun 1. Review.
- Pain: clinical manual for nursing practice Pain: clinical manual for nursing practice Margo McCaffery Alexander Beebe Mosby Yearbook UK £17.25 0 7234 1992 2. Nurs Stand. 1994 Dec 7;9(11):55. doi: 10.7748/ns.9.11.55.s69.
- Pezaro C, Omlin A, Lorente D, Rodrigues DN, Ferraldeschi R, Bianchini D, Mukherji D, Riisnaes R, Altavilla A, Crespo M, Tunariu N, de Bono J, Attard G. Visceral disease in castration-resistant prostate cancer. Eur Urol. 2014 Feb;65(2):270-273. doi: 10.1016/j.eururo.2013.10.055. Epub 2013 Nov 22.
- Portenoy RK. Treatment of cancer pain. Lancet. 2011 Jun 25;377(9784):2236-47. doi: 10.1016/S0140-6736(11)60236-5. Review.
- Rehberg B, Mathivon S, Combescure C, Mercier Y, Savoldelli GL. Prediction of Acute Postoperative Pain Following Breast Cancer Surgery Using the Pain Sensitivity Questionnaire: A Cohort Study. Clin J Pain. 2017 Jan;33(1):57-66.
- Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Int J Surg. 2011;9(8):672-7. doi: 10.1016/j.ijsu.2011.09.004. Epub 2011 Oct 13.
- Sun J, Zhou YQ, Chen SP, Wang XM, Xu BY, Li DY, Tian YK, Ye DW. The endocannabinoid system: Novel targets for treating cancer induced bone pain. Biomed Pharmacother. 2019 Dec;120:109504. doi: 10.1016/j.biopha.2019.109504. Epub 2019 Oct 15. Review.
- Wiffen PJ, McQuay HJ. Oral morphine for cancer pain. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003868. Review. Update in: Cochrane Database Syst Rev. 2013;7:CD003868.
- Yanae M, Fujimoto S, Tane K, Tanioka M, Fujiwara K, Tsubaki M, Yamazoe Y, Morishima Y, Chiba Y, Takao S, Komoike Y, Tsurutani J, Nakagawa K, Nishida S. Increased risk of SSEs in bone-only metastatic breast cancer patients treated with zoledronic acid. J Bone Oncol. 2017 Aug 31;8:18-22. doi: 10.1016/j.jbo.2017.08.004. eCollection 2017 Sep.
- MDC-NB-P3-01