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oncology > cancer pain > Flashcards

cancer pain Flashcards

1
Q

what are the 3 physical pain syndromes

A

somatic (nociceptive)
visceral (nociceptive)
neuropathic

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2
Q

what is somatic pain

A

pain arising from damage to muscle, bone, skin: well localized
sharp, intense, throbbing, localized

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3
Q

what is visceral pain

A

pain arising from damage to organs; not well localized- can be referred
gnawing, cramping, squeezing, diffuse, distant

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4
Q

what is neuropathic pain

A

pain arising from a lesion or disease of the somatosensory nervous system
shooting, burning, numb, tingling, enhanced sensitivity to heat/cool

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5
Q

what is the PQRSTUV of pain assessment

A

Precipitating/palliating
Quality
Region/radiating
Severity
Timing/temporal
Utilization
Values

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6
Q

how to treat tumor-related pain

A

first line: APAP, NSAIDs, OPIOIDS

non opioids:
-nociceptive: NSAID, APAP, corticosteroid, ketamine
-neuropathic: gabapentin, TCA, SNRI, lidocaine

radiation, anti-tumor therapy

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7
Q

how to treat bone metastasis pain

A

APAP, NSAID, OPIOID, corticosteroid, bisphosphonates, radation, surgery

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8
Q

how to treat chemotherapy-induced peripheral neuropathy (CIPN)

A

duloxetine (Cymbalta) 30 mg PO daily x 1 week, then increase to 60 mg PO daily: THE ONLY PHARM THERAPY RECOMMENDED IN THE ASCO GUIDELINES FOR CIPN
+/- adjunct therapy with topical agents, TCAs, anticonvulsants (gabapentin, pregabalin) though data limited

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9
Q

what are risk factors for chemotherapy-induced peripheral neuropathy (CIPN)

A

higher initial/cumulative doses
longer treatment duration
advanced age
race
concomitant therapy
pre-existing conditions associated with peripheral neuropathy development such as diabetes

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10
Q

which non-pharm therapies have a higher level of evidence in cancer pain

A

massage and acupuncture

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11
Q

bisphosphonates are indicated for ____

A

bone pain

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12
Q

cannabinoids are indicated for ____

A

opioid-refractory cases of cancer pain
though evidence is NOT strong for its use with cancer pain

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13
Q

corticosteroids are indicated for _____

A

cancer pain related to inflammation (bone pain, lymphedema, increased intracranial pressure)

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14
Q

what are some class ADRs of opioids

A

GI: n/v, constipation
Autonomic: xerostomia, urinary retention
Derm: pruritis, sweating
Neuro: sedation, dizziness, delirium, hallucinations, myoclonus, hyperalgesia
Cardiopulmonary: respiratory depression, bradycardia, hypotension
Immuno: immune suppression
Endo: hypogonadism, sexual dysfunction

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15
Q

ADRs specific to CODEINE

A

ultra-rapid metabolizers have higher risk of respiratory depression

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16
Q

ADRs specific to methadone

A

QTc prolongation

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17
Q

ADRs specific to morphine

A

higher rates of itching, hypotension due to histamine release upon binding

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18
Q

ADRs specific to tramadol/tapentadol

A

lower seizure threshold and increased risk of serotonin syndrome

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19
Q

management of opioid-induced constipation

A

prevention is the best treatment: initiate scheduled bowel regimen when starting opioid therapy
try senna, miralax, bisacodyl
DOCUSATE IS NOT RECOMMENDED BECAUSE IT SOFTENS THE STOOL BUT DOESN’T MAKE YOU GO

lubiprostone, methylnaltrexone, naldemedine, naloxegol are for refractory opioid-induced constipation

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20
Q

management of nausea/vomiting with opioids

A

prochlorperazine 5-10 mg PO/IV Q6H PRN

21
Q

management of itching with opioids

A

diphenhydramine 25 mg PO q6h prn
hydroxyzine 25 mg PO q6h prn

22
Q

management of sedation/lethargy with opioids

A

sedation/lethargy occurs before respiratory depression
utilize naloxone for reversal of overdose
consider ordering naloxone as a precaution for patients on high dose opioids >50 mg OME per CDC

23
Q

avoid _____ in renal dysfunction due to?

A

morphine
high number of active metabolites

24
Q

codeine active metabolites

A

morphine
M6G

25
Q

oxycodone active metabolites

A

oxymorphone

26
Q

hydrocodone active metabolites

A

hydromorphone

27
Q

tramadol active metabolites

A

M1

28
Q

which drugs don’t have active metabolites

A

fentanyl

29
Q

how to initiate opioids in opioid-naive patients

A

select a short acting (immediate release) PO medication (ex morphine, oxycodone, hydromorphone)– but if they are in the hospital with acute pain you can use IV

do not use long-acting agents, fentanyl patches, or methadone

30
Q

define “opioid tolerant”

A

patients who require at least 60 mg OME daily x 1 week

31
Q

IV opioids: what is the onset, peak, duration

A

onset 5 min
peak 15 min
duration 3-4 hours (2 hours for fentanyl)

32
Q

PO opioids: what is the onset, peak, duration

A

onset 30 min
peak 60 min
duration 3-4 hours

33
Q

when can you safely re-dose an opioid?

A

after it reaches its peak effect
(ex after 15 minutes for IV)

34
Q

how can you modify opioids for uncontrolled pain?

A
  1. increase the dose (by 25-50% if mild-moderate pain <6, by 50-100% if severe pain >7)
  2. utilize a long-acting agent if the patient’s pain is constant
35
Q

true/false: patients have to have chronic pain to be prescribed a long-acting agent

A

FALSE: it has to be constant, but not chronic

36
Q

true/false: patient has to be opioid tolerant to be prescribed a long acting agent

A

FALSE

37
Q

how do you initiate a long-acting agent?

A
  1. calculate total daily dose used in PRNs and use 2/3 of that dose towards long acting
  2. PRN dose is 10-15% of long-acting regimen, every 4 hours PRN
  3. do not titrate up for at least 3 days for PO, and 7 days for TD
38
Q

true/false: it is necessary to reduce for cross tolerance when switching from a different opioid to a fentanyl patch

A

FALSE

the conversion on the package insert is conservative already

39
Q

true/false: the equianalgesic table applies to both IV and transdermal fentanyl

A

FALSE it only applies to IV fentanyl

NOT transdermal: use package insert

40
Q

what is the 5 step approach to opioid conversions

A
  1. assess the patient (PQRSTUV)
  2. determine total daily usage of current opioid in the last 24 hours: long acting and breakthrough
  3. set up ratio
  4. adjust for cross tolerance (reduce by 33%)
  5. follow up
41
Q

______ cannot be used in opioid-naive patients

A

transdermal fentanyl, methadone

42
Q

which drugs are specifically problematic that Dr. Lowry hates

A

Tramadol: it lowers seizure threshold, risk of serotonin syndrome is high

codeine is problematic because ultra rapid metabolizers have a higher risk of respiratory depression

43
Q

when is transdermal fentanyl (duragesic) indicated

A

constant (non-acute) pain for opioid-tolerant patients: meaning they require at least 60 mg OME per day x 1 week

44
Q

onset, peak, duration of transdermal fentanyl

A

onset: 12 hours
peak: 24 hours
duration: 72 hours

45
Q

how is fentanyl able to be absorbed transdermally

A

it is highly lipophilic so it can absorb through SC fat/tissue

46
Q

true/false: you can cut fentanyl patches

A

false

47
Q

how do you convert TO versus FROM fentanyl patch

A

TO: use the package insert

FROM: fentanyl dose (mcg/h) x 2 = oral morphine equivalent per day (mg)

48
Q

how do you calculate a PRN regimen for transdermal fentanyl

A

calculate OME
take 10-15% of that total OME for each PRN dose

oncology (19 decks)

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