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personalised medicine and cancer > Cancer Part 6 > Flashcards

Cancer Part 6 Flashcards

1
Q

What is pain?

A

It is a complex physiological and emotional experience and not a simple sensation. Pain involves:
Unpleasant sensory experience
Unpleasant emotional experience
Social and spiritual components

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2
Q

What is the incidence of pain in cancer?

A

One quarter of patients do not experience pain
One third of those with pain have a single pain
One third have two pains
One third have three or more pains

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3
Q

list the two types of pain

A

Nociceptive
Neuropathic

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4
Q

Define Nociceptive pain

A

Pain arising from body transmitted through intact nervous system

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5
Q

Nociceptive pain is sub divided into

A

Somatic : Bone, soft tissue
visceral : Liver, bowel and cardiac

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6
Q

Define Neuropathic pain

A

Pain arising from damaged peripheral nervous system

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7
Q

what causes pain in cancer

A

cancer
treatment
cancer induced debility- pressure sore
Unrelated to cancer treatment- migraines, RA etc

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8
Q

State the goal of pain management

A

Pain relieved at night, allowing sleep
Patient is pain-free during the day, at rest
Patient is pain-free on movement

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9
Q

Facts about pain management in Palliative care

A

One third of patients do not develop severe pain
Pain is subjective, the patient’s own description should be the basis of assessment
Need to determine the origin and likely cause
Patients may have more than one pain
Pain from co-existing conditions should also be considered.

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10
Q

WHO analgesic ladder

A

step 1 - Non-opiod
step 2- Opiod(mild), non opiod
step 3- Opiod(moderate-severe), non opiod
all plus or - adjuvant

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11
Q

Step 1 Anagelsics

A

Paracetamol 1g four times a day
Regular rather than prn

NSAIDS – step 1 analgesic and adjuvant. Normal drug and dose choices (think ibuprofen and naproxen to start, remember interpatient variability).

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12
Q

Step 2 Opiods for mild to moderate pain

A

Codeine, dihydrocodeine
Continue paracetamol and NSAIDs
Combined preparations within therapeutic doses of opioids (e.g. Co-codamol 30/500)
Weak opioids have an analgesic ceiling
No advantage in substituting one weak opioid for another

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13
Q

Codeine is a pro-drug activated by CYP2D6. True/false

A

True

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14
Q

State how Codeine is metabolised by Causasians

A

5-10% Caucasians are poor activators – do not express enzyme - cannot convert codeine to morphine

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15
Q

List the drugs that inhibit the bioactivation of Codeine

A

haloperidol, metoclopramide,
TCAs – compete for 2D6 (deactivation – normal phase 1).

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16
Q

Step 3 strong analgesia

A

Morphine is the strong opioid of choice
Solid and liquid oral formulations
Initially 2.5 – 5mg qds, (higher if patient not opiate naiive) then convert to an equivalent dose of a long-acting preparation
Rescue doses of 1/6 daily dose should also be prescribed in short-acting form

Paracetamol and NSAIDs may be continued

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17
Q

State why Diamorphine should be used in step 3 analgesia

A

For continuous subcutaneous infusion diamorphine is preferable, because of greater solubility
In water: Morphine – 60mg/mL, diamorphine – 500mg/mL

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18
Q

State how to deal with constipation side effects when taking opiods

A

Constipation
all patients should have laxatives co-prescribed. A stimulant laxative and a faecal softener are required (e.g. lactulose plus senna, co-danthramer)

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19
Q

State how to deal with Nausea as a side effects when taking opioid

A

Nausea
(usually short-term)
- anti-emetics prn (e.g. haloperidol, metoclopramide)
Aim to stop after 1/52

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20
Q

State how to deal with sedation as a side effect when taking opioid

A

Advise patient. Sedation beyond a few days might indicate toxicity (e.g. norpethidine accumulation)

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21
Q

State how to overcome dry mouth as a side effect when taking opiods(particularly when other anti-cholinergic drugs are co-prescribed)

A

Good oral hygiene, can use artificial saliva solutions

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22
Q

What are Adjuvant analgesics?

A

Drugs whose primary indication is not analgesia but which provide pain relief

Can be added at any stage on the analgesic ladder

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23
Q

List examples of adjuvant analgesics

A

tricyclic and SSRI/ SNRI antidepressants
anticonvulsants
corticosteroids

24
Q

Facts about Neuropathic pain

A

Injured nervous system – alters pain signals travelling up spinal cord and inhibitory processes preventing all signals getting through to brain.

Poor quality of life for sufferers is common
Normal analgesics give incomplete pain relief

Adjuvants often required
Treatment limited by incomplete effect or drug side-effects

25
Q

State the mechanism of action of Tricyclic antidepressant

A

The mechanism of analgesic action is principally by facilitation of descending inhibitory pain pathways.

Note that amitriptyline can increase the bioavailability of morphine leading to opioid side-effects.

If no response by day five. increase the dose (or, according to clinical circumstances, consider

26
Q

Facts about Tricycline Antidepressant

A

Amitriptyline 25-100mg
Start with amitrip 25mg ON (10mg elderly)
Increase dose on day 5
May not see effect for 4-6 weeks or 50mg plus daily.
Switch to lofepramine or dosulepin if not tollerated

27
Q

What to do if patients cannot tolerate Amitriptyline?

A

many patients do not tolerate amitriptyline especially in higher doses, therefore consider changing to dosulepin

28
Q

State what drug should be offered to frail and elderly and those already suffering anti-muscarinic drugs

A

Use lofepramine for frail, elderly, or those already suffering anti-muscarinic side-effects from other drugs:

29
Q

State the dose of Lofepramine

A

Start at 70mg nocte
may increase to 70mg b.d. on day 5-7

30
Q

List examples of otherr antidepressants used in cancer pain management

A

venlafaxine high dose (above 150mg daily – see additional NA effect) or duloxetine.
Duloxetine first line from American Soc of clinical oncology for chemo-induced peripheral enuropathy
Doxepin cream– Apply TDS / QDS max 12g /day

31
Q

Facts about Anticonvulsants used in cancer pain management

A

Unlike TCAs the anticonvulsants have diverse actions and thus a variety of drugs may work for different patients
All agents used at ‘typical’ doses
Empirically better than TCA but…
Choice…

32
Q

Facts about effectiveness of Anticonvulsant

A

Anticonvulsants have for a long time been considered better than tricyclic antidepressants for lancinating or paroxysmal pain, but evidence from studies does not support this.

There is little data to compare anticonvulsants in terms of efficacy, although in one trial comparing the efficacy of different anticonvulsants for lancinating pain, the results suggested that clonazepam was superior others.

33
Q

Facts about the use of Carbamezepine in managing neuropathic pain

A

Carbamazepine has been used most extensively, but is often tolerated poorly by elderly, frail or ill patients. It has numerous drug interactions and tends to result in more side-effects, particularly when used in combination with other drugs. Doses should be built up slowly to minimize adverse effects

34
Q

List other antiepileptic drugs used in managing Neuropathic pain in cancer

A

carbamazepine 100-400mg b.d.
Poorly tolerated by frail, elderly, sick pts
++interactions and ADRs
Build up dose v slowly.

sodium valproate 100-600mg b.d.
V little data on palliative efficacy

Lamotrigine
Unpredictable results

35
Q

What is the only drug licensed for all types of neuropathic pain?

A

Gabapentin
Trials have shown it to be effective in non-malignant and cancer-related pain. It appears to be well tolerated in palliative care patients. Doses up to 2.4g/24h have been used successfully

NB No correlation between plasma levels and efficacy.

36
Q

State the dose of Gabapentin used for Neuropathic pain

A

gabapentin 100-600mg t.d.s.
Licensed for all forms of neuropathic pain
Up to 2.4g in 24hrs used
Start low and increase slowly. May ‘waste’ weeks titrating up with no final complete effect.

37
Q

State the side effects of Gabapentin

A

Dose limiting diarrhoea
Ataxia, confusion, drowsiness also common
Pregabalin an equivalent / (expensive) alternative

38
Q

State the mechanism of action of corticosteroids

A

Mechanisms:
reduce inflammatory sensitisation of nerves
reduce pressure on nerves due to oedema –inc. central raised intracranial pressure.
Sometimes ‘buy’ useful time whilst allowing other methods (e.g. radiotherapy or antidepressants) time to work

39
Q

State the dose of Dexamethasone used in the management of neuropathic pain

A

High initial dose to achieve rapid results
dexamethasone 8mg/day works in 1-3 days
Then rapidly reduce to minimum effective
Long-term use best avoided

40
Q

Hydrocortisone contains high —–

A

a high mineralocorticoid effect – fluid retention +++

41
Q

Dexamethasone has—–

A

less mineralo’ than prednisolone

42
Q

Prednisolone– less myopathy than dexamethasone, True/false

A

True

43
Q

What to do if steroids become ineffective within 5/7 days

A

Stop treatment

44
Q

What are syringe drivers used for

A

Used to aid in drug delivery when oral route is no longer feasible, e.g.:
Intractable vomiting
Severe dysphagia
Patient too weak to swallow oral drugs
Decreased level of consciousness
Poor GI absorption (rare)
Poor compliance / concordance

45
Q

What is the advantage of using a syringe driver

A

Don’t need a vein

46
Q

State how syringe driver works?

A

Intended to administer 24 hours of medication SUBCUTANEOUSLY though small bore canula inserted below skin.

Very slowly pushes syringe which is locked in place

47
Q

State the problem associated with the use of a syringe driver

A

Infusion running too fast:
Infusion running too slow:
Site reaction:
Precipitation:

48
Q

List examples 0of antiemetics used in cancer treatment

A

Cyclizine (NB NaCl incompatible)
Haloperidol
Hyoscine hydrobromide
Metoclopramide
Granisetron / ondansetron
levomepromazine

49
Q

What is Glycopyrronium indicated for in cancer ?

A

It dries secretion

50
Q

What is Hyoscine-n-butylbromide

A

dries secretions, reduces intestinal colic

51
Q

What is Midazalom indicated for ?

A

Sedative

52
Q

List drugs that cannot be used Sub cutaneously

A

Diazepam – too irritant
Chlorpromazine
Prochlorperazine

53
Q

List drugs that needs a separate syringe when using a syringe driver

A

Dexamethasone, phenobarbital, diclofenac due to incompatabilites

54
Q

list samples of compatible regimen when using a syringe driver

A

diamorphine plus haloperidol plus midazolam
Diamorphine plus cyclizine plus hyoscine hydrobromide (if in water)
Diamorphine plus midazolam plus glycopyrronium

55
Q

state the problems associated with using syringe drivers

A

Infusion running too fast: Overdose
Infusion running too slow: Underdose
Site reaction: Cyclizine /levomepromazine most common
Precipitation: Stick to compatible combos. May happen e.g. with > 75 mg cyclizine plus >160mg diamorphine.

personalised medicine and cancer (16 decks)

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