Lecture 10 - Supportive Care II

Question 1

Why do cancer pts have pain?

Answer 1

cancer itself
invasion of disease into nerves - neuropathic pain; invasion of disease into organs - liver, brain metastases
surgery
treatment related - radiation, chemotherapy

Question 2

Types of pain

Answer 2

many have combo of acute and chronic pain

Question 3

Assessment of pain: OPQRSTU

Answer 3

O: what is the onset of pain
P: what provokes the pain
Q: what is the quality of pain
R: does the pain radiate
S: how severe is the pain
T: time of pain
U: understanding and impact
do you have other sx associated with pain?; are you having regular bowel movements?; what meds have you used in the past?; any med allergies?

Question 4

Principles of pain management

Answer 4

understand the cause of pain
systematic approach consisting of: regular administration of around clock agents combined with PRN agents
individualized therapy; necessary to monitor for therapeutic and AEs; use lowest dose necessary
pain assessment is subjective

Question 5

Level 1 pain: 2-3 on scale

Answer 5

non-opioid +/- adjuvant

Question 6

Level 2 pain: 4-6 on scale

Answer 6

opioid for mild to moderate pain +/- non-opioid +/- adjuvant

Question 7

Level 3 pain: 6-10 on scale

Answer 7

opioid for moderate to severe pain +/- non-opioid +/- adjuvant

Question 8

Common pharmacologic options

Answer 8

opioids (~7-10)
combination products/mild opioids (~4-6)
non-opioids (~1-3)

Question 9

Opioids

Answer 9

don’t have a max dose!
morphine, oxycodone, hydromorphone, fentanyl, methadone

Question 10

Combination products/mild opioids

Answer 10

hydrocodone/acetaminophen
hydrocodone/ibuprofen
tramadol
codeine/acetaminophen
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
have max dose b/c of tylenol and ibuprofen component

Question 11

Non-opioids

Answer 11

acetaminophen
aspirin
ibuprofen
have max dose b/c of tylenol and ibuprofen component

Question 12

Morphine

Answer 12

metabolized in liver to morphine-3-glucoronide, morphine-6-glucoronide, normorphine, and codeine; metabolites are excreted renally and will accumulate in renal insufficiency
use with caution in liver dysfunction
dosage forms: short and long-acting tabs, solutions, IV, PR

Question 13

Hydromorphone

Answer 13

metabolized in liver to hydromorphone-3-glucoronide, 6-hydroxy metabolites; all renally excreted; give lower doses or longer dosing intervals in renal insufficiency
use with caution in liver dysfunction
dosage forms: short and long-acting tabs, solution, IV, PR

Question 14

Oxycodone

Answer 14

metabolized by CYP2D6 to combo of conjugated and free oxycodone, nor-oxycodone, and oxymorphone
over sedation and CNS toxicity in renal failure pts
use with caution in liver dysfunction
dosage forms: short and long-acting tabs, solution, NO IV

Question 15

Fentanyl

Answer 15

metabolized in liver primarily to nor-fentanyl
appears safe in renal dysfunction because no active metabolites are renally cleared, also safe in liver dysfunction
dosage forms: patch, IV, buccal, nasal spray, lozenges
great alternative in pts with: refractory N/V; head/neck/esophageal cancer pts who may not be able to maintain PO intake

Question 16

Fentanyl REMS

Answer 16

risks of addiction, abuse, and misuse
respiratory depression
accidental exposure to duragesic
avoid direct external heat sources at application site
don’t start pt on patch if opioid naive

Question 17

Methadone

Answer 17

consider for pts: with true morphine allergy, with opioid induced ADRs, with pain refractory to other opioids, with neuropathic pain, who need long-acting oral dosage form at low cost
avoid in pts with: numerous drug interactions, risks for syncope or arrhythmias, h/o unpredictable adherence, poor cognition

Question 18

Methadone metabolites

Answer 18

are excreted in urine and feces
no AEs in pts with renal failure
NOT advised in severe liver dysfunction
very unpredictable half-life; risk of QT prolongation

Question 19

Common toxicities of pain meds

Answer 19

constipation
sedation
N/V
pruritus
hallucinations
confusion/delirium
myoclonic jerking
respiratory depression

Question 20

Managing constipation

Answer 20

always add bowel regimen when opioid therapy is initiated! - mild stimulant laxative/stool softener
pts do NOT develop tolerance to constipation!

Question 21

Managing sedation

Answer 21

tolerance usually within a few days
hold sedative/anxiolytics
consider dosage reduction

Question 22

Managing nausea/vomiting

Answer 22

change opioid
consider addition of sheduled anti-emetic therapy

Question 23

Managing pruritus

Answer 23

most often seen with morphine
decrease dose or change opioid
consider addition of scheduled anti-histamine therapy such as diphenhydramine

Question 24

Managing hallucinations

Answer 24

decrease dose or change opioid
consider adding neuroleptic med

Question 25

Managing confusion/delirium

Answer 25

decrease dose or change opioid
consider adding neuroleptic med

Question 26

Managing myoclonic jerking

Answer 26

may be sign of toxicity
consider changing opioid or treating underlying causes

Question 27

Managing respiratory depression

Answer 27

sedation precedes respiratory depression
hold opioid
give low dose naloxone if on opioids for chronic pain

Question 28

Different therapeutic options

Answer 28

patient controlled analgesia
celiac plexus block
intrathecal pain pump
radiation therapy
bisphosphonate therapy

Question 29

Patient controlled analgesia (PSA)

Answer 29

pt demands +/- basal infusion of opioid with a lockout interval - pt can’t receive additional drugs more than the prescribed limits
pt must be awake + oriented to self administer; ONLY the pt can press the demand button
use with caution in pts with sleep apnea
pt in 1st 24 hrs after surgery have highest risk of over sedation and respiratory depression

Question 30

Common PCA regimens in opioid-naive pts

Answer 30

use caution with continuous basal dosing initially for opioid naive pts

Question 31

Adjusting PCA pumps

Answer 31

cut or stop basal rate when pt no longer needs it
if they have received multiple boluses, then increase basal rate
to assess total usage: total 24-hour dose (basal + # of hits used) to determine changes in therapy

Question 32

Once PCA is controlled, how to change?

Answer 32

step 1: calculate 24 hour dose of current drug
step 2: convert to an equi-analgesic 24 hour dose of new agent using convesion chart
step 3: reduce dose by ~25% to account for incomplete cross-tolerance and titrate up
step 4: divide total 24 hour dose into appropriate dose
step 5: always add breakthrough PRN dosing, generally 10-20% of total 24-hour oral dose available q4h PRN (same drug is recommended)

Question 33

Celiac plexus block

Answer 33

used commonly in patients with pancreatic cancer due to involvement of celiac plexus, which is a group of nerves that supply organs in abdomen
nerves are deactivated, pain relieved for 3-5 months

Question 34

Intrathecal pain pump

Answer 34

used in pts refractory to opioids or increased toxicities - especially in pts who aren’t obtaining relief with elevated doses of opioid therapy
can use smaller doses of opioids when delivered intrathecally
tubing in CSF or spine deliver intrathecal meds - morphine, hydromorphone, fentanyl, clonidine, baclofen, ziconotide, bupivacaine

Question 35

Radiation therapy commonly used in

Answer 35

painful bony metastases, brain metastases, spinal cord compression

Question 36

Adjuvant pain therapy alternatives

Answer 36

dexamethasone, NSAIDs (work well for bony metastases
don’t treat anxiety/depression with opioids

Question 37

Treatment planning for determining therapy

Answer 37

performance status
histology
staging

Question 38

Performance status

Answer 38

activities of daily living
Karnofsky scale, eastern cooperative oncology group

Question 39

Histology

Answer 39

tissue required for treatment
cell type and features indicating primary tumor site is essential

Question 40

Staging

Answer 40

guides therapy and prognosis for a given tumor type

Question 41

Evaluating response: RECIST criteria

Answer 41

response evaluation criteria in solid tumors
complete response: disappearance of all target lesions
partial response: 30% decrease in sum of longest diameter of target lesions
progressive disease = 20% increase in sum of longest diameter of target lesions
stable disease: small changes that don’t meet above criteria

Question 42

Assessing toxicity

Answer 42

common toxicity criteria by cancer research groups
based on scale of 0-4 with 4 being most severe toxicity and 5=death
grade III and IV considered in phase I trials to determine dose limiting toxicity