Pain, bone mets, and spinal cord compression Flashcards
cancer pain %’s
30-50% during tx
70-90% when advanced CA
universal screening for all pts
barriers to adequate pain mgmt
#patient and family related #provider related #system related
quantify pain intensity and characterize quality in pain
location, quality, pain hx, etiology, response to current tx, medical hx, psychosocial, risk factors for undertreatment, physical exam, lab, imaging studies
rating scales for pain
numerical, categorical, visual analog scale (10cm line with descriptions), faces
PQRST algorithm for characterizing pain
P=palliative (what makes pain better?) and provacative (what makes worse)
Q=quality (somatic vs neuropathic description)
R=radiation (where is the pain, local vs diffuse/systemic)
S=severity/intesity (how does it compare with other pain you have experienced)
T=temporal (intensity changes with time, certain activities, nightime only)
what makes cancer pain different? (3pts)
#unique combination types (somatic, visceral, neuropathic, chronic, acute) #source of pain (tumor vs treatment induced) #pain progression (ofter linked to tumor progression)
WHO pain relief ladder
1= non-opiod up to 3=epidural
NSAIDs
#antipyretic, analgesic, anti-inflammatory #ceiling effect for analgesia #no tolerance or dependence #best for nociceptive pain #individual response varies
NSAID ADR
#GI, MI #heme (dec plt aggregation, caution if existing or anticipated thrombocytop) #renal - dec GFR (caution if other agents are also renal tox, cisplatin, HD mtx)
COX-2 dose and ADR
100-200mg bid celecoxib
no anti-platelet effects, reduced GI irritation, CV effects black box waring (avoid if co-morbid)
rofecoxib removed because of CV eventss
skin rxns rash, mouth sores
preferred opioids for renal failure
fentanyl, methadone
why methadone?
#prolonged duration of action with repeated dosing up to 40 hours, antagonizes NMDA, blocks reuptake of 5HT and NE #can use in renal failure (lack of neuroactive metab) #good bioavail CAUTION: equianalgesic conversion difficult, qt prolongation
example methadone conversion
300mg = 12:1
tramadol
#low affinity for mu-receptor #inhibits reuptake of NE and 5HT #lowers seizure threshold #no ceiling effect
codeine
#N/V is dose limiting #CYP2D6 poor metabolizer minimal conc of morphine ->minimal effect: ultra rapid -> risk of tox
meperidine
#avoid #short DOA #lowers seizure threshold
propoxyphine - PULLED FROM MARKET 2010
questionably efficacy, neuroactive metab, short DOA
is nausea less common in the elderly for opioids?
Yes
respiratory failure “warning signs
pain control ->somnolence -> respiratory depression
why do pts >65yo have 2-fold higher incidence of constipation?
sedentary lifestyle, dec bowel motility, concurrent medications
use softener +stimulant
how long until methylnaltrexone works?
majority 1-2 hours, then up to 4 hours
works for 50%
response to opioid adverse effects
- decreased dose by 25-50%
- opioid rotation
- add additional med to control side effect
general principles of opioid conversion - why are you changing
- lack of efficacy (why not inc dose)
- intolerable side effects (why not treat effect)
- change in pt status
- practical considerations (cost)
opioid conversion codeine
30mg po MS = 200mg po codeine
general principles of opioid conversion - dosing
indiividualize: cut back 25%, straight, inc 25%
prn dose should equal AT LEAST 100% of long acting pdt (can use for PCA hourly dosing too)
opioid MYTHS
#amount of pain relief has a ceiling #more potent are more superior #often leads to dependence/addiction
addiction definition (often confused with other terms such as physical dependence / psychological dependence)
dependence on the regular use of a substance to satisfy physical, emotional, and psychological needs DESPITE harm
duloxetine for chemotherapy induced neuropathy
sig improvement in average decrease in pain score vs placebo
duloxetine had increased sedation
skeletal complications due to bone mets (7pts)
pain, pathologic fx, hyperca++, spinal cord compression, bone marrow infiltration, nerve root compression, reduced mobility and qol
bisphosphonate MOA
inhibit osteoclast maturation and function (affinity for areas of osteolysis)
bisphosphonate proven reduced SRE in these dz’s
breast CA, MM, prostate CA, other solid tumors
bisphosphonate renal dysfunction
guidelines vary by agent and cancer type (SEE HANDOUT)
ASCO MM bisphosphonate guidelines
check 24h urine for Cr, albumin, and azotemia q3-6 mo; HOLD tx is albumin in urine >500mg/24h
bisphosphonate lab monitoring
SCr before each dose
periodic electrolytes, Ca, phos, Mg (last 3 hypo), Hgb/Hct
recommend 500mg Ca daily supplement
bisphosphonate ADR
#myalgias, arthralgias, flu-like sx (usually within 48h of 1st/2nd dose, manage with NSAIDs) #ocular effects #?a fib #ONJ- incidence unknown, 2.9-9.9%, probably underdiagnosed, incidence rare if less than 12 months exposure, zolpidem > risk than PAM
ONJ stage 1 management
antibacterial mouth rinse, 3mo f/u, pt education, review continued need for BP
ONJ stage 2 management
symptomatic tx with systemic abx, abx mouth rinse, pain control, superficial debridement to relieve soft tissue irritation
ONJ stage 3 management
symptomatic tx with systemic abx, abx mouth rinse, pain control, SURGICAL debridement for long- term palliation of infx and pain
to minimize ONJ risk
dental exam prior to starting tx, avoid dental procedures during tx if possible as dental surgery may exacerbate risk, no data to suggest stoping BP reduces risk
denosumab MOA and dosing
human IgG2 monoclonal antibody that binds to RANK ligand
120 mg SQ q4wks
denosumab vs ZA phase III
superior in delaying or preventing SRE in breast CA and CRPC
NONinferiority for MM and other solid tumors
denosumab advantages (2pts)
SQ admin (do not need infusion center), no concerns about renal dysfunction FYI: same ONJ risks
spinal cord compression basics
5-10% of pts with malignancy, progressive radicular pain which is followed by neurologic sx, MRI preferred imaging method
spinal cord compression - management
spinal column involvement largely incurable
GOALS: relieve pain, preserve or improve function, provide local control, stabilize spine
spinal cord compression - steroids
immediate administration increases number of ambulatory pts after XRT - 81 vs 63%
dex is DOC: minimum 4mg q6h (10-100mg range)
spinal cord compression - surgery followed by XRT
preferred (level I) as increased ability to regain ambulatory function BUT significant morbidity and mortality issues with surgery-> careful pt selection based off of life expectancy and overall health
spinal cord compression - XRT alone
#excellent response rates if not surgery candidate #35% of non-ambulatory pts regain walking ability #efficacy depends on histology (heme malig > solid tumors)
NEED TO STUDY
ONJ Guidelines for monitoring BP’s
