Pain In Cancer Management

Question 1

WHO analgesia guidelines:

Answer 1

1. By mouth
2. By the clock
3. By the ladder

Question 2

Analgesia administration routes

Answer 2

PO, Transdermal
SC
Sublingual (If eliminated first pass)
Rectal
Inhaled:methoxypenthol
Topical
Intranasal
Epidural
Intrathecal
Ventrcularly

Question 3

Which Meds wiped out first pass metabolism?

Answer 3

Bupremorphine

Fentanyl

Question 4

When move away from oral route?

Answer 4

Dysphagia
Gastric Tumours
Bowel obstruction

Question 5

Fentanyl used when?

Answer 5

Kidney failure

Older individuals

Question 6

Morphine orally lasts how long? (Non extended release)

Answer 6

4 hours

Question 7

Ladder of analgesia

Answer 7

1st rung: simple analgesia, NSAIDS
2nd: weak opiates: codeine, tramadol, tapentadol
3rd: strong opiates: morphine, fentanyl, hydromorphine(strongest), oxycodon/norm/contin, methadone, MS Contin
4th:

Question 8

Conversion of hydromorphone?

Challenge of using hydromorphone?

Answer 8

50 morphine is 10 of hydromorphone

Challenge is initiating ppl on it

Question 9

Methadone features and MOA:

Answer 9

Full agonist at Mu receptors
Lasts 5-150 hours based on genetics
Prevent withdrawals/cravings from opiate abuse
NMDA receptor blocker
Can be used in neuropathic pain

Question 10

Targin is:
What is Max Dose?
Probs?

Answer 10

Oxycodone + naloxone

40/20 bd

Probs: cancer, cirrhosis, liver needs to be good

Question 11

Pethidine probs?

Answer 11

poor Promotes convulsions
Good anxiolytics
Very addictive

Question 12

Codeine probs?

Answer 12

Attached to paracetomol so can OD on paracetomol
Reliant on CYP 2D6 conversion to morphine.

Erratic due to racial groups.
Constipates you.
VERY addictive.

Question 13

Side effects of opiates

Answer 13

N/V - 40% (can be given metaclopramide)
Constipation (must give with Aperients - titrate)
Respiratory depression
Pruritus
Less saliva: poor dentition due to methadone syrup
Tolerance
Cerebral dysfunction, myoclonus: toxicity sign
Immune suppression
?bone metastasis (in vitro)
Bone density
Hypothyroid, gonadal, Hypothalamus-Pituitary-adrenal Axis.
Opioid induced hyperalgesia (see it within hours)

Question 14

What is toxicity sign of opioids?

Answer 14

Myoclonus

Cerebral dysfunction: hallucination

Question 15

Longer and more you’re on, more likely to get what side effect of opioid?

Answer 15

Opioid induced hyperalgesia

Question 16

what is Analgesic adjuvants? Eg.?

Answer 16

Provides analgesia even though it’s primary purpose isn’t analgesia

Eg. 
Antidepressants: TCA, Clonidine
NMDA - ketamine
Anticonvulsants: Topiramate (migraine), (carbamazepine - trigeminal neuralgia)
Steroids

Question 17

Clonidine is?

Answer 17

A2 adrenergic agonist

Increased descending signal from brain to decrease pain

Question 18

Ketamine SFx?

Answer 18

Hallucinations (Happy in kids, frightening in adults)

Gait

Question 19

Topiramate used for

Answer 19

Migraine

Question 20

Carbamazepine adjuvant for what?

Answer 20

Trigeminal

Question 21

Steroids as adjuvants affects how?

Answer 21

Mainly dexamethasone

Euphorics
Appetite
Decreased oedema

Question 22

When especially specifically use steroids for pain?

Answer 22

Brain tumour (raised ICP)
Spinal cord compression

Question 23

How much of bone must be missing to show up on X-ray for eg. metastasis?

Answer 23

40%

Question 24

What investigations if think metastasis of vertebra?

Answer 24

CT

Bone scan

Question 25

NSAIDS SFX

Answer 25

Fluid retaining (CCF)
Pro-thrombotic
Kidney
Gastritis: Diarrhoea, mouth ulcers

Question 26

What dose to start someone on opioids?

Answer 26

10mg OxyContin BD, titrate as needed

Question 27

Cancer analgesics

Answer 27

Treat or shrink the tumour.
Radio, immuno, chemo, surgical
Psycho
Rehab
SNAP
Complimentary/alternatives
EnvironMent
Acupuncture

Question 28

Immediate pain management for someone who’s really in distress

Answer 28

PCA (maybe)
Fentanyl (but REALLY short acting)

5mg SC or IV morphine, oxycodone, give another 5 if needed but depends on patient