Pain in Palliative Care: Treatment Flashcards
how is pain classified? what is the tool?
ESAS-r on a scale of 1-10
what is indicated for an ESAS-r 1-3
nonopioid + adjuvant
what is indicated for an ESAS-r 4-6
opioid like codeine or tramadol + nonopioid + adjuvant
what is indicated for an ESAS-r 7-10
opioid like morphine or hydromorphone + nonopioid + adjuvant
the WHO analgesic ladder was originally developed for
cancer pain
____ should be rx along with opioids
laxatives
which step is often questioned in the WHO analgesic ladder
step 2- insuff evidence that weak opioids better than NSAIDs
which WHO step may be skipped if pain is rapidly prorgessing
step 2
BTP is usually dosed by
10% of TDD q1h PRN
what meds are used for step 1 of ladder
acetaminophen + NSAIDs
max ST acetamiophen dose
4g/d
max LT (>7d) acetaminophen dose
3g/d
acetaminophen dose of 2g/d or avoid should be done for pts with
heavy alcohol use
malnutrition
LBW
advanced age
febrile illness
advanced liver disease
intx meds
T or F: NSAIDs are v robust for bone pain
F- not as good as previously thought but still benefit in soem cases
NSAID AEs limit use in
frail elderly, those with increased bleed risk (GI, kidney)
T or F: if opioids are started too early and pain worsens at EOL, there may be no alternative
F- pain doesn’t always increase at EOL- can always rotate opioids
T or F: opioids are v sedating
F- can be at the beginning but most overcome this in a few days
a pain pt has requested a naloxone kit as they use fentanyl. what should you tell them
using naloxone may cause pain crisis
codeine is ___ as potent as morphine
10%
codeine is metabolized by
CYP2D6
codeine starting dose
8-15yrs
max codeine dose
300-400mg
tramadol MOA
Weak opioid + inhibitor of NE and 5HT uptake
tramadol starting dose
50-100mg q6hr
maz tramadol dose
400-600mg daily
caution with ____ and ____ with tramadol due to lowered seizure threshold
TCAs
SSRIs
morphine starting dose
5-10mg PO q4h PO
hydromorphone starting dose
1-2mg PO q4h
oxycodone starting dose
2.5-5mg PO q4h
fentanyl starting dose
25mcg/h
fentanyl is ____x stronger than morphine
100
fentanyl is not active _______ (route)
orally
fentanyl routes of administration
injection
sublingual
patch
methadone is
1. a synthetic opioid
2. a hydrophilic opioid
3. a semisynthetic opioid
4. a lipophilic opioid
5. combo- state the combo
1, 4
methadone has _____ elimination
biphasic
methadone renal elimination is dependent on urinary ___
pH
methadone is a
____ agonist
____ antagonist __________ reuptake inhibitor
mu, k, delta agonist
NMDA angatonist
NE and 5HT reuptake inhibitor
methadone is metabolized by
CYP3A4, 1A2, 2D6
main methadone AE
prolongs QTc interval with doses of 300-600mg/d
what other agents result in cumulative QTc prolongation with methadone
levofloxacin, fluconazole, arsenic
advantages of methadone
Potent and effective
Inexpensive
Less neurotoxicities
Long half life (few daily doses)
Neuropathic pain (NMDA, NOR, 5HT)
Can be administered to those highly tolerant to other agents
Incomplete cross tolerance helps control intractable pain
Tablets and syrup commercial available
disadvantages of methadone
Kinetics unpredictable = prescribers must take a course
Rectal and injectable forms not commercially available = must compound
can methadone be used with other opioids? what might be some advantages/ issues?
yes- as a coanalgesic
doesn’t require the full 4 day rotation or expertise
but pt doesn’t get full benefit of methadone + more difficult to determine orgins of toxicity with more than one opioid o nboard
T or F: an ambulance must still be called if naloxone was given
T
what are some classes used as adjuvants in cancer pain
NSAIDs/ acetaminophen
gabapentinoids
antidepressants
corticosteroids
gabapentin and pregabalin for cancer pain mostly targets ______ pain
neuropathic
gabapentin dosing for neuropathic pain
start at 100-300mg hs and increase to 900-3600mg/d in 2-3 div doses
pregabalin dosing for neuropathic pain
25-75mg po bid and increase up to 300mg po bid
which antidepressants can be used as an adjuvant for cancer pain
TCAs
duloxetine
corticosteroids are used in cancer pain for ___, ___, and _____ pain
bone, neuropathic, and visceral pain
CS is cancer pain are usually used for ___ courses of ___wks to manage pain crisis
short
1-3wks
what is the CS fo choice for cancer pain
dexamethasone
which of the following if false about dex
1. Minimum mineralocorticosteroid effects
2. causes less fluid retention
3. first line corticosteroid for cancer pain
4. increases risk of GI ulceration
4- only if taken with NSAIDs
why might BPs be used in cancer pain
to prevent skeletal fractures
caution with BP use in ___
renal impairment
T or F: clodronate is usually tolerated fine
F- 4 large capsules on empty stomach + no food 1hr after + cant lie down
AEs of BPs
flu like sx
osteonecrosis of mandible with pamidronate and zoledronic acid
