Pain management Flashcards
What are causes of ACUTE cancer pain
- Diagnostic procedures (I.e., biopsies)
- Therapeutic procedures
(chemo, radiotherapy, immunotherapy, myeloid growth factors, hormone therapy) - Post-operative pain
- Infection
- Tumor-related pain (more common in metastatic disease)
What does chemotherapy pain present as?
Causative agents? (3)
Onset?
Management (2)
Neuropathy
- taxanes
- oxaliplatin
- Vinca alkaloids
Onset
- weeks to months after starting treatment
Management (trouble with daily activities)
- Reduce dose 20-30%
- Add pregablin/gabapentin/duloxetine
Taxane-associated pain syndrome (TAPS)
Causative agent (1)
Presentaiton (3)
Onset, duration
Causative agent (1)
- Paclitaxel
Presentaiton (3)
- Diffuse, achy myaglia
- arthralgias
Onset
- 24-48h after admin
- last up to 7 days
What are good treatment options for TAPS (3)
Acetaminophen
Gabapentin
Loratadine
AVOID NSAIDs (increases risk of bleeding) and OXYCODONE (not ideal)
Note: Prednisone can be used in theory – but not common in practice.
What kind of pain for myeloid growth factors present with
Causative agents (2)
Management (2)
Causative agents
- Filgrastim
- pegfilgrastim
Presentation
- Bone pain in large bones (legs, back, femur, skull, ribs)
Management (2)
- Acetaminophen
- Steroids
- can use opioids
What is the management of G-CSF (granulocyte colony-stimulating factor) related pain
Use Loratadine
- It has mixed results (worked in some trails and not in others)
- BUT it has minimal s/e - so it is worth trying
Which hormonal therapies cause the most pain
Presentation (2)
Mostly from aromatase inhibitors:
- Anastrozole
- Letrozole
- Exemestane
(tamoxifen less common)
Presentation
- Arthralgia/joint pain
- Asymmetrical pain
Management of hormonal pain
1st line
Pain <5/10
Pain 6+/10
1st line
- lifestyle modifications
- exercise/ weight loss/OT/PT
Pain <5/10
- Acetaminophen
- NSAIDs
- Cox2
Pain 6+/10
- Opioids
**can also consider switching classes
What are causes of CHRONIC cancer pain (5)
- Neoplastic involvement of viscera, bones, or nerves
- Lymphedema
- Post-surgical nerve damage
- Spinal cord compression (emergency)
- Paraneoplastic pain syndromes (tumour producing something causing pain)
What are causes of lymphedema (4)
- Surgical removal of lymph nodes (breast cancer arm lymph nodes removed)
- Damage to vessels
- Radiation
- Chronic venous insufficiency
What are causes of paraneoplastic pain (2)
Presentation (2)
- Caused by heightened immune response to tumor affecting normal tissue
- Most common caused by lung, breast, ovarian cancers
Marked by:
- Neuropathy/nerve damage
- Dermatomyositis
What scale is used to calculate pain severity
What does it look at?
ESAS scales (part of nurses assessment)
- Looks at pain, mood, neuropathy, nausea, etc.
- For pain, we have patients indicate where the pain is
Which non-opioid analgesic do we use
Caution (4)
Acetaminophen
Caution in:
- Malnutrition
- Impaired liver function
- liver cancer
- myleosupression
**Avoid NSADIs
What are advantages (4) and disadvantages (2) of using opioids
Advantages
- Predictable ADRs
- No ceiling dose
- Equianalgesia (can easily convert doses)
- Few drug interactions (avoid meperidine, tramadol, methadone)
Disadvantages
- Bad reputation
- Patients/clinicians reluctant to take/give due to severity of ADR, addiction, masking disease
What considerations do you have to take when dosing for opioids
- Elderly/renal impairement
- Hepatic impairment
- Caution with morhphine/hydromorphone (can accumulate)
Fentanyl
When to use
Contraindication
Peak concentration
When to use
- If patients on >60mg/day of po morphine
Contraindication
- opioid-naïve patients or unstable pain
Peak concentration
- 24-36 hours
- Blood levels continue to rise with 2-3 consecutive applications
Methadone considerations
Use?
Half-life? bioavailability
- in adjunct to existing pain management or in place of them
- Long half-life, variable bioavailability
- MANY DDIs
- Do not use if you cannot dose titrate
What are some ADRs of opioids (8)
- Sedation (subsides in 3-7 days)
- Constipation
- Mycoclonus (spasm)
- Hyperalgesia (sensitive to pain)
- Respiratory depression
- N/V (subsides in 1 week)
- Pseudoallergy (from histamine release)
- Anaphylaxis (rare)
Management of N/V in opioids (3)
PRN:
- Prochlorperazine
- Metoclopramide
- Dimenhydrinate
(due to reduced gut motility)
Management of Constipation in opioids
Drug of choice: PEG
- May consider senokot (8 tabs/day)
Docusate sodium is used by physicians (but not recommended)
AVOID bulk forming agents (risk of obstruction)
Treatment for chronic cancer neuropathic pain
Anticonvulsants
- Gabapentin
- Pregablin
(initiate low and titrate up)
Antidepressants
- TCA (amitriptyline etc..)
- SNRI (venlafaxine, DULOXETINE)
- SSRIs (paroxetine, fluoxeitine, sertraline)
(initiate low and titrate up)
Do not increase dose more frequently than q3-5 days
Lamotrigine (anticonvulsant) dosing
Lamotrigine requires more slow titration (due to risk for SJS if titrated too quickly)
ADRs for gabapentin/pregablin (2)
- Drowsiness
- Edema
ADRs for carbamazepine/oxcarbazepine (3)
- myelosuppression
- hepatic changes
- Rash
ADRs for SSRIs and SNRIs
- Nausea, insomnia, restlessness
- Sexual dysfunction
- hypertension (venlafaxine)
**MAY GET ADR BEFORE BENEFIT
- benefit (3-4 weeks)
What are potential pros of medical cannabis (3)
- Pain relief without opioid
- Appeitite stimulation
- Sleep improvement
When is palliative sedation used?
What agents (2)
Reasons for use:
- agitation/restlessness, severe pain, confusion, respiratory distress
- last 2-4 days of life
- Consent of patient or surrogate required.
Goal: Make patient comfortable (it does NOT shorten their life)
Agents:
- Midazolam
- propofol
