Supportive Care II

Question 1

Assessment of Pain: OPQRSTU

O: onset
P: What ___ the pain? What causes the pain? What makes it better/worse?
Q: What is the ___ of pain? What does it feel like? Give a descriptor. This will help determine the type of pain and how to treat
R: Does the pain ___?
S: How ___ is the pain? On a scale of 0-10 with 0 being no pain and 10 being
the worse pain in your life, how would you rate it?
T: ___ of pain. When did the pain start? How long does it last?
U: ___ and Impact:

Is this pain affecting your activities of daily living/interactions with family? Appetite? Sleep? Mood? Anxiety?

Answer 1

• provokes
• quality
• radiate
• severe
• time
• understanding

Question 2

Common Pharmacologic Options

Opioids (~ 7-10)
- (5)

Combo Products/Mild Opioids (~4-6)
- (6)

Non-opioids (~1-3)
- (3)

Answer 2

Question 3

PRN vs ATC dosing

Answer 3

Question 4

Opioid Therapy

morphine
- most familiarity
- metabolized in the ___
- metabolites excreted ___ and will accumulate in insufficiency (not appropriate)
- use caution with ___ dysfunction
- dosage forms - short and long acting tabs, solutions (regular and concentrated), IV, PR

Answer 4

• liver
• renally
• liver

Question 5

Opioid Therapy

hydromorphone
- metabolized by ___
- metabolites ___ excreted
- would suggest lowering doses or longer dosing intervals in ___ insufficiency
- use with caution in ___ dysfunction
- dosage forms: short and long acting tabs, solution, IV, PR

Answer 5

• liver
• renally
• renal
• liver

Question 6

Opioid Therapy

Oxycodone
- metabolized by ___
- Over sedation and CNS toxicity have been reported in ___ failure patients
- Use with caution in ___ dysfunction
- Short acting tablets, long-acting tablets, solution, no ___formulation

Answer 6

• CYP2D6
• renal
• liver
• IV

Question 7

Opioid Therapy

Fentanyl
- metabolized in the ___
- appears to be safe to use in ___ dysfunction because no active metabolites are ___ cleared
- also appears safe in ___ dysfunction
- Dosage forms: Patch, IV, buccal, nasal spray, lozenges

Great alternative in patients:
- Refractory ___
- Head/neck/esophageal cancer patients who may not be able to maintain adequate ___ intake

___ protocols for transmucosal and nasal preparations
- black box warnings

Answer 7

• liver
• renal, renally
• liver
• N/V
• PO
• REMs

Question 8

Opioid Therapy

Methadone
consider for patients with:
- true ___ allergy
- opioid induced ADRs
- pain ___ to other opioids (high doses)
- with ___ pain
- who need long acting oral doseage form at a low cost

avoid in patients
- numerous drug reactions
- risks for syncope or ___
- history of unpredicatble adherence
- poor cognition

Answer 8

• morphine
• refractory
• neuropathic
• arrhythmias

Question 9

Opioid Therapy

Methadone
- metabolites are excreted in the urine and feces
- no reported adverse effects related to methadone in patients with ___failure
- not advised in severe ___ dysfunction
- t1/2 very ___ (8-59hrs)
- risk of ___ : assess other meds

Answer 9

• renal
• liver
• unpredicatable
• QT prolongation

Question 10

• There are no ___ doses with opioids
• Treat with the ___ starting dose that is needed
• Use around the clock agents when needed with agents for ___ pain
• When switching between agents, may dose reduce by ___% due to cross tolerance

Answer 10

• max
• lowest
• breakthrough
• 25%

Question 11

common toxicities and management

Constipation
- always add a bowel regimen
- mild ___ laxative +/- stool softener

Answer 11

stimulant

Patients do not develop tolerance to constipation!

Question 12

common toxicities and management

Sedation
- ___ typically develops within a few days
- hold sedatives and/or anxiolytics
- consider a dosage reduction

Answer 12

• tolerance

Question 13

common toxicities and management

N/V
- Change opioid
- Consider the addition of scheduled anti-emetic therapy (example: __ or __ )
- Often this is a transient side effect that resolves in 7 to 10
days

Answer 13

• metoclopramide
• prochlorperazine

Question 14

Common Toxicities and Management

pruritus
- Most often seen with ___ administration
- Decrease the dose or change opioid
- Consider the addition of scheduled anti-histamine therapy such as __

Answer 14

• morphine
• diphenhydramine

Question 15

Common Toxicities and Management

Hallucinations/Confusion/Delirium
- decease to dose/change opioid
- Consider the addition of a ___ medication to the regimen

Answer 15

neuroleptic

Question 16

Common Toxicities and Management

Myoclonic Jerking
- May be a sign of ___
- Consider changing opioid or treating underlying causes

Answer 16

toxicity

Question 17

Common Toxicities and Management

Respiratory Depression
- ___ precedes respiratory depression
- Hold opioid
- Give low dose ___ if on opioids for chronic pain
- ___ 1 mL 0.4 mg/mL naloxone with 9 mL 0.9% sodium chloride
- Give 0.02 mg/0.5 mL naloxone slowly IV Push over 2
minutes, titrate to effect
- Reassess patient every 15 minutes
- Many opioids have a longer half life than naloxone which
requires re-dosing

Answer 17

• sedation
• naloxone
• dilute

Question 18

Different Therapeutic Options

• PCA
• Celiac ___ block
• Intrathecal pain pump
• ___ therapy
• ___ therapy

Answer 18

• plexus
• radation
• bisphosphonate

Question 19

Patient Controlled Analgesia (PCA)

• Patient demand +/- ___ infusion of opioid
  with a lockout interval
• Patient must be ___ and oriented to self administer their doses
• Use with caution in patients with ___
• Patients in the first 24 hours after surgery have the highest risk of over ___ and ___

Answer 19

• basal
• awake
• sleep apnea
• sedation, respiratory depression

Question 20

Patient Controlled Analgesia (PCA)

• Use caution with continuous ___ dosing initially for opioid naïve patients
• If a patient is on oral opioids and still in pain, convert to ___ and then ___ dose
• stop ___ rate when patient no longer needs it

Answer 20

• basal
• IV, increase
• basal

Question 21

Celiac Plexus Block

• Used commonly in patients with ___ cancer due to involvement of celiac plexus
• Celiac plexus: group of nerves that supply organs in the abdomen

Answer 21

pancreatic

Question 22

Intrathecal Pain Pumps

Used in patients who are ___ to
other opioid therapy or increased toxicities
- Used especially in patients who are not obtaining relief with elevated doses of opioid therapy
- Patients generally have more toxicities than benefit from traditional opioid therapy
- Use much ___ doses of opioids as
delivered intrathecally
- Typical initial intrathecal dose range
= ___ to ___ mg/day

Answer 22

• refractory
• smaller
• 0.2, 1

test dose first to make sure it
works before doing procedure

Question 23

Radiation Therapy

Radiation therapy is commonly used in:
– Painful ___ metastases, ___ metastases, spinal cord ___

Answer 23

• bony
• brain
• compression

Question 24

RECIST Criteria

___ Response (CR) = disappearance of all target lesions

___ Response (PR) = 30% decrease in the sum of the longest diamter of target lesions

___ Disease (PD) = 20% increase in the sum of the longest diameter of target lesions

___ Disease (SD) = Small changes that don’t meet above criteria

Answer 24

• complete
• partial
• progressive
• stable

Efficacy of treatment of solid tumors
evaluated with RECIST criteria