Supportive care II Flashcards
Why do cancer patients have pain?
Cancer itself
invasion of disease into nerves
invasion of disease into organs
surgery
treatment related - radiation and chemotherapy
Assessment of pain: OPQRSTU
Onset of pains?
what Provokes the pain?
what is the Quality of pain?
Does the pain Radiate
How Severe is the pain?
Time of pain
Understanding and impact
stepwise approach to treatment
1- Non-opioid +/- Adjuvant
2- Opioid for mild to moderate pain +/- Non-opioid +/- adjuvant
3- opioid for moderate to severe pain +/- non-opioid +/- Adjuvant
Morphine
Prodrug
Not for patients with renal problems
use in caution with those with liver dysfunction
Dosage forms: short acting tablets, long-acting tablets, solutions, IV, PR
Hydromorphone
renally excreted - lower dosing and longer dosing intervals in renal insufficiency
use with caution in liver dysfunction
Dosage forms: short acting tablets, long-acting tablets, solution, IV, PR
Oxycodone
Metabolized by CYP2D6
Over sedation and CNS toxicity have been reported in renal failure patients
use with caution in liver dysfunction
Dosage forms: Short acting tablets, long acting tablets, solution, NO IV formulation
Fentanyl
SAFE for renal and liver dysfunction
Dosage form: Patch, IV, Buccal, nasal spray, lozenges
great alternative for: Patients with refractory nausea/vomiting
patients with head/neck/esophageal cancer who may not be able to maintain adequate PO intake
REMS protocols
Methadone
Excreted in the urine and feces, Not advised in severe liver dysfunction, RISK of QTC prolongation
This would be a good alternative for patients that have a morphine allergy, opioid induced ADRs, pain refractory to other high dose opioids, neuropathic pain, or those who need long acting oral dosage for a low cost
Avoid in patients with numerous drug interactions, those with risk of syncope or arrythmias, history of unpredictable adherence, poor cognition
Common Toxicities and how to treat them
Constipation - always add stimulant laxative
Sedation - tolerance typically develops within a few days
N/V - change opioid, or add anti-emetic
Pruritus (itching) - most often seen with morphine administration
Hallucinations - decrease the dose of the opioid
Confusion - decrease dose
Myoclonic jerking - May be a sign of toxicity (change
Respiratory depression
Celiac Plexus block
used commonly in patients with pancreatic cancer due to involvement of celiac plexus
Intrathecal pain pump
used in patients who are refractory to other opioid therapy or increased toxicities
uses much smaller doses of opioids
can be used intrathecal: morphine, hydromorphone, fentanyl, clonidine, baclofen, ziconotide, bupivacaine
initial dose is usually 0.2-1m/day
Adjuvant pain therapy alternatives
Dexamethasone
NSAIDS
Pregabalin, gabapentin for neuropathic pain
ECOG performance status (PS)
0= fully active, able to carry on all pre-disease performance without restriction
1= restricted in physically strenuous activity, but ambulatory and able to carry out work of light and sedentary nature
2= ambulatory and capable of all self care but unable to cary out any work activities
3= capable of only limited self-care, confined to bed or chair more than 50% of waking hours
4= completely disabled. cannot carry on any self-care and totally confined to bed or chair
5= dead
RECIST Criteria
