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Flashcards in 12 Cancer Pain Management Chow Deck (45):
1

What are the causes of pain in cancer patients?

Organ invasion/bone metastasis. Nerve damage. Endothelial/Vascular inflammation. Injection site pain. Perioperative pain

2

What is Nociceptive pain?

Result of nociceptor activation d/t injury to somatic and visceral structures. "Aching", "Throbbing", "Pressure", usually "Localized"

3

What are some examples of Nociceptive Pain?

Bruises, burns. Bone fractures/metastasis. Obstruction, inflammation

4

What is Neuropathic Pain?

Injury to central or peripheral nervous system. "Numb", "Tingling", "Shooting pain", "Electric Shock"

5

What are some examples of Neuropathic Pain?

Spinal stenosis. Diabetic neuropathy. Chemotherapy (Paclitaxel, Vincristine)

6

For the NCCN Adult Cancer Pain, what is done for Mild Pain (1-3)?

Non-opiods: Acetaminophen, NSAIDs. Re-evaluate at each contact

7

For the NCCN Adult Cancer Pain, what is done for Moderate Pain (4-6)?

Titrate short-acting opiods: Codeine, Tramadol, Morphine, etc. Reassess pain score within 15-60 minutes

8

For the NCCN Adult Cancer Pain, what is done for Severe Pain (7-10)?

RAPIDLY titrate short-acting opiod: Morphine, etc. Reassess pain score within 15-60 minutes

9

What is done for Opioid-Tolerant patients?

Calculate opioid usage for the previous 24hrs. Give 10-20% of previous 24hr-requirement as initial dose for breakthrough pain. Reassess efficacy (chain in pain score) and adverse effects

10

What is done for Maintenance opiod analgesics for CHRONIC cancer pain?

Consider converting to long-acting or extended release formulations. Provide around-the-clock AND breakthrough medications. Use the same opiod for extended-release and short-acting formulations if possible. Consider opioid conversion/rotation to provide adequate pain control and minimize side effects

11

What are "Mild" Opioids?

Tramadol, Codeine

12

What are "Strong" Opioids?

Morphine, Fentanyl

13

What are the 1st line analgesics for mild to moderate pain?

NSAIDs

14

What are the cons with NSAIDS?

Caution in patients with thrombocytopenia, bleeding disorder, or renal insufficiency. Many drug-drug interactions (e.g. decreases clearance of MTX)

15

What are some considerations with Acetaminophen use?

No anti-inflammatory properties. Caution in hepatic impairment. Often in combination pain medications (increased risk of accidental overdose). Anti-pyretic (increased risk of masking fever in neutropenic patients)

16

What are the characteristics of Codeine?

For acute pain. Prodrug of morphine with 5-10% conversion via CYP 2D6. Requires dosage adjustment based on renal function. Usual dose: 30-120mg PO Q4-6hrs PRN pain

17

What are the characteristics of Tramadol?

For acute pain. Weak m-receptor agonist, serotonin inhibitor, NE reuptake inhibitor. Usual dose: 50-100mg PO Q4-6hrs PRN pain (Max of 400mg/day)

18

What are some cautions with Tramadol use?

Decreases seizure threshold. Increases risk of serotonin syndrome with SSRI/MAOI

19

What are the general characteristics of Morphine?

Gold standard of opioid analgesics, in practice and in clinical studies. Many dosage forms. Oral and parenteral formulations are effective for acute pain; long-acting formulations are available for chronic pain management

20

What are the initial starting doses for Morphine?

PO: 5-15mg. IV/IM: 2-5mg. SQ: 2-5mg. For Opioid-tolerant patients: give 10-20% of 24hr-requirements as breakthrough dose

21

What are some general things to remember when using Opioid analgesics for Chronic Pain?

Oral route should be considered first. ATC, scheduled regimens are preferred for continuous pain control. "Rescue" doses of short-acting opioids should be available for breakthrough pain relief. Many oral "modified-release" products are available, in addition to transdermal delivery

22

What is MS Contin?

Controlled release morphine Q8-12h. Dual-control polymer matrix that consists of a hydrophilic polymer and a hydrophobic polymer

23

What is Kadian?

Sustained Release Morphine Q12-24h. Polymer coated extended-release pellets of morphine. Capsule may be opened and sprinkled onto applesauce; do not crush pellets

24

What is Avinza?

Extended Release Morphine: Q24h. An immediate release component and an extended release component. Capsule may be opened and sprinkled onto applesause; do not crush pellets. Not interchangeable with other extended-release morphine products

25

What is Exalgo?

Hydromorphone extended release. Usual dose: 8-64mg PO QD. Do NOT chew or crush tablets; avoid alcohol or sedatives

26

What is Fentanyl?

One of the most potent m-receptor agonists (100x morphine). Less histamine release effect vs. morphine (lower hypotension and flushing)

27

When is the Fentanyl transdermal patch used?

Only for OPIOID-TOLERANT patients receiving > 60mg PO morphine equivalent/day for 1 week or longer

28

When should you use caution with Fentanyl Transdermal Patch?

Patients with elevated body temperature (e.g. febrile, strenuous exercise)

29

What is Actiq?

Fentanyl Transmucosal Lozenge. Used for breakthrough cancer pain in opioid-tolerant patients

30

What is Fentora?

Fentanyl Buccal tablet

31

What are the key points about Fentayl Products?

Fentanyl patch is for the management of chronic pain in opioid-tolerant patients. Fentanyl lozenge, tablet, buccal soluble film, nasal spray products are for management of acute, breakthrough cancer pain in opioid-tolerant patients

32

What should you do because of incomplete cross tolerance?

If pain has been adequately controlled, reduce dose by 25-50% dose when switching between opioids

33

What are the exceptions for incomplete cross tolerance?

May not need dose reduction if patient has severe pain. No reduction when converting to transdermal fentanyl patch using conversion table. Larger reduction when changing to methadone, depending on opioid usage history. Larger reduction in elderly patients, or those with renal hepatic dysfunction

34

What are the side effects of opiate narcotics?

Nausea. Pruritus. Urine retention. Sedation. Delirium. Constipation. Respiratory depression

35

Which opiates have the highest constipation rate?

Morphine > Codeine, Meperidine

36

What are the peripheral m-Opioid receptor antagonists?

Oral Naloxone. Methylnaltrexone (Relistor). Alvimopan (Entereg)

37

What is used for neuropathic pain?

Antidepressant. Anticonvulsant

38

What is used for bone pain?

Bisphosphonates. Corticosteroids. NSAIDs

39

Which Antidepressants are used?

Bupropion. Duloxetine. Venlafaxine. Amitriptyline, Imipramine, Nortriptyline, Desipramine

40

Which Anticonvulsants are used?

Gabapentin. Pregabalin

41

What are the general characteristics of Bone metastasis and Bone Pain?

Pain if often very severe and progressive as disease worsens, profoundly compromising quality of life. Complications: falls, bone fractures, hypercalcemia

42

What are the common cancer types to cause bone metastasis and bone pain?

Breast. Prostate. Lung. Multiple myeloma

43

What is used in the treatment of bone pain?

Combination of: RT, chemotherapy and/or hormonal therapy for primary diagnosis, Surgical intervention for fractures and compression, Pharmacological therapy (for pain relief)

44

What are Bisphosphonates used for?

Bone metastases. Zoledronic acid, Pamidronate. MOA: binds to bone surface and inhibits osteoclast bone resorption

45

What are RANK Ligand Inhibitors used for?

Bone metastases. Denosumab. MOA: binds to RANK ligand (signaling molecule that stimulates function and survival of osteoclasts)