Pain, bone mets, and spinal cord compression

Question 1

cancer pain %’s

Answer 1

30-50% during tx
70-90% when advanced CA
universal screening for all pts

Question 2

barriers to adequate pain mgmt

Answer 2

#patient and family related 
#provider related
#system related

Question 3

quantify pain intensity and characterize quality in pain

Answer 3

location, quality, pain hx, etiology, response to current tx, medical hx, psychosocial, risk factors for undertreatment, physical exam, lab, imaging studies

Question 4

rating scales for pain

Answer 4

numerical, categorical, visual analog scale (10cm line with descriptions), faces

Question 5

PQRST algorithm for characterizing pain

Answer 5

P=palliative (what makes pain better?) and provacative (what makes worse)
Q=quality (somatic vs neuropathic description)
R=radiation (where is the pain, local vs diffuse/systemic)
S=severity/intesity (how does it compare with other pain you have experienced)
T=temporal (intensity changes with time, certain activities, nightime only)

Question 6

what makes cancer pain different? (3pts)

Answer 6

#unique combination types (somatic, visceral, neuropathic, chronic, acute)
#source of pain (tumor vs treatment induced)
#pain progression (ofter linked to tumor progression)

Question 7

WHO pain relief ladder

Answer 7

1= non-opiod up to 3=epidural

Question 8

NSAIDs

Answer 8

#antipyretic, analgesic, anti-inflammatory
#ceiling effect for analgesia
#no tolerance or dependence
#best for nociceptive pain
#individual response varies

Question 9

NSAID ADR

Answer 9

#GI, MI
#heme (dec plt aggregation, caution if existing or anticipated thrombocytop)
#renal - dec GFR (caution if other agents are also renal tox, cisplatin, HD mtx)

Question 10

COX-2 dose and ADR

Answer 10

100-200mg bid celecoxib
no anti-platelet effects, reduced GI irritation, CV effects black box waring (avoid if co-morbid)
rofecoxib removed because of CV eventss
skin rxns rash, mouth sores

Question 11

preferred opioids for renal failure

Answer 11

fentanyl, methadone

Question 12

why methadone?

Answer 12

#prolonged duration of action with repeated dosing up to 40 hours, antagonizes NMDA, blocks reuptake of 5HT and NE
#can use in renal failure (lack of neuroactive metab)
#good bioavail
CAUTION: equianalgesic conversion difficult, qt prolongation

Question 13

example methadone conversion

Answer 13

300mg = 12:1

Question 14

tramadol

Answer 14

#low affinity for mu-receptor
#inhibits reuptake of NE and 5HT
#lowers seizure threshold
#no ceiling effect

Question 15

codeine

Answer 15

#N/V is dose limiting
#CYP2D6 poor metabolizer minimal conc of morphine ->minimal effect: ultra rapid -> risk of tox

Question 16

meperidine

Answer 16

#avoid
#short DOA
#lowers seizure threshold

Question 17

propoxyphine - PULLED FROM MARKET 2010

Answer 17

questionably efficacy, neuroactive metab, short DOA

Question 18

is nausea less common in the elderly for opioids?

Answer 18

Yes

Question 19

respiratory failure “warning signs

Answer 19

pain control ->somnolence -> respiratory depression

Question 20

why do pts >65yo have 2-fold higher incidence of constipation?

Answer 20

sedentary lifestyle, dec bowel motility, concurrent medications
use softener +stimulant

Question 21

how long until methylnaltrexone works?

Answer 21

majority 1-2 hours, then up to 4 hours

works for 50%

Question 22

response to opioid adverse effects

Answer 22

1. decreased dose by 25-50%
2. opioid rotation
3. add additional med to control side effect

Question 23

general principles of opioid conversion - why are you changing

Answer 23

1. lack of efficacy (why not inc dose)
2. intolerable side effects (why not treat effect)
3. change in pt status
4. practical considerations (cost)

Question 24

opioid conversion codeine

Answer 24

30mg po MS = 200mg po codeine

Question 25

general principles of opioid conversion - dosing

Answer 25

indiividualize: cut back 25%, straight, inc 25% | prn dose should equal AT LEAST 100% of long acting pdt (can use for PCA hourly dosing too)

Question 26

opioid MYTHS

Answer 26

``` #amount of pain relief has a ceiling #more potent are more superior #often leads to dependence/addiction ```

Question 27

addiction definition (often confused with other terms such as physical dependence / psychological dependence)

Answer 27

dependence on the regular use of a substance to satisfy physical, emotional, and psychological needs DESPITE harm

Question 28

duloxetine for chemotherapy induced neuropathy

Answer 28

sig improvement in average decrease in pain score vs placebo | duloxetine had increased sedation

Question 29

skeletal complications due to bone mets (7pts)

Answer 29

pain, pathologic fx, hyperca++, spinal cord compression, bone marrow infiltration, nerve root compression, reduced mobility and qol

Question 30

bisphosphonate MOA

Answer 30

inhibit osteoclast maturation and function (affinity for areas of osteolysis)

Question 31

bisphosphonate proven reduced SRE in these dz's

Answer 31

breast CA, MM, prostate CA, other solid tumors

Question 32

bisphosphonate renal dysfunction

Answer 32

guidelines vary by agent and cancer type (SEE HANDOUT)

Question 33

ASCO MM bisphosphonate guidelines

Answer 33

check 24h urine for Cr, albumin, and azotemia q3-6 mo; HOLD tx is albumin in urine >500mg/24h

Question 34

bisphosphonate lab monitoring

Answer 34

SCr before each dose periodic electrolytes, Ca, phos, Mg (last 3 hypo), Hgb/Hct recommend 500mg Ca daily supplement

Question 35

bisphosphonate ADR

Answer 35

``` #myalgias, arthralgias, flu-like sx (usually within 48h of 1st/2nd dose, manage with NSAIDs) #ocular effects #?a fib #ONJ- incidence unknown, 2.9-9.9%, probably underdiagnosed, incidence rare if less than 12 months exposure, zolpidem > risk than PAM ```

Question 36

ONJ stage 1 management

Answer 36

antibacterial mouth rinse, 3mo f/u, pt education, review continued need for BP

Question 37

ONJ stage 2 management

Answer 37

symptomatic tx with systemic abx, abx mouth rinse, pain control, superficial debridement to relieve soft tissue irritation

Question 38

ONJ stage 3 management

Answer 38

symptomatic tx with systemic abx, abx mouth rinse, pain control, SURGICAL debridement for long- term palliation of infx and pain

Question 39

to minimize ONJ risk

Answer 39

dental exam prior to starting tx, avoid dental procedures during tx if possible as dental surgery may exacerbate risk, no data to suggest stoping BP reduces risk

Question 40

denosumab MOA and dosing

Answer 40

human IgG2 monoclonal antibody that binds to RANK ligand | 120 mg SQ q4wks

Question 41

denosumab vs ZA phase III

Answer 41

superior in delaying or preventing SRE in breast CA and CRPC | NONinferiority for MM and other solid tumors

Question 42

denosumab advantages (2pts)

Answer 42

``` SQ admin (do not need infusion center), no concerns about renal dysfunction FYI: same ONJ risks ```

Question 43

spinal cord compression basics

Answer 43

5-10% of pts with malignancy, progressive radicular pain which is followed by neurologic sx, MRI preferred imaging method

Question 44

spinal cord compression - management

Answer 44

spinal column involvement largely incurable | GOALS: relieve pain, preserve or improve function, provide local control, stabilize spine

Question 45

spinal cord compression - steroids

Answer 45

immediate administration increases number of ambulatory pts after XRT - 81 vs 63% dex is DOC: minimum 4mg q6h (10-100mg range)

Question 46

spinal cord compression - surgery followed by XRT

Answer 46

preferred (level I) as increased ability to regain ambulatory function BUT significant morbidity and mortality issues with surgery-> careful pt selection based off of life expectancy and overall health

Question 47

spinal cord compression - XRT alone

Answer 47

``` #excellent response rates if not surgery candidate #35% of non-ambulatory pts regain walking ability #efficacy depends on histology (heme malig > solid tumors) ```

Question 48

NEED TO STUDY

Answer 48

ONJ Guidelines for monitoring BP's