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• 2) SYMPTOMATIC Tx:
‣
NON-pharma Tx?
physical therapy
•Massage •Stretching •Heat •Splints and physical supports •TENS •Aids and appliances (hoist, wheel chair, walking frame etc...) •Wound care
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💊 CANCER PAIN Tx

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The KEY ELEMENTS of PHARMA Tx of CANCER pain are? (5)



👉🏽

- By the mouth - By the clock - By the ladder - For the individual - Attention to detail

*For the individual: right dose = satisfactory pain relief + minimum SE

*Attention to detail: incl. regular administration, PRN availability (rescue dose), SE anticipation (prophylactic laxatives + PRN anti-emetics)

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What if oral intake is Ø possible?

parenteral → subcutaneous

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WHO-pain ladder? (with drug examples)

🪜

PAIN LADDER → 📷

❗

NEVER COMBINE a STEP 3 opioid AND a STEP 2 opioid. ONLY COMBINE with NON-OPIOID analgetic = STEP 1

*PCA

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Adjuvant drugs (aka Co-Analgetics)?

💡

⚡ - Anticonvulsants 🎭  - Antidepressents 💉  - Steroids 💪🏼  - Muscle relaxants

1. Neuropathic-pain → Anticonvulsants + antidepressants + steroids
2. Spasticity → Muscle relexants

(+biphosphonates in bone mets)

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STARTING STEP: How do you decide on which step of the ladder you start?

💡

Assess pain severity on pain scale

MILD PAIN = <3 ⇒ step 1

MOD. PAIN = 4-6⇒ step 2

SEV. PAIN >7 ⇒ step 3

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INTERVAL: What should be the interval between doses?

GENERAL RULES:

• STEP 3 OPIATES (i.e. morphine) ⇒ every 4h
💡
- if 🍑HEPATIC OR 🥐RENAL impairment ⇒ ↑dose-interval (6-8h) - prolonged release morphin → every 12h
• STEP 1+2 ⇒ every 6h

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DOSAGES

STAGE 1:

‣

Paracetamol?

1000 mg = 1g PO every 6 hours =4000mg/day

(=max dose)

❗

if hepatic dysfunction → max dose = 3000mg/day

‣

IBU?

400 mg PO every 6 h

(=max dose)

❗

Cave if kidney problem

Stage 2:

‣

Tramadol?

50mg every 6h

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Codein?

30mg every 6h

‣

major system



50=lasso

30=maus

tramadol = tram/train

codein = syrup

Stage 3:

‣

ORAL Morphine?

‣

⭐ STARTING DOSE = 5-10mg every 4h

old lecture:

<65y ⇒ 10mg oral + 5mg injectable

>65y ⇒ 5mg oral + 2.5mg inject.

Amboss: STARTING DOSE : Immediate-release morphine 2.5–10 mg PO every 4 hours as needed

‣

major system



💡

Step 3 opiods should be started at a low dose + titrated according to response.

‣

PARENTERAL Morphine?

💡

when severe pain + refract. to oral

Morphine  2–10 mg SC/IV every 4 hours as needed

💡

“The correct dose is the one that works”

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Whats the RESCUE DOSE?

for breakthrough pain (incident or predicted)

→ additional immediate-release of the opioid used ⇒ 1/6 of total daily dose

⇒alternative: buccal/intranasal fentanyl

ex. 10mg every 4h = 60mg/day ⇒ rescue dose = 10mg

‣

SE of OPIOIDS? How do you Tx them?

❗

give 💩 prophylactic LAXATIVES + 🤢 PRN ANTI-EMETICS

constipation ⇒ LAXATIVES

‣

💬

#1 Softener (docusate) + Stimulant (senna, bisacodyl)

#2 Add Osmotic agent (PEG, Lactulose)

Nausea/vomiting ⇒ 🤢 PROKINETIC ANTIEMETIC since opoids → constipation

⇒ metoclopramide / domperidone

⇒ give with opioid for first 1-2weeks

OR

Antipsychotic (Haloperidol)

Other SE: Sedation, Opioid induced neurotoxicity (stop/change opioid)

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• 3) Adress OTHER HOLISTIC aspects 😇

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• 4) REASSESS ♻️ (SE + pain adjustment)