Upda te in Pa llia tive Ca re L I SA ANSE L MO PHARM.D BCOP - - PDF document
9/29/2016 Upda te in Pa llia tive Ca re L I SA ANSE L MO PHARM.D BCOP UNI VE RSI T Y OF NE W ME XI CO CANCE R CE NT E R Ca se 64 yo fe ma le with me ta sta tic o va ria n c a nc e r T re a te d with pa c lita xe l c
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L I SA ANSE L MO PHARM.D BCOP UNI VE RSI T Y OF NE W ME XI CO CANCE R CE NT E R
64 yo fe ma le with me ta sta tic o va ria n c a nc e r
T
re a te d with pa c lita xe l c a rb o pla tin
Se ve ra l surg e rie s
Ma in c o mpla int ne uro pa thy in fe e t a nd le g s Anxio us a b o ut dise a se a nd pro g re ssio n Ma na g ing pa in with me dic a l ma rijua na
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Oxyc o do ne fo r pa in Bo we l re g ime n Co unse ling fo r a nxie ty
Appro xima te ly 2.6 millio n pe o ple die in the US Usua lly a s a re sult o f a c hro nic illne ss (c a nc e r a nd he a rt dise a se ) Pa llia tive c a re
Sympto m ma na g e me nt Pa tie nts g o a ls Ca re g ive r suppo rt
Whe n pro vide d to pa tie nts with so me type s o f c a nc e r it c a n
a c tua lly pro lo ng life Pa tie nt a nd fa mily-c e nte re d c a re tha t o ptimize s q ua lity o f life b y a ntic ipa ting , pre ve nting , a nd tre a ting suffe ring
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Wo rld He a lth Org a niza tio n Pa llia tive c a re
I
mpro ve s the q ua lity o f life o f the pa tie nt thro ug h sympto m c o ntro l
I
mpro ve s QOL fo r fa mily Also a ddre sse s spiritua l a nd psyc o so c ia l a spe c ts o f pa tie nt c a re Do e s no t ha ste n o r impe de de a th T
e a m a ppro a c h
Physic ia ns, nurse s, so c ia l wo rke rs, pha rma c ists, c ha pla in, music the ra pist
Ca n b e utilize d a t a ny time during the c o urse o f a c hro nic illne ss
Ho spic e
A ho me pro viding c a re fo r the te rmina lly ill Ho spic e c a re is tre a ting sympto ms a t the e nd o f life so the pa tie nt c a n die
with dig nity.
Also pro vid e e mo tio na l a nd spiritua l suppo rt fo r the pa tie nt a nd fa mily.
T
re a tme nts fo r the te rmina l illne ss a re sto ppe d whe n ho spic e c a re is initia te d.
T
c o ntro l no t dise a se tre a tme nt.
http:/ / www.nhpc o .o rg / a b o ut/ ho spic e -c a re
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Pa rtic ipa te in te a m me e ting s Re vie w me dic a tio ns fo r drug inte ra c tio ns Re vie w me dic a tio ns fo r dise a se sta te inte ra c tio ns Re c o mme nda tio ns fo r sympto m ma na g e me nt E
duc a te pa tie nts a nd fa milie s
Pa in Na use a / vo miting Co nstipa tio n Dyspne a L
ive r dise a se
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Asse ssme nt
Sc a le , 1-10. Wha t is the pa tie nt’ s g o a l? Wha t c a n the y live with? L
No c ic e ptive vs ne uro pa thic pa in
No c ic e ptive is so ma tic o r visc e ra l pa in
So ma tic pa in re sults fro m b o ne , jo int, musc le o r c o nne c tive tissue L
Re spo nsive to NSAI
Ds o r ste ro ids o r ra dia tio n
Orig ina te s in inte rna l o rg a ns
Cra mping , a c hing , pre ssure Ca use d b y b o we l o b struc tio n o r c a nc e r me ta sta sis to live r Opio ids , a ntie me tic s o r a ntic ho line rg ic s mig ht he lp
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Ca use d b y dysfunc tio n in the CNS Numb ne ss, ting ling , b urning , o r ra dia ting pa in Opio ids ma y wo rk, o fte n ne e d a me dic a tio n with a diffe re nt
me c ha nism o f a c tio n
T
CAs, musc le re la xa nts, a nti e pile ptic s
Ste p wise a ppro a c h Ac e ta mino phe n…. No ne e d to disc uss NSAI
Ds-
COX 2s
Opio ids
http:/ / pa indr.c o m/ ho me /
Anti e pile ptic s
Ga b a pe ntin a nd pre g a b a lin
ste ro ids
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Me ta a na lysis pub lishe d in F
e b 2015
I
nc lude d tria ls tha t la ste d a t le a st 3 we e ks
F
irst line re c o mme nda tio ns:
g a b a pe ntin o r e xte nde d re le a se g a b a pe ntin o r e na c a rb il 1200mg to
3600mg / da y
Pre g a b a lin 300 mg to 600 mg / da y Dulo xe tine 60 mg to 120 mg / da y Ve nla fa xine E
R 150-225 mg / da y
T
ric yc lic a ntide pre ssa nts (o ne no t re c o mme nde d o ve r o the rs)
Se c o nd line use - we a k e vide nc e
Ca psa ic in 8% pa tc he s- o ne to 4 pa tc he s a pplie d fo r up to 60 mins e ve ry
3 mo nths
L
ido c a ine pa tc he s o ne to 3 pa tc he s o nc e a da y fo r up to 12 ho urs
T
ra ma do l 200-400 mg / da y
T
a pe nta do l
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T
hird line
Bo tulinum to xin A sub Q 50-200 units e ve ry 3 mo nths Opio ids
Me tha do ne fo r ne uro pa thic pa in Blo c ks the NMDA re c e pto rs
T
itra te slo wly
Opio id a dve rse e ffe c ts QT
c pro lo ng a tio n a t hig he r do se s ha s b e e n se e n a t 200 mg do se s
Ge t b a se line E
K G
Co mb ina tio n re g ime ns
Pe g a b a lin o r g a b a pe ntin a nd dulo xe tine o r T
CAs
Go o d re g ime n to c o mb ine inste a d o f trying to push the do se s o f the
individua l me dic a tio ns
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F
DA o pio id a c tio n pla n
Ab use de te rre nt fo rmula tio ns Wa rning s a nd sa fe ty info rma tio n o n sho rt a c ting fo rmula tio ns I
nc re a se pro vide r tra ining
Re vie wing the pa in ma na g e me nt re c o mme nda tio ns
Physic a l c he mic a l b a rrie rs
Use ta b le t fo rmula tio n to pre ve nt e xtra c ting the o pio id thro ug h so lve nts
Ag o nist/ Anta g o nist c o mb ina tio ns
Anta g o nist c a n b e se q ue ste re d a nd re le a se d upo n ma niupula tio n
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No ve l a g e nt- c o nta ins pe lle ts o f mo rphine a nd se q ue ste re d na ltre xo ne
I
nitia l do se s sta rt a t 20mg / 0.8mg o nc e a da y
T
itra te e ve ry 1 to 2 da ys Co nve rsio n fro m o ra l mo rphine Give ha lf o f the to ta l da ily mo rphine do se a s E
mb e da q 12 ho urs OR a ll o f the pa tie nt’ s to ta l da ily do se a s E mb e da o nc e a da y
Co nve rsio n fro m o the r o pio ids to E
mb e da
Dc a ll o pio ids, initia te E
mb e da a t 30mg / 1.2mg o nc e a da y
No e sta b lishe d c o nve rsio n ra tio s to E mb e da
Ora l do se 3x the I
V
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Zo hydro E
R (hydro c o do ne )
Opa na E
R (o xymo rpho ne )
E
xa lg o E R 24hr (hydro mo rpho ne )
No stric t de finitio ns
Pa tie nt pe rc e ptio n o f a wa re ne ss o f b re a thing a nd unc o mfo rta b le ne ss Ca use s pa nic wo rry, c o nfusio n, frustra tio n a nd a ng e r
T
re a t the unde rlying c a use if po ssib le
COPD, CHF
, pne umo nia , PE , lympho ma
Re po sitio n the pa tie nt mo re upwa rd po sitio n Oxyg e n ma y no t b e e ffe c tive , pa tie nts who re po rt b re a thle ssne ss
ma y no t b e hypo xe mic
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Opio ids c a n re duc e the se nsa tio n o f b re a thle ssne ss b y de c re a sing
the ve ntila to r drive
Opio ids na ïve – sta rt 5 to 15 mg a nd titra te to re spo nse All ro ute s e ffe c tive
Da ta o n ne b ulize d mo rphine is limite d Co c hra ne re vie w o f da ta fo r pa llia tio n o f b re a thle ssne ss
Mo st studie s lo w q ua lity, sma ll n a nd no t a c o ntro l a rm No e vide nc e tha t inha le d mo rphine is e ffe c tive
Anxio lytic s a re he lpful, b ut no t a s e ffe c tive a s o pio ids
Additio na l se da tio n a nd po te ntia l to c a use c o nfusio n
Co rtic o ste ro ids ma y tre a t unde rlying dise a se COPD, a sthma
Ma ke pa tie nts fe e l g o o d Re duc e e de ma o r tumo r g ro wth Adve rse e ffe c ts, inso mnia
Administe r e a rly in the da y
Bro nc ho dila to rs c a n b e use ful fo r b ro nc ho spa sm
No t muc h da ta in dyspne a
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Co mmo n sympto m in pa tie nts with c a nc e r
F
e ma le s
Yo ung e r tha n 65 Sto ma c h o r pa nc re a tic c a nc e r Re c e nt c he mo the ra py
I
mpo rta nt to try a nd fig ure o ut the e tio lo g y fo r se le c tio n o f tre a tme nt
Die ta ry me a sure s a re impo rta nt
Avo id, swe e t, sa lty, fa tty o r spic y fo o ds Sma ll fre q ue nt me a ls
Do pa mine a nta g o nists, a ntihista mine s, a ntic hlo line rg ic s, se ro to nin
a nta g o nists a nd pro kine tic me dic a tio ns a re ma insta y o f tre a tme nt
Pro c hlo rpe ra zine , pro me tha zine a nd c hlo rpro ma zine
Ca n c a use se da tio n, a ntic ho line rg ic a dve rse e ffe c ts b e c a use the y a ffe c t
mo re tha n just the do pa mine re c e pto rs Butyro phe no ne s- spe c ific fo r do pa mine
Pa rkinso ns like sympto ms a s a dve rse e ffe c ts
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No ra ndo mize d tria ls fo r dro pe rido l, ha lo pe rido l a nd na b ilo ne
Co ho rt study fa vo rs ha lo pe rido l Me to c lo pra mide a s first line a g e nt Ha lo pe rido l a s se c o nd line
Adding de xa me tha so ne do e s no t impro ve na use a c o ntro l
I
n a study in pa tie nts who ha d re fra c to ry c he mo the ra py na use a a nd vo miting o la nza pine wa s a dde d o n to the a ntie me tic re g ime n.
CI
NV is drive n b y se ro to nin re c e pto rs a nd do pa mine re c e pto r a c tiva tio n
Ola nza pine a nta g o nize s multiple se ro to nin a nd do pa mine re c e pto rs Do se 5 to 10 mg / da y Appro xima te ly 70% o f pa tie nts re spo nde d to o la nza pine
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No t a s muc h da ta a s the re is in CI
NV
Ca se se rie s o f 14 pa tie nts with diffic ult to c o ntro l na use a g ive n
No sympto m re lie f with mo re tha n o ne a g e nt Adve rse e ffe c ts to tre a tme nt
Na use a c o ntro lle d b y pa tie nt re po rt
One pa tie nt ha d no re lie f One pa tie nt c o mpla ine d o f e xc e ssive se da tio n a fte r 2 we e k, b ut
na use a wa s c o ntro lle d
All o the r pa tie nts na use a c o ntro lle d with minima l a dve rse e ve nts
Antise c ra to ry me dic a tio ns like o c tre o tide a re e ffe c tive fo r na use a
a sso c ia te d with ma lig na nt b o we l o b struc tio n
Adding a ntie me tic s impro ve s e ffic a c y Oc tre o tide 300 to 600 mc g / da y + pro c hlo rpe ra zine o r ha lo pe rido l
Co mb ina tio n o f a ntie me tic s g ra nise tro n + de xa me tha so ne +
ha lo pe rido l a lso e ffe c tive
Ola nza pine e ffe c tive in pa tie nts re fra c to ry to o the r tre a tme nts
Ave ra g e do se 5 mg / da y a ve ra g e tre a tme nt dura tio n 23 da ys De c re a se the a ve ra g e na use a sc o re b y 90% a nd de c re a se d vo miting
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I
nc ide nc e o f mo de ra te to se ve re na use a a nd vo miting 19% with a 40% inc ide nc e o f vo miting
No e vide nc e fo r using pro phyla c tic a ntie me tic s Pa tie nts do de ve lo p to le ra nc e to this a dve rse e ffe c t No g o o d e vide nc e fo r using a ny a ntie me tic s fo r tre a tme nt o f
na use a due to o pio ids me to c lo pra mide , o nda nse tro n we re no t supe rio r to pla c e b o in o ne sma ll study
Be st to try to de te rmine me c ha nism o f na use a , ve stib ula r o r
c o nstipa tio n a nd le t tha t g uide tre a tme nt o ptio ns
Opio id induc e d mo st c o mmo n
No da ta to suppo rt o ne la xa tive o ve r a no the r T
ry to ke e p the b o we l re g ime n a s simple a s po ssib le
Me thylna ltre xo ne
E
ffe c tive whe re tra ditio na l la xa tive s ha ve fa ile d
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Se le c tive a nta g o nist o f pe riphe ra l mu re c e pto rs Do e sn’ t a ffe c t a na lg e sia
Pilo t study in lo ng te rm me tha do ne pa tie nts did no t put pa tie nts in
withdra wa l
I
n a ra ndo mize d pla c e b o c o ntro lle d tria l
Me thylna ltre xo ne sub Q e ve ry o the r da y o r ma tc he d pla c e b o Co ntinue o n la xa tive s
Sig nific a ntly ma re pa tie nts ha d a b o we l mo ve me nt 4 ho urs a fte r the
me thylna ltre xo ne do se a nd did no t ne e d re sc ue la xa tive s
Adve se e ve nts: a b do mina l pa in, fla tule nc e , na use a , inc re a se b o dy
te mp
L
ive r fa ilure , a dva nc e d dise a se o r c irrho sis
Only c ure is tra nspla nta tio n E
stima te d tha t 2% o f the US po pula tio n a re a ffe c te d b y E SL D
Ma in c a use s he pa titis C a nd a lc o ho l
Pro g no sis pre dic to r ME
L D sc o re
Mo de l fo r E
nd-Sta g e L ive r Dise a se
I
NR, b ilirub in, a nd c re a tinine to pre dic t surviva l
Hig he r the c o re the wo rse the dise a se
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ME L D Sc or e 6 month 12 months 24 months
10-19 92% 86% 80% 20-29 78% 71% 66% 30-36 40% 37% 33%
Clinic al L ive r Dise ase Vo lume 6, I ssue 1, pa g e s 19-21, 28 JUL 2015 DOI : 10.1002/ c ld.478 http:/ / o nline lib ra ry.wile y.c o m/ do i/ 10.1002/ c ld.478/ full# c ld478-fig -0001
Sympto m b urde n in pa tie nts with E SL D
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Ba rrie rs to pa llia tive c a re fo r pa tie nts with live r dise a se
Dise a se c a n de c o mpe nsa te the n b e c o me sta b le Pa tie nts ma y ha ve a po o r unde rsta nding o f the ir dise a se Ove r e stima te o f life e xpe c ta nc y I
s pa tie nt c a pa b le o f ma king de c isio ns
Pa in, c ra mping , na use a a no re xia F
e a r o f dying , g uilt
F
a miliy distre ss o r c o nflic t
Ac c e le ra te d ne e ds fo r sympto m c o ntro l (mo re fre q ue nt
pa ra c e nte sis)
Pa tie nt de nie d tra nspla nt L
a c k o f c ura tive o ptio ns
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I
nc re a se d risk o f a dve rse e ffe c ts, mo st drug me ta b o lize d in the live r
Mo rphine ,o xyc o do ne a nd hydro mo rpho ne c le a ra nc e is de la ye d,
c o nstipa tio n ma y e xa c e rb a te e nc e pha lo pa thy
F
e nta nyl ma y b e the b e st c ho ic e , a ltho ug h little da ta
Asc ite s the mo st c o mmo n re a so n fo r a dmissio n He pa tic e nc e pha lo pa thy
Pa llia tia ve c a re while o n tra nspla nt list
Ca n b e diffic ult situa tio n Symto m ma na g e me nt Ca re g ive r suppo rt
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F inne rup NB, e t a l Pha rma c o the ra py fo r ne uro pa thic pa in in a dults: a syste ma tic re vie w a nd me ta -a na lysis. L a nc e t Ne uro l 2015;162-173
Altie r, N e t a l, Ma na g e me nt o f c hro nic Ne uro pa thic pa in with Me tha do ne : A re vie w o f 13 c a se s Clin J o f Pa in july/ a ug 2005 364-369.
Opio ids fo r the pa llia tio n o f re fra c to ry b re a thle ssne ss in a dults with a dva nc e d dise a se a nd te rmina l illne ss. Cho c hra ne re vie w pub lishe d Ma rc h 2016
MASCC/ E SMO re c o mme nda tio ns fo r ma na g e me nt o f n/ v in a dva nc e d c a nc e r
Ra ko ski MA, e t a l Pa llia tive c a re fo r pa tie nts with e nd-sta g e live r dise a se : An o ve rvie w CL D 6, July 2015;19-21.
Po to se k j, e t a l. inte g ra tio n o f pa llia tive Ca re in E nd-Sta g e L ive r dise a se a nd L ive r tra nspla nta tio n, J Pa ll me d No v 2014 17;1271-277.
T ho ma s J e t a l. Me thylna ltre xo ne fo r Opio id-induc e d Co nstipa tio n in Adva nc e d I llne ss. N E ng l J Me d 2008; 358:2332-2343
Vig S, e t a l Ola nza pine is e ffe c tive fo r re fra c to ry c he mo the ra py-induc e d na use a a nd vo miting irre spe c tive o f c he mo the ra py e me to g e nic ity. J Ca nc e r Re s Clin Ono c l
Ma K into sh d. Ola nza pine in the Ma na g e me nt o f Diffic ult to Co ntro l Na use a a nd Vo miting in a Pa llia tive c a re po pula tio n. Jo f Pa ll me d. 2016.