Upda te in Pa llia tive Se ve ra l surg e rie s Ma in c o mpla int - - PDF document

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Upda te in Pa llia tive Ca re

L ISA ANSE L MO PHARM.D BCOP UNIVE 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 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 d ic a l ma rijua na

Pa llia tive c a re re c s

 Oxyc o do ne fo r pa in  Bo we l re g ime n  Co unse ling fo r a nxie ty

Pa llia tive c a re

 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 d ise 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 vid e 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

De finitio ns

 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

De finitio n

 Ho spic e  A ho me pro vid ing 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 d ie with d ig 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

• b e e lig ib le fo r the ho spic e b e ne fit tre a tme nt must fo c us o n sympto m

c o ntro l no t d ise 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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Ro le o f the Pha rma c ist

 Pa rtic ipa te in te a m me e ting s  Re vie w me d ic a tio ns fo r d rug 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 nd a tio ns fo r sympto m ma na g e me nt  E

d uc a te pa tie nts a nd fa milie s

Sympto m ma na g e me nt

 Pa in  Na use a / vo miting  Co nstipa tio n  Dyspne a  L

ive r d ise a se

Pa in ma na g e me nt

 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

• c a tio n, q ua lity, o nse t, type o f pa in

 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

• c a tlize d, a c hing thro b b ing pa in

 Re spo nsive to NSAI

Ds o r ste ro ids o r ra dia tio n

Visc e ra l pa in

 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

Ne uro pa thic pa in

 Ca use d b y dysfunc tio n in the CNS  Numb ne ss, ting ling , b urning , o r ra d ia ting pa in  Opio id s ma y wo rk, o fte n ne e d a me d ic a tio n with a d iffe 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

WHO pa in ma na g e me nt la dde r

 Ste p wise a ppro a c h  Ac e ta mino phe n…. No ne e d to d isc uss  NSAIDs-  COX 2s  Opio id s  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 id s

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Ne uro pa thic pa in

 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 nd a 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 / d a 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)

Ne uro pa thic pa in

 Se c o nd line use - we a k e vid e 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

Ne uro pa thic pa in

 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

 Op io id a d ve rse e ffe c ts  QT

c p ro lo ng a tio n a t hig he r d o se s ha s b e e n se e n a t 200 mg d o se s

 Ge t b a se line E

K G

Ne uro pa thic pa in

 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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Opio ids

 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

Ab use de te rre nt fo rmula 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

Mo rphine / na ltre xo ne (E mb e da )

 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

Mo rphine / na ltre xo ne (E mb e da )

 Initia l d o se s sta rt a t 20mg / 0.8mg o nc e a d a 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 d a ily mo rphine d o se a s E

mb e d a q 12 ho urs OR a ll o f the pa tie nt’ s to ta l d a ily d o se a s E mb e d a o nc e a d a y

 Co nve rsio n fro m o the r o pio id s 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 d a  Ora l do se 3x the I

V

Othe r a b use de te rre nt fo rmula tio ns

 Zo hydro E

R (hyd ro c o do ne )

 Opa na E

R (o xymo rpho ne )

 E

xa lg o E R 24hr (hyd ro mo rpho ne )

Dyspne a

 No stric t d e 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 und e 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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Dyspne a

 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 d rive

 Opio id s 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 id s  Additio na l se da tio n a nd po te ntia l to c a use c o nfusio n

Dyspne a

 Co rtic o ste ro id s ma y tre a t und e rlying d ise 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 d a ta in d yspne a

Na use a a nd vo miting

 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

Na use a a nd Vo miting

 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 d ic 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

Na use a a nd Vo miting

No ra nd o mize d tria ls fo r d ro pe rid o l, ha lo pe rid o 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

Ola nza pine fo r Na use a / Vo miting

 In a stud y 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 d d e 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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Ola nza pine in pa llia tive c a re

 No t a s muc h d a ta a s the re is in CINV  Ca se se rie s o f 14 pa tie nts with d iffic ult to c o ntro l na use a g ive n

• la nza pine 5 mg a t b e d time

 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 d ve rse e ve nts

Ma lig na nt b o we l o b struc tio n

 Antise c ra to ry me d ic a tio ns like o c tre o tid e 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 + d e xa me tha so ne +

ha lo pe rid o 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

Opio id induc e d na use a a nd vo miting

 Inc id e nc e o f mo d e ra te to se ve re na use a a nd vo miting 19% with a

40% inc id e nc e o f vo miting

 No e vid e nc e fo r using pro phyla c tic a ntie me tic s  Pa tie nts d o d e ve lo p to le ra nc e to this a d ve rse e ffe c t  No g o o d e vid e nc e fo r using a ny a ntie me tic s fo r tre a tme nt o f

na use a d ue to o pio id s me to c lo pra mid e , o nd a 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 d e 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 uid e tre a tme nt o ptio ns

Co nstipa tio n

 Opio id ind uc 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

Me thylna ltre xo ne

 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  In a ra nd o 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 d a 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

Pa llia tive c a re in e nd sta g e live r dise a se

 L

ive r fa ilure , a d va nc e d d ise 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 o re a nd surviva l

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%

L ive r dise a se

Clinic al L ive r Dise ase Vo lume 6, Issue 1, pa g e s 19-21, 28 JUL 2015 DOI: 10.1002/ c ld.478 http:/ / o nline lib ra ry.w ile 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

L ive r dise a se

 Ba rrie rs to pa llia tive c a re fo r pa tie nts with live r d ise 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

I ndic a tio ns fo r pa llia tive c a re in live r dise a se

 Pa in, c ra mping , na use a a no re xia  F

e a r o f d ying , g uilt

 F

a miliy d istre ss o r c o nflic t

 Ac c e le ra te d ne e d s fo r sympto m c o ntro l (mo re fre q ue nt

pa ra c e nte sis)

 Pa tie nt d e nie d tra nspla nt  L

a c k o f c ura tive o ptio ns

L ive r dise a se

 Inc re a se d risk o f a d ve rse e ffe c ts, mo st d rug me ta b o lize d in the live r  Mo rphine ,o xyc o d o ne a nd hyd ro mo rpho ne c le a ra nc e is d e 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 d missio n  He pa tic e nc e pha lo pa thy

L ive r dise a se

 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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Que stio ns? Re fe re nc e s



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 d ults: 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 d o ne : A re vie w o f 13 c a se s Clin J o f Pa in july/ a ug 2005 364-369.



Op io id s fo r the pa llia tio n o f re fra c to ry b re a thle ssne ss in a d ults with a d va nc e d d ise 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 nd a tio ns fo r ma na g e me nt o f n/ v in a d va 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 d ise 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 d ise 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 Op io id -ind uc e d Co nstipa tio n in Ad va 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-ind uc 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 p ine 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.