Transcript Case 1: - Kidney Supportive Care

Pain Management
in ESRD
Alvin H. Moss, MD
Section of Nephrology
West Virginia University
1
Pain and ESRD




Most common and severe symptom
Impairs quality of life
Undertreated in 75% of ESRD patients*
Lack of knowledge in nephrology
community
*Davison SN. Pain in hemodialysis patients:
Prevalence, cause, severity, and management.
Am J Kidney Dis, 42:1239-1247, 2003
2
Objectives





Demonstrate the importance of pain
management within palliative care
Present cases
Document efficacy of WHO pain
management approach in ESRD study
Describe adverse effects of opioids
Explain use of pain management
principles
3
Association Between Reports of
Symptoms and Quality of Life Measures
160 138
140
119
120
94.5
100
80
60
37.6
24.6 23.4
29
40
21.7
18.3
7.56.5
5.3
20
0
MQOL Total MQOL QOL Single SWLS
Score
Physical Item Index
Subscale
no symptoms 1 symptom 2+ symptoms
Note: All results statistically significant, p values <.01
4
Causes of Pain in Hemodialysis Patients
N=103/205*
Cause
Musculoskeletal
Osteoarthritis
Skeletal s Dx
Osteoporosis
RA, Bone Dis, Osteo
Related to dialysis
Peripheral Neuropathy
Periph Vasc Disease
Carpal tunnel
Other
* 19 > one type of pain.
# Patients
65
20
19
12
14
14
13
10
2
19
Percent
63
19
19
12
14
14
13
10
2
19
Davison, AJKD 2003;42:1239-1247
5
A Role for Palliative Care
The patient is an 87 yr old man with ESRD from
hypertension who was admitted from a NH with
altered mental status. The patient has been on
dialysis for 4 years and is transported by
ambulance for his treatments. Other medical
problems include inoperable coronary artery
disease, CVA with L hemiplegia, dementia, UGI
bleeding, COPD, and PVD with gangrene of
three toes on his right foot. He and his wife have
refused surgery for the PVD.
6
A Role for Palliative Care
The patient is unable to walk or transfer
himself from chair to stretcher. He
complains of severe pain in his right foot.
He usually screams during dialysis and
seems uncomfortable. The wife does not like
him to receive pain medication because he
becomes less responsive. What should be
done?
7
What’s the problem?
A 57 year-old dialysis patient is admitted with
severe pain all over her body, especially in her
joints. She has nephrogenic fibrosing
dermopathy. Her current pain medicine is
extended-release morphine 200mg po q8h.
Despite this dose, she is still in pain. She also
complains of increasingly severe jerking. It is so
bad that her body jumps six inches off her chair
at times. What’s going on and what should you
do?
8
Patients’ Concerns
Regarding End-of-Life Care





Receiving adequate pain and symptom
control
Avoiding inappropriate prolongation of dying
Achieving a sense of control
Relieving burden on loved ones
Strengthening relationships with loved ones
Singer PA, et al. JAMA 1999; 281:163-168.
9
Top 5 Attributes of a Good Death





Freedom from pain
At peace with God
Presence of family
Mental awareness
Treatment choices followed
Steinhauser, et al. Factors considered important at the end of life by
patients, family, physicians, and other health care providers.
10
JAMA 2000:284:2476-2482.
Definition
Palliative care is comprehensive,
interdisciplinary care of patients and
families facing a chronic or terminal illness
focusing primarily on comfort and support.
Billings JA. Palliative Care. Recent Advances. BMJ
2000:321:555-558.
11
Elements of Palliative
Care






Meticulous pain and symptom control
Psychosocial and spiritual support
Advance care planning incl goals of care
Family-oriented care
Delivery of coordinated services
Attention to disposition
12
Nociceptive pain . . .
Direct stimulation of intact nociceptors
 Transmission along normal nerves
 sharp, dull, aching, throbbing

– somatic

easy to describe, localize
– visceral

difficult to describe & localize
14
Neuropathic pain . . .
Disordered peripheral or central nerves
 Compression, transection, infiltration,
ischemia, metabolic injury
 Pain may exceed observable injury
 Described as burning, tingling,
shooting, stabbing, electrical

15
Nociceptive = Neuropathic

Nociceptive Pain
– Activation of pain
receptors
– Associated with acute
or ongoing tissue
injury
– Sharp, aching,
throbbing, dull

Neuropathic
– Nerve injury
– Aberrant processing
in CNS or PNS
– Burning, pins and
needles, shock-like,
electrical, numb,
stabbing
Patients report equal severity for both types of painRequire different medications
16
WHO 3-step
Pain Ladder
moderate
(5-6)
severe
(7-10)
Morphine
Hydromorphone
Methadone
A/Codeine
Levorphanol
A/Hydrocodone
Fentanyl
A/Oxycodone
Oxycodone
ASA
A/Dihydrocodeine
± Adjuvants
Acetaminophen
Tramadol
NSAIDs
± Adjuvants
mild
(1-4)
± Adjuvants
17
Principles of Analgesic Use
for the WHO Ladder







By the mouth-use the simplest route
By the clock-give scheduled doses
By the ladder- select level by pain
intensity
Individualize treatment
Monitor response
Use adjuvant drugs as needed
Prevent and treat side-effects
18
Efficacy of WHO Analgesic
Ladder to Treat Pain in ESRD
Ahmad S. Barakzoy, MD
Alvin H. Moss, MD
Section of Nephrology
WVU School of Medicine
19
172 Eligible Hemodialysis Patients
29 excluded because they lacked decision-making
capacity, had a prior history of drug abuse, or were
hospitalized during the study.
143 Patients (83%) Participated in the Study
65 Reported No Pain
78 (54%) Reported Pain
16 Already Being Treated for Pain
17 Refused to Take Pain Medications
45 (58%) Completed the pre-andpost-treatment evaluation
Demographics
n = 45
Mean Age
Gender
Race
Diabetics
65 ± 12.5 years
53% Male
47% Female
38 Caucasian (84%)
7 African American (16%)
49%
Mean Initial Pain Score by Demographic
10
9
8.0
7.9
7.6
7.5
8
7.8
7.4
7
6
5
4
3
2
1
Men
Women
P=0.13
Under 65
65 and Over
P=0.544
White
P=0.406
Black
Comparison of Initial and Post Treatment Mean Pain Scores
n = 45
10
7.8
9
8
7
6
5
4
1.6
3
2
1
Initial
P < 0.001
Post Treatment
Type of Pain Reported by Patients
50%
40%
45%
40%
31%
29%
35%
30%
25%
20%
15%
10%
5%
0%
Neuropathic
Nociceptive
Type of Pain
Both
Qualitative Description of Pain
60%
55%
Percent of Patients
50%
40%
27%
30%
21%
20%
10%
9%
10%
4%
4%
Cramping
Gnawing
0%
Burning
Aching
Sharp
Stabbing
Throbbing
Comparison of Initial and Post-Treatment Pain Scores
10
9
8.1
7.4
8
7
6
Initial Pain Score P=0.110
Post Treatment Pain Score
5
P=0.524
4
3
1.5
1.8
2
1
0
Neuropathic Pain
Nociceptive Pain
Type of Pain
Oxycodone and Hydrocodone Initial and Post Treatment
Comparison
8.9
10
9
7.4
8
Initial Pain Score P=0.001
7
Post Pain Score P=0.801
6
5
4
3
1.4
1.5
2
1
Oxycodone
Hydrocodone
Comparison of Initial and Post Treatment Pain Scores by Age
10
9
7.9
7.6
8
7
6
5
Initial Pain Score P=0.544
Post Treatment Pain Score
4
P=0.003
2.1
3
0.94
2
1
0
Under 65
65 and Over
Reduction of Total McGill Pain Questionaire Score
17.3
18
16
14
12
10
8
4.3
6
4
2
0
Initial
P<0.001
Post Treatment
Percentage of Patients Who Were Prescribed Drug
*Percentages do not add up to 100% due to 24% of patients receiving a
combination of drugs
40
38%
35
27%
30
24%
Percent
25
20%
16%
20
15
10
2%
5
0
gabapentin
hydrocodone
tramadol
oxycodone
nortriptyline
propoxyphene
Studies included in review
CC=cancer center; PCU=palliative care unit; IMH=internal medicine hospital;
GH=general hospital; PRU=pain relief unit
Jadad et al. The WHO Analgesic Ladder for Cancer Pain Management.
31
JAMA 1995;274:1870-1873
Efficacy of WHO 3-Step Analgesic
Ladder Approach
100%
2005
WV Palliative Care Network
N=218
100%
WVU Dialysis Patients
N=45
96%
85%
60%
40%
20%
80%
% Adequate Analgesia
% Adequate Analgesia
80%
60%
40%
20%
27%
0%
0%
0%
T0
T48
Hours
T0
T4
Weeks
32
QOL Outcomes from
Pain Management

Improved function
– “I am able to walk to my mailbox,
something I could not do before because
of hip and leg pain.”

Better ability to tolerate dialysis
– “I am able to tolerate 4 hours of dialysis
without the severe back pain.”

More restful sleep
– “I have more energy because I am
resting better at night.”
33
Pain Medications in ESRD
Safe and
Effective
Use with
Caution
Fentanyl
Methadone
Hydromorphone
Oxycodone
Do Not Use
Codeine
Meperidine
Morphine
Propoxyphene
Expanded from Dean M: Opioids in Renal Failure and Dialysis Patients.
34
J Pain Symptom Manage 28:497-504. 2004.
Opioid Dose Adjustment





Dose escalation until development of adequate
analgesia or unacceptable side effects.
Rate of escalation depends on severity of pain.
Increase daily dose by 25 -50 % for mild to
moderate pain, 50-100% for severe pain.
Increase rescue dose as baseline dose is
increased-10% of total daily dose
Add adjuvant medications to improve analgesia
Prevent and treat side-effects
35
Indications for
Opioid Rotation






Intolerance to side-effects of drug
Pain not satisfactorily controlled
Loss of oral route (emesis,dsyphagia)
Cost issues
Convenience/compliance issues
Drug abuse concerns
36
Incomplete Cross-Tolerance


Subtle differences in the molecular structure of each
opioid and the way they interact with receptors
Helps explain variance between patient’s effective
ratio and equianalgesic ratio calculations
Approach to deal with this phenomenon:
1) if pain well controlled --> start with 5075% of calculated dose, and titrate up
2) if pain poorly controlled, use 90-100%
calculated dose
37
Transdermal Fentanyl



Good choice for patients with stable
level of pain
Good choice for dysphagic patients
Do not use in the opioid-naïve
38
Transdermal Fentanyl

Steady state between patch, subdermal pool,
and circulation
Patch size: mcg/hr: 25,50,75,100 $$$
Change q 3 days ( 20% q 2 days)
Fever, heat increase drug effect
Assure good contact with skin
Cover with ATC opioids for first 15-20 hours

Requires short-acting opioid for rescue





39
Barriers to Effective Pain
Management in ESRD




Lack of recognition of the problem
Complicated pharmacokinetics
Until our study treatment algorithms
for cancer patients had not been
validated for ESRD patients
Uremic symptoms may mimic opioid
toxicity
40
Safe Pain Management
41
Distinguish Opioid State

Opioid-naïve patients
– “Start low, go slow”
– e.g., hydromorphone 0.2 mg IV bolus or
1 mg po

Opioid-tolerant
– Use equianalgesic table
– Adjust for incomplete cross-tolerance
– CNS depression precedes respiratory
42
Equianalgesic Doses of Opioid Analgesics
Oral/rectal Dose (mg)
Drug
Parenteral dose (mg)
30
Morphine
10
10-15
Oxycodone
-
150
Meperidine
50
7.5
Hydromorphone
1.5
2
Levorphanol
15
Hydrocodone
1
43
Incomplete Cross-Tolerance


Subtle differences in the molecular structure of each
opioid and the way they interact with receptors
Helps explain variance between patient’s effective ratio
and equianalgesic ratio calculations
Approach to deal with this phenomenon:
1) if pain well controlled --> start with 5060% of calculated dose, and titrate up
2) if pain poorly controlled, use 90-100%
calculated dose
44
Opioid adverse effects
Common
Uncommon
Constipation
Bad dreams / hallucinations
Dry mouth
Dysphoria / delirium
Nausea / vomiting
Myoclonus / seizures
Sedation
Pruritus / urticaria
Sweats
Respiratory depression
Urinary retention
When should methadone
be considered?

Inadequate analgesia from other
opioids
– neuropathic component to pain



Opioid intolerance due to other sideeffects
Neurotoxicity with other opioids
Cost is a primary factor
46
A Role for Palliative Care
The patient is an 87 yr old man with ESRD
from hypertension who was admitted from a
NH with altered mental status. The patient
has been on dialysis for 4 years and is
transported by ambulance for his treatments.
Other medical problems include inoperable
coronary artery disease, CVA with L
hemiplegia, dementia, UGI bleeding, COPD,
and PVD with gangrene of three toes on his
right foot.
47
A Role for Palliative Care
The patient is unable to walk or transfer
himself from chair to stretcher. He
complains of severe pain in his right foot.
He usually screams during dialysis and
seems uncomfortable. The wife does not like
him to receive pain medication because he
becomes less responsive. What should be
done?
48
What did we do?



Start low, go slow with oxycodone
Added acetaminophen as adjuvant RTC
Educated wife about pain management
49
What’s the problem?
A 57 year-old dialysis patient is admitted with
severe pain all over her body, especially in her
joints. She has nephrogenic fibrosing
dermopathy. Her current pain medicine is
extended-release morphine 200mg po q8h.
Despite this dose, she is still in pain. She also
complains of increasingly severe jerking. It is so
bad that her body jumps six inches off her chair
at times. What’s going on and what should you
do?
50
What did we do?

Diagnosed opioid neurotoxicity
– Morphine metabolites accumulate in CKD

Need to distinguish from uremic
encephalopathy from underdialysis
– Myoclonus in both
– Asterixis in both
– Somnolence in both
– Hallucinations in both
51
Opioid Neurotoxicity




Myoclonus-uncontrollable twitching and
jerking of muscles or muscle groups,
usually occurs in the extremities.
Hyperalgesia-increased sensitivity to
noxious stimuli or even light touch
Delirium with hallucinations
Grand mal seizures-late
52
How to Treat Opioid
Neurotoxicity



Stop opioid or reduce dose if pain
allows
Start new opioid
Treat jerking with benzodiazepines
– clonazepam 0.5mg BID or TID po
– lorazepam 1-2 mg po q8h
53
Conclusions


Use of the WHO 3-step analgesic
ladder results in adequate pain relief
in most ESRD patients.
Opioids have significant adverse
effects which can be anticipated and
treated.
54
Kidney End-of-Life Coalition
www.kidneyeol.org







American Association of
Kidney Patients
American Kidney Fund
American Nephrology Nurses’
Association
Center for Medicare &
Medicaid Services
DaVita
Dialysis Clinics, Inc.
Forum of ESRD Networks







Fresenius Medical Care
National Hospice and
Palliative Care Organization
National Kidney Foundation
National Renal Administrators
Association
Renal Advantage, Inc.
Renal Physicians Association
West Virginia University
55
Take-Home Messages





Assess pain systematically
Choose drugs that are safe in CKD
Start pain meds according to severity
and nature of pain and titrate
Anticipate adverse effects and warn
patient
Start stimulant laxative at same time
as opioid
56