Transcript Difficult to Manage symptoms

Dr. Diana Barnard
Dr. Ursula McVeigh
 Review common causes and presentations of Nausea,
Vomiting, Bowel obstruction, and Pain Crisis
 Review practical approaches to symptom management
 Provide opportunity for dialogue and questions
 Improve the quality of care and decrease the
frustrations of care providers!
 Review causes of N/V
 Review different medication classes based on etiology
 Review etiology of bowel obstruction
 Review medication and non medication management
Wood G et al. Management of Intractable Nausea and Vomiting in Patients at the End of Life: “I Was Feeling
Nauseous All of the Time . . . Nothing Was Working” JAMA. 2007;298(10):1196-1207.
Wood G et al. Management of Intractable Nausea and Vomiting in Patients at the End of Life: “I Was Feeling
Nauseous All of the Time . . . Nothing Was Working” JAMA. 2007;298(10):1196-1207.
 Cause: Vestibular
 Motion sickness
 Mediated thru Cholinergic, histamine receptors
 Treatment
 Limit triggering movement
 Anti-cholinergic-Scopolamine patch –one every 3 days
 Anti-histamines- Diphenhydramine, Promethazine,
Meclizine
 Requires medications that cross the blood:brain barrier and
are therefore sedating- meclizine 12.5-25 mg
 Low dose benzodiazepines also may be helpful- ativan
.5mg of valium 2.5 mg due to anxiety triggering
component
 Cause: Opiods
 Common with initiation or dose escalation and often
resolves within 3-5 days.
 Stimulation of the Chemoreceptor Trigger Zone (CTZ)
 Gastroparesis
 Constipation
 Treatment of Opiate related N/V
 Switch Opiates –limited benefit for some
 Pre-medicate, or once present –treat agressively around the clock
with meds ; then taper back as tolerated
 Metoclopromide (Reglan)
 D2 receptor in GI tract
 Dose range is 5-20 mg qid before meals and at bedtime.
 Haldol – effective and under-utilized
 D2 receptor in CTZ
 Dose range is 0.5-2.o mg PO/intensol/SQ/IV every 6 hours
 Non sedating at lower doses
 Prochlorphenazine (compazine)
 D2 receptor in CTZ
 Dose 10mg PO or 25 mg PR every 6 hours
 Bowel stimulants
 Senna dose range 2-12 tabs per day)
 Miralax 17 grams per day and taper up
 Cause: Metastatic or primary disease in the brain
 Leads to increased intracranial pressure
 Meningeal irritation causes release of hormones which
trigger the CNS vomiting center
 Treatment
 Steroids. Start with generous dose (e.g dexamethasone 8
mg bid) and taper down over days to weeks depending
on effect and prognosis
 Steroids work fast, effect can be dramatic
 Radiation Therapy can also have fast, dramatic effects on
N/V and other CNS symptoms associated with Edema in
/around the brain.
 Cause: Chemotherapy related N/V
 5HT3 released in gut
 CTZ stimulation
 Anxiety which triggers central pathways
 Treatment-premedicate
 Dexamethasone 2-8 mg po on day of chemo
 Ondansetron (Zofran) 4-8 mg PO or IV every 4-8 hours
 5HT3 antagonist
 Lorazepam (ativan) 0.5-2.0 mg PO/intensol/SL/IV every
4-8 hours
 Cause: Constipation
 Treatment
 Diagnose by history and exam ( rectal exam, x-ray)
 First, relieve existing constipation
 Stimulants- Miralax, lactulose, MOM, enemas, suppositories
 Prevent future Constipation
 Colace (stool softener)is NOT enough
 Goal is normal BM frequency for patient of every 1-2 days
 Senna 2 tabs PO bid-taper up to 6 tabs bid
 Miralax 17 grams 1-2 times a day
 Taper meds until goal is consistantly achieved; taper down
but DO NOT stop if diarrhea developes
 Patient education , tracking BMs very important
 Cause: Bowel obstruction
 Most common with colon, ovarian cancer
 Presents with nausea, vomiting and PAIN
 Identify most likely cause and location
 Ileus- is it temporary or reversible?
 Partial SBO- could there be disease progression?
 Transition Point tumor/mass in intestine
 Due to diffuse intra-abdominal tumor, ascites
 All trigger CTZ, 5HT3
 Treatment
 Meds more likely to be effective in partial obstruction
 Goal is to reduce bowel distension, spasm
 Metoclopromide trail (5-20 mg qid)- only if PARTIAL
 Steroids to reduce inflammatory response (Dexamethasone 8
mg po bid ; taper if effective, d/c if not effective
 Haldol 0.5-4.0 mg PO/Intensol/SC/IV every 6 hours
 Good Pain control with opiates
 Octreotide 50-100 micrograms SQ/IV TID; long term IM
depo form
 Mimics somatostatin to decrease secretions, reduce paristalsis
 Very expensive- useful in carcinoid related diarrhea; efficacy in
obstruction and use in non tertiary care centers lacking
 If complete obstruction
 Surgery can be effective but burdensome. Not appropriate for
limited life expectancy (<2 months) due to lack of success,
complications, poor healing
 NG tube effective often necessary for immediate relief
 Effective, bothersome, requires suctioning
 Venting G Tubes for small bowel obstruction
 Stents for Esophageal, gastroduodenal or Large Bowel
obstruction
 REMEMBER:
 Goals of care
 Accurate Prognosis
 Informed consent (understanding of risks, benefits, alternatives)
 Shared Decision Making vitale, chalanging
 Concept of I want to live vs. I want to live for an event
 Venting G tubes- Increasingly offered for SBO
 Benefits
 Non surgical procedure
 Comfort without a tube in your nose
 Allows some po intake- range of possibilities
 If early in illness, can be clamped, allow absorption of
nutrients, building “strength”
 Burdens
 TIME in or out of hospital
 IR procedure (lab draw, medication, waiting)
 Healing delayed / impaired in presence of ascites
 Gastrointestinal stents for focal intestinal cancers
 Benefits
 non surgical treatment
 Effect can be long lasting; depending on prognosis
 Early in non operable presentation, allows intake of a more
“regular” diet
 symptom relief can be dramatic, last a while
 Burdens
 Requires endoscopy/colonoscopy, with GI prep, sedation
 Effect is time limited as disease progresses
 Risks: TIME, migration, perforation, partial relief of
symptoms
 Availability in hospitals variable and limited by experience of
GI providers
 PEARLS:
 Consider etiology of N/V/Obstruction
 Pre-medicate Opiates with anti-emetics
 Don’t forget CONSTIPATION
 Many causes are multi-factorial; use what has worked
 If one class of medication is not working, switch classes
 Think about non pill form (PR, Liquid, ODT)
 Haldol is a very useful medication
 Obstructive symptoms are challenging, difficult to
manage, possibly becoming more common
 For Intractable symptoms, remember to focus on the
GOALS of care…Is going to the hospital a good or bad
thing???
 An EMERGENCY which requires rapid response
 A patient in pain will have limited capacity to consider
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any other issues until pain is well managed
Clear principles and guidelines exist in the literature
2009 NCCN Guidelines
Side effects can be avoided and/or managed
Very different from Chronic pain management
Effective communication is key
 Patient, family, care staff, prescribing provider
 GOAL:
 Rapid symptom relief
 BASIC PAIN PRINCIPLES APPLY
 Give repeated doses until comfort reached
 Re-evaluate OFTEN
 Calculate total dose needed to achieve comfort and then
dose on a schedule, monitor effect
 UNDERtreatment is as concerning as OVERtreatment
SEDATION comes before Respiratory depression
 Reference and follow established guidelines
 If opiate naïve
 give 2-5 mg morphine IV; recheck in 15 minute
 Give 5-15 mg PO; recheck in 1 hr
 Time frame for peak therapeutic effect AND peak sideeffects
 If on regular opiates
 Calculate total use in past 24 hours and give 10-20% of
this dose (TDD) PO or IV and reassess
10-20 % TDD IV
Reassess at peak
IV: 15 minutes; PO: 1hr
No Change in Pain
Increase dose
50%- 100% and reassess
IV 15 min/PO 1hr
Some relief
Repeat same dose
And reassess:
Pain decreased 50%
Reassess 2-3 hrs
IV 15 min/ PO 1hr
National Comprehensive Cancer Network Cancer Pain Guidelines 2009
Tools for success:
 Be deliberate, use guidelines, monitor your patient
 Don’t be irrationally afraid of overdosing
 Re-evaluate dose and effect frequently
 Use the medication you are most familiar with; be
willing to try something new if not effective
 For PO meds, use short acting medications for crisis,
then add long acting forms for more even effect
 If on IV infusion, once basal rate has started remember
it takes 5 half lives to reach steady state (MS4 and HM =
10 hrs), so additional boluses will be needed in the
interim
 ORAL medication route:
 Continue long acting scheduled medications
 PRN doses for breakthru pain should be 10-20% of the
total daily dose on a routine basis
 In a pain crisis, increase the scheduled dose by 50-100%
and give extra doses of prn medication, until comfort
achieved.
 Convert total dose into new scheduled medication
dosing and INCREASE breakthru dose accordingly
 PCA guidelines (IV, SQ)
 SQ route highly effective; requires coordination
 SQ rate limit is 2 cc per hour
 Start with basal rate based on previous 24 hour need
 Demand dose should be EQUAL to basal rate
 Demand dose can be offered every 10 minutes
 Total hourly dose can be “locked out”
 It will take about 8 hours for basal rate to have effect
 Additional bolus doses will be needed until then
 PCA doses may be used more in first hours
 Rapid dose escalation issues
 Always consider acute /reversible cause for pain crisis
 One change at a time helpful for cause/effect, but
rapid response may require multiple changes
 Pain may be “total pain” or psychic pain
 Adding anxiolytics (e.g ativan) very helpful .5-2 mg PO
every 4-8 hours scheduled or as needed
 Rotating / switching narcotics may be helpful
 Calculate equivalent dose, then 30-50% dose reduction
for incomplete cross tolerance.
 “Intolerance”
 Asses symptom carefully; consider dose adjustment
before changing opiates too quickly
 Sedation
 More common when opiate naïve
 Occurs well before respiratory depression
 Decrease dose 20% ; cautiously more to avoid
uncontrolled pain
 Nausea
 Pre-medicate for first few days
 Constipation
 Avoid first; if present, treat aggressively
 Intolerance of dose form
 Consider patch, intensol, subcutaneous
 Rectal forms can be compounded
 Limited research available for topical dosing
 Opioid toxicity
 More likely with large doses, rapid escalation
 Includes hyperalgesia, twitching, myoclonus, seizures,
delirium
 Consider hydration if c/w GOC
 Decrease dose (25%) or rotate opiates
 Add Lorazepam to suppress myoclonus if sedation
OK/EOL
 Consider and document reasons for switching
 Use Equal Analgesic tables for conversion
 Different charts/tables exist
 They are meant as a guide, NOT absolute conversion like
a measurement ( 1 cup = 8 ounces)
 Patients vary in response to different opiates
 Decrease total equal analgesic dose by 30-50% for
incomplete cross tolerance
 Check and recheck your math!
 Re-evaluate frequently for best practice “dose finding”
 MORPHINE
 IR/ER/Intensol/SQ/IV
 Many fears, bad experiences, family stories
 No such thing as a good drug or bad drug
 If persistant fear, chose something else
 Particularly useful in dyspnea, but likely a class effect
 Itching, nausea, fuzzy-headedness at age 2o with
wisdom teeth are not symptoms of allergies.
 Hydromorphone
 Preferred drug at FAHC for renal impairment which
causes accumulation of metabolites… but occurs with
many meds
 IV/PO, no intensol formulas, new long acting formula
 Oxycodone
 Avoid combination with Tylenol to limit toxicity as
doses are increased
 ER,IR, intensol formulas
 NO IV formula
 High street value, especially in Oxycontin form
 Should not stop appropriate use
 Careful monitoring of amounts of medication- especially
with frequent dose changes
 Remind patients about safety (accidental or intentional
diversion)
 FENTANLY
 IV/patch forms. Various po forms – safety issues
 Patch can be beneficial for stable medication effect and
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to avoiding po meds
Lipophillic so best to have subcutaneous fat for
reservoir.
Takes 12 plus hours to have some effect
Takes 24 hours to get to steady state AND to leave the
body if poorly tolerated
Expensive, especially if using two patches
?less constipating ?less nauseating
 Methadone
 Most practitioners have a DEA license to prescribe for
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PAIN, not for ADDICTION
Cheap
Effective, especially for neuropathic pain
Pharmacokinetics –long time to steady state (3-7 days),
very long half life so dose changes must be SLOW
Can be high risk; requires experience
Not commonly used
Like Oxycontin (and all narcotics), has high street value
PO
IV
Morphine
30mg
10mg
Hydrocodone
60mg
Hydromorphone 7.5mg
Oxycodone
20mg
Codeine
200mg
Fentanyl
1.5mg
100 mcg
Route
Onset
(min)
Peak
(min)
Duration of T ½
effect (hrs) (hr)
SS
IV
5
10
1-4
2
8
PO
30
60
3-4
3
3
8
1-4
2
PO
20
100
3-4
3
Oxycodone
PO
20
60
3-4
3
Fentanyl
IV
<1
6
3-4
3
TD
6-12 hr
1-3 d
IV
15
60
4
PO
60
120
6
Morphine
Hydromorphone IV
Methadone
8
4d
8-60 2d12
Trescot. Opioid pharmacology. Pain Physician, 2008
Dose
Cost/month
Methadone
5mg po TID
$10
Morphine ERT
60mg BID
$200
Fentanyl TD
50mcg/hr q3d
$240
Oxycontin ERT
40mg BID
$420
CRI
HD
Notes
Fentanyl
OK
OK
Limited data
Not dialyzed
Methadone
OK
OK
Not dialyzed
Hydromorphone Caution
Caution
Lower dose,
longer interval
Oxycodone
Caution
Caution
Poor data
Morphine
Avoid
Avoid
active metab
Codeine
Avoid
Avoid
Active metab
Dean, Opioid in Renal Failure and Dialysis Patients. JOSM, 2004
Normal
Cirrhosis
Notes
T 1/2
T 1/2
Fentanyl
263 min
304 min
No change
Drug of choice
Methadone
11-35 hr
11-35 hrs
↓dose w/ svr
failure
Hydromorphone 2.5
no data
↓ dose
Morphine
3 hr
5 hr
↓ dose
Oxycodone
3 hr
14 hr
↓ dose and freq.
Rhee, Palliation and Liver Failure: Palliative Medications Dosage Guidelines. JPM, 2007