Post on 16-Mar-2018
CANCER PAIN(2003)
PAIN MANAGEMENT CENTER ST. LUKE’S MEDICAL CENTER
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Pain Management Center
Officers & Board of Trustees
Director Emeritus Director
Training Officer
St. Luke's Medical CenterTel# 727-5416, 723-0301, 723-0101 ext. 4403/5416 Fax# 723-1023Website: www.stluke.com.ph
Cenon R. Cruz, M.D.Francis O. Javier, M.D.Antonio N. B. Yap, M.D.
ActiveconsultAnts
Ma. Victoria M. Abesamis, M.D. Pediatric Oncology Erlinda T. Arambulo, M.D. Merlina L. Cabrera, M.D. Luzviminda A. Salomon-Kwong, M.D. Anesthesiology/Pain Medicine Agnes C. Bueno, M.D. Psychiatry Rafael S. Claudio, M.D. Orthopedic Oncology Agnes M. del Rosario, M.D. Pulmonary Medicine Luisito O. Llido, M.D. Nutrition Support Service Gloria C. Luna, M.D. Medical Oncology Lyde A. Magpantay, M.D. Reynaldo Rey-Matias, M.D. Rehabilitation Medicine Amado M. San Luis, M.D. Edmundo G. Saniel, M.D. Neurology Miguel A. Ramos, M.D. Geriatric Medicine Ricardo B. Boncan, D.M.D. Oral Surgery/TMJ Specialist
visitingconsultAnts
Romulo S. De Villa, M.D.Molecular Biology
Roberto O. Bolinas, M.D.Medical Oncology
Eric C. Legaspi, M.D.Neurosurgery
Juan Javier T. Lichauco, M.D.Rheumatoogy
Randy S. Mercado, M.D.Gastroenterology
Jose M. Paiso, M.D.Orthopedic/Spine SurgeonFlorizel Del Prado, M.A.
PsychologyAntonio C. Sison, M.D.
Psychiatry
HonorAryconsultAnts
Mayvelyn D. Gose, M.D.Neurology
Leonor F. Rivera, M.D.Anesthesiology
Fellows
Salvador E. Brodit, Jr., M.D.Laarni P. Remorque, M.D.
Jefferson R. Castillo Lee, M.D.Ma. Patria C. Flores, M.D.
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Algorithm for Cancer Pain Managementnotes:1.A.somaticpain2.B.neuropathic pain- use of adjuvants (anticonvulsants, antidepressants, anxiolytics, etc).3.c.visceral - use of other adjuvants (antiemetics, proki-netics, antispasmodics, antacids, H2-blockers, proton pump inhibitors, etc.)4.1.Blocks - peripheral or field blocks- diagnostic/ palliative/ neurolytic- continuous or single injection techniques- e.g.celiac plexus block for pancreatic cancer, sup. hypogastric block for rectal cancer5.i.oralOpioids: Morphine - oralNSAIDS (non-steroidal anti-inflammatory drugs)AdjuvantsIa. Transdermal/ Transmucosal PharmacotherapyFentanyl - transdermal (Durogesic), transmucosal (Actiq)6.ii.parenteral (Intravenous/Intramuscular/Subcutaneous)Opioids: a. morphineb. fentanylNSAIDS - diclofenac, ketorolacAdjuvants7.iii.epiduralanalgesia- continuous/single injection tech-niques alone or in combination with opioids (bupivacaine/ropivacaine)- use of implantable devices8. iv. intrathecal analgesia - continuous/single injection techniques- use of opioids/local anesthetics or combinations- use of implantable devices9.v. surgical interventions - neurotomy, rhizotomy, my-elotomy, cordotomy
Figure1
Use WHO Ladder accordingly
1
2
3
6
Oral treatment
effective?y
n
y
n
y
n
y
4
5
7 8
9 10
11
n
See Figure 1a
Use:• Fentanyl (transdermal or transmucosal)
• Peripheral or field blocks• Diagnostic/palliative/neurolytic• Continuous or single injection techniques, e.g.
celiac plexus block for Pancreatic Ca; sup. hypogastric block for Rectal Ca
Use:• Opioids• NSAIDs• Adjuvants
Blocks effective?
Transdermal/trans-mucosal Pharma-cotherapy effective?
Parenteral treatment effective?
See Figure 1b
• Somatic• Neuropathic• Visceral
Evaluation of pain
Cancer Pain
10
See Figure 1c
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Figure1a
Figure1b
Titration?
Continue managementPain Relief?
May transfer to I-IaRescue doses apply
Use PCA/PCEA for titration and
pain control
Continue management
Re-evaluate patient
Parenteral treatment
y
4
n
7
52
6
8
3
1
y
n
y
n
y
1
4
Figure 1
2 3
n
See Figure 1a
Surgical Interventions (Palliative/Ablative)
Intrathecal analgesia effective?
Epidural analgesia effective?
Use:• Continuous/single injection techniques• Opioids/local anesthetics or
combinations• Implantable devices• Other complementary interventions
(Radiotherapy, Chemotherapy, etc)
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Figure1c
1
2
3
6
4
5
7
8
9 10
Adequate pain control
WHO Ladder
Pain due to: Anticancer therapy
such as: • Surgery• Radiation• Chemotherapy
Use Analgesic drug ladder steps
1 and 2
Analgesic drug ladder steps 1 and 2
11
Pain persists
Use Ana lges i c d rug ladder
steps 2 and 3
Switch to alternative opioid, change route/timing of administration, use of adjuvant analgesics
Failed primary modalities, side effects unacceptable
Severe persistent pain
Localized regional pain• Neurolytic nerve blocks (e.g. intercoastal block, celiac plexus block)• Neurosurgical procedures (e.g. cordotomy)
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Cancer PainThe Pain Management Center of St. Luke's Medical Center follows the WHO three-step analgesic ladder for managing cancer-related pain. Pain not amenable to oral route, or if fast opioid titration is necessary, the use of the PCA (Patient-Controlled-Analgesia Machine) is mandatory.
More than 65% of referrals to the Center are pain secondary to cancer. (See WHO Three-Step Analgesic Ladder.)
For patients who are in need of a faster titration of opioid, steps 2-3 may be done using the IV PCA technique.
The PCA allows for a faster drug titration and the drugs computed based on patient's demands. An equivalent oral opioid is prescribed once pain control has been stabilized.
The use of transdermal fentanyl (Durogesic) is another option in providing pain relief of cancer patients. For rescue doses, oral morphine is used. The transmucosal fentanyl citrate lozenge (ACTIQ) is only available as "compassionate prescription".
The introduction of the sustained-release oxycodone (Oxycontin) has made it easier for patients to begin opioid therapy as it does not have the "morphine stigma". This drug may be used from step 2 onwards. The limitation of the sustained-release oxycodone is the unavailability of the immediate-release preparation for rescue dose purposes. Morphine tablet (immediate-release) may be substituted for this.
cancerpaincensus(top10)
A lot of cancer patients seen by medical oncologists are in advanced stages. This is basically economic in nature as people tend to postpone consultation to the doctor. By the time the patient is seen at the Pain Management Center, majority have difficult cancer pain syndromes that require multidisciplinary management.
Pain secondary to metastatic lung cancer accounts for the most number of pain patients followed by metastatic breast cancer.step1
ASA, NSAIDS (if no contraindications)
COX-2 inhibitors
Used in combination with adjuvant drugs
(TCA, antihistamine, benzodiazepam, anticonvul-sants, steroid, laxatives, phenothiazine)
step2
Non-opioid + mild opioid + adjuvant drugs
Tramadol is the Step 2 drug in the Philippines
Rescue medications apply.
step3
Non-opioid + strong opioid + adjuvants
Morphine is the drug of choice
Rescue medication apply.
Adjuvant drugs like TCA's, anticonvulsants, steroids, bisphosphonates etc, maybe added in all steps.
wHothree-stepAnalgesicladder
STEP 3 Severe
STEP 2 Moderate
STEP 1 Mild Pain
January2000-December2002
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Drugs Mentioned in the Treatment GuidelineThis index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these drugs can be found in PPD reference systems.
AnalgesicscoxibsCelecoxib Celebrex CoxidEtoricoxib Arcoxia/Arcoxia ACParecoxib DynastatRofecoxib Vioxx
nsAiDsAcemetacin RantudilAspirin Bayer Aspirin CortalDiclofenac Abicfen Acloren Cataflam Denkoran Diclowal/Diclowal Retard Difenax Dolfastad Doloflam Neo-Pyrazon/ Neo-Pyrazon SR UL Diclofenac Na VCP Diclofenac Na Voltaren Voren/Voren Forte/Voren SRIbuprofen Advil Buroid Dalnor Dolan FP Laberfen Midol Morexen Nurofen Syrup Painrex Skelan ForteIbuprofen/Aspirin AnadolIbuprofen/Paracetamol Alaxan Femol
Muskelax Relaxid SelxanIndomethacin IndocidIndomethacin farnesil Infree Ketoprofen Ketofen Orudis EC Orudis IVKetorolac ToradolLeflunomide AravaLonazolac Exflame/ Exflame ARMefenamic Acid Abicfen Acidan Analcid Aprostal Biogenerics Mefenamic Acid C&M Mefenamic Acid Calibral DLI Mefenamic Acid Dolfenal Dolmetine Drugmaker's Biotech
Mefenamic Acid Escandar Fendal Fenexan Gardan Gisfen Harpinac Isagesic Istan Medianon Pacimic Penomor Pharex Mefenamic Acid Ponstan Proxyl Ralgec Revalan RiteMED Mefenamic Acid
Selmac Sensomef Spegic Totagesic Tynostan ZapanMeloxicam MobicNaproxen Flanax/ Flanax Forte Lefaine Naprelan Naprosyn LLE/ Naprosyn LLE
ForteNimesulide AulinPiroxicam Drugmaker's Biotech Piroxicam Feldene/ Feldene Flash Flaxine Macroxam Maxipin Parixam Pirostad TroxiflamProglumetacin AfloxanSulindac ClinorilTenoxicam Tilcotilnon-opioidAnalgesicsParacetamol Aeknil Afebrin Aldep Aminofebrin Baropyrine Biogenerics Paracetamol Biogesic Calpol/Calpol Six Plus Carpacet Crocin Delgin DLI Paracetamol Dolexpel Drugmaker's Biotech
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Paracetamol Europharma Paracetamol Franciphen Gendol Susp/Tab Genpyra Gifaril-P Lenor Medgenol Medicol-A Metagesic Myremol Naprex Naprinol Neo-Aspilets Nopain Forte Norgesic Octagesic/Octagesic Forte Opigesic Pacigesic Pharex Paracetamol Pynal Rexidol Reximed RiteMED Paracetamol Rufenal Saridon Tempain Syr/Forte Tab/ Forte
Syr/ Drops Temperal Tempra/ Tempra Forte TylenolParacetamol/Vitamin B-Complex Dolo-Neurobion
opiates&AntagonistsButorphanol StadolFentanyl Durogesic SublimazeMorphine sulfate Hizon Morphine Sulfate Relimal CRTramadol Dolotral Siverol TDL Tradonal Tramal
skeletalmusclerelaxantsBaclofen Lioresal
Eperisone MyonalOrphenadrine Norgesic
localAnestheticsBupivacaine Marcaine Sensorcaine SpinalLidocaine Abbott 2% Lidocaine
(Premixed) Dentocaine 2% Lidocaine HCl 2% Inj-Elin XylocaineLidocaine/Prilocaine EmlaProparacaine AlcaineRopivacaine NaropinTetracaine Pontocaine
AdjuvantsAnticonvulsantsCarbamazepine TegretolClonazepam RivotrilDiazepam Anxionil Trazepam UL Diazepam ValiumDivalproex sodium EpivalGabapentin NeurontinLamotrigine LamictalMagnesium sulfate Elin Magnesium Sulfate Hizon Magnesium SulfatePhenobarbital Rhea PhenobarbitalPhenytoin DilantinTopiramate TopamaxOxcarbazepine TrileptalValproic acid
Depakene
AnxiolyticsAlprazolam XanorBromazepam LexotanClorazepate dipotassium TranxeneDiazepam Anxionil Trazepam UL Diazepam ValiumFlurazepam DalmaneHydroxyzine Iterax
AntidepressantsCitalopram LupramClomipramine AnafranilFluoxetine ProzacFluvoxamine FaverinImipramine TofranilMirtazapine RemeronMoclobemide AurorixParoxetine SeroxatSertraline ZoloftTianeptine StablonTrazodone DepresilTrimipramine SurmontilVenlafaxine Efexor XR
AntiemeticsBetahistine Merislon SercCinnarizine Calzirine Drugmaker's Biotech
Cinnarizine
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Sugeron/Stugeron ForteDifenidol CephadolDimenhydrinate Drugmaker's Biotech
DimenhydrinateGranisetron KytrilMeclizine BonamineMeclozine PostadoxineMetoclopramide Cardo Perten Clovomet PlasilOndansetron ZofranPromethazine Phenergan ThaprozineRamosetron Nasea Injection Nasea ODTropisetron Navoban
prokineticsActivated dimethicone DisflatylDomperidone MotiliumMetoclopramide PlasilPancreatin/amylase PankreoflatPromethazine Thaprozine
AntispasmodicsButropium ColiopanDicycloverine Bentyl Cynergic Dilomin DLI Dicycloverine HCl Drugmaker's Biotech
Dicycloverine Hydrochloride Relestal Smodic UL DicycloverineHyoscine
Ascopen Buscopan Buscopan Plus
AntacidsHydrotalcite/Simethicone/Dicy-
cloverine Algelan-Plus Kremil-SAluminum hydroxide/Magnesium
carbonate Almax Drugmaker's Biotech Aluminum
Hydroxide/ Magnesium Carbonate
Aluminum hydroxide/Magnesium carbonate/ Oxethacaine
MucaineAluminum hydroxide Alu-TabAluminum hydroxide/
Magnesium hydroxide Asikit Creamalin Drugmaker's Biotech Aluminum
Hydroxide/ Magnesium Hydroxide
Gel-Malicid Laxadan Maalox Magalum Mylanta 2 Pepticon PromulaxAluminum hydroxide/
Magnesium hydroxide/ Dimethicone
Maalox PlusAluminum hydroxide/
Magnesium carbonate/ Magnesium hydroxide/
NovaluzidCalcium carbonate Harveytums TumsHydrotalcite/ Simethicone Mucilan UL Antacid SimecoMagnesium hydroxide Philips Milk of MagnesiaCitric acid/ Piperazine/ Sodium
bicarbonate/ Tartaric acid
Roche Piperazine
BisphosphonatesAlendronate Sodium FosamaxDisodium Clodronate BonefosRisedronate Sodium ActonelZoledronic Acid Zometa
H2-receptorAntagonistsCimetidine Antag Biogenerics Cimetidine Ciclem Drugmaker's Biotech Cimeti-
dine Duogastril Europharma Cimetidine Getidin Gitadene Mestulcer RiteMED Cimetidine TagametFamotidine H2 Bloc PepcidineNizatidine AxidRanitidine Drugmaker's Biotech Ranitidine Incid Novopharm Ranitidine Pharex Ranitidine Ramadine Raxide Tagamet Ulcin Zantac/Zantac FRRanitidine/ Bismuth citrate PyloridprotonpumpinhibitorsEsomeprazole NexiumLansoprazole PrevacidOmeprazole Losec OAC HP7*Pantoprazole Pantoloc
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UlceprazSodium rabeprazole Pariet
laxatives/enemasBisacodyl DulcolaxDietary fiber FibrosineDSS/Sorbitol Clyss-GoGlycerin Rhea Glycerin SuppositoryIspaghula husk Mucofalk Apple/Orange
GranulesLactulose Duphalac Duphalac DryLactitol ImportalMonabasic sodium phosphate/
dibasic sodium phosphate Fleet EnemaSodium picosulfate LaxoberalStandardized senna concentrate Senokot
steroidsBetamethasone Betnelan Celestone DiprospanDexamethasone Decilone Drenex Inflam Oradexon Oradexon Forte RiteMED Dexamethasone Scancortin 4 Scancortin 5Hydrocortisone Hydrocort Hydrotopic Inj Pharmacort Phoenix Hydrocortisone So-
dium Succinate
Solu-CortefMethylprednisolone Depo-Medrol
Medrol Solu-MedrolPrednisone Drazone Drugmaker's Biotech Pred-
nisone GXI Prednisone Orasone 5/Orasone 20 Organon Prednisone Pred 5/10/30 RoidrenalPrednisolone Liquipred RiteMED PrednisoloneTriamcinolone Kenacort Kenacort-A Intra-articular/