Management of Non-Management of Non-Pain SymptomsPain Symptoms

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in Palliative Medicinein Palliative MedicineDouglas D. Ross, MD, PhDDouglas D. Ross, MD, PhD

General Principles• Listen to the Patient.• Make a diagnosis before you treat:

– History, exam, [lab], working diagnosis

• Know the drugs you prescribe...• Keep it simple!• Not everything that hurts responds to

analgesics• There is always something that can be done.

Prevalence of Symptoms in Patients with Cancer

Asthenia (fatigue) 74-90% Anorexia 44-85% Pain 62-76% Nausea 44-68% Constipation 35-65% Sedation/Confusion 60% Dyspnea 12-51%

Urgent Symptoms

• Pathologic Fracture• Seizure• Spinal Cord Compression• Increased Intracranial Pressure• Superior Vena Cava Syndrome• Hypercalcemia

Major Symptom AreasMajor Symptom Areas

• AnorexiaAnorexia

• Gastrointestinal:Gastrointestinal:– Oral / Dysphagia / Nausea-vomiting / Oral / Dysphagia / Nausea-vomiting /

constipation / bowel obstructionconstipation / bowel obstruction

• DyspneaDyspnea

• Delirium and terminal restlessnessDelirium and terminal restlessness

Reversible causes of AnorexiaA Aches and Pains

N Nausea and GI dysfunction

O Oral Candidiasis

R Reactive/organic Depression

E Evacuation problems

X Xerostomia (dry mouth)

I Iatrogenic--chemo, radiation

A Acid related: GERD, PUD

Before you place that IV or G-tube in a terminally ill patient....CONSIDER:

• Tube or forced feedings:– Do not prolong survival– Increase the discomfort– Aspiration, secretions, edema, ascites,

effusions, pulmonary congestion, nausea, diarrhea, use of restraints

• TPN is associated with decreased survival in terminal cancer patients

Terminal patient refusal of food and water:

• Frequently more traumatic to the family than the patient

• Chronic/terminal starvation and dehydration per se are not uncomfortable

Useful Interventions:• Sensible dietary advice:

– small portions of favorite foods– avoid foods with strong odors– do not force intake

• Family Conference• TRIAL of Appetite Stimulants

– Megace 80 to 200 mg tid or qid– Prednisone 1 to 2 mg qd or bid– Marinol 2.5 to 5 mg bid or tid

Dysphagia:Some causes and treatments

• Dry mouth caused by radiation– Synthetic saliva q 1 to 2 hrs– Pilocarpine 5-10 mg tid **caution

• Dryness caused by drugs such as– Compazine, thorazine, amitryptyline

Dysphagia, continued:Infectious causes and treatments

• Oral Candidiasis– Nystatin; Clotrimazole troches– Ketoconazole 200 mg qd x 14 d– Fluconazole 100 mg qd x 14 d

• Bacterial: periodontal disease

• Viral--Herpes simplex– Acyclovir 400 mg 5 times/day x 10 d

Dysphagia, continued:More causes and treatments

• Reflux esophagitis• Mucosal damage--soothing agents

– Benadryl and kayopectate mouthwash– Viscous lidocaine– May require parenteral opioids

• Systemic dehydration– ice chips, sips of fluid, moist sponge stick

Dyspnea

• “An uncomfortable awareness of breathing” (UNIPAC #4)

• DISTINGUISH dyspnea from hyperpnea and tachypnea

• DIAGNOSE and treat underlying cause when possible and reasonable

Dyspnea, treatable causesDyspnea, treatable causes

BB BronchospasmBronchospasm

RR Rales--CHF, volume overloadRales--CHF, volume overload

EE EffusionsEffusions

AA Airway obstructionAirway obstruction

TT Thick SecretionsThick Secretions

HH Hemoglobin low--cautionHemoglobin low--caution

AA AnxietyAnxiety

II Interpersonal issuesInterpersonal issues

RR Religious concernsReligious concerns

When to treat dyspnea symptomatically

• No treatable etiology identified

OR

• The treatments do not completely relieve the distressing symptom (dyspnea)

Opioid Therapy for Dyspnea:Considerations

• safe and effective when titrated– start with usual anti pain doses, increase dose

30 to 50% q 4 to 12 hrs until patient is comfortable

• In COPD patients, opioids increase exercise tolerance with decreased breathlessness, reduce O2 need

Opioid Therapy for Dyspnea Continued...

• Mild Dyspnea– Hydrocodone 5 mg q4h and q2h prn– Codeine (30 mg)- 1 tab q4h and q2h prn

• Severe Dyspnea– for patients on no or weak opioids

• Oxycodone 3-10 mg q4h and q2h prn• Oral morphine-3-10 mg q4h and q2h prn• Hydromorphone 0.5-2 mg q4h and q2h prn• Nebulized morphine...

Therapy of Severe Dyspnea Continued...

• Patients already taking strong opioids...

• Consider the anxiety component of dyspnea:– ADD Benzodiazipines (short acting)

• mild: PO lorazapam 0.2 to 2 mg q8h• severe: may need midazolam titration-start with

0.25 mg SQ q hr--TITRATE

Dyspnea: other considerations

• Use of Oxygen– Reserve for hypoxic patients??– Opioids are first choice for dyspnea, the

symptom– Use least invasive delivery--nasal prongs

• The terminal state– benzodiazepines

Nausea and Vomiting• Frequency in terminal cancer:

– Nausea--50% to 60% of patients– Vomiting--30% of patients

• Can be controlled in 90% of cases

• Pathophysiology:– Cerebral cortex– Vestibular apparatus– Chemoreceptor trigger zone– Gastrointestinal tract

Nausea and Vomiting:Nausea and Vomiting:Some treatable causesSome treatable causes

• Cortical:– CNS tumor– Intracranial pressure

– Anxiety, uncontrolled pain

• Vestibular / Middle ear– Vestibular disease– Middle ear infections

Nausea and Vomiting:More treatable causes

• Chemoreceptor Trigger Zone– Drugs– Metabolic--e.g., renal, liver– Hyponatremia, Hypercalcemia

• Gastrointestinal Tract– Gastritis/esophagitis– Constipation, impaction– Obstruction– Tube feedings

Persistent nausea...in a terminally ill patient

• Rule out bowel obstruction

• Start with– Haloperidol 1 mg PO or SC bid or tid, increase to 10

to 15 mg/day, as needed

• If needed, add:– Antihistamine (e.g., hydroxyzine) and /or– Metoclopramide (beware in bowel obstruction)– Other: Ondansetron (Zofran), Granisitron (Kytril),

methotrimeprazine (Levoprome)

Bowel Obstruction...in advanced cancer

• Incidence--3% overall in Hospice– Ovarian Cancer: 5% to 42%– Colorectal Cancer: 10% to 30%

• Mechanism: mechanical, paralytic

• Symptoms...

• Surgery...limited usefulness in terminally ill cancer patients

Bowel Obstruction...in advanced cancer

• GOAL: no cramps, no pain, minimal nausea, no more than 1 emesis/day

• Achieved IN MOST CASES– WITH analgesics, anticholinergic and

antiemetic drugs– WITHOUT the use of decompression tubes,

surgery or IV fluids

Pharmacologic treatment of malignant bowel obstruction• Pain: strong opioids• Nausea:

– haloperidol, antihistamines, phenothiazines (anticholinegic effect);

– metoclopramide: may make sx worse in mechanical obstruction

• Mechanical: vomiting of GI secretions, cutaneous fistulas– Octreotide (Sandostatin)

Octreotide (SandostatinTM)• Synthetic analogue of Somatostatin:

– Decreases intestinal secretion, bile flow– Increases intestinal absorption

• Adverse effects:– Dry mouth, Flatulence– Hypo- or hyperglycemia– Pain at injection site...

• Dosage and administration– 150g SC, bid OR

– 300g over 24h by SC infusion. Max. 600 g/day

Delirium and terminal agitationDelirium and terminal agitation

• Delirium: up to 85% of terminal cancer patients

• Features may include– Clouding of consciousness, altered attention– Perceptual disturbances– Acute onset, fluctuating course

Delirium--CausesD Drugs, especially psychotropics

E Electrolyte imbalance

L Liver failure

I Ischemia or hypoxia

R Renal failure

I Impaction of stool

U Urinary tract or other infection

M Metastases, other neurological

Drug Treatment of Delirium

• Haloperidol 1-2 mg PO or SC q1h to calm the crisis, then q6-12 hr

• If more sedation is desired, or for the AIDS dementia complex, use– Thioridazine (Mellaril) 25-50 mg PO q1h until

calm then q6-12 hr OR– Chlorpromazine 25-50 mg PO or IV until calm

then q6-12 hr

Severe Agitated Delirium

• Consider ADDING – Lorazepam (Ativan) 1-2 mg q1hr until calm

(PO, SL or IV)– Midazolam (Versed) 0.4-4 mg/hr continuous

SC infusion– Chlorpromazine (Thorazine) 100 mg q1h PO,

PR or IV until calm– Methotrimeperazine (Levoprome) 20 mg q1h

IM or IV, until calm

Smelly Tumors• Cause: Necrotic exposed tumor mass

– Breast (25%), Lung 7%, Renal (5%), Colon (3%)

• Treatment– Pain Control– Debridement– Control odor: etiol. Bacteroides sp.

• apply METRONIDAZOLE gel (0.8%) + systemic treatment (200-400 mg PO tid)

• Charcoal Dressings• MAALOX

– Soak dressings off

Other Non-pain Symptom Areas

• Pressure Sores• Stomas/fistulas• Edema/lymphedema• Pruritis/skin problems• Other GI-diarrhea,

ascites, impactions• Hemoptysis• Pleural effusions

• Incontinence• Urinary retention• Hematuria• Drug reactions• Seizures, other

neurological• Metabolic symptoms• Fever, infections

SUMMARYNon-pain symptom management

• Listen to the Patient.• Make a diagnosis before you treat:

– History, exam, [lab], working diagnosis

• Know the drugs you prescribe...• Keep it simple!• Not everything that hurts responds to

analgesics• There is always something that can be done.