Treatment in Palliative Care

Symptom management

evaluation individualized treatmentexplanationsupervisionattention to detail

ACUTE PAIN Rapid pulseRaised blood pressureDilated pupilsQuiet, rubbing part, guarding painful areaReports pain

CHRONIC PAIN Normal blood pressureNormal pupil sizeNormal activity, perhaps limited in natureMay not even mention pain unless questioned

Main problems PainConstipationLack of appetiteLoss of weightSleepnessnessAnxietyNausea and vomitingPowerlessnessDyspnoe

Main problems

Pain is what the patient says hurts

Total painPhysical pain basal disease, coexisting illnesses, results of treatment Psychological suffering anxiety, depressionSpiritual suffering existential and religious problems, DAME CECILY SAUNDERS

PAIN

PHYSICALPSYCHOLOGICALSOCIALSPIRITUALTOTAL PAIN Saunders 1967

Skale bluSkala wzrokowo- analogowa Skala oceny liczbowej NRS

0 10Brak blu bl nie do zniesienia

1 10Brak ulgi w dolegliwociach cakowita ulga1 2 3 4 5 6 7 8 9 10

Pain ACUTE - CHRONIC NOCICEPTIVE NEUROPATHIC PSYCHOLOGICAL

Nociceptive pain STIMULATION OF NERVE ENDINGS

visceral ( colic, migraine, cancer)somatic ( cancer, infection, tension headache, cramp, bone)muscles tension

Neuropathic pain nerve compression nerve injury * peripheral (de-afferentation) - Somatic (peripheral neuropathy, phantom) - Visceral ( infiltration of para-aortic visceral nerves) * central ( poststroke, spinal cord compression) *sympathetically maintained ( causalgia)

Analgetic Ladder WHO 1986 I0 non-opioids + adjuvants II0 weak opioids + non-opioids + adjuvants III0 strong opioids + non-opioids + adjuvants

Principles of analgesic useBy the mouthBy the clockBy the ladderIndividual treatmentSupervisionAdjuvant drugs

But...Chronic pain needs to be treated by slow acting medicine PERSISTANTLY...Breakthrough pain ( predictable , non-predictable, pain of the end dose) needs using occasionally short acting medicine.

Non opioidsParacetamolNon- steroid Antiinflamatory Drugs (COX1)IbuprofenDiclofenacKetoprofenPiroxicam etcNon- steroid Antiinflamatory Drugs (COX2) Acetylsalicylic acid

Weak opiois ( II0 WHO) Tramadol 1/5 Codein 1/10 Dihydrocodein 1/10 Oxycodon 1,5 / 1Dextropropoxyphen

Pentazocin DO NOT USE !!!

Tramadol caps 50mg, tabl. forte 100mg, SR-tabl. retard- 150, 200mg guttae 1g/10ml (1ml=40gtt.) agonist of -,-, - receptor presynaptic bloker of rec. MAO convulsions threshold is lowered

Pentazocin ( Fortral)Partial agonist receptorAgonist receptorPure antagonist receptorShort acting 2-3 hPsychotomimetic effects

DO NOT USE IN CHRONIC PAIN

Strong opioids III0 WHOMorphine hydrochloride ( substance, Sevredol, Vendal,)Morphine sulphate (Doltard, MST-Continuous, M-Eslon, Vendal, ) 1/1 Fentanyl ( Durogesic TTS) 150/1Buprenorphine (Bunondol, Transtec TTS) 60/1Methadone 5-10/1Diamorfina ( heroin) 2/1Dextromoramid (Palfium) 2/1Pethidine (Dolargan) 1/8 DO NOT USE!!!

MorphinePure agonist of receptorWithout ceiling-effectM6G is 10-20x , M3G (toxic), First dose 30 mg/24h ( 15mg/24h )Dose is arised 50% if ineffective 10% of Codein is metabolised to M6G

MorphineMorphine hydrochloride SubstanceSevredol tabl. 10- 20mg short acting VendalMorphinum sulphate 10,30,60,100mg M-Eslon MST-Continuous Doltard Kapanol

Rp.Morphini hydrochlorici 4,0 Aquae destillatae ad 400,0 ml M.f. Solutio D.s. ml q4h 600, 1000, 1400, 1800, 2200, ( 200 )

FentanylPure agonist Fentanyl is 150 x than MFLipophilic ( peripheral side effects are not so strong as MF)

PethidineAgonist Action time 2-3 hCeiling effect 600mg/24hToxic methabolite norpethidine Siede effects: myoclonus, dysphoria,Indications: acute pain, not use longer than 48 h, Contraidications: renal failure

Sensitization PERIPHERAL activation of sleeping receptorsinflammatory soup

CENTRAL activation of the NMDA receptor-channel complex

Wind-up Chronic irritation of C-fibers , which are proliferated in posterior horns of medullae spinalis and are responsible for potencialization of the impulses ( allodynia)

MethadoneAgonist -receptor and -receptorRacemic forms: L- i D NMDA receptor antagonist The plasma halflife ranges 8-80 hBioavailibility 80% (parenteral)LipophilicEliminated by alimentary tract in 80% (in renal failure may be used)5-10 x than MF, 3-5mg start dose

Receptor NMDA

Opioid Rotation Non effective, toxicBecause- of different types of opioid receptors Differences in pharmacocinetics and methabolizm of opioidsBe careful in equivalent dosesupports of tolerance metadon ma wiksz wewntrzn aktywno ni MF

Muscle spasm MiorelaxantsBaclofen (GABA- agonist) tabl. 10 i 25mg 3 x 5-10 mgTyzanidine

Benzodiazepins Midazolam 7,5 15 mg p.o. Clonazepam 0,5 mg /nocte Diazepam 5-20 mg p.o.

Adverse effects of opioidsConstipation 100%Nausea and vomiting 50%Drowsiness 100% unsteadiness, confusion initialStop urination be careful !!Central depressant effectsPsychological dependence Physical dependence Occasional dry mouth, inflammation of mouth, candidiasis, sweating, myoclonus

Never say I have tried everything...There is nothing more I can do ...

Czynniki obniajce prg blu: zmczenie, bezsenno, lk, zo, depresja, izolacjaNeuropat obwodowy = de -aferentacyjny : moe by somatyczny (bl fantomowy, neuropatia obwodowa, neuralgia poppacowa) i trzewny ( np.naciekanie nerww trzewnych ok.. Paraaortalnej). Neuropat obwodowy = de -aferentacyjny : moe by somatyczny (bl fantomowy, neuropatia obwodowa, neuralgia poppacowa) i trzewny ( np.naciekanie nerww trzewnych ok.. Paraaortalnej). Tramadol dziaanie presynaptycznego blokera wychwytu zwrotnego monoamin ( jak trjcykl. ) . Uwaga obnia prg drgawkowy ! U osb z wywiadem drgawk nie dysphoria, depersonalisation, frightening dreams, hallucinations

silny agonista kappa , na rec. kappa rdzenia krg. dziaa silniej od MFagonista sigmabyc moze dziaa na rec. delta

metabolity nieaktywne jako glukuroniany Approximate oral analgisic equivalence to Morphine Buprenorphine ( poch Tebain) small intrinsic activity, partial agonist ( agonist antagonist) to , ? , non- effect. Sl, Metabolites are inactive, 2-3 days patients are advised to take dose q3h as needed , later bd or tds regimenKetamine blockade of NMDA receptor-channel complex . Methadone lipophilic like FentanylMetadone useful, when renal failure ( because M6G is collected and causes drowsiness and delirium )Rec NMDA Aminokwasy pobudzajce CUN :Kw` glutaminowy g przekanik pobudzajcy w mzgu. Oraz endogenny ligand rec. NMDAKw. asparaginowy nawet drgawkiRec NMDA zoony o wielu miejscach wizanialigandw endog ktre bior udzia w otwarciu kanau wapniowego.

Miejsca dla: - kw. glutaminKw.N-metylo-D-asparaginowegoMiejsce poliaminMiejsce glicynoweMiejsce wizania jonw Mg i Zn. zlokalizowane w obrbie kana`u wapniowego i hamujce funkccj receptora. Przy potencjale spoczynk. Wikszo``sc rec NMDA jest zablokowana przez MG ,ktry blokuje wejcie.

Baclofen hamuje przewodzenie odruchw mono -i polisynaptycznych na poziomie rdzenia, prawd. Przez stymulacj rec. GABA