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BCOP > Pain, bone mets, and spinal cord compression > Flashcards

Pain, bone mets, and spinal cord compression Flashcards

1
Q

cancer pain %’s

A

30-50% during tx
70-90% when advanced CA
universal screening for all pts

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2
Q

barriers to adequate pain mgmt

A 
#patient and family related 
#provider related
#system related
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3
Q

quantify pain intensity and characterize quality in pain

A

location, quality, pain hx, etiology, response to current tx, medical hx, psychosocial, risk factors for undertreatment, physical exam, lab, imaging studies

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4
Q

rating scales for pain

A

numerical, categorical, visual analog scale (10cm line with descriptions), faces

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5
Q

PQRST algorithm for characterizing pain

A

P=palliative (what makes pain better?) and provacative (what makes worse)
Q=quality (somatic vs neuropathic description)
R=radiation (where is the pain, local vs diffuse/systemic)
S=severity/intesity (how does it compare with other pain you have experienced)
T=temporal (intensity changes with time, certain activities, nightime only)

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6
Q

what makes cancer pain different? (3pts)

A 
#unique combination types (somatic, visceral, neuropathic, chronic, acute)
#source of pain (tumor vs treatment induced)
#pain progression (ofter linked to tumor progression)
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7
Q

WHO pain relief ladder

A

1= non-opiod up to 3=epidural

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8
Q

NSAIDs

A 
#antipyretic, analgesic, anti-inflammatory
#ceiling effect for analgesia
#no tolerance or dependence
#best for nociceptive pain
#individual response varies
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9
Q

NSAID ADR

A 
#GI, MI
#heme (dec plt aggregation, caution if existing or anticipated thrombocytop)
#renal - dec GFR (caution if other agents are also renal tox, cisplatin, HD mtx)
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10
Q

COX-2 dose and ADR

A

100-200mg bid celecoxib
no anti-platelet effects, reduced GI irritation, CV effects black box waring (avoid if co-morbid)
rofecoxib removed because of CV eventss
skin rxns rash, mouth sores

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11
Q

preferred opioids for renal failure

A

fentanyl, methadone

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12
Q

why methadone?

A 
#prolonged duration of action with repeated dosing up to 40 hours, antagonizes NMDA, blocks reuptake of 5HT and NE
#can use in renal failure (lack of neuroactive metab)
#good bioavail
CAUTION: equianalgesic conversion difficult, qt prolongation
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13
Q

example methadone conversion

A

300mg = 12:1

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14
Q

tramadol

A 
#low affinity for mu-receptor
#inhibits reuptake of NE and 5HT
#lowers seizure threshold
#no ceiling effect
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15
Q

codeine

A 
#N/V is dose limiting
#CYP2D6 poor metabolizer minimal conc of morphine ->minimal effect: ultra rapid -> risk of tox
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16
Q

meperidine

A 
#avoid
#short DOA
#lowers seizure threshold
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17
Q

propoxyphine - PULLED FROM MARKET 2010

A

questionably efficacy, neuroactive metab, short DOA

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18
Q

is nausea less common in the elderly for opioids?

A

Yes

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19
Q

respiratory failure “warning signs

A

pain control ->somnolence -> respiratory depression

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20
Q

why do pts >65yo have 2-fold higher incidence of constipation?

A

sedentary lifestyle, dec bowel motility, concurrent medications
use softener +stimulant

21
Q

how long until methylnaltrexone works?

A

majority 1-2 hours, then up to 4 hours

works for 50%

22
Q

response to opioid adverse effects

A
  1. decreased dose by 25-50%
  2. opioid rotation
  3. add additional med to control side effect
23
Q

general principles of opioid conversion - why are you changing

A
  1. lack of efficacy (why not inc dose)
  2. intolerable side effects (why not treat effect)
  3. change in pt status
  4. practical considerations (cost)
24
Q

opioid conversion codeine

A

30mg po MS = 200mg po codeine

25
Q

general principles of opioid conversion - dosing

A

indiividualize: cut back 25%, straight, inc 25%

prn dose should equal AT LEAST 100% of long acting pdt (can use for PCA hourly dosing too)

26
Q

opioid MYTHS

A 
#amount of pain relief has a ceiling
#more potent are more superior
#often leads to dependence/addiction
27
Q

addiction definition (often confused with other terms such as physical dependence / psychological dependence)

A

dependence on the regular use of a substance to satisfy physical, emotional, and psychological needs DESPITE harm

28
Q

duloxetine for chemotherapy induced neuropathy

A

sig improvement in average decrease in pain score vs placebo

duloxetine had increased sedation

29
Q

skeletal complications due to bone mets (7pts)

A

pain, pathologic fx, hyperca++, spinal cord compression, bone marrow infiltration, nerve root compression, reduced mobility and qol

30
Q

bisphosphonate MOA

A

inhibit osteoclast maturation and function (affinity for areas of osteolysis)

31
Q

bisphosphonate proven reduced SRE in these dz’s

A

breast CA, MM, prostate CA, other solid tumors

32
Q

bisphosphonate renal dysfunction

A

guidelines vary by agent and cancer type (SEE HANDOUT)

33
Q

ASCO MM bisphosphonate guidelines

A

check 24h urine for Cr, albumin, and azotemia q3-6 mo; HOLD tx is albumin in urine >500mg/24h

34
Q

bisphosphonate lab monitoring

A

SCr before each dose
periodic electrolytes, Ca, phos, Mg (last 3 hypo), Hgb/Hct
recommend 500mg Ca daily supplement

35
Q

bisphosphonate ADR

A 
#myalgias, arthralgias, flu-like sx (usually within 48h of 1st/2nd dose, manage with NSAIDs)
#ocular effects
#?a fib
#ONJ- incidence unknown, 2.9-9.9%, probably underdiagnosed, incidence rare if less than 12 months exposure, zolpidem > risk than PAM
36
Q

ONJ stage 1 management

A

antibacterial mouth rinse, 3mo f/u, pt education, review continued need for BP

37
Q

ONJ stage 2 management

A

symptomatic tx with systemic abx, abx mouth rinse, pain control, superficial debridement to relieve soft tissue irritation

38
Q

ONJ stage 3 management

A

symptomatic tx with systemic abx, abx mouth rinse, pain control, SURGICAL debridement for long- term palliation of infx and pain

39
Q

to minimize ONJ risk

A

dental exam prior to starting tx, avoid dental procedures during tx if possible as dental surgery may exacerbate risk, no data to suggest stoping BP reduces risk

40
Q

denosumab MOA and dosing

A

human IgG2 monoclonal antibody that binds to RANK ligand

120 mg SQ q4wks

41
Q

denosumab vs ZA phase III

A

superior in delaying or preventing SRE in breast CA and CRPC

NONinferiority for MM and other solid tumors

42
Q

denosumab advantages (2pts)

A 
SQ admin (do not need infusion center), no concerns about renal dysfunction
FYI: same ONJ risks
43
Q

spinal cord compression basics

A

5-10% of pts with malignancy, progressive radicular pain which is followed by neurologic sx, MRI preferred imaging method

44
Q

spinal cord compression - management

A

spinal column involvement largely incurable

GOALS: relieve pain, preserve or improve function, provide local control, stabilize spine

45
Q

spinal cord compression - steroids

A

immediate administration increases number of ambulatory pts after XRT - 81 vs 63%
dex is DOC: minimum 4mg q6h (10-100mg range)

46
Q

spinal cord compression - surgery followed by XRT

A

preferred (level I) as increased ability to regain ambulatory function BUT significant morbidity and mortality issues with surgery-> careful pt selection based off of life expectancy and overall health

47
Q

spinal cord compression - XRT alone

A 
#excellent response rates if not surgery candidate
#35% of non-ambulatory pts regain walking ability
#efficacy depends on histology (heme malig > solid tumors)
48
Q

NEED TO STUDY

A

ONJ Guidelines for monitoring BP’s

BCOP (32 decks)

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