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Treatment in Palliative Care. Problems Problems Symptom management evaluation evaluation individualized treatment individualized treatment explanation.

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Presentation on theme: "Treatment in Palliative Care. Problems Problems Symptom management evaluation evaluation individualized treatment individualized treatment explanation."— Presentation transcript:

1 Treatment in Palliative Care

2 Problems Problems

3 Symptom management evaluation evaluation individualized treatment individualized treatment explanation explanation supervision supervision attention to detail attention to detail

4 Main problems Pain Pain Constipation Constipation Lack of appetite Lack of appetite Loss of weight Loss of weight Sleepnessness Sleepnessness Anxiety Anxiety Nausea and vomiting Nausea and vomiting Powerlessness Powerlessness Dyspnoe Dyspnoe

5 ObjawBedard 1991 N=952 (%) Coyle 1990 N=90 (%) Ból Duszność928 Nudności1613 Wymioty16- Bezsenność557 Zaburzenia orientacji428 Zmęczenie-52 Anorexia146 Nietrzymanie moczu46 Główne problemy lecznicze

6 Pain is what the patient says hurts

7 Total pain Physical pain basal disease, coexisting illnesses, results of treatment Physical pain basal disease, coexisting illnesses, results of treatment Psychological suffering anxiety, depression Psychological suffering anxiety, depression Spiritual suffering existential and religious problems, Spiritual suffering existential and religious problems, DAME CECILY SAUNDERS DAME CECILY SAUNDERS

8 PAIN

9 PHYSICAL PSYCHOLOGICAL SOCIAL SPIRITUAL TOTAL PAIN Saunders 1967

10 Pain scales Visual-analog scale Visual-analog scale Numeric Rate scale NRS Numeric Rate scale NRS 0 10 Lack of Pain Unburreable Pain 1 10 Brak ulgi w dolegliwościach całkowita ulga

11 Pain ACUTE - CHRONIC ACUTE - CHRONIC NOCICEPTIVE NOCICEPTIVE NEUROPATHIC NEUROPATHIC PSYCHOLOGICAL PSYCHOLOGICAL

12 Nociceptive pain STIMULATION OF NERVE ENDINGS STIMULATION OF NERVE ENDINGS visceral ( colic, migraine, cancer) visceral ( colic, migraine, cancer) somatic ( cancer, infection, tension headache, cramp, bone) somatic ( cancer, infection, tension headache, cramp, bone) muscles tension muscles tension

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

14 Analgetic Ladder WHO 1986 I 0 non-opioids + adjuvants I 0 non-opioids + adjuvants II 0 weak opioids + non-opioids + adjuvants II 0 weak opioids + non-opioids + adjuvants III 0 strong opioids + non-opioids + adjuvants III 0 strong opioids + non-opioids + adjuvants

15 Principles of analgesic use By the mouth By the mouth By the clock By the clock By the ladder By the ladder Individual treatment Individual treatment Supervision Supervision Adjuvant drugs Adjuvant drugs

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

17 Non opioids Paracetamol Paracetamol Non- steroid Antiinflamatory Drugs (COX–1) Non- steroid Antiinflamatory Drugs (COX–1) Ibuprofen Ibuprofen Diclofenac Diclofenac Ketoprofen Ketoprofen Piroxicam etc Piroxicam etc Non- steroid Antiinflamatory Drugs (COX–2) Non- steroid Antiinflamatory Drugs (COX–2) Acetylsalicylic acid Acetylsalicylic acid

18 Weak opiois ( II 0 WHO) Tramadol 1/5 Tramadol 1/5 Codein 1/10 Codein 1/10 Dihydrocodein 1/10 Dihydrocodein 1/10 Oxycodon 1,5 / 1 Oxycodon 1,5 / 1 Dextropropoxyphen Dextropropoxyphen Pentazocin – DO NOT USE !!! Pentazocin – DO NOT USE !!!

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

20 Pentazocin ( Fortral) Partial agonist μ receptor Partial agonist μ receptor Agonist κ receptor Agonist κ receptor Pure antagonist δ receptor Pure antagonist δ receptor Short acting 2-3 h Short acting 2-3 h Psychotomimetic effects Psychotomimetic effects DO NOT USE IN CHRONIC PAIN

21 Strong opioids III 0 WHO Morphine hydrochloride ( substance, Sevredol, Vendal,) Morphine hydrochloride ( substance, Sevredol, Vendal,) Morphine sulphate (Doltard, MST-Continuous, M-Eslon, Vendal, ) 1/1 Morphine sulphate (Doltard, MST-Continuous, M-Eslon, Vendal, ) 1/1 Fentanyl ( Durogesic TTS) 150/1 Fentanyl ( Durogesic TTS) 150/1 Buprenorphine (Bunondol, Transtec TTS) 60/1 Buprenorphine (Bunondol, Transtec TTS) 60/1 Methadone 5-10/1 Methadone 5-10/1 Diamorfina ( heroin) 2/1 Diamorfina ( heroin) 2/1 Dextromoramid (Palfium) 2/1 Dextromoramid (Palfium) 2/1 Pethidine (Dolargan) 1/8 – DO NOT USE!!! Pethidine (Dolargan) 1/8 – DO NOT USE!!!

22 Morphine Pure agonist of  receptor Pure agonist of  receptor Without ceiling-effect Without ceiling-effect M6G is 10-20x , M3G (toxic), M6G is 10-20x , M3G (toxic), First dose 30 mg/24h ( 15mg/24h ) First dose 30 mg/24h ( 15mg/24h ) Dose is arised 50% if ineffective Dose is arised 50% if ineffective 10% of Codein is metabolised to M6G 10% of Codein is metabolised to M6G

23 Morphine Morphine hydrochloride Morphine hydrochloride Substance Substance Sevredol tabl mg – short acting Sevredol tabl mg – short acting Vendal Vendal Morphinum sulphate 10,30,60,100mg Morphinum sulphate 10,30,60,100mg M-Eslon M-Eslon MST-Continuous MST-Continuous Doltard Doltard Kapanol Kapanol

24 Rp. Morphini hydrochlorici 4,0 Aquae destillatae ad 400,0 ml M.f. Solutio D.s. ½ ml q4h Morphini hydrochlorici 4,0 Aquae destillatae ad 400,0 ml M.f. Solutio D.s. ½ ml q4h 6 00, 10 00, 14 00, 18 00, 22 00, ( 2 00 ) 6 00, 10 00, 14 00, 18 00, 22 00, ( 2 00 )

25 Fentanyl Pure agonist  Pure agonist  Fentanyl is 150 x  than MF Fentanyl is 150 x  than MF Lipophilic ( peripheral side effects are not so strong as MF) Lipophilic ( peripheral side effects are not so strong as MF)

26 Pethidine Agonist  Agonist  Action time – 2-3 h Action time – 2-3 h Ceiling effect 600mg/24h Ceiling effect 600mg/24h Toxic methabolite– norpethidine Toxic methabolite– norpethidine Siede effects: myoclonus, dysphoria, Siede effects: myoclonus, dysphoria, Indications: acute pain, not use longer than 48 h, Indications: acute pain, not use longer than 48 h, Contraidications: renal failure Contraidications: renal failure

27 Sensitization PERIPHERAL PERIPHERAL activation of „sleeping receptors” activation of „sleeping receptors” „inflammatory soup” „inflammatory soup” CENTRAL – activation of the NMDA receptor-channel complex CENTRAL – activation of the NMDA receptor-channel complex

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

29 Methadone Agonist  -receptor and  -receptor Agonist  -receptor and  -receptor Racemic forms: L- i D Racemic forms: L- i D NMDA – receptor antagonist NMDA – receptor antagonist The plasma halflife ranges 8-80 h The plasma halflife ranges 8-80 h Bioavailibility 80% (parenteral) Bioavailibility 80% (parenteral) Lipophilic Lipophilic Eliminated by alimentary tract in 80% (in renal failure may be used) Eliminated by alimentary tract in 80% (in renal failure may be used) 5-10 x  than MF, 3-5mg start dose 5-10 x  than MF, 3-5mg start dose

30 Receptor NMDA

31 Opioid Rotation Non effective, toxic Non effective, toxic Because- of different types of opioid receptors Because- of different types of opioid receptors Differences in pharmacocinetics and methabolizm of opioids Differences in pharmacocinetics and methabolizm of opioids Be careful in equivalent dose Be careful in equivalent dose supports of tolerance – metadon ma większą wewnętrzną aktywność niż MF supports of tolerance – metadon ma większą wewnętrzną aktywność niż MF

32 Muscle spasm Miorelaxants Miorelaxants Baclofen (GABA- agonist) tabl. 10 i 25mg 3 x 5-10 mg Baclofen (GABA- agonist) tabl. 10 i 25mg 3 x 5-10 mg Tyzanidine Tyzanidine Benzodiazepins Midazolam 7,5 – 15 mg p.o. Clonazepam 0,5 mg /nocte Diazepam 5-20 mg p.o. Benzodiazepins Midazolam 7,5 – 15 mg p.o. Clonazepam 0,5 mg /nocte Diazepam 5-20 mg p.o.

33 Adverse effects of opioids Constipation 100% Constipation 100% Nausea and vomiting – 50% Nausea and vomiting – 50% Drowsiness – 100% Drowsiness – 100% unsteadiness, confusion – initial unsteadiness, confusion – initial Stop urination – be careful !! Stop urination – be careful !! Central depressant effects Central depressant effects Psychological dependence Psychological dependence Physical dependence Physical dependence Occasional – dry mouth, inflammation of mouth, candidiasis, sweating, myoclonus Occasional – dry mouth, inflammation of mouth, candidiasis, sweating, myoclonus

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


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