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Adjuvant Analgesics In Palliative And End-Of-Life Care

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Presentation on theme: "Adjuvant Analgesics In Palliative And End-Of-Life Care"— Presentation transcript:

1 Adjuvant Analgesics In Palliative And End-Of-Life Care
Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, WRHA Palliative Care Medical Director, Pediatric Symptom Management Service

2 Case Presentation 55 yo man Metastatic CA lung, large L apical tumour
Chemotherapy completed, no response Metastatic disease to bone, liver Presents with worsening L arm pain and numbness, allodynia, tingling and burning Motor exam normal

3 Case Presentation Current Medications
Morphine 100 mg po q4h Ibuprofen over the counter Sennosides, docusate

4 Adjuvant Analgesics first developed for non-analgesic indications
subsequently found to have analgesic activity in specific pain scenarios Common uses: pain poorly-responsive to opioids (eg. neuropathic pain), or with intentions of lowering the total opioid dose and thereby mitigate opioid side effects.

5 Adjuvants Used In Palliative Care
General / Not specific corticosteroids cannabinoids (very uncommonly used) Neuropathic Pain gabapentin antidepressants topiramate ketamine clonidine Bone Pain bisphosphonates (calcitonin)

6 } CORTICOSTEROIDS AS ADJUVANTS ¯ inflammation ¯ edema
¯ spontaneous nerve depolarization } ¯ tumor mass effects

IMMEDIATE LONG-TERM Psychiatric Hyperglycemia ­ risk of GI bleed gastritis aggravation of existing lesion (ulcer, tumor) Immunosuppression Proximal myopathy often < 15 days Cushing’s syndrome Osteoporosis Aseptic / avascular necrosis of bone

8 DEXAMETHASONE minimal mineralcorticoid effects
po/iv/sq/?sublingual routes perhaps can be given once/day; often given more frequently If an acute course is discontinued within 2 wks, adrenal suppression not likely

9 Cannabinoids As Adjuvants

10 Isolated pure compounds (>400)
Cannabis sativa THC content approx. 5% THC content 10 – 20% Marijuana dried leaves, flowers Hashish resin from leaves, buds Isolated pure compounds (>400) Noncannabinoids Cannabinoids Psychoactive 8-THC 9-THC cannabinol Active, not psychoactive cannabidiol Inactive > 60 Kalant, Pain Res Manage 2001

11 Cannabinoid Receptors CB1 And CB2
Central and peripheral nervous system Highest density in globus pallidus, basal ganglia, substantia nigra, cerebellum, hippocampus, afferent spinal cord pathways Main effect is ¯ neurotransmitter release –dopamine, NE, serotonin Low levels in cardiorespiratory centres ® high therapeutic index CB2 – certain nonneural tissues, eg. immune cells Cannabinoids also bind to NMDA receptors – possible role in neuropathic pain Kumar et al, Anaesthesia 2001; 56

12 Cannabinoids The only clinical indication is in chemotherapy-induced nausea Mixed results in human studies for pain control; animal studies suggest possible role for neuropathic pain Double-blind, placebo-controlled trials indicate a similar analgesic potency to codeine, however high adverse effects

13 Marijuana Use in Pain Five RCTs on cancer pain
Tetrahydrocannabinol (THC) or nabilone vs placebo or opioids High rate of side effects 128 pts total, single dose x-over design THC = codeine (60, 120 mg) > placebo Nabilone > placebo Higher doses had unacceptable S/E Poor evidence for pain control Campbell et al, BMJ 323:13-16, 2001

14 Marijuana - Acute Effects
Increased pulse, BP unaffected or slight ¯ Conjunctival reddening No effect on pupil size, resp. rate, DTRs Initial euphoria then relaxation Appetite stimulation Slowed reaction time, altered perception, impaired coordination May cause paranoia, delusions, hallucinations, depersonalization

15 Inhaled Marijuana has all (except one) the same chemical carcinogens found in tobacco > 400 chemicals High tar content Respiratory epithelium damage Obstruction on PFTs COPD in chronic users H & N, lung cancer reports

16 What’s A Reasonable Dose Of Inhaled Marijuana For Symptom Control?
Bioavailability of THC in smoked marijuana ranges from 10 – 27%; significantly influenced by technique/experience Typical cannabis cigarette has a mass between gm Informal surveys in US of medicinal cannabis users indicate avg. use of gm/wk, or g/day Carter GT, Weydt P, Kyashna-Tocha M, Abrams DI. Medicinal cannabis: rational guidelines for dosing. IDrugs 2004; 7(5):






22 College of Physicians & Surgeons of MB Oct. 2001 Newsletter
“Physicians who recommend, support the use of, or prescribe this substance, must be fully knowledgeable of the risks, benefits, potential complications, and drug interactions associated with its use. Based on the available scientific evidence, the medicinal use of smoked marijuana is at present generally without valid scientific foundation and physicians should not feel obliged to recommend, support, or prescribe this substance”

23 Oral Cannabinoids ∆9-tetrahydrocannabinol (THC; Marinol; Dronabinol)
Nabilone – synthetic derivative of THC 90 – 95% absorbed, but only 10 – 20% reaches circulation due to hepatic first-pass metabolism 1 hr to peak effect vs. 15 min. if smoked

24 Available Cannabinoids
Nabilone is officially indicated for severe nausea and vomiting associated to chemotherapy treatment. (However, the main usage is in pain and body wasting) Dronabinol is officially indicated for severe nausea and vomiting associated to chemotherapy treatment and also body wasting syndrome, anorexia associated with HIV. There is an initiative of the Canadian government to allow patients to use cannabis for medical purposes, and pain is one of the most common reasons for these requests. Nabilone is the sole cannabinoid fully reimbursed by most provincial and private plans. It ’s use is limited in Saskatchewan for body wasting syndrome associated with HIV. Comparing equivalent dosages according to the body surface, the cost of nabilone is 20% lower than dronabinol Sources: Provincial Drug List; CPS 2002; Marihuana Medical Access Regulations (MMAR), April 2001, Health Canada

25 Available cannabinoids: Pharmacokinetics
Nabilone is a synthetic cannabinoid. When metabolized, it is converted in the active metabolite carbinol. Dronabinol is a 9-THC cannabinoid. It is metabolized chiefly in the liver where it is converted to 11-hydroxy-  9-THC and more than 20 other metabolites not clearly identified. Marijuana contains more than 400 components including more than 60 types of cannabinoids. There is psychoactive, active and non-active cannabinoids. Also, there is hundreds of compounds which are not cannabinoid-type in which contaminants are found. Nabilone, compared to dronabinol and inhaled marijuana, has a shorter half-life of 2 hours and a longer duration of action between 8-12 hours which reduce the potential for accumulation and toxicity. Sources: Néron A, Le medecin du Québec 2001; Product monograph NCesamet ICN Canada 2002; Product monograph NMarinol Sanofi-Synthelabo 2002

26 Management of Bone Pain
Pharmacologic treatment Acetaminophen Opioids NSAIDs – be aware of adverse effects! Corticosteroids (not with NSAIDS) Bisphosphonates: pamidronate (Aredia), clodronate (Bonefos), zoledronate (Zometa)

27 Bisphosphonates Osteoclast inhibitors
Ross et al;Systematic review of role of bisphosphonates on skeletal morbidity in metastatic cancer. BMJ 2003; 327(7413):469 Osteoclast inhibitors bone metastases: pooled results ® signif. ¯ in all skeletal morbidity end points except spinal cord compression signif. ­time to first skeletal related event, suggesting they should be started when bone metastases are diagnosed ¯ skeletal morbidity and should be continued until no longer clinically relevant do not affect survival Most evidence supports use of IV aminobisphosphonates, but further studies needed to determine best drug & route

28 Bisphosphonates Tolerability And Adverse Effects
Renal toxicity Flu-like syndrome Hypocalcemia Avascular necrosis of the jaw

29 Bisphosphonates Renal Implications
Renal toxicity – IV bisphosphonates In rare cases can be life-threatening 9% of patients receiving 4 mg zoledronate and 8% of those receiving 90 mg pamidronate with normal baseline renal function developed increased creatinine levels (Rosen et al; J Clin Oncol 2003) Should monitor creatinine before each dose, and hold repeat dosing until within 10% of baseline Make sure patient is well hydrated prior to administration (eg. in hypercalcemia)

30 Bisphosphonates ctd Flu-Like Reaction Hypocalcemia
Esp. with intravenous bisphosphonates Up to 36% of patients Usually managed with acetaminophen Hypocalcemia Usually compensate by increased PTH secretion Hypomagnesemia, previous parathyroid removal, Vit D deficiency are risk factors Recommendations are to give 500 mg Calcium and 400 IU Vit. D as daily supplements

31 Bisphosphonates Avascular Necrosis of Jaw
Robinson NA, Yeo JF. Bisphosphonates--a word of caution. Ann Acad Med Singapore 2004; 33(4 Suppl):48-49. Greenberg MS. Intravenous bisphosphonates and osteonecrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98(3): Schwartz HC. Osteonecrosis and bisphosphonates: correlation versus causation. J Oral Maxillofac Surg 2004; 62(6): Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg 2004; 62(5): Pogrel MA. Bisphosphonates and bone necrosis. J Oral Maxillofac Surg 2004; 62(3): Carter GD, Goss AN. Bisphosphonates and avascular necrosis of the jaws. Aust Dent J 2003; 48(4):268. Migliorati CA. Bisphosphanates and oral cavity avascular bone necrosis. J Clin Oncol 2003; 21(22): Tarassoff P, Csermak K. Avascular necrosis of the jaws: risk factors in metastatic cancer patients. J Oral Maxillofac Surg 2003; 61(10): Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; 61(9):

32 Bisphosphonates Avascular Necrosis of Jaw ctd
Retrospective chart review Feb – Nov. 2003 63 patients with chronic osteonecrosis of jaw while on bisphosphonates; 7 for osteoporosis 4 patients during that time period with similar presentation while not on bisphosphonates; 3 of them had prior local radiation for sq. cell CA Localized vascular insufficiency, similar to osteoradionecrosis Correlation with dental procedures - suggest a complete dental exam prior to long-term bisphosphonate treatment, and any dental pathology addressed

33 Adjuvants in Neuropathic Pain

34 Gabapentin a second line anticonvulsant
shown to be effective in neuropathic pain; has become a first-line agent in neuropathic pain structural analog of GABA, but does not bind to GABA receptors increases concentration and synthesis of GABA in the brain GABA receptors have been shown to mediate pre- and postsynaptic inhibition in sensory afferent fibers

35 Gabapentin Common Starting Regimen Frail patients
300 mg hs Day 1, 300 mg bid Day2, 300 mg tid Day 3, then gradually titrate to effect up to 1200 mg tid Frail patients 100 mg hs Day 1, 100 mg bid Day 2, 100 mg tid Day 3, then gradually titrate to effect

36 TCAs increase in monoamine activity in descending pain modulating pathways inhibition of reuptake of NE and serotonin at spinal dorsal horn synapses alt. mechanisms include blockade of Na+ channels, GABA effects, K+ channel blockade, adenosine neuropathic pain, esp. continuous dysaesthesia anticholinergic adverse effects; amitriptyline > nortriptyline > desipramine lower doses and earlier response than depression

37 SSRIs And Newer Antidepressants
less convincing evidence for independent analgesic effects; those affecting both noradrenaline and serotonin levels have more potent and efficacious antinociceptive effects than SSRIs newer meds with mixed neurotransmitter effects: Serotonin and Noradrenergic Reuptake Inhibitors (SNaRI) – eg. Venlafaxine (Effexor), nefazodone (Serzone), duloxetine Noradrenergic and Specific Serotoninergic Antidepressants (NaSSA) – eg. mirtazapine (Remeron) Noradrenaline Reuptake Inhibitors (NaRI) – eg. reboxetine

38 Topiramate Multiple neurostabilizing actions: Neuropathic Pain
anti-glutamate effects at AMPA receptors; blockade of voltage activated Na+ channels; enhancement of GABA-mediated neuroinhibition; inhibition of L-type high voltage-activated Ca++ currents; activation of potassium conductance Neuropathic Pain Consider if gabapentin failed Typically start with 25 mg/day Effectiveness demonstrated in diabetic neuropathy Ocular adverse effects include secondary angle-closure glaucoma, transient myopia, and uveal effusions Decreased serum bicarbonate in up to 67%

39 Ketamine Disassociative anesthetic Analgesic in subanesthetic doses
Most potent NMDA receptor antagonist available for clinical use NMDA-receptor activation is associated with windup, hyperalgesia and reduced opioid sensitivity. Ketamine is widely used in cancer pain to improve opioid analgesia when tolerance has developed or the pain is considered to be opioid resistant. Randomised and controlled trials are rare; data from two of these trials suggest potential benefit of ketamine as adjuvant to morphine in cancer pain (Bell et al., 2003).

40 Ketamine Often use oral dosing of intravenous preparation
A common starting dose is 10 mg qid po (low dose) Concomitant benzodiazepine administration may attenuate adverse CNS effects (eg. Lorazepam 0.5 – 1 mg sl bid – tid) Decrease concurrent opioid dose by 25 – 50%

41 Clonidine alpha-2 agonist
decrease sympathetic transmitter release through pre and post-synaptic inhibition Considered in refractory neuropathic pain Literature predominantly regarding spinal administration Recent literature suggests possible topical role

42 Calcitonin Osteoclast inhibition
Cochrane review 2003: “The limited evidence currently available for systematic review does not support the use of calcitonin to control pain from bone metastases. Until new studies provide additional information on this treatment, other therapeutic approaches should be considered ”

43 Case Presentation ctd Rule out opioid-induced neurotoxicity d/c NSAID
Add gabapentin and dexamethasone Consider: CT to determine anatomy; ? Radiation Methadone Ketamine TCA Topiramate Spinal analgesia

44 Opioid-Induced Neurotoxicity (OIN)
Potentially fatal neuropsychiatric syndrome of: Cognitive dysfunction Delirium Hallucinations Myoclonus/seizures Hyperalgesia / allodynia Increasing incidence – practitioners more comfortable and aggressive with opioids NMDA receptor involved Early recognition is critical


46 Misinterpreted as Pain Misinterpreted as Disease-Related Pain
Spectrum of Opioid-Induced Neurotoxicity Opioid tolerance Mild myoclonus (eg. with sleeping) Severe myoclonus Seizures, Death Delirium Agitation Misinterpreted as Pain Opioids Increased Hyperalgesia Misinterpreted as Disease-Related Pain Opioids Increased

47 OIN: Recognition Myoclonus – twitching of large muscle groups Delirium
Rapidly escalating dose requirement Pain “doesn’t make sense”; not consistent with recent pattern or known disease

48 OIN: Treatment Switch opioid (rotation) or reduce opioid dose; usually much lower than expected doses of alternate opioid required… often use prn initially Hydration Benzodiazepines for neuromuscular excitation


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