CANCER PAIN(2003)

PAIN MANAGEMENT CENTER ST. LUKE’S MEDICAL CENTER

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Pain Management Center

Officers & Board of Trustees

Director Emeritus Director

Training Officer

St. Luke's Medical CenterTel# 727-5416, 723-0301, 723-0101 ext. 4403/5416 Fax# 723-1023Website: www.stluke.com.ph

Cenon R. Cruz, M.D.Francis O. Javier, M.D.Antonio N. B. Yap, M.D.

ActiveconsultAnts

Ma. Victoria M. Abesamis, M.D. Pediatric Oncology Erlinda T. Arambulo, M.D. Merlina L. Cabrera, M.D. Luzviminda A. Salomon-Kwong, M.D. Anesthesiology/Pain Medicine Agnes C. Bueno, M.D. Psychiatry Rafael S. Claudio, M.D. Orthopedic Oncology Agnes M. del Rosario, M.D. Pulmonary Medicine Luisito O. Llido, M.D. Nutrition Support Service Gloria C. Luna, M.D. Medical Oncology Lyde A. Magpantay, M.D. Reynaldo Rey-Matias, M.D. Rehabilitation Medicine Amado M. San Luis, M.D. Edmundo G. Saniel, M.D. Neurology Miguel A. Ramos, M.D. Geriatric Medicine Ricardo B. Boncan, D.M.D. Oral Surgery/TMJ Specialist

visitingconsultAnts

Romulo S. De Villa, M.D.Molecular Biology

Roberto O. Bolinas, M.D.Medical Oncology

Eric C. Legaspi, M.D.Neurosurgery

Juan Javier T. Lichauco, M.D.Rheumatoogy

Randy S. Mercado, M.D.Gastroenterology

Jose M. Paiso, M.D.Orthopedic/Spine SurgeonFlorizel Del Prado, M.A.

PsychologyAntonio C. Sison, M.D.

Psychiatry

HonorAryconsultAnts

Mayvelyn D. Gose, M.D.Neurology

Leonor F. Rivera, M.D.Anesthesiology

Fellows

Salvador E. Brodit, Jr., M.D.Laarni P. Remorque, M.D.

Jefferson R. Castillo Lee, M.D.Ma. Patria C. Flores, M.D.

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Algorithm for Cancer Pain Managementnotes:1.A.somaticpain2.B.neuropathic pain- use of adjuvants (anticonvulsants, antidepressants, anxiolytics, etc).3.c.visceral - use of other adjuvants (antiemetics, proki-netics, antispasmodics, antacids, H2-blockers, proton pump inhibitors, etc.)4.1.Blocks - peripheral or field blocks- diagnostic/ palliative/ neurolytic- continuous or single injection techniques- e.g.celiac plexus block for pancreatic cancer, sup. hypogastric block for rectal cancer5.i.oralOpioids: Morphine - oralNSAIDS (non-steroidal anti-inflammatory drugs)AdjuvantsIa. Transdermal/ Transmucosal PharmacotherapyFentanyl - transdermal (Durogesic), transmucosal (Actiq)6.ii.parenteral (Intravenous/Intramuscular/Subcutaneous)Opioids: a. morphineb. fentanylNSAIDS - diclofenac, ketorolacAdjuvants7.iii.epiduralanalgesia- continuous/single injection tech-niques alone or in combination with opioids (bupivacaine/ropivacaine)- use of implantable devices8. iv. intrathecal analgesia - continuous/single injection techniques- use of opioids/local anesthetics or combinations- use of implantable devices9.v. surgical interventions - neurotomy, rhizotomy, my-elotomy, cordotomy

Figure1

Use WHO Ladder accordingly

1

2

3

6

Oral treatment

effective?y

n

y

n

y

n

y

4

5

7 8

9 10

11

n

See Figure 1a

Use:• Fentanyl (transdermal or transmucosal)

• Peripheral or field blocks• Diagnostic/palliative/neurolytic• Continuous or single injection techniques, e.g.

celiac plexus block for Pancreatic Ca; sup. hypogastric block for Rectal Ca

Use:• Opioids• NSAIDs• Adjuvants

Blocks effective?

Transdermal/trans-mucosal Pharma-cotherapy effective?

Parenteral treatment effective?

See Figure 1b

• Somatic• Neuropathic• Visceral

Evaluation of pain

Cancer Pain

10

See Figure 1c

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Figure1a

Figure1b

Titration?

Continue managementPain Relief?

May transfer to I-IaRescue doses apply

Use PCA/PCEA for titration and

pain control

Continue management

Re-evaluate patient

Parenteral treatment

y

4

n

7

52

6

8

3

1

y

n

y

n

y

1

4

Figure 1

2 3

n

See Figure 1a

Surgical Interventions (Palliative/Ablative)

Intrathecal analgesia effective?

Epidural analgesia effective?

Use:• Continuous/single injection techniques• Opioids/local anesthetics or

combinations• Implantable devices• Other complementary interventions

(Radiotherapy, Chemotherapy, etc)

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Figure1c

1

2

3

6

4

5

7

8

9 10

Adequate pain control

WHO Ladder

Pain due to: Anticancer therapy

such as: • Surgery• Radiation• Chemotherapy

Use Analgesic drug ladder steps

1 and 2

Analgesic drug ladder steps 1 and 2

11

Pain persists

Use Ana lges i c d rug ladder

steps 2 and 3

Switch to alternative opioid, change route/timing of administration, use of adjuvant analgesics

Failed primary modalities, side effects unacceptable

Severe persistent pain

Localized regional pain• Neurolytic nerve blocks (e.g. intercoastal block, celiac plexus block)• Neurosurgical procedures (e.g. cordotomy)

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Cancer PainThe Pain Management Center of St. Luke's Medical Center follows the WHO three-step analgesic ladder for managing cancer-related pain. Pain not amenable to oral route, or if fast opioid titration is necessary, the use of the PCA (Patient-Controlled-Analgesia Machine) is mandatory.

More than 65% of referrals to the Center are pain secondary to cancer. (See WHO Three-Step Analgesic Ladder.)

For patients who are in need of a faster titration of opioid, steps 2-3 may be done using the IV PCA technique.

The PCA allows for a faster drug titration and the drugs computed based on patient's demands. An equivalent oral opioid is prescribed once pain control has been stabilized.

The use of transdermal fentanyl (Durogesic) is another option in providing pain relief of cancer patients. For rescue doses, oral morphine is used. The transmucosal fentanyl citrate lozenge (ACTIQ) is only available as "compassionate prescription".

The introduction of the sustained-release oxycodone (Oxycontin) has made it easier for patients to begin opioid therapy as it does not have the "morphine stigma". This drug may be used from step 2 onwards. The limitation of the sustained-release oxycodone is the unavailability of the immediate-release preparation for rescue dose purposes. Morphine tablet (immediate-release) may be substituted for this.

cancerpaincensus(top10)

A lot of cancer patients seen by medical oncologists are in advanced stages. This is basically economic in nature as people tend to postpone consultation to the doctor. By the time the patient is seen at the Pain Management Center, majority have difficult cancer pain syndromes that require multidisciplinary management.

Pain secondary to metastatic lung cancer accounts for the most number of pain patients followed by metastatic breast cancer.step1

ASA, NSAIDS (if no contraindications)

COX-2 inhibitors

Used in combination with adjuvant drugs

(TCA, antihistamine, benzodiazepam, anticonvul-sants, steroid, laxatives, phenothiazine)

step2

Non-opioid + mild opioid + adjuvant drugs

Tramadol is the Step 2 drug in the Philippines

Rescue medications apply.

step3

Non-opioid + strong opioid + adjuvants

Morphine is the drug of choice

Rescue medication apply.

Adjuvant drugs like TCA's, anticonvulsants, steroids, bisphosphonates etc, maybe added in all steps.

wHothree-stepAnalgesicladder

STEP 3 Severe

STEP 2 Moderate

STEP 1 Mild Pain

January2000-December2002

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Drugs Mentioned in the Treatment GuidelineThis index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these drugs can be found in PPD reference systems.

AnalgesicscoxibsCelecoxib Celebrex CoxidEtoricoxib Arcoxia/Arcoxia ACParecoxib DynastatRofecoxib Vioxx

nsAiDsAcemetacin RantudilAspirin Bayer Aspirin CortalDiclofenac Abicfen Acloren Cataflam Denkoran Diclowal/Diclowal Retard Difenax Dolfastad Doloflam Neo-Pyrazon/ Neo-Pyrazon SR UL Diclofenac Na VCP Diclofenac Na Voltaren Voren/Voren Forte/Voren SRIbuprofen Advil Buroid Dalnor Dolan FP Laberfen Midol Morexen Nurofen Syrup Painrex Skelan ForteIbuprofen/Aspirin AnadolIbuprofen/Paracetamol Alaxan Femol

Muskelax Relaxid SelxanIndomethacin IndocidIndomethacin farnesil Infree Ketoprofen Ketofen Orudis EC Orudis IVKetorolac ToradolLeflunomide AravaLonazolac Exflame/ Exflame ARMefenamic Acid Abicfen Acidan Analcid Aprostal Biogenerics Mefenamic Acid C&M Mefenamic Acid Calibral DLI Mefenamic Acid Dolfenal Dolmetine Drugmaker's Biotech

Mefenamic Acid Escandar Fendal Fenexan Gardan Gisfen Harpinac Isagesic Istan Medianon Pacimic Penomor Pharex Mefenamic Acid Ponstan Proxyl Ralgec Revalan RiteMED Mefenamic Acid

Selmac Sensomef Spegic Totagesic Tynostan ZapanMeloxicam MobicNaproxen Flanax/ Flanax Forte Lefaine Naprelan Naprosyn LLE/ Naprosyn LLE

ForteNimesulide AulinPiroxicam Drugmaker's Biotech Piroxicam Feldene/ Feldene Flash Flaxine Macroxam Maxipin Parixam Pirostad TroxiflamProglumetacin AfloxanSulindac ClinorilTenoxicam Tilcotilnon-opioidAnalgesicsParacetamol Aeknil Afebrin Aldep Aminofebrin Baropyrine Biogenerics Paracetamol Biogesic Calpol/Calpol Six Plus Carpacet Crocin Delgin DLI Paracetamol Dolexpel Drugmaker's Biotech

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Paracetamol Europharma Paracetamol Franciphen Gendol Susp/Tab Genpyra Gifaril-P Lenor Medgenol Medicol-A Metagesic Myremol Naprex Naprinol Neo-Aspilets Nopain Forte Norgesic Octagesic/Octagesic Forte Opigesic Pacigesic Pharex Paracetamol Pynal Rexidol Reximed RiteMED Paracetamol Rufenal Saridon Tempain Syr/Forte Tab/ Forte

Syr/ Drops Temperal Tempra/ Tempra Forte TylenolParacetamol/Vitamin B-Complex Dolo-Neurobion

opiates&AntagonistsButorphanol StadolFentanyl Durogesic SublimazeMorphine sulfate Hizon Morphine Sulfate Relimal CRTramadol Dolotral Siverol TDL Tradonal Tramal

skeletalmusclerelaxantsBaclofen Lioresal

Eperisone MyonalOrphenadrine Norgesic

localAnestheticsBupivacaine Marcaine Sensorcaine SpinalLidocaine Abbott 2% Lidocaine

(Premixed) Dentocaine 2% Lidocaine HCl 2% Inj-Elin XylocaineLidocaine/Prilocaine EmlaProparacaine AlcaineRopivacaine NaropinTetracaine Pontocaine

AdjuvantsAnticonvulsantsCarbamazepine TegretolClonazepam RivotrilDiazepam Anxionil Trazepam UL Diazepam ValiumDivalproex sodium EpivalGabapentin NeurontinLamotrigine LamictalMagnesium sulfate Elin Magnesium Sulfate Hizon Magnesium SulfatePhenobarbital Rhea PhenobarbitalPhenytoin DilantinTopiramate TopamaxOxcarbazepine TrileptalValproic acid

Depakene

AnxiolyticsAlprazolam XanorBromazepam LexotanClorazepate dipotassium TranxeneDiazepam Anxionil Trazepam UL Diazepam ValiumFlurazepam DalmaneHydroxyzine Iterax

AntidepressantsCitalopram LupramClomipramine AnafranilFluoxetine ProzacFluvoxamine FaverinImipramine TofranilMirtazapine RemeronMoclobemide AurorixParoxetine SeroxatSertraline ZoloftTianeptine StablonTrazodone DepresilTrimipramine SurmontilVenlafaxine Efexor XR

AntiemeticsBetahistine Merislon SercCinnarizine Calzirine Drugmaker's Biotech

Cinnarizine

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Sugeron/Stugeron ForteDifenidol CephadolDimenhydrinate Drugmaker's Biotech

DimenhydrinateGranisetron KytrilMeclizine BonamineMeclozine PostadoxineMetoclopramide Cardo Perten Clovomet PlasilOndansetron ZofranPromethazine Phenergan ThaprozineRamosetron Nasea Injection Nasea ODTropisetron Navoban

prokineticsActivated dimethicone DisflatylDomperidone MotiliumMetoclopramide PlasilPancreatin/amylase PankreoflatPromethazine Thaprozine

AntispasmodicsButropium ColiopanDicycloverine Bentyl Cynergic Dilomin DLI Dicycloverine HCl Drugmaker's Biotech

Dicycloverine Hydrochloride Relestal Smodic UL DicycloverineHyoscine

Ascopen Buscopan Buscopan Plus

AntacidsHydrotalcite/Simethicone/Dicy-

cloverine Algelan-Plus Kremil-SAluminum hydroxide/Magnesium

carbonate Almax Drugmaker's Biotech Aluminum

Hydroxide/ Magnesium Carbonate

Aluminum hydroxide/Magnesium carbonate/ Oxethacaine

MucaineAluminum hydroxide Alu-TabAluminum hydroxide/

Magnesium hydroxide Asikit Creamalin Drugmaker's Biotech Aluminum

Hydroxide/ Magnesium Hydroxide

Gel-Malicid Laxadan Maalox Magalum Mylanta 2 Pepticon PromulaxAluminum hydroxide/

Magnesium hydroxide/ Dimethicone

Maalox PlusAluminum hydroxide/

Magnesium carbonate/ Magnesium hydroxide/

NovaluzidCalcium carbonate Harveytums TumsHydrotalcite/ Simethicone Mucilan UL Antacid SimecoMagnesium hydroxide Philips Milk of MagnesiaCitric acid/ Piperazine/ Sodium

bicarbonate/ Tartaric acid

Roche Piperazine

BisphosphonatesAlendronate Sodium FosamaxDisodium Clodronate BonefosRisedronate Sodium ActonelZoledronic Acid Zometa

H2-receptorAntagonistsCimetidine Antag Biogenerics Cimetidine Ciclem Drugmaker's Biotech Cimeti-

dine Duogastril Europharma Cimetidine Getidin Gitadene Mestulcer RiteMED Cimetidine TagametFamotidine H2 Bloc PepcidineNizatidine AxidRanitidine Drugmaker's Biotech Ranitidine Incid Novopharm Ranitidine Pharex Ranitidine Ramadine Raxide Tagamet Ulcin Zantac/Zantac FRRanitidine/ Bismuth citrate PyloridprotonpumpinhibitorsEsomeprazole NexiumLansoprazole PrevacidOmeprazole Losec OAC HP7*Pantoprazole Pantoloc

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UlceprazSodium rabeprazole Pariet

laxatives/enemasBisacodyl DulcolaxDietary fiber FibrosineDSS/Sorbitol Clyss-GoGlycerin Rhea Glycerin SuppositoryIspaghula husk Mucofalk Apple/Orange

GranulesLactulose Duphalac Duphalac DryLactitol ImportalMonabasic sodium phosphate/

dibasic sodium phosphate Fleet EnemaSodium picosulfate LaxoberalStandardized senna concentrate Senokot

steroidsBetamethasone Betnelan Celestone DiprospanDexamethasone Decilone Drenex Inflam Oradexon Oradexon Forte RiteMED Dexamethasone Scancortin 4 Scancortin 5Hydrocortisone Hydrocort Hydrotopic Inj Pharmacort Phoenix Hydrocortisone So-

dium Succinate

Solu-CortefMethylprednisolone Depo-Medrol

Medrol Solu-MedrolPrednisone Drazone Drugmaker's Biotech Pred-

nisone GXI Prednisone Orasone 5/Orasone 20 Organon Prednisone Pred 5/10/30 RoidrenalPrednisolone Liquipred RiteMED PrednisoloneTriamcinolone Kenacort Kenacort-A Intra-articular/