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Palliative care

Analgesia

  • Pain is the commonest and most feared symptom associated with cancer
  • Chronic pain can be controlled in more than 80% of patients
  • WHO analgesia guidelines form the most common template for pain control
  • Consists of a three-stepped ladder

WHO analgesic ladder

  • With increasing pain increasing strength of analgesia is required
  • On each step of the ladder the maximum dose and frequency should be used
  • Drugs should be prescribed on a regular basis not 'as required'
  • Co-analgesic agents often have a synergistic effect
  • May increase efficacy of a particular analgesic agent

Morphine

  • Most commonly used strong analgesic in palliative care
  • Should initially be prescribed as an immediate release preparation (e.g. oramorph)
  • Can be given as 5-10 mg every four hours
  • Dose can be increased every 24 hours until pain is adequately controlled
  • Once pain controlled total daily dose can be calculated
  • Immediate release can then be substituted for delayed release preparations
  • Most commonly used are MST given twice daily or MXL given once daily
  • Immediate release preparations can still be given for breakthrough pain
  • No ceiling exists for the maximum permissible dose of morphine
  • Laxative should be prescribed to prevent constipation
  • Patients may also require antiemetic
  • Complications include itch, hallucinations, dry mouth
  • Respiratory depression is rarely a problem
  • Physical dependence may occur
  • Psychological dependence and addiction are not a problem in the palliative care setting
  • If oral route unavailable consider subcutaneous diamorphine or fentanyl patches

Co-analgesia

  • Co-analgesics have little intrinsic analgesic activity
  • Have additive effects to analgesic agents
  • NSAIDs useful in bone pain
  • Anticonvulsants and antidepressants useful in neuropathic pain
  • Steroids increase well being
  • Benzodiazepines reduce muscle spasm

Other symptoms

Bone pain

  • Often well controlled with single fraction of radiotherapy
  • NSAID may have useful co-analgesic effect
  • Biphosphonates reduce osteoclastic activity and reduce bone pain

Neuropathic pain

  • Often resistant to treatment
  • Anticonvulsants and antidepressants may have useful effect
  • Neurolytic blocks may be considered if fails to respond to pharmacological agents

Liver capsule pain

  • NSAID often have excellent additive effect in this situation
  • Steroids can reduce swelling, inflammation and pain
  • Dexamethasone is usually the drug of choice

Dyspnoea

  • Not always due to underlying malignancy
  • Consider treatment of any underlying infection, cardiac failure etc.
  • Causes of breathlessness related to malignancy include:
    • Pleural effusion
    • Lymphangitis carcinomatosis
    • Intrapulmonary metastases
    • Constricting chest wall disease
  • Aspiration of a pleural effusion often produces symptomatic improvement
  • Pleurodesis with talc or bleomycin only effective drained to dryness
  • A pleuro-peritoneal shunt may produce symptomatic improvement
  • Steroids produce symptomatic improvement in those with lymphangitis and intrapulmonary metastases
  • The respiratory depressant effect of morphine will also reduce dyspnoea

Nausea and vomiting

  • Nausea and vomiting is usually multifactorial in origin
  • Causes include:
    • Hypercalcaemia
    • Liver metastases
    • Constipation
    • Drug side effects
    • Intestinal obstruction
  • Metaclopramide, domperidone and cyclizine useful if gastric stasis or intestinal obstruction
  • 5-HT3 blockers (e.g. ondansetron) useful for chemotherapy induce nausea
  • Haloperidol useful in morphine-induced nausea
  • Can be administered as a continuous subcutaneous infusion

Constipation

  • Treatment should be continuous and anticipatory
  • Often a side effect of opiate analgesia
  • Can be worsened by inactivity, dehydration and hypercalcaemia
  • Opiate-induced constipation best treated with compound preparations
  • Contain both a stool softener and stimulant (e.g. co-danthrusate)

Bibliography  

Davis C L,  Wee B L.  Recent advances in palliative care.  In:  Johnson C D,  Taylor I eds.  Recent advances in surgery 20.  Churchill Livingstone,  Edinburgh 1997;  161-176.

Hanks G W,  de Conno F,  Hanna M et al.  Morphine in cancer pain:  modes of administration.  Br Med J 1996;  312:  823-826.

Hardy J R.  Medical management of bowel obstruction. Br J Surg 2000;  87:  1281-1283.

Twycross R.  Corticosteroids in advanced cancer.  Br Med J 1992;  305:  969-970.

Ventafridda V,  Tamburini M,  Caraceni A,  de Conno F,  Naldi F.  A validation study of the WHO method for cancer pain relief.  Cancer 1987;  59:  850-856.

 

 
 

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