Management of NonPain Symptoms

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Management of Non-Pain Symptoms

• Junior Student Rotation
• in Palliative Medicine
• Douglas D. Ross, MD, PhD

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General Principles

• Listen to the Patient.
• Make a diagnosis before you treat
• History, exam, lab, working diagnosis
• Know the drugs you prescribe...
• Keep it simple!
• Not everything that hurts responds to analgesics
• There is always something that can be done.

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Prevalence of Symptoms in Patients with Cancer
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Urgent Symptoms

• Pathologic Fracture
• Seizure
• Spinal Cord Compression
• Increased Intracranial Pressure
• Superior Vena Cava Syndrome
• Hypercalcemia

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Major Symptom Areas

• Anorexia
• Gastrointestinal
• Oral / Dysphagia / Nausea-vomiting / constipation
  / bowel obstruction
• Dyspnea
• Delirium and terminal restlessness

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Reversible causes of Anorexia

• A Aches and Pains
• N Nausea and GI dysfunction
• O Oral Candidiasis
• R Reactive/organic Depression
• E Evacuation problems
• X Xerostomia (dry mouth)
• I Iatrogenic--chemo, radiation
• A Acid related GERD, PUD

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Before you place that IV or G-tube in a
terminally ill patient....CONSIDER

• Tube or forced feedings
• Do not prolong survival
• Increase the discomfort
• Aspiration, secretions, edema, ascites,
  effusions, pulmonary congestion, nausea,
  diarrhea, use of restraints
• TPN is associated with decreased survival in
  terminal cancer patients

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Terminal patient refusal of food and water

• Frequently more traumatic to the family than the
  patient
• Chronic/terminal starvation and dehydration per
  se are not uncomfortable

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Useful Interventions

• Sensible dietary advice
• small portions of favorite foods
• avoid foods with strong odors
• do not force intake
• Family Conference
• TRIAL of Appetite Stimulants
• Megace 80 to 200 mg tid or qid
• Prednisone 1 to 2 mg qd or bid
• Marinol 2.5 to 5 mg bid or tid

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DysphagiaSome causes and treatments

• Dry mouth caused by radiation
• Synthetic saliva q 1 to 2 hrs
• Pilocarpine 5-10 mg tid caution
• Dryness caused by drugs such as
• Compazine, thorazine, amitryptyline

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Dysphagia, continuedInfectious causes and
treatments

• Oral Candidiasis
• Nystatin Clotrimazole troches
• Ketoconazole 200 mg qd x 14 d
• Fluconazole 100 mg qd x 14 d
• Bacterial periodontal disease
• Viral--Herpes simplex
• Acyclovir 400 mg 5 times/day x 10 d

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Dysphagia, continuedMore causes and treatments

• Reflux esophagitis
• Mucosal damage--soothing agents
• Benadryl and kayopectate mouthwash
• Viscous lidocaine
• May require parenteral opioids
• Systemic dehydration
• ice chips, sips of fluid, moist sponge stick

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Dyspnea

• An uncomfortable awareness of breathing
  (UNIPAC 4)
• DISTINGUISH dyspnea from hyperpnea and tachypnea
• DIAGNOSE and treat underlying cause when possible
  and reasonable

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Dyspnea, treatable causes

• B Bronchospasm
• R Rales--CHF, volume overload
• E Effusions
• A Airway obstruction
• T Thick Secretions
• H Hemoglobin low--caution
• A Anxiety
• I Interpersonal issues
• R Religious concerns

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When to treat dyspnea symptomatically

• No treatable etiology identified
• OR
• The treatments do not completely relieve the
  distressing symptom (dyspnea)

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Opioid Therapy for DyspneaConsiderations

• safe and effective when titrated
• start with usual anti pain doses, increase dose
  30 to 50 q 4 to 12 hrs until patient is
  comfortable
• In COPD patients, opioids increase exercise
  tolerance with decreased breathlessness, reduce
  O2 need

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Opioid Therapy for Dyspnea Continued...

• Mild Dyspnea
• Hydrocodone 5 mg q4h and q2h prn
• Codeine (30 mg)- 1 tab q4h and q2h prn
• Severe Dyspnea
• for patients on no or weak opioids
• Oxycodone 3-10 mg q4h and q2h prn
• Oral morphine-3-10 mg q4h and q2h prn
• Hydromorphone 0.5-2 mg q4h and q2h prn
• Nebulized morphine...

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Therapy of Severe Dyspnea Continued...

• Patients already taking strong opioids...
• Consider the anxiety component of dyspnea
• ADD Benzodiazipines (short acting)
• mild PO lorazapam 0.2 to 2 mg q8h
• severe may need midazolam titration-start with
  0.25 mg SQ q hr--TITRATE

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Dyspnea other considerations

• Use of Oxygen
• Reserve for hypoxic patients??
• Opioids are first choice for dyspnea, the symptom
• Use least invasive delivery--nasal prongs
• The terminal state
• benzodiazepines

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Nausea and Vomiting

• Frequency in terminal cancer
• Nausea--50 to 60 of patients
• Vomiting--30 of patients
• Can be controlled in 90 of cases
• Pathophysiology
• Cerebral cortex
• Vestibular apparatus
• Chemoreceptor trigger zone
• Gastrointestinal tract

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Nausea and VomitingSome treatable causes

• Cortical
• CNS tumor
• Intracranial pressure
• Anxiety, uncontrolled pain
• Vestibular / Middle ear
• Vestibular disease
• Middle ear infections

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Nausea and VomitingMore treatable causes

• Chemoreceptor Trigger Zone
• Drugs
• Metabolic--e.g., renal, liver
• Hyponatremia, Hypercalcemia
• Gastrointestinal Tract
• Gastritis/esophagitis
• Constipation, impaction
• Obstruction
• Tube feedings

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Persistent nausea...in a terminally ill patient

• Rule out bowel obstruction
• Start with
• Haloperidol 1 mg PO or SC bid or tid, increase to
  10 to 15 mg/day, as needed
• If needed, add
• Antihistamine (e.g., hydroxyzine) and /or
• Metoclopramide (beware in bowel obstruction)
• Other Ondansetron (Zofran), Granisitron
  (Kytril), methotrimeprazine (Levoprome)

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Bowel Obstruction...in advanced cancer

• Incidence--3 overall in Hospice
• Ovarian Cancer 5 to 42
• Colorectal Cancer 10 to 30
• Mechanism mechanical, paralytic
• Symptoms...
• Surgery...limited usefulness in terminally ill
  cancer patients

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Bowel Obstruction...in advanced cancer

• GOAL no cramps, no pain, minimal nausea, no
  more than 1 emesis/day
• Achieved IN MOST CASES
• WITH analgesics, anticholinergic and antiemetic
  drugs
• WITHOUT the use of decompression tubes, surgery
  or IV fluids

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Pharmacologic treatment of malignant bowel
obstruction

• Pain strong opioids
• Nausea
• haloperidol, antihistamines, phenothiazines
  (anticholinegic effect)
• metoclopramide may make sx worse in mechanical
  obstruction
• Mechanical vomiting of GI secretions, cutaneous
  fistulas
• Octreotide (Sandostatin)

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Octreotide (SandostatinTM)

• Synthetic analogue of Somatostatin
• Decreases intestinal secretion, bile flow
• Increases intestinal absorption
• Adverse effects
• Dry mouth, Flatulence
• Hypo- or hyperglycemia
• Pain at injection site...
• Dosage and administration
• 150 mg SC, bid OR
• 300 mg over 24h by SC infusion. Max. 600 mg/day

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Delirium and terminal agitation

• Delirium up to 85 of terminal cancer patients
• Features may include
• Clouding of consciousness, altered attention
• Perceptual disturbances
• Acute onset, fluctuating course

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Delirium--Causes

• D Drugs, especially psychotropics
• E Electrolyte imbalance
• L Liver failure
• I Ischemia or hypoxia
• R Renal failure
• I Impaction of stool
• U Urinary tract or other infection
• M Metastases, other neurological

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Drug Treatment of Delirium

• Haloperidol 1-2 mg PO or SC q1h to calm the
  crisis, then q6-12 hr
• If more sedation is desired, or for the AIDS
  dementia complex, use
• Thioridazine (Mellaril) 25-50 mg PO q1h until
  calm then q6-12 hr OR
• Chlorpromazine 25-50 mg PO or IV until calm then
  q6-12 hr

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Severe Agitated Delirium

• Consider ADDING
• Lorazepam (Ativan) 1-2 mg q1hr until calm (PO, SL
  or IV)
• Midazolam (Versed) 0.4-4 mg/hr continuous SC
  infusion
• Chlorpromazine (Thorazine) 100 mg q1h PO, PR or
  IV until calm
• Methotrimeperazine (Levoprome) 20 mg q1h IM or
  IV, until calm

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Smelly Tumors

• Cause Necrotic exposed tumor mass
• Breast (25), Lung 7, Renal (5), Colon (3)
• Treatment
• Pain Control
• Debridement
• Control odor etiol. Bacteroides sp.
• apply METRONIDAZOLE gel (0.8) systemic
  treatment (200-400 mg PO tid)
• Charcoal Dressings
• MAALOX
• Soak dressings off

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Other Non-pain Symptom Areas

• Pressure Sores
• Stomas/fistulas
• Edema/lymphedema
• Pruritis/skin problems
• Other GI-diarrhea, ascites, impactions
• Hemoptysis
• Pleural effusions

• Incontinence
• Urinary retention
• Hematuria
• Drug reactions
• Seizures, other neurological
• Metabolic symptoms
• Fever, infections

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SUMMARYNon-pain symptom management

• Listen to the Patient.
• Make a diagnosis before you treat
• History, exam, lab, working diagnosis
• Know the drugs you prescribe...
• Keep it simple!
• Not everything that hurts responds to analgesics
• There is always something that can be done.