9/29/2016 Upda te in Pa llia tive Ca re L I SA ANSE L MO PHARM.D BCOP UNI VE RSI T Y OF NE W ME XI CO CANCE R CE NT E R Ca se 64 yo fe ma le with me ta sta tic o va ria n c a nc e r T re a te d with pa c lita xe l c a rb o pla tin Se ve ra l surg e rie s Ma in c o mpla int ne uro pa thy in fe e t a nd le g s Anxio us a b o ut dise a se a nd pro g re ssio n Ma na g ing pa in with me dic a l ma rijua na 1
9/29/2016 Pa llia tive c a re re c s Oxyc o do ne fo r pa in Bo we l re g ime n Co unse ling fo r a nxie ty Pa llia tive c a re Appro xima te ly 2.6 millio n pe o ple die in the US Usua lly a s a re sult o f a c hro nic illne ss (c a nc e r a nd he a rt dise a se ) Pa llia tive c a re Sympto m ma na g e me nt Pa tie nts g o a ls Ca re g ive r suppo rt Whe n pro vide d to pa tie nts with so me type s o f c a nc e r it c a n a c tua lly pro lo ng life Pa tie nt a nd fa mily-c e nte re d c a re tha t o ptimize s q ua lity o f life b y a ntic ipa ting , pre ve nting , a nd tre a ting suffe ring 2
9/29/2016 De finitio ns Wo rld He a lth Org a niza tio n Pa llia tive c a re I mpro ve s the q ua lity o f life o f the pa tie nt thro ug h sympto m c o ntro l I mpro ve s QOL fo r fa mily Also a ddre sse s spiritua l a nd psyc o so c ia l a spe c ts o f pa tie nt c a re Do e s no t ha ste n o r impe de de a th T e a m a ppro a c h Physic ia ns, nurse s, so c ia l wo rke rs, pha rma c ists, c ha pla in, music the ra pist Ca n b e utilize d a t a ny time during the c o urse o f a c hro nic illne ss De finitio n Ho spic e A ho me pro viding c a re fo r the te rmina lly ill Ho spic e c a re is tre a ting sympto ms a t the e nd o f life so the pa tie nt c a n die with dig nity. Also pro vid e e mo tio na l a nd spiritua l suppo rt fo r the pa tie nt a nd fa mily. T re a tme nts fo r the te rmina l illne ss a re sto ppe d whe n ho spic e c a re is initia te d. T o b e e lig ib le fo r the ho spic e b e ne fit tre a tme nt must fo c us o n sympto m c o ntro l no t dise a se tre a tme nt. http:/ / www.nhpc o .o rg / a b o ut/ ho spic e -c a re 3
9/29/2016 Ro le o f the Pha rma c ist Pa rtic ipa te in te a m me e ting s Re vie w me dic a tio ns fo r drug inte ra c tio ns Re vie w me dic a tio ns fo r dise a se sta te inte ra c tio ns Re c o mme nda tio ns fo r sympto m ma na g e me nt E duc a te pa tie nts a nd fa milie s Sympto m ma na g e me nt Pa in Na use a / vo miting Co nstipa tio n Dyspne a L ive r dise a se 4
9/29/2016 Pa in ma na g e me nt Asse ssme nt Sc a le , 1-10. Wha t is the pa tie nt’ s g o a l? Wha t c a n the y live with? L o c a tio n, q ua lity, o nse t, type o f pa in No c ic e ptive vs ne uro pa thic pa in No c ic e ptive is so ma tic o r visc e ra l pa in So ma tic pa in re sults fro m b o ne , jo int, musc le o r c o nne c tive tissue L o c a tlize d, a c hing thro b b ing pa in Re spo nsive to NSAI Ds o r ste ro ids o r ra dia tio n Visc e ra l pa in Orig ina te s in inte rna l o rg a ns Cra mping , a c hing , pre ssure Ca use d b y b o we l o b struc tio n o r c a nc e r me ta sta sis to live r Opio ids , a ntie me tic s o r a ntic ho line rg ic s mig ht he lp 5
9/29/2016 Ne uro pa thic pa in Ca use d b y dysfunc tio n in the CNS Numb ne ss, ting ling , b urning , o r ra dia ting pa in Opio ids ma y wo rk, o fte n ne e d a me dic a tio n with a diffe re nt me c ha nism o f a c tio n T CAs, musc le re la xa nts, a nti e pile ptic s WHO pa in ma na g e me nt la dde r Ste p wise a ppro a c h Ac e ta mino phe n…. No ne e d to disc uss NSAI Ds- COX 2s Opio ids http:/ / pa indr.c o m/ ho me / Anti e pile ptic s Ga b a pe ntin a nd pre g a b a lin ste ro ids 6
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9/29/2016 Ne uro pa thic pa in Me ta a na lysis pub lishe d in F e b 2015 I nc lude d tria ls tha t la ste d a t le a st 3 we e ks F irst line re c o mme nda tio ns: g a b a pe ntin o r e xte nde d re le a se g a b a pe ntin o r e na c a rb il 1200mg to 3600mg / da y Pre g a b a lin 300 mg to 600 mg / da y Dulo xe tine 60 mg to 120 mg / da y Ve nla fa xine E R 150-225 mg / da y T ric yc lic a ntide pre ssa nts (o ne no t re c o mme nde d o ve r o the rs) Ne uro pa thic pa in Se c o nd line use - we a k e vide nc e Ca psa ic in 8% pa tc he s- o ne to 4 pa tc he s a pplie d fo r up to 60 mins e ve ry 3 mo nths L ido c a ine pa tc he s o ne to 3 pa tc he s o nc e a da y fo r up to 12 ho urs T ra ma do l 200-400 mg / da y T a pe nta do l 8
9/29/2016 Ne uro pa thic pa in T hird line Bo tulinum to xin A sub Q 50-200 units e ve ry 3 mo nths Opio ids Me tha do ne fo r ne uro pa thic pa in Blo c ks the NMDA re c e pto rs T itra te slo wly Opio id a dve rse e ffe c ts QT c pro lo ng a tio n a t hig he r do se s ha s b e e n se e n a t 200 mg do se s Ge t b a se line E K G Ne uro pa thic pa in Co mb ina tio n re g ime ns Pe g a b a lin o r g a b a pe ntin a nd dulo xe tine o r T CAs Go o d re g ime n to c o mb ine inste a d o f trying to push the do se s o f the individua l me dic a tio ns 9
9/29/2016 Opio ids F DA o pio id a c tio n pla n Ab use de te rre nt fo rmula tio ns Wa rning s a nd sa fe ty info rma tio n o n sho rt a c ting fo rmula tio ns I nc re a se pro vide r tra ining Re vie wing the pa in ma na g e me nt re c o mme nda tio ns Ab use de te rre nt fo rmula tio ns Physic a l c he mic a l b a rrie rs Use ta b le t fo rmula tio n to pre ve nt e xtra c ting the o pio id thro ug h so lve nts Ag o nist/ Anta g o nist c o mb ina tio ns Anta g o nist c a n b e se q ue ste re d a nd re le a se d upo n ma niupula tio n 10
9/29/2016 Mo rphine / na ltre xo ne (E mb e da ) No ve l a g e nt- c o nta ins pe lle ts o f mo rphine a nd se q ue ste re d na ltre xo ne Mo rphine / na ltre xo ne (E mb e da ) I nitia l do se s sta rt a t 20mg / 0.8mg o nc e a da y T itra te e ve ry 1 to 2 da ys Co nve rsio n fro m o ra l mo rphine Give ha lf o f the to ta l da ily mo rphine do se a s E mb e da q 12 ho urs OR a ll o f the pa tie nt’ s to ta l da ily do se a s E mb e da o nc e a da y Co nve rsio n fro m o the r o pio ids to E mb e da Dc a ll o pio ids, initia te E mb e da a t 30mg / 1.2mg o nc e a da y No e sta b lishe d c o nve rsio n ra tio s to E mb e da Ora l do se 3x the I V 11
9/29/2016 Othe r a b use de te rre nt fo rmula tio ns Zo hydro E R (hydro c o do ne ) Opa na E R (o xymo rpho ne ) E xa lg o E R 24hr (hydro mo rpho ne ) Dyspne a No stric t de finitio ns Pa tie nt pe rc e ptio n o f a wa re ne ss o f b re a thing a nd unc o mfo rta b le ne ss Ca use s pa nic wo rry, c o nfusio n, frustra tio n a nd a ng e r T re a t the unde rlying c a use if po ssib le COPD, CHF , pne umo nia , PE , lympho ma Re po sitio n the pa tie nt mo re upwa rd po sitio n Oxyg e n ma y no t b e e ffe c tive , pa tie nts who re po rt b re a thle ssne ss ma y no t b e hypo xe mic 12
9/29/2016 Dyspne a Opio ids c a n re duc e the se nsa tio n o f b re a thle ssne ss b y de c re a sing the ve ntila to r drive Opio ids na ïve – sta rt 5 to 15 mg a nd titra te to re spo nse All ro ute s e ffe c tive Da ta o n ne b ulize d mo rphine is limite d Co c hra ne re vie w o f da ta fo r pa llia tio n o f b re a thle ssne ss Mo st studie s lo w q ua lity, sma ll n a nd no t a c o ntro l a rm No e vide nc e tha t inha le d mo rphine is e ffe c tive Anxio lytic s a re he lpful, b ut no t a s e ffe c tive a s o pio ids Additio na l se da tio n a nd po te ntia l to c a use c o nfusio n Dyspne a Co rtic o ste ro ids ma y tre a t unde rlying dise a se COPD, a sthma Ma ke pa tie nts fe e l g o o d Re duc e e de ma o r tumo r g ro wth Adve rse e ffe c ts, inso mnia Administe r e a rly in the da y Bro nc ho dila to rs c a n b e use ful fo r b ro nc ho spa sm No t muc h da ta in dyspne a 13
9/29/2016 Na use a a nd vo miting Co mmo n sympto m in pa tie nts with c a nc e r F e ma le s Yo ung e r tha n 65 Sto ma c h o r pa nc re a tic c a nc e r Re c e nt c he mo the ra py I mpo rta nt to try a nd fig ure o ut the e tio lo g y fo r se le c tio n o f tre a tme nt Die ta ry me a sure s a re impo rta nt Avo id, swe e t, sa lty, fa tty o r spic y fo o ds Sma ll fre q ue nt me a ls Na use a a nd Vo miting Do pa mine a nta g o nists, a ntihista mine s, a ntic hlo line rg ic s, se ro to nin a nta g o nists a nd pro kine tic me dic a tio ns a re ma insta y o f tre a tme nt Pro c hlo rpe ra zine , pro me tha zine a nd c hlo rpro ma zine Ca n c a use se da tio n, a ntic ho line rg ic a dve rse e ffe c ts b e c a use the y a ffe c t mo re tha n just the do pa mine re c e pto rs Butyro phe no ne s- spe c ific fo r do pa mine Pa rkinso ns like sympto ms a s a dve rse e ffe c ts 14
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