Upda te in Pa llia tive Se ve ra l surg e rie s Ma in c o mpla int - PDF document

9/29/2016 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 Upda te in Pa llia tive  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 Ca re  Ma na g ing pa in with me d ic a l ma rijua na L ISA ANSE L MO PHARM.D BCOP UNIVE RSI T Y OF NE W ME XI CO CANCE R CE NT E R Pa llia tive c a re re c s Pa llia tive c a re  Oxyc o do ne fo r pa in  Appro xima te ly 2.6 millio n pe o ple die in the US  Bo we l re g ime n  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 d ise a se )  Co unse ling fo r a nxie ty  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 vid e 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 De finitio ns De finitio n  Ho spic e  Wo rld He a lth Org a niza tio n Pa llia tive c a re  A ho me pro vid ing c a re fo r the te rmina lly ill  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  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 d ie  I mpro ve s QOL fo r fa mily with d ig nity.  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  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.  Do e s no t ha ste n o r impe de de a th  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 e a m a ppro a c h  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 d ise a se tre a tme nt.  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  http:/ / www.nhpc o .o rg / a b o ut/ ho spic e -c a re 1

9/29/2016 Ro le o f the Pha rma c ist Sympto m ma na g e me nt  Pa rtic ipa te in te a m me e ting s  Pa in  Re vie w me d ic a tio ns fo r d rug inte ra c tio ns  Na use a / vo miting  Re vie w me dic a tio ns fo r dise a se sta te inte ra c tio ns  Co nstipa tio n  Re c o mme nd a tio ns fo r sympto m ma na g e me nt  Dyspne a  E d uc a te pa tie nts a nd fa milie s  L ive r d ise a se Pa in ma na g e me nt Visc e ra l pa in  Asse ssme nt  Orig ina te s in inte rna l o rg a ns  Sc a le , 1-10.  Cra mping , a c hing , pre ssure  Wha t is the pa tie nt’ s g o a l? Wha t c a n the y live with?  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  L o c a tio n, q ua lity, o nse t, type o f pa in  Opio ids , a ntie me tic s o r a ntic ho line rg ic s mig ht he lp  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 Ne uro pa thic pa in WHO pa in ma na g e me nt la dde r  Ca use d b y dysfunc tio n in the CNS  Ste p wise a ppro a c h  Numb ne ss, ting ling , b urning , o r ra d ia ting pa in  Ac e ta mino phe n…. No ne e d to d isc uss  Opio id s ma y wo rk, o fte n ne e d a me d ic a tio n with a d iffe re nt  NSAIDs- me c ha nism o f a c tio n  COX 2s  T CAs, musc le re la xa nts, a nti e pile ptic s  Opio id s  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 id s 2

9/29/2016 Ne uro pa thic pa in Ne uro pa thic pa in  Me ta a na lysis pub lishe d in F e b 2015  Se c o nd line use - we a k e vid e nc e  I nc lude d tria ls tha t la ste d a t le a st 3 we e ks  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  F irst line re c o mme nd a tio ns:  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  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  T ra ma do l 200-400 mg / da y 3600mg / d a y  T  Pre g a b a lin 300 mg to 600 mg / da y a pe nta do l  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 Ne uro pa thic pa in  T hird line  Co mb ina tio n re g ime ns  Bo tulinum to xin A sub Q 50-200 units e ve ry 3 mo nths  Pe g a b a lin o r g a b a pe ntin a nd dulo xe tine o r T CAs  Opio ids  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  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  Op io id a d ve rse e ffe c ts  QT c p ro lo ng a tio n a t hig he r d o se s ha s b e e n se e n a t 200 mg d o se s  Ge t b a se line E K G 3

9/29/2016 Opio ids Ab use de te rre nt fo rmula tio ns  F DA o pio id a c tio n pla n  Physic a l c he mic a l b a rrie rs  Ab use de te rre nt fo rmula tio ns  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  Wa rning s a nd sa fe ty info rma tio n o n sho rt a c ting fo rmula tio ns  Ag o nist/ Anta g o nist c o mb ina tio ns  I nc re a se pro vide r tra ining  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  Re vie wing the pa in ma na g e me nt re c o mme nda tio ns Mo rphine / na ltre xo ne (E mb e da ) 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  Initia l d o se s sta rt a t 20mg / 0.8mg o nc e a d a 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 d a ily mo rphine d o se a s E mb e d a q 12 ho urs OR a ll o f the pa tie nt’ s to ta l d a ily d o se a s E mb e d a o nc e a d a y  Co nve rsio n fro m o the r o pio id s 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 d a  Ora l do se 3x the I V Othe r a b use de te rre nt fo rmula tio ns Dyspne a  Zo hydro E R (hyd ro c o do ne )  No stric t d e finitio ns  Opa na E R (o xymo rpho ne )  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  E xa lg o E R 24hr (hyd ro mo rpho ne )  T re a t the und e 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 4