Case Study 4 Samuel is a 94-year-old man in the late stages of metastatic prostate cancer. The cancer was initially treated 16 years earlier with a radical prostatectomy and adjuvant radiation therapy, but it has recurred with infiltration to his pelvic bones. He has been under home hospice care for the past month. His pain is being treated with transdermal fentanyl which has reduced the nausea he was experiencing with oral ER/LA oxycodone. Now, however, he says he often feels “fuzzy” and “out of it” to the point that he can’t remember conversations he has had with his wife or daughter. On a visit by the hospice nurse, Sam complains about this, saying “I want to be able to say goodbye to people, and thank them, but I just feel like a zombie half the time.” Questions 1. How might Sam’s competing desires for pain relief and mental clarity be addressed? _________________________________________________________________________________________ 2. Are there any alternative pharmacological or non-pharmacological analgesic options that might be appropriate for Sam? _________________________________________________________________________________________ 3. What other types of health care professionals might be called on to help Sam achieve the kinds of end-of-life communication he desires? _________________________________________________________________________________________ Non-steroidal Anti-inflammatory (NSAID) Analgesics and Acetaminophen
NSAIDs or acetaminophen may be useful in the treatment of pain conditions mediated by inflammation, including those caused by cancer, such as bone metastases. 41 NSAIDs typically cause less nausea than opioids, though this is most true with low doses. NSAIDS also do not cause constipation, sedation, or adverse effects on mental functioning. NSAIDs may, therefore, be useful for the control of moderate to severe pain, usually as an adjunct to opioid analgesic therapy. 50 The addition of NSAIDs to an opioid may allow a reduction in the opioid dose, although such combinations must be used with care. Typically, the non-opioid co-analgesic agent, such as acetaminophen or an NSAID, has a ceiling dose above which efficacy will plateau as risk for adverse effects increases. Thus, combining these products, either as separately-administered agents or in combination products, are typically used for patients who are not expected to need substantial dose escalations. 19 Using a combination product when dose escalation is required risks increasing adverse effects from the non- opioid co-analgesic, even if an increase of the opioid dose is appropriate. In such cases, using a pure opioid may be preferable. (Single-agent formulations are available for many types of opioids, such as morphine, oxycodone, and hydromorphone.) The FDA has limited to 325 mg the Adjuvant Analgesics Although opioid medications are a mainstay of pain management at the end-of-life, many other classes of medications have proven effective and, in some cases, preferable to opioids (see Table 6). Some exert a direct analgesic effect mediated by non-opioid receptors
amount of acetaminophen allowed in prescription opioid combination products in an attempt to limit liver damage and other ill effects primarily due to excessive doses of combined products. 51 Contraindications for NSAIDs include decreased renal function (relatively common at the end of life) and liver failure. Platelet dysfunction or other potential bleeding disorders, common due to cancer or its treatment, are also contraindications to non-selective NSAIDS because of their inhibitory effects on platelet aggregation, with resultant prolonged bleeding time. 52 Concurrent use of anticoagulants (Coumadin for example) is also a contraindication. Proton pump inhibitors or misoprostol may be considered to prevent GI bleeding. 53 Attention has recently been focused on the potential limited efficacy of acetaminophen in older patients. Although it has been considered a viable co-analgesic with opioids, and to be first-line therapy in elderly patients with musculoskeletal pains or pain associated with osteoarthritis, the relative limited efficacy and significant adverse effects of this agent, particularly hepatic and renal toxicity, have raised concerns. 54 Reduced doses of 2000 mg/day or the avoidance of acetaminophen is recommended in the face of renal insufficiency or liver failure, and particularly in individuals with a history of significant alcohol use. 55 centrally or peripherally. Other adjuvant “analgesics” have no direct analgesic qualities but may provide pain relief indirectly by affecting organs or body systems involved in painful sensations.
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Book Code: CA23CME
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