Cancer pain causes tumor-associated



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tarix31.01.2017
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CANCER PAIN Causes

  • tumor-associated

    • infiltration or compression of nerves
    • soft tissue
    • bones
  • paraneoplastic syndromes

    • Veinous thrombosis
    • neuralgia
  • treatment-related

    • chemotherapy (taxanes, vinca-alkaloids)
    • radiation therapy (fibrosis)
    • surgery (phantom-pain)




PAIN Acute/chronic pain

  • Acute pain

  • warning function

  • localizable

  • correlates with pain intensity

  • short-lived

  • tolerable



General principles of pain management



PAIN Analgesic medication

  • Non-opioid analgesics

    • nonsteroidal anti-inflammatory drugs
    • paracetamol
  • Opiod analgesics

    • step-2-opiods
    • step-3-opiods
  • Adjuvant analgesics

    • tricyclic antidepressants
    • spamolytics
    • anticonvulsants
    • corticosteroids
    • oral local anesthesics
    • bisphosphonates




PAIN Routes of administration

  • non-invasive administration: preferred

    • oral
    • mucosal: sublingual, nasal, rectal
    • transdermal
  • invasive administration: dysphagia, after surgery,...

    • subcutaneous
    • intramuscular
    • intravenous
    • spinal


PAIN Effect of non-opioids



PAIN Side-effects of non-opioids

  • erosive gastritis

  • inhibition of platelet-aggregation

  • allergic reactions

  • agranulocytosis (rare!!)

  • liver-/renal-impairment

  • thrombocytopenia

  • pulmonary obstruction



PAIN Step -2- opioids

  • Tramadol

    • analgetic
    • max. daily dose 600mg/every 4-6h, or „ret.“/every12h
  • Codein

    • analgetic, antitussive
    • 180mg/every 4h
  • Dihydrocodein

    • analgetic, antitussive
    • 240mg/every 12h


PAIN Step -3- opioids

  • Morphine

  • Hydromorphone

  • Oxycodone

  • L-Methadon

  • Pethidine

  • Piritramid

  • Fentanyl transdermal system

  • Sufentanil

  • Buprenorphine partial agonist





Cancer pain

  • Compression

    • Radio-, chemotherapy, steroids
  • Osteolytic bone metastases

    • Radio-, chemotherapy
    • Bisphosphonates, calcitonin, strontium
  • Osteoblastic bone metastases

    • Radio-, chemotherapy
    • Calcitonin, Radionuclides (strontium, samarium)
  • Neuropathic pain (taxanes.,..)

    • Anticonvulsants, antidepressants, opioids
    • Opioids, NSAR, metamizol, antidepressants,...


PAIN Adjuvant medication

  • antidepressants

  • neuroleptics

  • spasmolytics

  • anticonvulsants

  • anxiolytics

  • steroids

  • biphosphonates

  • calcitonin



PAIN Approaches to cancer pain management

  • radiation therapy

  • chemotherapy

  • neurosurgical interventions

  • epidural catheter

  • plexus blockade

  • acupuncture



PAIN Rules for pain management



Durogesic® Why Fentanyl ?

  • Fentanyl has a selective, high affinity for the μ-opioid receptor

  • 100 times more potent than morphine

  • highly lipid-soluble

  • low molecular weight

  • suitable for transdermal administration



Durogesic® Schema of the delivery system

  • Administration of TTS fentanyl every 72 hours provides a sustained serum fentanyl concentration more conveniently than intravenous or subcutaneous opioids.

  • Fentanyl TTS is composed of 4 layers plus a removable protective lining.

  • Occlusive backing

  • Drug reservoir

  • Release membrane

  • Contact adhesive

  • Protective peel strip



Durogesic® Dosage



Durogesic® Opioid-naíve patients

  • Start on 25μg/h fentanyl TTS.

  • Maintainace of previous analgesic medication during the first 12-24 hours is recommended.

  • Adequate rapid-onset, short-action rescue medication, such as immediate release oral morphine, should be availbale.

  • The first titration should be at least 3 days after initial patch application.

  • Subsequent titration at 3- to 6-day intervals.

  • Upward titration increments should be based on the daily supplementary analgesia requirements; a ratio of 25μg/h fentanyl TTS to 90 mg/24 hours of oral morphine is recommended.



Durogesic® Conversion of patients from other opiods to fentanyl TTS



Durogesic® Dosage

  • Adequate rapid-onset, short-action rescue medication, such as immediate release oral morphine, should be available in all patients who receive long-acting opioids.

  • Not all patients will achieve acceptable analgesia on he 72-hour administration regimen; some may require more frequent (i.e. 48-hour) patch replacement.

  • The maximum number of patches is determined by the area of suitable skin available for application.



Durogesic ® Increase absorption rate

  • Changes of skin - erythema,... - trauma (i.e. after shaving)

  • Changes of body temperature - fever (>39°C) - sauna - heat lamps - heat pads



Durogesic ® Interaction with other agents



Conclusions

  • Pain is a significant health problem currently undertreated.

  • Opioids are the mainstay in pharmacological treatment of chronic, moderate-to-severe pain.

  • Choosing an appropriate opioid and delivery route is important for optimal pain relief.

  • Fentanyl TTS is clinically proven to be effective in treating different types of chronic non-cancer pain.



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