* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
“Top Ten” Clinical Tips on Symptom Management for Patients with Advanced Cancer Dr. José Pereira Head Division of Palliative Care, University of Ottawa Medical Chief, Palliative Care Service, Bruyère Continuing Care & The Ottawa Hospital Provincial Medical Lead for Palliative Care, Cancer Care Ontario Dr. Sandy Buchman Palliative Care Consultant, Temmy Latner Centre, Toronto & University of Toronto Quality & Primary Care Engagement Lead, Palliative Care Program, Cancer Care Ontario Faculty/Presenter Disclosure Faculty: Dr. José Pereira Program: 51st Annual Scientific Assembly Relationship with commercial interests: – Grants/Research Support: Takeda (past) Education grant to conduct review of breakthrough pain – Speakers Bureau/honoraria: Nil to report – Consulting Fees: Nil to report – Other: Nil to report Disclosure of Commercial Support This program has NOT received financial support This program has NOT received in-kind support (except for myself and my organization who have allowed me to be here to present on their time) No potential for conflict(s) of interest to declare Mitigating potential bias Jose Pereira – Takeda: Product has very limited role & prohibitively expensive Faculty/Presenter Disclosure Faculty: Dr. Sandy Buchman Program: 51st Annual Scientific Assembly Relationship with commercial interests: – – – – Grants/Research Support: Nil to report Speakers Bureau/honoraria: Nil to report Consulting Fees: Nil to report Other: Nil to report Disclosure of Commercial Support This program has NOT received financial support This program has NOT received in-kind support (except for myself and my organization who have allowed me to be here to present on their time) No potential for conflict(s) of interest to declare Mitigating potential bias Sandy Buchman – Nil to declare Any burning questions?? 1. Systematic Screening of Symptoms Cancer patients experience many symptoms across the illness trajectory Symptom Intensity & Tumor Stage (Non-hematological cancers) N= 240 Median # of symptoms = 8 per patient No evidence of disease Local disease Regional disease Metastatic disease No. of symptoms 9 (0-24) 7 (0-17) 6 (0-15) 10 (0-25) Moderate to severe symptoms 4 (0-14) 3 (0-12) 3 (0-12) 6 (0-20) Chang VT et al. Symptom and Quality of Life Survey of Medical Oncology Patients: A Role for Symptom Assessment. Cancer 2000;88:1175-1183 Symptoms are under-reported by patients unless standardized questionnaire used White C, et al. ‘‘Now that You Mention it, Doctor . . . ’’:Symptom Reporting and the Need for Systematic Questioning in a Specialist Palliative Care Unit, J Pall Med 2009; 12(5):447-450 Symptoms: Patient reporting versus systematic assessment Total symptoms identified: 2,397 – Of these, only 14% (322) were volunteered Homsi J, et al. Symptom evaluation in palliative medicine: Patient report vs systematic assessment. Support Care Cancer 2006;14:444–453. Edmonton Symptom Assessment Scale (ESAS) ISAAC II • ESAS R • Patient Self-Report Functional Status (ECOG) • Additional questions • Beginning process of tailoring kiosk to clinics & needs Clinicians can fail to recognize 50-80% of patients concerns during consultation Significantly reduced symptom distress across a number of symptoms 2. Useful Clinical Tools The Palliative Performance Scale (PPS) Palliative Performance Scale (PPS) ECOG Stable 0 % Ambulation Activity & Evidence of Disease Self-Care Intake Level of Consciousness 100 Full Normal activity No evidence of disease Full Normal Full 90 Full Normal activity Evidence of disease Full Normal Full 80 Full Normal activity with effort Evidence of disease Full Normal/ Reduced Full 70 Reduced Unable to do normal work Evidence of disease Full Normal/ Reduced Full 60 Reduced Unable to do house work Significant disease Occasional Assistance Normal/ Reduced Full or Confusion 50 Mainly Sit/Lie Unable to do any work Evidence of disease Considerable Assistance Normal/ Reduced Full or Confusion 40 Mainly in Bed As Above Mainly Assistance Normal/ Reduced Full or Drowsy or Confusion 30 Totally Bed Bound As Above Total Care Reduced Full or Drowsy or Confusion 20 As Above As Above Total Care Minimal Sips Full or Drowsy or Confusion 10 As Above As Above Total Care Minimal/nil Drowsy or Coma 1 Transitional 2 E-of-life 3 4 20 Encourage patient to see family physician regularly or find one. Palliative Alerts Establish plans to deal with emergencies (e.g. pain crisis) DNR & Advanced directives % Advance care planning. Explore pt’s Discuss code status understanding of illness, Review treatment plan discuss prognosis & goals of care. Ensure ESAS & PPS/ECOG done at Initiate each visit. home care Consult Palliative Care Team as needed Discuss preferred versus optimal place of death based on needs & circumstances For some patients the decline may be more gradual while for others it may be more precipitous Death ILLNESS TRAJECTORY IN PROGRESSIVE CANCER 21 Prognosticating using the PPS in Cancer Patients Lau F, Downing M, et al. J Pain, PainSympt Manage. 2009;38(1) Transitioning End-of-life www.advancecareplanning.ca Cancer Care Ontario Symptom Management Guidelines Mobile Smartphone App & Pocket Guides: Symptom screening tools https://www.cancercare.on.ca/toolbox/symptools/ 3. Palliative Care Earlier Than Later Old model of Palliative Care Palliative Care: Earlier in illness, not only at end-of-life Palliative and End of Life Trajectories 29 Palliative and End of Life Trajectories 30 Palliative and End of Life Trajectories 31 4. Selecting an analgesic: The WHO Ladder Pain: A Multidimensional construct “I have pain” Total Suffering/Pain Several domains merging Pain Spiritual & existential Other symptoms Total Suffering Psychological Cultural 34 Social & financial WHO Analgesic Ladder Selecting between different opioids Morphine remains first line strong opioid Inter-individual variability between opioids No large studies to demonstrate that one opioid is superior to another Less constipation with fentanyl – Clinical significance? Renal impairment – May still use morphine but reduce dose/prolong dosing intervals & monitor – Fentanyl & buprenorphine – Beware of methadone Opioid Formulations Short-acting formulations for Opioid-naïve patients Pain crises 37 Long-acting formulations Reserve for stable situations Add short-acting opioids for breakthrough pain Opioid Neurotoxicity Clinical Presentation – Myoclonus, hallucinations, cognitive impairment, delirium, severe somnolence, dysesthesia, allodynia Mechanism unclear Management strategies – Switching opioid (opioid rotation) – Decreasing opioid dose (if pain is well controlled) – Hydration 38 Adjuvants for neuropathic pain 1st line – – – – – TCA, gabapentin, pregabalin Start low & go slow Trial of at least 5-7 days before increasing dose Monitor for side effects NNT=3-4 2nd line – Pregabalin, corticosteroids 3rd line – Ketamine, lidocaine Adjuvants for Bone Pain NSAIDs – Limited use in severe pain – Renal and gastro-intestinal side effects – Limitations of Cox-2 specific NSAIDs recently noted Steroids – Useful in pain crises Radiotherapy – 75% to 85% response rate (decreased pain) – Few side effects with palliative therapy – Response within 1 to 2 weeks (maximum response up to 4 weeks later) – Duration of analgesia is several months 40 Adjuvants for Bone Pain Bisphosphonates – Reduction of skeletal events (good evidence) – Management of more acute pain with parenteral infusion (some controversy) Calcitonin – Not effective 41 5. Managing Breakthrough Pain Breakthrough Pain (BTP) Transient exacerbation of pain on a background of well controlled baseline pain. Variable in intensity, duration, frequency & cause Types – Unpredictable – Predictable • Incident Pain “End-of-Dose” failure not BTP • Treatment – Use a short acting opioid formulation – Use same opioid as background treatment if possible – Exceptions: Fentanyl patch – 10% of total daily dose – Then titrate breakthrough dose (5% to 20%) Breakthrough pain Breakthrough dose needs titration (5-20%) once baseline pain controlled Role of new sublingual formulations of fentanyl very limited – Expensive – Patient must be on at least 60mg of oral morphine per day – Limited role 6. Management of Dyspnea Is this patient short of breath? 46 47 Management Approach to Dyspnea Screen Assess Identify and treat underlying causes if possible and if appropriate 48 + Treatment of symptom + Communicate: Explain situation to patient and family and reassure Pharmacological Measures to Control Dyspnea? 49 Pharmacological Measures to Control Dyspnea Oxygen Opioids Adjuvant therapies 50 Non-Pharmacological Management Use a fan Position: lean forward, head up Avoid exacerbating activities 51 7. Management of Nausea Brain cortex(rare) Transmitter: GABA, Ach Causes: Anxiety, anticipatory nausea Anti-emetic: Anxiolytic Vomiting Centre Transmitter: Ach, Dop Causes: co-ordinates vomiting reflex Nausea & Vomiting: mechanisms Chemoreceptor Trigger Zone Neuro-transmitter: Dopamine, 5HT3 Causes Drugs (chemotherapy, opioids, SSRIs) Toxins (infections, cytokines) Biochemical (hypercalcemia, uremia) Anti-emetic: 1st line: Metoclopramide, domperidone 2nd line: Haloperidol (small dose) 3rd line: ondansetron Anti-emetic: Same as CTZ Gastro-intestinal tract Vestibular apparatus (rare) Neuro-transmitter: Histamine Causes: Motion sickness Anti-emetic: Antihistamine 53 Neuro-transmitter: Dopamine, 5HT3 Causes: Tumors & tumor bulk, Obstruction, ileus, constipation Anti-emetic: Same as CTZ Selecting an anti-emetic Depends on underlying mechanism 1st line agents: – Usual (one of the following) • Metoclopramide 10mg PO QID PO/Subcut • Domperidone 10mg TID PO (max dose 30mg/day) – In case of bowel obstruction (one of the following) • Haloperidol 0.5-1mg subcut BID • Dimenhydrinate 2nd line agents: • • • • Dexamethasone Ondansetron Methotrimeprazine Cannibinioids If antidopamine agent: monitor for EPS & akitisea 8. The Management of Delirium in patients with advanced cancer CLINICAL PRESENTATION Clinical Subtypes Delirium presents in one of three forms. Hyperactive form Mixed form Hypoactive form Meagher D. Motor subtypes of delirium: Past, present and future. Int Rev Psychiatry 2009;21:59-73; Lawlor P et al. Occurrence, causes and outcomes of delirium in advanced cancer patients: a prospective study. Archives of Internal Medicine. 2000;160:786-794. CAUSES OF DELIRIUM Causes per episode Often multifactorial etiology per episode – On average, 3 causes per episode • E.g. opioid neurotoxicity, dehydration and hypercalcemia Consider several causes concurrently Sometimes the causes are unclear or cannot be found Urinary retention aggravates delirium Consider underlying dementias in very elderly patients Lawlor P, et al. Occurrence, causes and outcomes of delirium in advanced cancer patients. Archives of Internal Medicine. 2000;160:786-794. Bruera E et al. Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer 2009;115:2004-2012 57 Common Causes of Delirium in Palliative Care Drugs – – – – Opioids Anticholinergic drugs such as tricyclic antidepressants Anticonvulsants Benzodiazepines Infections Dehydration Metabolic/Organ failure – Renal or liver failure, hypercalcemia, hyponatremia 58 Hypoxemia Brain disease: metastases or primary brain tumors BZP withdrawals (uncommon) Full bladder (aggravates) Overall management approach Role of benzodiazepines in Palliative Care Benzodiazepines Appear to worsen delirium in palliative patients. Generally avoided. Breitbart W et al. Doubleblind trial of haloperidol vs chlorpromzine vs lorazepam in palliative AIDS pts. J Am Psych 1996;153(2):231-237 DELIRIUM Management Guidelines. Cancer Care Ontario 2010 Pharmacological management Symptom Management- 1st line Mild Haloperidol 0.5mg or 1mg po or subcut OD or BID PLUS Haloperidol 0.5mg or 1mg PO /subcut q1hr PRN Then titrate dose if initial dose ineffective (see “moderate” doses) Moderate Haloperidol 2mg or 2.5mg po or subcut BID to TID PLUS Haloperidol 2mg PO /subcut q1hr PRN OR Methotrimeprazine Then titrate dose if initial dose ineffective Severe Single dose of midazolam 2.5mg to 5mg subcut stat PLUS Haloperidol 5mg subcut stat OR Methotrimeprazine Follow with haloperidol 2.5mg or 5mg q 30min PRN subcut (max of 10-15mg /day) The Role of the Atypical versus Traditional Antipsychotic medications Haloperidol remains 1st line Methotrimeprazine 2nd line Newer atypical antipsychotics reserved for: – Pts requiring longer term treatment – Pts with EPS on haloperidol – Olanzapine can be given SC The Myth of the “PLEASANT CONFUSION” 54% of pts whose delirium resolved recalled the delirium experience. 78%: delirium as highly distressing Patients with hypoactive delirium were just as prone to experiencing distressing delirium as those with hyperactive delirium. Breitbart W et al. The Delirium experience: Psychosomatics. 2002;43:183-194 9. Depression at the End of Life Diagnosing depression in palliative care context What is the prevalence of a major depression in patients with advanced disease? Diagnosing depression in palliative care context What is the prevalence of a major depression in patients with advanced disease? – 10-15% – 25% in pancreas cancer Challenge – Somatic symptoms non-specific • Weight loss, fatigue Pervasice Worthlessness, guilt, hopelessness, death wish Management Supportive Counseling in all Pharmacological management in some (where ability function is affected) – – – – – Citalopram (sedating) Venlafaxine (stimulating) Mirtazapine (sedating, appetite stimulation) Duloxetine (if requires adjuvant analgesic) Methylphenidate (short onset of action) 10. Airway secretions Airway “rattle” at end of life Differentiate between upper and lower airway secretions. Upper airway secretions: – If mild to moderate: • Reposition & reassure family – If severe • Reposition, reassure, anticholinergic Glycopyrrolate 0.4mg Subcut q2 hrs prn OR Scopolamine 0.4mg Subcut q 4 hrs prn Lower airway secretions (Pulmonary edema) – Furosemide 20mg-40mg subcut stat End of Life “Comfort measures” (last hrs/days) Avoid blanket orders No need to start “morphine drip” if there was no pain before No need to start midazolam drip if there is no refractory symptom and palliative sedation is not required QUESTIONS??