Management of Refractory Cancer Pain

Case 세 여자 NSCLC, metastasis to rib, spine 치료병력 –Radiation to rib & spine 현재증상 – 늑골 및 척추부위 통증 – 통증정도 : NRS 8

질문 1-1 통증조절을 위해서 사용할 약제는 ? 1.MS-contin 2.Tramadol 3.Acetaminophen 4.Naproxen 5.Oxycontin 6.dihydrocodein

통증조절 통증 7-10 통증 5-6 통증 1-4 속효성 마약성진통제 약한 마약성진통제 혹은 속효성 마약성 진통제 비마약성 진통제 시간내 통증 재평가 조절이 안될 경우 통증의 원인, 용량의 적정성, 약의 변경, 마취통증의학과적 / 신경외과적 방법을 고려

심한 통증의 용량 적정 통증 7-10 속효성 경구용 모르핀주사용 모르핀

Case 1-2 용량적정 – 속효성 경구몰핀 15mg(N-MS15) q 2-4hr 비마약성 진통제 Naproxen 1T qd 하루 투여 용량 –24hrs total 120mg 다음날 처방 –Ms contin 60mg q 12hrs –Rescue dose short acting morphin (N-MS15), 15mg q 2hr (PRN)

Case 일째 처방 –MS contin 200mg q 12hr –Short acting morphin, 30mg q 2hr (PRN) 5 일째 처방 –MS contin 200mg q 8hr –Short acting morphin, 30mg q 2hr (PRN, x3) Pain assessment –NRS 6 부작용 : Nausea, sedation

질문 1-2 다음으로 고려해야 할 조치는 ? 1.Coadministration of psychostimulant 2.Intraspinal morphin therapy 3.Nerve block 4.Switch to another opioid

질문 1-3 Oxycodon 으로 switch 하기로 하였다. 용량은 어떻게 결정할 것이며, Rescue dose 는 어떻게 할 것인가 ? 1. 용량결정의 conversion ratio 는 ? 2.Rescue dose 는 하루 총용량의 몇 % 를 어떻게 투여 할 것인가 ?

Dose Conversion Guideline Calculate equianalgesic dose Decrease equianalgesic dose by 25-50% –Exception Methadone: 75-90% Fentanyl: same dose –Consideration Elderly or cardiopulmonay, hepatic, renal disease Severe pain Rescue dose: 5-15% of total daily dose Reassess and titrate new opioid

Equianalgesic dose Equianalgesic dose(sc) Half life(hr) Morphine Codein200- Tramadol Hydromorphone Oxycodone Methadone Fentanyl patch 100  g/h = morphine 4 mg/h 16-24

Case 1-4 Long-acting(200mg q 8hrs) + immediate-release morphine (3 doses of 30mg) –Total for 24 hours – 690mg po Conversion to oxycodone –Morphine 30mg po = oxycodone 20mg po –Morphine 690mg po = oxycodone 460mg po Oxycodone schedule –Long-acting oxycodone 230mg q 12hrs Rescue dosage –460mg x 10% = 46mg –Immediate-release oxycodone 45mg q 2hrs (PRN)

Case 주일 후 –NRS 3 – 환자는 더이상의 용량증가를 원하지 않음. 투약 양이 많기 때문. – 양이 적은 진통제로 바꿔주기를 원함.

질문 1-3 가장 적절한 진통제는 ? 1.Methadone 2.Hydromorphone 3.Meperidine 4.Fentanyl patch

Case 1-5 현재 처방 –Oxycontin 240mg po q 12hrs = 480mg –Oxycodone 45mg po x3 doses/d = 135mg –Total 480mg + 135mg = 615mg/d Fentany patch conversion –Morphine 4 mg iv/h = fentanyl 100  g/h 용량 계산은 ?

Case 1-6 현재 처방 –Oxycontin 240mg po q 12hrs = 480mg –Oxycodone 45mg po x3 doses/d = 135mg –Total 480mg + 135mg = 615mg/d Fentany patch conversion –Oxycodone 20mg po = morphine 10mg iv –Oxycodone 615 mg/d po = morphine 308 mg/d iv –Morphine 308 mg iv/24hrs = 12.8 mg iv/h –Morphine 4 mg iv/h = fentany 100  g/h –Morphine 13 mg iv/h = fentanyl 325  g/h (6 patches of 50  g/h) Rescue dose –Fentanyl 300  g/h = morphine 288 mg/d iv –Morphine 10mg iv = hydromorphone 7.5 mg po –Morphine 288 mg/d iv = hydromorphone 216 mg po –216mg x 10% = 21.6 mg of hydromorphone

Case 세 여자, colon cancer Liver & paraaortic LNs metastasis Abdomianl pain Morphin sulfate + acetaminophen 3 개월후, MS contin 1,200mg, rescue dose 120mg x6 doses Switch to fentanyl patch increasing dose to 30 patches of 50  g/h Somnolence, pain intensity NRS 8 Abdominal CT –Hepatomegaly with multiple SOLs –Paraaortic LNs enlargement

질문 1-3 적절한 통증조절 방법은 ? 1.Radiation 2.Neurolytic celiac plexus block 3.Morphin spinal delivery 4.Cordotomy

Adjunctive analgesic therapy Neurolytic celiac plexus block –Upper abdominal visceral pain –Effective for 3-6 months –Presence of alternate pain pathway  need opioid Intraspinal drug delivery –Intrathecal, epidural routes –1% of required iv morphine

Case 2-2 Neurolytic celiac plexus block –NRS 8  4 –Remove fentany patch –Need iv morphin Spinal delivery system –4 mg intrathecal test dose of morphin –Next day 6 mg IT test dose –Spinal drug delivery infusion pump