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CONTROLLING DISTRESSING SYMPTOMS IN THE CANCER PATIENT – OLD STANDARDS AND NEW APROACHES. Thomas J. Keating, MD, MS MaineGeneral Medical Center Augusta, Maine. OBJECTIVES. Identify the underlying pathophysiologic factors contributing to pain and GI distress in the cancer patient.
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CONTROLLING DISTRESSING SYMPTOMS IN THE CANCER PATIENT – OLD STANDARDS AND NEW APROACHES Thomas J. Keating, MD, MS MaineGeneral Medical Center Augusta, Maine
OBJECTIVES • Identify the underlying pathophysiologic factors contributing to pain and GI distress in the cancer patient. • Understand the rationale and the therapeutic mechanisms of selected new medications and interventions. • Integrate optimal symptom management in the comprehensive care of the patient with progressive cancer.
CANCER-RELATED SYMPTOMS • Pain • Respiratory • Gastrointestinal • Constitutional • Psychiatric
CANCER-RELATED SYMPTOMS • Pain • Respiratory • Gastrointestinal • Constitutional • Psychiatric
PAIN IN THE CANCER PATIENT • Common • Somatic vs Visceral vs Neuropathic Pain • BONE METASTASES
BONE METASTASES • Frequently seen in : Breast, Prostate, Lung, Renal, Melanoma and Multiple Myeloma • Blastic vs Lytic Mets • Pathophysiology of pain
ANALGESIC REGIMEN FOR BONE PAIN • Acetaminophen, NSAIDS • “Weak” opioids • “Strong” opioids • Corticosteroids
External beam radiation therapy Intramedullary rod placement INTERVENTIONS FOR BONE PAIN DUE TO METS
“NEWER” INTERVENTIONS FOR PAIN DUE TO BONE METS • Radiopharmaceuticals * Strontium-89 (Metastron) * Samarium-153 (Quadramet) • Kyphoplasty / Vertebroplasty
GI ADVERSE EFFECTS OF CANCER AND ITS THERAPIES • Nausea / Vomiting • Constipation
PATHOPHYSIOLOGY OF NAUSEA Chemical mediators of the nausea /vomiting pathway : • Dopamine • Histamine • Acetylchline • Serotonin
THERAPEUTIC OPTIONS IN N/V • Dopamine anatagonists • Anti-histamines • Anti-cholinergics • Serotonin antagonists
OTHER OPTIONS IN N/V • Prokinetic agents • Corticosteroids • Dronabinol • Anxiolytics
CONSTIPATION Causes • Opioids !!! • Abdominal Carcinomatosis
TREATMENT OF CONSTIPATION • Stimulants • Osmotics • Lubricants • Detergents • Large volume enemas
NEW OPTION FOR OPIOID-INDUCED CONSTIPATION Methylnaltrexone Bromide (Relistor)
Methylnaltrexate • Peripherally-acting mu receptor antagonist • Does not cross the blood-brain barrier • Indicated for “opioid-induced contipation in pts with advanced disease when response to laxative therapy has not been sufficient • Subcutaneous injection
REFERENCES • Berger, A. et al. Principles and Practice of Palliative Care and Supportive Oncology, Lippincott Williams & Wilkins, Philadelphia. 2007. • Doyle D., et al. Oxford Textbook of Palliative Medicine. Oxford University Press, Oxford. 2003. • The EPEC Project – Education in Palliative and End-of-Life Care http://www.epec.net/EPEC/webpages/index.cfm