Pain at the end of life: Difference between revisions
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+ | == Management == |
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− | Including use of opioids and other medications |
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− | == |
+ | ===General approach=== |
− | * |
+ | *Assess the symptom |
− | * |
+ | *Reverse what you can |
− | * |
+ | *Treat what remains |
− | * |
+ | *Monitor frequently |
− | == |
+ | ===Opioids=== |
− | * |
+ | *[[Codeine]]: ~10% lack enzyme to convert to morphine |
− | * |
+ | *[[Morphine]]: has toxic products that cause delirium that are renally cleared |
+ | *See [[opioids]] for more information, including an equianalgesia chart |
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− | * Oxycodone |
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− | ** Percocet (5mg oxycodone, 325mg acetaminophen) |
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− | * Hydromorphone |
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− | * Fentanyl |
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− | * Methadone |
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− | == |
+ | ====Starting Dose==== |
− | * |
+ | *If naive (<7-10 days), low is best |
− | ** |
+ | **[[Morphine]] 2.5-5.0mg po q4h |
− | ** |
+ | **[[Hydromorphone]] 0.5-1.0mg po q4h |
− | == |
+ | ====Breakthrough==== |
− | * |
+ | *10% of TDD (i.e. 1/2 of the q4h dose) q1h prn |
− | * |
+ | *Peak effectiveness reached around 1h after oral dose |
+ | ====Titration==== |
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− | == Opioid Equivalence Chart == |
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⚫ | |||
− | {| class="wikitable" |
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⚫ | |||
− | ! Opioid |
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− | !align="center"| PO dose (mg) |
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− | !align="center"| SC/IV dose (mg) |
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− | |- |
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− | | Codeine |
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− | |align="center"| 100 |
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− | |align="center"| — |
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− | |- |
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− | | Morphine |
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− | |align="center"| 10 |
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− | |align="center"| 5 |
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− | |- |
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− | | Oxycodone |
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− | |align="center"| 5 |
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− | |align="center"| — |
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− | |- |
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− | | Hydromorphone |
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− | |align="center"| 2 |
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− | |align="center"| 1 |
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− | |- |
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− | | Fentanyl |
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− | |align="center"| |
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− | |align="center"| |
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− | |} |
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− | == |
+ | ==== Rotation ==== |
+ | * Opioid rotation may decrease some side effects, including hyperanalgesia and delirium |
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⚫ | |||
+ | * Use the [[Opioids|equianalgesia chart]] to convert to and from oral morphine equivalents |
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⚫ | |||
+ | * In general, decrease the total daily dose by about 20% when rotating to a new opioid |
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+ | ====Management of side effects==== |
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− | == Side Effects == |
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− | * |
+ | *[[Constipation]] |
− | * |
+ | *Drowsiness: |
− | ** |
+ | **Decrease dose if can't keep eyes open or can't complete a conversation |
− | * |
+ | *[[Nausea]] |
− | ** |
+ | **Add [[dimenhydrinate]] unless already on an antiemetic |
− | ** |
+ | **Should settle within a week |
− | * |
+ | *[[Delirium]] |
− | ** |
+ | **Opioid rotation |
− | ** |
+ | **[[Haloperidol]] (standing, if necessary) |
[[Category:Palliative care]] |
[[Category:Palliative care]] |
Latest revision as of 11:35, 29 July 2020
Management
General approach
- Assess the symptom
- Reverse what you can
- Treat what remains
- Monitor frequently
Opioids
- Codeine: ~10% lack enzyme to convert to morphine
- Morphine: has toxic products that cause delirium that are renally cleared
- See opioids for more information, including an equianalgesia chart
Starting Dose
- If naive (<7-10 days), low is best
- Morphine 2.5-5.0mg po q4h
- Hydromorphone 0.5-1.0mg po q4h
Breakthrough
- 10% of TDD (i.e. 1/2 of the q4h dose) q1h prn
- Peak effectiveness reached around 1h after oral dose
Titration
- When stable, add breakthrough doses to standing
- Don't add it if used for incident pain (e.g. associated with specific activities)
Rotation
- Opioid rotation may decrease some side effects, including hyperanalgesia and delirium
- Use the equianalgesia chart to convert to and from oral morphine equivalents
- In general, decrease the total daily dose by about 20% when rotating to a new opioid
Management of side effects
- Constipation
- Drowsiness:
- Decrease dose if can't keep eyes open or can't complete a conversation
- Nausea
- Add dimenhydrinate unless already on an antiemetic
- Should settle within a week
- Delirium
- Opioid rotation
- Haloperidol (standing, if necessary)