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Guidelines on Pain Management & Palliative Care

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Guidelines on Pain Management & Palliative Care GUIDELINES ON PAIN MANAGEMENT & PALLIATIVE CARE (Text update March 2013) A. Paez Borda (chair), V. Fonteyne, E.G. Papaioannou, F. Charnay-Sonnek This pocket version aims to synthesise the important clinical messages described in the full text and is presented as a series of algorithms and graded ‘action based recommenda- tions’, which follow the standard for levels of evidence used by the EAU (see Introduction chapter). Pain Management & Palliative Care 261 Cancer pain treatment in urology Pain in patient with urological cancer Pain assessment using OPQRSTUV and physical assessment (pain area, pain type, pertinent history, risks of addiction, associated symptoms-nausea, vomiting, constipation, dyspnoea, tingling, urinary retention) Mild pain (score 1-3) Moderate pain (score 4-6) Severe pain (score 7-10) • Paracetamol ± NSAIDs at the lowest effective dose (need for periodical pain assessment) Opioid naïve patient Patient in opiod Opioid naïve patient Patient in opiod • Consider gastric • Morphine 5 mg x treatment • Morphine 5-10 mg treatment protection in long 6 per os and 2.5-5 • Increase the x 6 per os and 5 • Increase the regular term NSAIDs use mg every hr prn regular and mg prn every 1hr, and breakthrough • Weak opioids (codeine for breakthrough breakthrough or doses by 25%. or tramadol) at low pain. For elderly doses by 25% • Hydromorphone 1 -2 • Titrate dose every doses in combination or debilitated • Titrate dose every mg x 6 per os and 24hrs. with non-opioids consider starting 24hrs 1mg prn every 1hr, dose of 2.5 mg x 6 • Make frequent or • Hydromorphone assessments and • Morphine 2.5-5 Mg 1 mg x 6 per os opioid titration x 6 sc and 2.5 Mg sc In case of inadequate with 0.5-1 mg until pain is prn every 30 min, pain control every hr prn. controlled. or For elderly and • Hydromorphone debilitated 0.5 mg 0.5-1 mg x 6 sc and x 6 0.5 mg sc prn every • Oxycocone 2.5 mg 30 min. x 6 per os with 2.5 mg every hr prn for breakthrough pain If pain persists • If pain persists consider opioid switching • Consult a palliatve care specialist Severe pain crisis Consult a palliative care specialist iv access present No iv access present Opioid-naïve patient Patient on opioids Opioid-naïve patient Patient on opioids Morphine 5-10 mg Give the usual per os Morphine 5-10 mg sc Give the usual per every 10 min until pain morphine dose iv every every 20-30 min until os morphine dose sc is relieved 10 min until pain is pain is relieved every 20-30 min until relieved pain is relieved Titrate dose by 25% every 1 -2 doses until pain is relieved 262 Pain Management & Palliative Care Pain management in prostate cancer patients cancer patients in management prostate Pain Prostate cancer LOCAL SPINAL CORD METASTASES IMPAIRMENT COMPRESSION • Soft tissue invasion • Document number and location • Bladder outlet obstruction (scintigraphy) • Ureteric obstruction Start iv dexamethasone • Start hormone therapy (and • Lymphoedema 8 mg/12 hours analgesics if painful, see • Ileus addendum) • Hematuria Pain Management & Palliative Care Multiple painful Paraplegia < 48h Paraplegia > 48h Single painful lesions Act accordinlgy lesions Life expectancy > 3 months Life expectancy < 3 months • Drain, insert catheter • Stockings • Treat constipation or obstructive ileus (if present) • Palliative hormonal therapy Consider limited field Consider radioisotopes Consider decompressive surgery Consider radiotherapy radiotherapy If pain persists, consider bisphosphonates/denosumab 263 Prostate cancer pain management Recommendations LE GR Systemic pain management WHO analgesic ladder step 1: NSAID or para- 1a A cetamol Opioid administration Opioids use (see Cancer pain treatment in 1a A urology) Access to breakthrough analgesia 1b A Tricyclic antidepressant and/or anticonvulsant 1a A in case of neuropathic pain Pain due to painful or unstable bony metastases (single lesions) External beam irradiation 1b A Pain due to painful bony metastases (widespread, opioid refractory) Radioisotopes (89Sr or 153Sm-EDTMP) 2 B Bisphosphonates 1b A Denosumab 1b A 264 Pain Management & Palliative Care Pain management in bladder cancer patients Bladder cancer LOCAL METASTASES IMPAIRMENT • Bladder outlet obstruction Document number and location • Ureteric obstruction (scintigraphy) • Bowel invasion • Soft tissue invasion • Act accordingly (TURBT, insert catheter or percutaneous Single lesions Multiple lesions nephrostomy, treat obstructive ileus if present) • Consider pallative pelvic exenteration for selected cases of advanced disease • Consider chemotherapy for selected cases of advanced disease • Consider local radiotherapy for selected cases of advanced disease Consider single-fraction • Consider hemi-body irradation radiotherapy • Consider radioisotopes Pain management in upper urinary tract cancer patients Upper urinary tract cancer Local impairment Bone metastases Document number and location • Ureteric obstruction (scintigraphy) • Invasion of surrounding areas • Soft tissue invasion • Nephroureterectomy Single lesions Multiple lesions • Consider extended operations (nephroureterectomy+bowel/ spleen/abdominal wall muscle resection) for selected cases of advanced disease • Consider chemotherapy for locally advanced and/or metastatic cancer Consider single-fraction • Consider hemi-body irradation radiotherapy • Consider radioisotopes Pain Management & Palliative Care 265 Transitional cell carcinoma pain management Recommendations LE GR Always disclose bladder outlet obstruction as - GCP source of local pain In locally advanced bladder cancer, palliative 3 B cystectomy or exenteration might be an option for symptom relief. Use radiotherapy to reduce pain and symptoms 1a B of locally advanced bladder cancer. Use radiotherapy to reduce pain due to bone 1b A metastases. Pain management in renal cell carcinoma patients Renal cell carcinoma Local impairment Metastases • Ureteric obstruction Document number and location • Invasion of surrounding areas (scintigraphy) (posterior abdominal wall, nerve roots, bowel, spleen, liver) • Soft tissue invasion Bone Brain • Nephrectomy • Consider extended operations (nephroureterectomy+bowel/spleen/ abdominal/wall muscle resection) for selected cases of painful advanced disease • Consider radiotherapy Consider radiosurgery • Consider radioisotopes 266 Pain Management & Palliative Care Renal cell carcinoma pain management Recommendations GR Obstruction of the upper urinary tract due to haem- GCP orrhage and subsequent formation of blood clots is effectively treated by radical nephrectomy in non- metastatic tumour. If the patient is physically fit for surgery, this should be GCP done to increase the QoL, e.g., palliative nephrectomy in cases of metastatic tumour. GCP = good clinical practice. Pain management in patients with adrenal carcinoma Pain management in patients with malignant pheochromocytoma Malignant pheochromocytoma Soft tissue and/or bone metastases Consider palliative 131I-MIBG Symptomatic treatment radiotherapy Pain Management & Palliative Care 267 Pain management in patients with adrenocortical carcinomas Adrenocortical carcinoma Soft tissue and/or bone metastases Consider palliative Symptomatic treatment radiotherapy Adrenal carcinoma Recommendations malignant phaeochromo- LE GR cytoma 131I-MIBG may reduce pain 2b B Radiation therapy can induce partial remission 3 C Recommendations adrenocortical carcinoma Surgical removal of the primary tumour and 3 C local lymph nodes can decrease pain Radiotherapy can be effective for palliation and 2b B pain management 268 Pain Management & Palliative Care Pain management in penile cancer patients Penile cancer Pain in early stages: disclose voiding dysfunction secondary to invasion of corpus spongiosum Pain due to Pain due to local impairment Pain due to metastases lymphoedema • Bladder outlet obstruction Consider partial/total penectomy • Ureteric obstruction Wraps, pressure stockings or approach with a multimodal regimen: • Bowel invasion pneumatic pumps chemotherapy, • Soft tissue invasion radiotherapy and surgical resection • Act accordingly (TURP, insert If erosion of femoral vessels is catheter or percutaneous anticipated, insert prophylactic nephrostomy, treat obstructive ileus endoluminal vascular stent if present) • Consider palliative pelvic exenteration under certain circumstances Penile cancer pain management Recommendations LE GR Advanced penile cancer must be approached 2b B with a multimodal treatment regimen that includes neoadjuvant chemotherapy, radiother- apy and surgical resection Radiotherapy might decrease pain from fixed 3 C nodes and bone metastases Pain Management & Palliative Care 269 Pain management in testicular cancer patients Testicular cancer pain management Testicular cancer Pain due to local impairment Pain due to metastases • Chemotherapy regimes + analgesia Orchiectomy • Consider ureteral stenting or percutaneous nephrostomy if hydronephrosis • Consider urgent spinal cord decompression if vertebral metastases and neurological symptoms Recommendations LE GR Systemic chemotherapy is effective for the back 2b B or flank pain due to retroperitoneal lymphaden- opathy Back pain and neurological symptoms due to 3 C spinal cord compression may require urgent surgery 270 Pain Management & Palliative Care PAIN MANAGEMENT AFTER UROLOGICAL OPERATIONS Postoperative pain management Acute postoperative pain Exclude medical/surgical emergency Refer to appropriate level of treatment Access pain level Mild (VAS score 1-3) Moderate (VAS score 4-6) Severe (VAS score 7-10) (SWL, transurethral,
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