neuropathic agents in cancer pain: do they work? · chris kane consultant in palliative medicine...
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Neuropathic Agents in Cancer Pain:
Do They Work?Chris Kane
Consultant in Palliative Medicine
Sue Ryder Wheatfields Hospice
Leeds Teaching Hospitals NHS Trust
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• Tramadol NNT 4.7 NNH 12.6
• Opioids NNT 4.3 NNH 11.7
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• Rapid titration• Included a secondary analysis of neuropathic v nociceptive• NNT 25 NNH 6
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Overall conclusion
• Not enough evidence
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• Multicentre RCT
• Predominately post treatment neuropathic pain
• Previously failed other analgesic treatment
• No benefit and no increase in adverse outcomes
Fallon et al Jama oncology 04/2018
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Is that surprising?
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Antiepileptic and antidepressant drugs
• Pregabalin and Gabapentin • Quoted NNT ~ 4.2 -6.4
• SNRIs• Quoted 6.4
• Amitriptyline• Quoted 3.6
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• Systematic Review• Mainly cancer induced peripheral neuropathy
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Overall conclusion
• No evidence currently of benefit in cancer tumour pain
• Likely benefit in treatment associated pain
• Need more studies
• May be appropriate to try BUT review regularly
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Benzodiazepines
• GABAa receptor modulators
• Muscle relaxation
• Anxiolysis
• Clonazepam
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’For Pain relief there did not seem to be much difference between methadone and morphine’
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Methadone
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Evidence
• Consistently low quality
• Very difficult to draw strong conclusions
• Patient selection
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The Pain Paradox
Despite rating their pain as high patients continue to rate their satisfaction of their pain management as high
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Measurement
Nociception Interference
in daily living
Poor quality of life
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Factors Associated with High Satisfaction
• Physician stating importance of pain control
• Receiving instructions to manage pain at home
• Managing side effects
• Allaying fears about addiction
Dawson R, Spross JA, Jablonski ES, Hoyer DR, Sellers DE, Solomon MZ. Probing the paradox of patients' satisfaction with inadequate pain management. J Pain Symptom Manage. 2002 Mar;23(3):211-20
Reid CM, Gooberman-Hill R, Hanks GW. Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer. Ann Oncol 2008;19(1):44-8.
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What Happens in Real life?
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Pain
Nociception
Lack of knowledge and understanding
Poor coping and low expectations
Experience of pain‘intensity’
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Conclusions
Clinically
• Think
•Review
Research
• Time to think again about how we measure ‘Pain’
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Thank You