Pedoman PenatalaksanaanNyeri Kanker

A. Husni Tanra

Universitas Hasanuddin

Fakultas Kedokteran, Bagian Ilmu AnestesiKetua Program Studi Sp2 Ilmu Anestesi

Makassar

Dibawakan pada acara Simposium dan Workshop “ Mewujudkan Bebas Nyeri Kanker 2020” Di RS Kanker “Dharmais” Jakarta, 2 November 2017

Objectives :

• What is Cancer pain ?

• Cancer pain assessment

• Cancer pain management using WHO 3 step ladder

• Available opioid in Indonesia.

• Clossing

What is cancer pain?

Just as Cancer is not 1 disease

Cancer Pain is not 1 entity

What is Cancer Pain? (Introduced by Dr. Cicely Saunders 1967)

‘TOTAL PAIN’

is the sum of 4 components:

1. Physical noxious stimuli

2. Emotional discomfort

3. Interpersonal conflicts

4. Nonacceptance

PHYSICAL DISTRESSS

SOCIAL DISTRESS

EMOTIONAL DISTRESS

SPIRITUAL DISTRESS

(Biopsychosociospiritul Disesase)

Paracetamol adjuvants

Weak Opioid for mild to moderate

pain

Paracetamol adjuvants

Strong Opioid for severe pain(Morphine)

Celecoxib adjuvants

Increasing pain

Three step ladder WHO

Multidisciplinary Approach

INTEGRATION OF OTHER INTERVENTIONS TO THE WHO LADDER

Of all the symptoms caused by

Cancer

PAIN is the most feared

Pain so severe that it crushes the human spirit

Orang India

Orang barat

Orang Indonesia

Etiology of cancer pain

Major sources of pain:

Cancer-related 93%

Therapy-related 21%

Coincidental causes 2%

Carenceni & Portenoy Pain 82:263-274, 1999

Causes of Cancer pain• CANCER RELATED

Causes of Cancer pain CANCER RELATED

Causes of Cancer pain cancer related

Pain in the Cancer Patient

Due to cancer treatment:

Cancer surgery – post-mastectomy,

post-thoracotomy pain

Chemotherapy – peripheral neuropathy

enterocolitis

Radiation therapy - mucositis, dermatitis

post-radiation fibrosis

Treatment related

Post mastectomy

Phantom pain

Pain in the scar

Pain in the arm

DUE TO CANCER SURGERY

Treatment related • FROM CHEMOTHERAPY

Treatment related • RADIATION THERAPY

COBALT RADIATION BURN

Pain in the Cancer Patient

Non related to cancer:

Herpes zoster ( acute or chronic)

Mucositis

Osteo arthritis

Musculoskeletal pain

Etc.

Non related to Cancer

Acute Herpes Zoster

Non related to Cancer

• OTHER FACTORS-Immunocompromisedstate

Non related to Cancer

Mucositis

Non related to cancerDUE TO OSTEOARTHRITIS

Kanker dan nyerinya

1/5 yang hanya 1 nyerinya

4/5 yang memiliki 2 atau lebih

1/3 memiliki 4 atau lebih nyeri

Nyeri kanker bukan hanya satu.

Key success in cancer pain management is

• Evaluasi dan asesmen yang berulang-ulang “With attention to detail”

• Assessment- Treatment and Reassessment.

• At least once a day.

Kenapa nyeri harus di ases sebelumdiobati?

• Karena nyeri itu adalah simptom/penyakit yang tidak bisa dilihat (Pain is invisible disease).

• You must believe what ever patient says.

• Tujuan utama dari Asesmen nyeri adalah meng-visualisasikan nyeri serta mengdiagnosenya:

A. Jenis nyerinya (type of Pain).

B. Intensitas nyerinya (intensity of pain)

A. Jenis nyeri kanker

1. Nyeri nosiseptif

• Nyeri somatik

• Nyeri Viseral

2. Nyeri neuropatik

3. Gabungan keduanya (mixed pain)4. Breakthrough pain

Incident pain

End of dose failure

Around-the-ClockMedication

Breakthrough pain

Over Medication

Breakthrough Pain

1. Nyeri Nosiseptif

• Nyeri konstan• Tajam• Lokalisasinya jelas• Sakit kalau digerakkan

Contohnya Nyeri tulang karena

metastase. Kerusakan jaringan lunak Dinding torak

Nyeri Somatik nosiseptif

1. Nyeri Nosiseptif

• Nyeri konstan• Terasa kram• Lokalisasinya tdk jelas • Kadang ada nyeri rifer

Contohnya– Karsinoma pangkreas – Hepatoma, setelah kapsunya

meregang.– Obstruksi usus (kolorektal)

Nyeri viseral nosiseptif

2. Nyeri Neuropatik

• Nyeri neuropatik adalah nyeri akibat adanyakerusakan , lesi atau disfunsi dari SS sarafperifer atau sentral.

• Umumnya pasien menyatakannya sebagainyeri yang lain dari biasanya.

• Paling sering drasakan sebagai nyeri yang terbakar, seperti memegang es, kontak listrikatau seperti tertusuk-tusuk.

Burning, feeling like the feet are on fire

Stabbing, like sharp knives Lancinating, like electric shocks

Freezing, like the feet are on ice,

although they feel warm to touch

Modified by Meliala 2006

B. Intensitas Nyeri Kanker

B. Intensitas Nyeri

None Mild Moderate Severe

Faces

Numerical

Categorical

No Pain

Ruler Scale

• Valid up to now more than 30 years ago.

• First Multimodal-Analgesia application.

• MA was first initiated by Henrik Kehlet 1993

• “Opioid Sparing effect” has not yet well known.

1986

1. World Health Organization. Cancer pain relief: with a guide to opioid availability. 2nd ed. Geneva:The Organization;1996.2. National Comprehensive Cancer Network (NCCN) GuidelinesTM Ver. 2.2011: Adult Cancer Pain

Pain management:WHO 3 steps ladder vs NCCN 2 steps Guidelines

WHO 1986NCCN 2011

What ever the Ladder do you use, WHO or NCCN

5 essential concepts,

must be apllied:

1. By mouth

2. By the clock

3. By the ladder

4. By individual

5. With attention to detail .

By this pharmacotherapy about 90% of cancer pain can be relieved

Analgesics for cancer pain should be given1

By the mouthBy the clock

By the ladderFor the individualWith attention to detail

1.World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability. World Health Organization; 1996.

Dr. Res. Anestesi, menerangkan tentang By the Clock.

Successive change

By the Ladder

Strong opioids

Step IIIFor moderate to severe pain,

Strong Opioid analgesics

± Non-opioid analgesics

± adjuvant analgesics

APAP/NSAIDs ± adjuvant analgesics

Step INon-opioid analgesics

± adjuvant analgesics

APAP/NSAIDs ± adjuvant analgesics

For mild to moderate pain,

Mild Opioid analgesics

Codeine or

Tramadol

Step II

± Non-opioid analgesics

± adjuvant analgesics

Pain

Pain

Pain

level

Paracetamol = APAP(Acetyl Para Amino Phenol)Courtesy by Dr. S. HattoriCancer Institute Hospital in Tokyo

Seiji Hattori

With attention to detailWe need to do careful comprehensive assessment and reassessment.Why? Cancer pain is dynamic porgressive pain specially at end life

Principles of Analgesic Prescribing

WHO Analgesic Ladder 1986 By this pharmacotherapy

about 90% of cancer pain can be relieved.

• Paracetamol

• NSAID or COXIB

•Adjuvants

• Paracetamol• NSAID or COXIB

•Weak Opioid(Codeine,or Tramadol)

•Adjuvants

• Paracetamol•NSAID or COXIB

•Strong Opioid(Morphine, Fentanyl, HydromorphonOxycodone)

•Adjuvants

STEP 1

STEP 2

STEP 3

Cancer Pain

NSAIDs,Adjuvant drugs

OpioidsPO・Trans dermal

NeurolysisInterventions by IVR

Opioid Injections（PCA)

SC・IV・Epidural・Intrathecal

Radiation, Rehabilitation, Bisphosphonates,

Fentanyl patch

OxycodoneMorphine

JMS i-fuosr PLUS

Only 10% need intervention pain management

AnalgesikNon-opioid, Opioid dan Ajuvan

• “Opioid “

(Kerja sentral)– Opioid Kuat– Opioid lemah (taramadol,

Ckodein)

• Adjuvants– Antidepressants– Anticonvulsants– Gabapentinoid– 2 agonist– Local Anesthestics– Ketamin

“ Non-Opioid ”(Kerja perifer)

• Parasetamol

• NSAIDs

• COX-2

1. Non-Opioid Paracetamol

• Paling aman asal tidak lebih 4 g/24 jam

• Bisa dikombinasi dengan NSAID atau COXIB.

NSAID non-selektif• Ibuprofen atau Ketoprofen• Paling lemah efek sampingnya

COXIB • Celecoxib• Yang paling aman dari yang ada.

!!! Kalau menggunakan Steroid jangan dikombinasi dengan NSAID atau COXIB

IbuprofenKetoprofen

DiclofenacMeloxicamNimesulide

CelecoxibRofecoxibValdecoxib

AcetosalKetorolac

IndomethacinPiroxicam

non-selective

COXinhibitor

preferentially

COX-2selectiveinhibitor

COX-2selectiveinhibitor

COX-1selectiveinhibitor

preferentially

COX-1selectiveinhibitor

COXIB

analgesic

anti-inflammatory

Less GI side effects

More GI side effects

NSAID Non-Selective vs COXIB

What is Opioid?

2. OpioidSenyawa yang biasa besifat agonis terhadap and K

reseptor

Opioid Lemah(agonis parsial)

• Kodein

• Tramadol

Opioid Kuat(agonis penuh)

1. Morphine tab IR atau Syrup IR MST continus tablet

2. Fentanyl iv, patch (transdermal) once in 3days

3. Hydromorphone tab once daily.

4. Oxycodone• tab IR, CR. and iv. .

1. Codeine Phosphate• Merupakan opioid lemah yang alami

• Memiliki kekuatan 1/10 dari Morfin

• Hasil metabolik melalui major pathway: Codeine-6-glucuronide

(merupakan parent drug yang memiliki efek analgesik minimal.)

• 2-10% diubah menjadi Morfin via minor pathway tapi menghasilkan

penyumbang analgesik utama dari kodein.

• 9% Caucasians lacked P450 cytochrome isoenzyme

• Bioavailability: 40% PO

• Onset of action: 30-60 min for analgesia

• Dose: 30-60mg q4h + paracetamol

• Very constipating, mild nausea and vomiting

2. Tramadol• Merupakan opioid lemah yang sintetis yang kekuatannya 1/10 Morfin

• Menghabat re-uptake baik nor-adrenaline maupun serotonin.

• Dimetabolik di hati menjadi O-demethyltramadol yang kekuatannya2-4X lebih poten dari tramadol sendiri.

• Bioavailability: 75% PO

• Onset of action: 30min

• 50-100 mg q6H, maximum 400mg /day

• High nausea/vomiting; less constipating

• Cautions: epilepsy, raised ICP, severe renal or liver impairment, in patients taking medication that lower seizure thresholds eg. TCA and SSRI

3. Morphine

• “Natural opioid”

• “Gold standard” for opioid agonist

• Widely available in multiple forms: oral pill and liquid, pills, parenteral

• Histamine relies

• Hydrophilic

4. FentanylRoutes of Administration I.v and transdermal

• Lipophilic tinggi

• iv Rapid onset 3’ duration 30-45 ‘

• Transdermal duration of action 72 transdermal

• 80 – 85% plasma protein bound

• 90 % metabolized in the liver to inactive metabolites

Other properties

100 X potensi analgesiknya dengan morfin

10 X potensi analgesiknya dengan hydromorphone

*high efficacy for mu 1 receptors.

*most effective opiate analgesic

Fentanyl

• Indication of Fentanyl :

morphine intolerance

renal failure

bowel obstruction

• Transdermal patches: 25, 50, 75, 100 mcg/hr

• 25 mcg/hr = 60 – 90 mg po morphine

• Slow onset 16-24 hours to peak analgesia, so additional

analgesia required at first and offset 12-24 hours

• Patches should not be used in opioid naïve patient

5. Hydromorphone

• Synthetic “sister” of morphine

• Potency is 5 X morphine

• Widely available in multiple forms: available in

Indonesia long acting form, once daily.

• More rapid onset and shorter half life

• Less histamine release than morphine

• Hydrophilic

6. Oxycodone

• Semi-Synthetic opioid from thebaine, is the “cousin” to morphine

• Act on both in mu and kappa receptors

• Bioavailability 60 -87 % compare to Morphine only 15-40 %.

• Oxycodone has 45 % protein binding

• Potency is 1.5-2X morphine

• Available in Indonesia tab IR and iv, include long acting Tab CR q 12h.

Dialemma Opioid di Indonesia

• Semua opioid long acting yang slow release yang harganya lebih mahal, tersedia di kota-kota besar.

• Tapi opioid short acting yang Immediate release yang harganya murah justru tidak, yang merupakan fondasi untuk titrasi.

• Opioid adalah obat yang harus diberi secara titrasi.

Opioid apa yang dibutuhkan di Indonesia untuk mengatasi nyeri

kanker?

Morphine IR (Immediate Release)

Liquid (syrup) or

Tablet

Morphine for free for cancer patient

Adjuvant Drugs

• Steroid (dexamethason)

• Antidepressant (tricyclic)

• Anticonvulsant (gabapentin&pregabaline)

• 2 agonist (Clonidine)

• Local Anesthetic.

• Ketamine ( Good and useful for end life cancer pain patint)

She was so exhausted and very depressed

She die after taking care for more than 2 years

Clossing• By 3 step ladder WHO cancer

pain management, 90 % of cancer pain can be relief.

• Since cancer patients cannot be cured, our main task is to let them die free of pain with Iman.

SEKIAN

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