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Written by

Dr Eva Masel Dr Eva Masel is from the Division of Palliative Medicine, Medical University of Vienna, Vienna, Austria

Professor Tony O'Brien Professor Tony O’Brien is a consultant physician in palliative medicine at Marymount University Hospice and Cork University Hospital, Ireland

Dr Eberhard A Lux Dr Eberhard Lux is from the Klinik für Schmerz- und Palliativmedizin, Klinikum St Marien Hospital, Lünen, Germany

Pain treatment in a cancer patient suffering from cachexia

Published 18 October 2017

Palliative care, including pain control at the end of life, requires an individualised approach in a cachexic patient with advanced lung cancer, explains Dr Eva Masel. With case reviews by Professor Tony O'Brien and Dr Eberhard Lux

Key learning points

  • The prevalence of pain in patients with all types of cancer is reported to be >50%, highlighting cancer pain as a common problem.
  • Adequate pain management must be based on the individual patient’s medical history as well as on clinical impression.
  • Opioids are used alone or together with non-opioids to treat moderate to severe pain.
  • Hydromorphone (Palladone®*) is a potent opioid analgesic that facilitates administration also of high oral opioid doses.

Background

Pain occurs in up to 70% of patients suffering from advanced cancer and those at the end of life; as a consequence, significant symptom relief is essential.1,2 Suboptimal pain control can be debilitating and lead to great distress; however, much can be done medically to improve quality of life in the form of appropriate pain treatment. In patients with refractory pain, intrathecal or spinal analgesia can be used to achieve analgesia in patients whose prior treatment has been unsuccessful, however, further studies are required to support this procedure.3,4 Hydromorphone is a potent analgesic and its adverse effect profile is similar to that of other mu-opioid receptor agonists.5,6 Here we present the case of a patient with advanced lung cancer and severe cancer pain successfully treated with oral hydromorphone.

Case assessment

A 42-year-old male patient was admitted to the palliative care unit. He had had stage IV small cell lung cancer for six months and had been diagnosed with multiple metastases to the lung and bone. The patient had received radiotherapy and two cycles of chemotherapy consisting of carboplatin and etoposide. Chemotherapy had to be discontinued because the patient had developed an episode of severe neutropenic fever. In view of a deteriorated performance status and high symptom burden (Figure 1), a transfer to the palliative care unit was discussed with the patient, to which he agreed.

Figure 1. Symptom severity

Symptom severity

On admission, the patient presented with diffuse bone pain, cachexia, chemotherapy-induced peripheral polyneuropathy and weight loss. The patient received continuous oxygen therapy and reported no dyspnoea. Pre-existing illnesses were arterial hypertension, chronic renal failure and type 2 diabetes. Pain therapy consisted of transdermal fentanyl 75 microgram/hour. Co-analgesics were dexamethasone, metamizole and pregabalin as well as denosumab for bone protection. Clinical examination revealed severe low back pain ranging from 6 to 8 on a numeric rating scale (NRS). Pathological fracture and neurological impairment were excluded.

NSAID treatment was not possible due to chronic kidney disease. Due to its high lipid solubility, absorption of transdermal fentanyl is reported to be impaired in cachectic cancer patients compared with those of normal weight,7 although large studies on this topic are lacking.

If opioid malabsorption is present, modifications to pain therapy must be carried out carefully because converting to equivalent doses can lead to overdose. Treatment was switched from transdermal fentanyl 75 microgram/hour to sustained-release hydromorphone capsules 8mg twice daily. Immediate-release hydromorphone (2.6mg) was prescribed for episodes of breakthrough pain.8 Co-analgesics were continued as previously prescribed. Therapy was well-tolerated and led to improvement of pain, resulting in NRS score of 2. Parenteral nutrition and physical therapy were started due to cancer cachexia.

During the hospital stay, the patient gained weight, his performance status improved and he was able to be discharged home after two weeks. Parenteral home nutrition and home oxygen treatment were organised, along with care by a mobile palliative care team.

The patient was seen in the palliative care outpatient clinic after two weeks, where the dosage of hydromorphone was increased to sustained-release hydromorphone capsules 16mg twice daily. After that, the patient continued to have adequate pain control. He continued to be cared for by a mobile palliative care team and died at home two months later.

Discussion

According to European Association for Palliative Care guidelines, there is evidence to support the efficacy and tolerability of hydromorphone for moderate to severe cancer pain*.8 It is reported to have similar efficacy for neuropathic and nociceptive pain.9 In this lung cancer patient with cachexia, the pain was well controlled after switching pain therapy from a fentanyl transdermal system to sustained-release oral hydromorphone twice daily.
  • Dr Eva Masel is from the Division of Palliative Medicine, Medical University of Vienna, Vienna, Austria
*Palladone® (hydromorphone) is licensed for the relief of severe pain in cancer. UK prescribing information can be found via link below.

Case review: Ireland

Professor Tony O’Brien

Consultant physician in palliative medicine at Marymount University Hospice and Cork University Hospital, Ireland

This case highlights many of the challenges commonly encountered when caring for a metastatic cancer patient with multiple co-morbidities. The frequently encountered combination of diabetes mellitus and chronic kidney disease will inform treatment choices particularly in respect of NSAID, steroid, anticonvulsant and opioid use. NSAIDs must ordinarily be avoided in such circumstances and steroid use in a diabetic patient requires close surveillance of blood glucose. The risk of blood dyscrasias and acute kidney injury is recognised in patients treated with metamizole and should prompt caution in a patient with chronic kidney disease who may be undergoing chemotherapy.1

Transdermal fentanyl 75 microgram/hour failed to provide adequate analgesia, although we are not advised if the patient manifested features of toxicity. In terms of the reported ‘low back pain’, consideration might be given to the role of palliative radiotherapy. Opioid switching is a well-established practice and certainly hydromorphone was a very reasonable and rational choice in this instance.2 The initial dose of 8mg twice daily represents a net dose reduction of approximately 33%, which is important in terms of the phenomenon of incomplete cross tolerance.  

By optimising pain and symptom management, the patient achieved and maintained an optimal quality of life and was cared for in the setting of his choice.

References

  1. Redondo-Pechon MD, Enriquez R, et al. Saudi Journal of Kidney Diseases and Transplantation 2014;25:121–125.
  2. Caraceni A, Hanks G, et al. The Lancet Oncology 2012;13(2):e58–68.

Case review: Germany

Dr Eberhard Lux

Klinik für Schmerz- und Palliativmedizin, Klinikum St Marien Hospital, Lünen, Germany

This case report describes a typical patient suffering not only a complex pain syndrome but also other symptoms including cachexia and dyspnoea, all impacting on social and emotional wellbeing. Pain was managed with non-opioids, opioids and an antiepileptic drug, based on the WHO treatment ladder;1 however, the result was dissatisfying.

Switching the fentanyl patch to hydromorphone would have been my recommendation in this case, as the adherence and absorption of opioids from patches in cachexic patients is often insufficient. The 75 microgram/hour fentanyl patch correlates to approximately 180mg oral morphine and 22.5mg oral hydromorphone; in this case, I think the dosage of hydromorphine was a little too low, amounting to an approximately 30% reduction in dosage (using a 1:8 ratio) once the switchover took place. The inclusion of hydromorphone immediate release 2.6mg meant that the patient was able to titrate the dose to meet his requirements (ultimately, 16mg twice daily). The patient suffered episodes of breakthrough, spontaneous or incident pain, and a sublingual tablet may have been useful in this case due to rapid onset of action.2

In this case the nutrition was insufficient due to lack of appetite but swallowing was not affected. Parenteral nutrition can be associated with infection, immobilisation, dependence and these aspects should always discussed before initiation.

References

  1. World Health Organization. WHO's cancer pain ladder for adults. Available at: www.who.int/cancer/palliative/painladder/en/ (accessed October 1 2015).
  2. Caraceni A, Hanks G, et al. The Lancet Oncology 2012;13(2):e58–68.

Date of preparation: October 2017; MINT/PAEU-15030