Non-Pain Symptom Management March 2012

Transcription

1 TXNMHO / TAPM Annual Convention March Ronald J Crossno, MD FAAHPM Chief Medical Officer, Kindred at Home (formerly Gentiva) ronald.crossno@gentiva.com Disclosures No relevant financial disclosures Off-Label indication is entered on slides as OL Identify common non-pain symptoms encountered in the hospice setting, including dyspnea, nausea, anxiety, and fatigue Describe the choice of appropriate therapeutic interventions to address these symptoms R J Crossno, MD 1

2 70-yo female living at home Diagnoses COPD, CAD, CHF, PVD Continued tobacco use Functional PPS 50% / cognitively intact (with oxygen on) Structural Dyspnea with any exertion & sometimes at rest rated up to 7 on the Borg scale Occasional angina; 2+ pedal edema; BMI = 17; SaO 2 = 84% on room air Current COPD meds / txs include 2L/m, prn Duoneb treatments every 4h as needed Xopenex neb twice daily Advair 1 inh twice daily Serevent 1 inh twice daily Spiriva 1 inh twice daily Combivent MDI 2 puffs twice daily Singulair daily What are your thoughts about these? Current cardiac meds Digoxin 0.25mg daily Lisinopril (Prinivil ) 40mg daily Carvedilol (Coreg )12.5mg twice daily Aspirin 325mg twice daily Valsartan ER (Diovan ) 160mg daily Isosorbide mononitrate (Imdur ) 60mg daily Furosemide (Lasix ) 80mg daily What are your thoughts about these? R J Crossno, MD 2

3 Central & peripheral chemoreceptors Some report severe dyspnea despite normal ABGs Some patients with severely abnormal ABGs are not burdened by breathlessness Mechanical receptors in chest wall & respiratory muscles Sense airflow obstruction and low lung volumes Vagal receptors in the airways & lungs Sense airflow obstruction and low lung volumes Extra-thoracic receptors on the face & in the CNS Persistent dyspnea despite maximal medical management of the underlying disease Breathlessness is defined by the patient Symptom distress is defined by the patient Independent of underlying etiology Therapies are general (global), not disease-specific Abernethy AP, et al BMJ 2003;327(7414): R J Crossno, MD 3

4 Focus on identifying and addressing underlying cause if possible Focus on What dyspnea means to the resident in relationship to their underlying illness Its effect on activities of daily living Concerns regarding possible treatment modalities, such as opioids or oxygen. Focus on psychological and spiritual distress Physical Psychological TOTAL DYSPNEA Social Spiritual Improved sensation of breathlessness Based on 9 crossover trials mainly in COPD patients. Central and peripheral action Relief not related to respiratory rate No significant change in O2 sats Survival time is unrelated to opioid administration Low doses are proven safe Higher dose opioids may mortality risk Nebulized opioids are no better than placebo No ethical or professional barriers J Pain Symptom Manage 1999;17(4): BMJ 2003;327(7414): BMJ 2014;348:g445. R J Crossno, MD 4

5 Not really effective Recent Cochrane review encompassing 200 individuals with advanced cancer or COPD no beneficial effect on the relief of dyspnea in patients slight, nonsignificant trend toward benefit Do mortality rates! Consider as a second-line or third-line treatment for refractory dyspnea associated with anxiety BMJ 2014;348:g445. Potent symbol of medical care Expensive Fan may do just as well RCT of O2 vs room air Randomized, double-blind, multicenter trial Non-hypoxic residents with life-limiting illness Oxygen delivery compared with room air by NC No additional symptomatic benefit for relief of refractory dyspnea Lancet 2010;376(9743): Fan Breathlessness Clinics Psychosocial support to alleviate anxiety/distress Positioning and pursed lip breathing Relaxation techniques (e.g. massage, guided imagery) Discuss symptom management with family to alleviate concerns (e.g., opioids at low doses do not hasten death) R J Crossno, MD 5

6 From Dyspnea Review for the Palliative Care Professional: Treatment Goals and Therapeutic Options, J Pall Med, 15(1), Her medications were reviewed Non-beneficial medications were discontinued Duplicative medications were eliminated / consolidated Meds for symptoms started upon hospice admission Morphine 5mg q 4h prn dyspnea was started and titrated as needed Oxygen started at 1.5L/m continuously Nitroglycerin 0.4mg SL q 5m prn angina, max 3/h APAP 650mg every 4h prn minor/musculoskeletal pain Non-pharmacologic measures Fan in room Hospice aides to help with ADLs SCC and SW to help assess/counsel regarding anxiety-inducing concerns Optimize disease-directed treatments Opioids are the mainstay of dyspnea management when other, definitive treatments are no longer effective Oxygen may help for dyspnea associated with hypoxemia Non-pharmacologic techniques are always worth trying Goals of care must be considered Never assume that interventions are always benign Sometimes our treatments may hasten death Try to anticipate what has a reasonable likelihood of happening, such as a respiratory crisis with severe pulmonary disease Ensure there is a plan in place to manage such crises R J Crossno, MD 6

7 31-yo M financial consultant Diagnoses HIV-AIDS, Visceral Kaposi s sarcoma, wasting syndrome Function PPS = 40% / FAST = 4 Structural BMI = 17 c/o pain, currently controlled with oxycodone c/o nausea, uncontrolled with meds; last BM 2 days ago with normal bowel sounds Has been unable to take HAART meds due to the gastrointestinal upset Current GI meds include Promethazine 25mg every 4h prn Prochlorperazine 10mg every 6h prn Ondansetron 8mg every 4h prn Other meds Oxycodone ER 80mg every 12h Oxycodone conc. 10mg every 2h prn BTP Lorazepam 1mg 3x daily and every 4h prn Key Anatomic Sites Important Receptors Evaluation Management R J Crossno, MD 7

8 From Basic & Clinical Pharmacology, 11th Ed (Fig 62-6), by Katzung BG, Masters SB, Trevor AJ, 2008, Philadelphia, PA: McGraw-Hill. Muscarinic Acetylcholine M1 Vestibular Dopamine D2 CTZ Histamine H1 Vestibular and Vomiting Center (VC) 5-Hydroxytryptamine 5-HT 3 (serotonin) GI, Chemoreceptor Trigger Zone (CTZ), VC Neurokinin 1 (a.k.a. Substance P) CTZ, VC Toxins Metabolic Derangement Enteral Dysfunction Hypo-kinetic Obstructive Vestibular Dysfunction Cortical R J Crossno, MD 8

9 Toxins Drugs Other Exposures Metabolic Derangement Uremia Hepatic Dysfunction Hypercalcemia Enteric Dysfunction Bowel Pattern, Pain Change in symptoms with vomiting Constipation! Vestibular Dysfunction Vertigo Cortical Anxiety Focal symptoms, headache etc. Vitals and Volume Status Abdominal Exam Distention Hyper or Hypo-active bowel sounds Abnormal Masses, Ascites etc. Tenderness Neurologic Exam Rectal Exam (!!!) R J Crossno, MD 9

10 Renal Function Liver Function Tests Calcium Obstruction Series MRI or CT of Brain *Appropriate to Goals and Patient s Condition Etiology Vestibular CNS Disease Constipation Impaired GI motility Anxiety Post-chemo General Management H1 or M1 blockade Corticosteroids Stimulant laxative Prokinetic agent Anxiolytics 5-HT 3 or NK-1 blockade D2 blockade Vestibular (H1 or M1 Blockade) Meclizine OL 25 to 50 mg PO TID Scopolamine via Patch, IV or SC CNS Disease Dexamethasone 8 to 16 mg PO, IV, SC Constipation Senna 2 tabs PO one to three times/day Methylnaltrexone 8 to 12 mg SC QOD for refractory cases Impaired GI motility (Prokinetic Agents) Metoclopramide 10 mg PO/IV AC TID + HS R J Crossno, MD 10

11 Anxiety (Anxiolytics) Lorazepam OL 0.5 to 2 mg PO/IV Q 4-6 hours Post Chemo (5-HT 3 and NK1) Ondansetron - variable dosing (4 to 32 mg) Granisetron 1 mg PO Q 12 hours Aprepitant 125mg day 1, then 80 mg day 2, 3 General (D2 Blockade) Haloperidol OL 0.5 to 1 mg PO, IV, SC Prochlorperazine 5 to 10 mg PO QID or 25 mg PR BID Frequent, small feedings Remove foods with unpleasant smells or visual appearance Serve meals in pleasant, comfortable surroundings Consider alternative therapies Guided imagery has the most data showing efficacy He is admitted to hospice Exam fails to reveal acute findings other than some constipation and general nausea Routine meds are started to help manage nausea Senna 2 po BID Haloperidol 1mg po BID Ondansetron is continued for prn usage These medications plus guided imagery are effective for nausea management R J Crossno, MD 11

12 Always rule-out impaction as a cause for nausea Be familiar with etiologies of nausea and use of various medications to cover different neuroreceptors involved in mediating nausea Combining meds that block other involved receptors may be needed Nonpharmacologic treatments may be helpful Topical gels for nausea are no more effective than placebo There are virtually no detectable blood levels of these drugs when administered topically 65-yo F former housekeeper living with her daughter Diagnosis ASHD, CHF Ongoing tobacco use Drinks 2 glasses of wine daily Functional PPS 50% / cognitively intact Structural BMI 35; NYHA IV At hospice admission, she c/o anxiety all the time Besides being on appropriate cardiac meds, she is taking Morphine for refractory pain is effective Lorazepam (Ativan ) 0.5mg TID routinely for anxiety What else do you need to know? What would you consider suggesting for management? R J Crossno, MD 12

13 Most common anxiety-related diagnoses Generalized Anxiety Disorder (GAD) Anxiety Secondary to a Medical Condition Medications that can cause or exacerbate anxiety Caffeine Steroids Nicotine Antidepressants, antipsychotics, stimulants Phenylephrine (Sudafed) Synthroid over-replacement Symptoms are common and distressing Significant anxiety symptoms 25-70% Subsyndromal PTSD 20-80% Often presents with somatic symptoms Tension or restlessness Jitteriness or autonomic hyperactivity Hypervigilance Insomnia Distractibility Worry, apprehension, rumination Shortness of breath Need to evaluate carefully for medical causes such as pain and dyspnea Often looks like GAD but can include panic attacks Actual underlying anxiety disorder Fear of death and the dying process Spiritual or existential concerns Chronic coping or personality style Medication side effects (akathisia from anti-emetics) Undertreated symptoms (pain, dyspnea, sepsis) Withdrawal states (sedatives, opioids) Delirium Anticipatory response to repeated aversive treatment (chemo) R J Crossno, MD 13

14 Explore fears/concerns in non-judgmental fashion Listen, acknowledge, normalize, remain available Reassurance not usually effective Can make highly anxious pts more anxious Supportive-expressive therapy Aims to reduce symptoms & maintain coping (not cure) Consider psychiatric referral Music Therapy Relaxation/ Guided Imagery/ Hypnosis Mindfulness Based Stress Reduction (MBSR) Psychotherapy Cognitive behavioral therapy Interpersonal therapy (IPT) grief work Antidepressants if life expectancy >8 weeks SSRI s Sertraline (Zoloft ) mg qd Citalopram OL (Celexa ) mg qd Escitalopram (Lexapro ) 5-20mg qd Mirtazapine OL (Remeron ) Also helps with sleep and appetite Antidepressants to avoid Paroxetine (Paxil ): anti-cholinergic and withdrawal Venlafaxine (Effexor ): withdrawal Bupropion (Wellbutrin ): seizure risk Start low and go slow to avoid increasing anxiety R J Crossno, MD 14

15 Benzodiazepines: drugs of choice at EOL Lorazepam (Ativan ) mg q4-6hrs prn Alprazolam (Xanax ) mg q4-6hrs prn Clonazepam (Klonopin ) for long-acting coverage Can cause sedation, confusion, tolerance, abuse, disinhibition, gait instability, falls, and increased risk of death Trazodone OL Sedating but can be given in low doses during the day ( mg q4hrs prn) Buspirone (BuSpar ) Should be scheduled, takes at least 4-6 weeks to see an effect ( mg BID-TID) Consider antipsychotics More sedating Chlorpromazine OL (Thorazine) mg q4hrs prn Olanzapine OL (Zyprexa) mg q 4hrs prn Quetiapine OL (Seroquel) mg q4hrs prn Less sedating Haloperidol OL (Haldol) mg q4hrs prn Risperidone OL (Risperdal) mg q4hrs prn Already on a benzodiazepine Sertraline 50mg daily is prescribed Encourage moderation of alcohol & tobacco intake Educate about Interactions between benzodiazepines and alcohol Adverse effects of alcohol and tobacco on anxiety Involve rest of IDG to offer possible nonpharmacological interventions Over the next 3 weeks, anxiety levels greatly improve R J Crossno, MD 15

16 Anxiety is a distressing symptom Benzodiazepines remains the drug of choice in EOL care But management involves more than just benzodiazepines SSRIs are very effective in managing anxiety if sufficient time for them to work Always consider Other modifiable causes of anxiety Offering non-pharmacological management 61 yo F librarian Diagnoses Breast cancer originally dx 8 yr ago Recurrent now with multiple bone mets Functional PPS 60% / cognitively intact Structural Several bone mets with pain better now, controlled with opioids and recent radiation therapy BMI 24, working 2 ½-days a week Oncologist referred to hospice One month after hospice admission, the patient begins to complain of increasing fatigue She wants to know what she can do for this She s been reading about various things on the internet What do you recommend to her R J Crossno, MD 16

17 Most common symptom in palliative care patients with cancer or other serious and/or life-threatening illness Definition Cancer-related fatigue is an unusual, persistent, subjective sense of tiredness related to cancer or cancer treatment, despite adequate rest, that interferes with usual functioning NCCN Guidelines Multiple scales for research use None in common practical use except linear analog scale Cut off for clinically significant fatigue No clearly defined demarcation Most suggest > 4 or 5 on a 1-10 scale R J Crossno, MD 17

18 Considered a multidimensional syndrome, often with multiple contributors, including Severity of psychological Sx s (e.g. anxiety / depression) Pain Sleep disturbances Dyspnea Anorexia Anemia Opioid use Various neuromodulators (cytokine dysregulation, HPA dysregulation, autonomic failure, drug interactions) Anemia transfusions and erythropoetic agents Deconditioning exercise Depression antidepressants Infections antibiotics Dehydration fluids Hypoxemia oxygen therapy Insomnia sleep hygiene Pain pain management (e.g. opioids) Metabolic / endocrine disorders correct problem Corticosteroids OL Megestrol acetate OL Thalidomide OL Methylphenidate OL Modafinil OL Melatonin OL L-carnitine OL Counseling Physical and occupational therapy R J Crossno, MD 18

19 Optimal dose and duration: unknown Mechanism: multiple proposed, but unknown Duration of benefit: unknown Still recommended as first-line if no contraindications Suggested dose: dexamethasone 8mg/d x 2 weeks Opioid-induced sedation Level 1 evidence for use in this Depression Hypoactive delirium Fatigue Some evidence for benefit and some showing no benefit Dose unclear, but suggest starting methylphenidate 5mg morning, then add 5mg mid-day Also no benefit with paroxetine or donepezil Evidence in literature for efficacy in managing CRF: Cognitive behavioral therapy Education Stress management groups Coping strategies training Availability may be limited for hospice patients with advanced disease Counseling of family to better understand what is happening also shown to have benefit R J Crossno, MD 19

20 She and her family are educated regarding Cancer Related Fatigue (CRF) She is started dexamethasone 8mg q am Sleep hygiene techniques are reviewed Zolpidem 5mg at bedtime, if unable to fall asleep within 20 minutes, is made available if needed She declines other psychological interventions at this time Fatigue is a very common symptoms May cause distress for our patients Education remains a mainstay of management Pharmacologic interventions have limited efficacy, but end up often being tried Know the facts regarding pharmacologic efficacy R J Crossno, MD 20