GUIDELINES FOR THE MANAGEMENT OF CANCER-RELATED NEUROPATHIC PAIN

Transcription

1 GUIDELINES FOR THE MANAGEMENT OF CANCER-RELATED NEUROPATHIC PAIN 28.1 GENERAL PRINCIPLES Neuropathic pain may be relieved in the majority of patients by multimodal management. 1, 2 A careful history and examination are essential. 1 Investigations such as computerised tomography (CT) or magnetic resonance imaging (MRI) may be appropriate. 2 It is important to have a logical and rational approach to prescribing. Chemotherapy or radiotherapy may be indicated if the tumour is chemosensitive or radiosensitive. 3, 4, 5, 6, 7 Non-pharmacological approaches should be considered including: transcutaneous electrical nerve stimulation (TENS); acupuncture; hydrotherapy and psychological interventions. 8, 9, 10 Interventional techniques may be indicated and should always be discussed at an early stage with an Anaesthetic Pain Specialist. 11, GUIDELINES The WHO analgesic ladder should be followed. 13 [ Level 2-] Strong opioids should be titrated against response. Adjuvants and non-opioids should be used as appropriate. 14 [Level 1-] The endpoint of titration is pain relief or intolerable side effects. If dose-limiting side effects occur despite the use of adjuvants or other interventions, a switch of opioid should be considered. 15 [Level 3] Figure 28.1 features a flow diagram which may be a useful guide for adjuvant prescribing in neuropathic pain. 16, 17 [ Level 1+] If nerve compression is suspected, a trial of corticosteroids should be considered e.g. dexamethasone 8mg for 5 days. 18, 19, 20 [Level 1-] Pain relief following the use of corticosteroids often predicts a favourable response to radiotherapy. 21 [ Level 4] Anaesthetic techniques may be indicated. They should always be discussed early with an Anaesthetic Pain Specialist whilst the patient remains fit enough to tolerate any appropriate procedure (see Guidelines on Interventional Pain Techniques). 11, 12 [ Level 3] Topical treatment with capsaicin cream may be of benefit in patients intolerant of other treatments. 22 [ Level 1-] In patients with symptoms that are difficult to control or who have severe allodynia / hyperalgesia, consider admission to a specialist centre. 23 [Level 4]

2 Figure 28.1 Approaches to the use of adjuvant analgesics in neuropathic pain 16, 17 [Level 4] Start amitriptyline or gabapentin and titrate dose. NO PARTIAL COMPLETE Stop chosen drug Continue chosen drug Switch to gabapentin or amitriptyline. Add gabapentin or amitriptyline. Stop chosen drug. NO PARTIAL COMPLETE Continue chosen drug(s). Consider alternative anticonvulsant from drugs listed in Table 28.1 Refer for specialist management. Methadone is a potent µ agonist and acts as a non-competitive antagonist at the N-methyl-Daspartate (NMDA) receptor. It has also been shown to inhibit the re-uptake of serotonin and noradrenaline. Morphine, hydromorphone, fentanyl and oxycodone do not exhibit this additional action. Methadone is therefore often used as a broad-spectrum opioid in the treatment of resistant cancer-related neuropathic pain, where there have been dose-limiting side effects and rapid development of tolerance to the previous opioid. Methadone should only be initiated in a specialist unit (see Guidelines on the Use of Methadone). 24 [ Level 1-] Ketamine may be given as an infusion prior to conversion to an oral preparation where appropriate. It should only be initiated under specialist supervision. It can be given intravenously 25 [Level 1-] or subcutaneously. Various regimens have been described and the choice will depend on the preference of the specialist team. 26, 27 [ Level 3]

3 Anaesthetic approaches (see Guidelines on Interventional Pain Techniques) If the pain is escalating despite the use of recommended guidelines, or if urgent control is required, consider early referral for an Anaesthetic Pain Specialist opinion. 11 [Level 4] The use of peripheral nerve blocks using local anaesthetic and / or corticosteroids may be effective for the relief of pain in the distribution of one or more peripheral nerves. 28, 29 [Level 3] Neurolytic procedures such as a saddle block using phenol may relieve some painful sacral neuropathies. 11, 30 However this may cause significant problems with bladder and bowel function. Some experts favour epidural catheters as an alternative. [Level 4] Epidural opioids +/- bupivicaine may be of use in patients with neuropathic pain, particularly in patients with intractable radicular pain or where systemic opioids have caused severe side effects. However, they may cause significant problems with bladder and bowel function. 31, 32 [Level 4] If unilateral pain below the shoulder and prognosis between three months and twelve months, consider referral for percutaneous cordotomy. 33, 34, 35 [Level 3] 28.3 STANDARDS 1. All patients with neuropathic pain should be monitored with a pain diary. 2, 23, 36 [Grade D] 2. Patients with poorly controlled neuropathic pain should have at least weekly follow up if an outpatient, and 48 hourly reassessment if an inpatient. 23 [Grade D] 3. If neuropathic pain is escalating, an Anaesthetic Pain Specialist should be contacted for advice within 48 hours. 11 [Grade D]

4 Table 28.1 Adjuvant oral analgesics used in the management of neuropathic pain Drug Name Initial dose Titration Side effects Notes Amitriptyline 16 [Level 1+] Capsaicin 0.075% cream 22 [Level 1-] Carbamazepine 37 [Level 1+] Clonazepam 38 [Level 3] Dexamethasone 21 [ Level 1-] Gabapentin 17 [Level 1+] 10mg-25mg at night. 10mg at night in the elderly. Median preferred dose of 75mg daily. Apply topically three or four times daily. 200mg daily. 100mg daily in elderly. 500 micrograms nocte. 8mg daily. 300mg nocte. 100mg nocte if elderly. Increase every 3 days as tolerated. Increase by 100mg- 200mg every three days. Give in divided doses. Increase by 500microgrammes every third day. Maximum dose is 8 mg. Give for 5 days. Discontinue if no response. Reduce to lowest dose to maintain effect (see Guidelines on Corticosteroids). Increase after 3 days to 300mg bd. Increase to 300mg tds after further 3 days. Maximum dose is 2400mg. Occur in 33% of patients. Include drowsiness and dry mouth. Skin burning and redness. Nausea, drowsiness, confusion and ataxia. Sedation. Sedation, dizziness. Speed of onset 1-7 days. May get improved sleep pattern and mood. Use with caution in the following: cardiac disease; arrhythmias; epilepsy; concurrent use of SSRIs; angle closure glaucoma; history of urinary retention. May take up to 10 days to have an effect. Always wear gloves when applying. Beware of drug interactions. May be given subcutaneously via a syringe driver. May adsorb to PVC so use non PVC equipment for infusions. A CSCI containing clonazepam should only run for a maximum of 12 hours as stability of diluted clonazepam currently only confirmed for 12 hours. If good response then may benefit from radiotherapy. Monitor blood sugar levels. Consider gastric protection. Reduce dose in renal failure/ impairment. Use with caution in patients with CCF. Diabetic patients may need to adjust hypoglycaemic treatment as weight gain may occur. Lidocaine plaster 39 [Level 1-] Pregabalin 40 [Level 1-] One strength. Apply for 12 hours daily over painful area and then remove. Day 1: 25mg od Day 2: 25mg bd Increase every two days by 25 mg bd. Note: May need to use slower titration regimen e.g. start at 100mg od and increase by 100mg every two days. Can use up to 3 patches at any one time 150mg-600mg daily in two divided doses. Avoid tds dosing. Treatment costs increase with no benefit. Skin reaction Sedation, dizziness. Current evidence is for post herpetic neuropathic pain. May be useful for post thoracotomy pain. Potential pharmacodynamic interactions with all opioids and sedatives. 42 Caution may be required in patients with chronic heart failure. 43 Diabetic patients may need to adjust hypoglycaemic treatment as weight gain may occur. Sodium valproate 41 [Level 2-] 200mg at night. Increase by 200mg every third day. Maximum dose is 1000mg daily. Nausea, ataxia. NB. Choice of adjuvant analgesic will depend on clinician experience and the side effect profile of individual drugs.

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