C C E E N N L L E E Pediatric Palliative Care Analgesics NSAIDs  Cyclooxygenase inhibition leads to interference with production of PGs (Cox-2)  Decreased PG’s also responsible for gastric SE’s (Cox-1)  Cox-2 inhibitors do not inhibit Cox-1, thereby limiting gastric SE’s  Can be used in mild, moderate, acute or chronic, pain alone  Use in severe pain in combination with opioid + adjuvant Dosing PRN or ATC depending on source of pain Acetaminophen/NSAIDs Acetaminophen  Little is known about mechanism of analgesia centrally mediated  Useful for mild pain, little anti- inflammatory action

C C E E N N L L E E Pediatric Palliative Care Analgesics Management of NSAID Side Effects  Gastric irritation, heart burn, ulceration and bleeding  Use gastroprotective for prolonged use  Effect on platelet aggregation – short acting, reversible  Renal effects – rare, insufficiency and nephrotoxicity can occur with prolonged high doses

C C E E N N L L E E Pediatric Palliative Care Analgesics Combination Analgesics (weak opioids)  Codeine  Use in mild pain only, limited use in severe pain  Maximum recommended dose (60mg) produces analgesia equal to 600mg aspirin  Combination product with acetaminophen  Hydrocodone  Only available in combination with acetaminophen, aspirin, or ibuprophen  Not appropriate for moderate to severe pain

C C E E N N L L E E Pediatric Palliative Care Analgesics Opioids  Morphine as gold standard  Variety of routes, formulations  Large body of research  Used for moderate to severe/intractable pain  Fentanyl  Used in anesthesia, procedural sedation  Acute moderate to severe pain  Patch has found use in some cancer and chronic non-malignant pain

C C E E N N L L E E Pediatric Palliative Care Analgesics Opioids  Hydromorphone  More potent than morphine  Available in high-potency formulations  Methadone  Gaining favor as analgesic in chronic pain  Long half-life therefore longer time to steady state  Not useful in breakthrough pain

C C E E N N L L E E Pediatric Palliative Care Analgesics Opioids  Meperidine  Causes CNS irritability, that can occur even at low doses.  Build up of toxic metabolite- normeperidine  Avoid if at all possible

C C E E N N L L E E Pediatric Palliative Care Adjuvants for Neuropathic Pain Co-analgesics - medications that are used in combination with opioids to enhance analgesia or treat specific types of pain  Antidepressants - amitriptyline, nortriptyline  Anticonvulsants – gabapentin, tegretol

C C E E N N L L E E Pediatric Palliative Care Adjuvants for Neuropathic & General Pain  Anesthetics - mexilletine, lidocaine, ketamine, propofol  Corticosteroids – dexamethasone  Anxiolytics - lorazapam, diazapam, midazolam  Barbiturates - phenobarbitol, pentobarbitol

C C E E N N L L E E Pediatric Palliative Care Analgesic Side Effects Constipation – Prevention is KEY!  Miralax, senna and ducosate sodium, casanthranol and ducosate sodium, bisacodyl, mag citrate Sedation – Tolerance w/in a few days  Dextroamphetamine, methylphenidate, caffeine

C C E E N N L L E E Pediatric Palliative Care Analgesic Side Effects (cont.) Urinary retention – oxybutynin Nausea/vomiting – zofran, promethazine hydroxyzine Pruritus - diphenhydramine, hydroxyzine

C C E E N N L L E E Pediatric Palliative Care Respiratory Suppression EXCEEDINGLY RARE Decreased depth and rate of respiration, increased sedation Use reversal drugs with caution

C C E E N N L L E E Pediatric Palliative Care Respiratory Suppression (cont.) Respiratory Suppression Protocol  If sedated and unresponsive to stimulation:  Add O2 and give Naloxone—CAUTIOUSLY!  For children >40kg Dilute 0.4mg vial in 10cc NS give 0.5 ml q 2min IV or SC until alert and RR returned to baseline  For children <40kg Dilute 0.1mg in 10ml to make 10mcg/ml solution Administer 0.5mcg/kg IV or SC q 2 minutes until alert and RR returned to baseline  If pt does not respond – look for other causes

C C E E N N L L E E Pediatric Palliative Care Titration Patients with new onset or escalating pain  Conduct thorough pain assessment  Provide PRN dose of medication  Reassess in 15 min if IV/SC, 30 if PO  If no relief - give another PRN dose  Repeat until pain relieved  Calculate dose needed for PCA/sustained prep Notify physician/APN if requiring frequent bolus doses, change in quality of pain

C C E E N N L L E E Pediatric Palliative Care Titration Changing route  Calculate total amount of meds in past 24 hours  Make appropriate equianalgesic conversions  If comfortable at current dose continue at same equianalgesic dose.  If pain is not controlled on current dose, increase equianalgesic dose by 25% to 50%

C C E E N N L L E E Pediatric Palliative Care Tapering Opioids Begin by giving half the previous days dose x 2 days Reduce doses by 25% daily until off medication Monitor for s/s of withdrawal  Runny/stuffy nose, diarrhea, abdominal cramping, nausea/vomiting  Return to dose prior to onset of symptoms Monitor for return of pain

C C E E N N L L E E Pediatric Palliative Care Pharmacological Pain Management- Equianalgesia The dose of one analgesic medication that is equivalent in pain relieving potential to another analgesic medication. Equianalgesia must be considered when switching from one opioid to another, or from one route to another Failing to consider equianalgesia is a leading cause of inconsistent pain control

C C E E N N L L E E Pediatric Palliative Care Equianalgesia Based on 10mg parenteral Morphine IV PO Conversion Morphine 10mg 30mg 3 Hydromorphone 1.5mg 7.5mg 5 Methadone 10mg 20mg 2

C C E E N N L L E E Pediatric Palliative Care Conversion Problem Child is currently on a Morphine PCA pump with basal 25mg IV q 24 and has received five 1mg PRN doses. Convert this to an oral equivalent.  Total 24 hr dose = 30 mg (25 + 5)  30mg IV multiplied by conversion of 3 = 90mg PO Convert the Oral Morphine to Oral Dilaudid:  Oral Morphine 90mg/24 hrs.  30 mg PO Morphine= 7.5 mg Hydromorphone(30/7.5 = 4)  90mg Morphine = 22.5 mg Hydromorphone

C C E E N N L L E E Pediatric Palliative Care Opioid Rotation Used when titration of opioid is ineffective or causing intolerable side- effects No clear guidelines for when to rotate due to ineffective pain control Cross-tolerance between opioids not always complete  Use equianalgesic conversion, decrease dose by 25% to 50%