2. PATIENT CASE Module 3 Date of preparation: June 2015 HQ/EFF/15/0024h

3. Cancer Pain Management with Opioids Dr Frank Elsner RWTH Aachen University Germany Referral from a GP to an outpatient pain clinic

4. Patient history 47 years old Pancoast tumour Male Profession and lifestyle: employee, middle class Comorbidities: none History of pain: increasing mixed pain within the last months

5. Current pain / Illnesses Burning pain attacks on the right shoulder, shooting in right hand, several times a day, even in the night (up to NRS 10/10) Duration of attacks seconds to only few minutes Background pain on the right shoulder under pharmacological treatment around NRS 7/10, not well-treated Impairment in moving right arm Current medication SR-Morphine 4x60mg/d, Fentanyl TTS 100 µg/h Diclofenac 3x75 mg/d, Amitriptyline 25 mg/d, IR-Morphine 80 mg

6. 10 8 6 4 2 0 20.7 NRS 22.8 Average pain SR-Morphine 800 mg/d Ibuprofen 3 x 600 mg/d Amitriptyline 75 mg/d IR-Morphine 120 mg Pain reduction after with first change of medication Average pain Reduction > 30%

7. 10 8 6 4 2 0 20.7 NRS 22.8 Average pain Most severe pain SR-Morphine 800 mg/d Ibuprofen 3 x 600 mg/d Amitriptyline 75 mg/d IR-Morphine 120 mg Pain reduction after with first change of medication Most severe pain Reduction > 30%

8. Additional pain reduction with dexamethasone 10 8 6 4 2 0 20.7 NRS 22.8 Average pain Most severe pain Reduction > 50% Dexamethasone 24 mg/d SR-Morphine 800 mg/d Ibuprofen 3 x 600 mg/d Amitriptyline 75 mg/d IR-Morphine 120 mg

9. However,…the most severe pain remains  10 8 6 4 2 0 NRS 22.8 Average pain Most severe pain Reduction > 50% SR-Morphine 800 mg/d, Ibuprofen 3x600 mg/d, Amitriptyline 75 mg/d IR-Morphine 120 mg, Dexamethasone 24 mg/d 20.7

10. Conclusions Background pain, pain attacks and breakthrough cancer pain have to be well differentiated Background pain is not always as continuous and stable as mostly stated If breakthrough cancer pain episodes are too short (< 5-8 min), a reactive treatment option will not work Always consider the potential benefit of adjuvant medication (for example: dexamethasone)

11. Thank you