1. The Basics of Symptom Management: Understanding, Assessment and Principles Dr. Leah Steinberg

2. Learning Objectives: List several good on-line resources; Review the model of pain and symptom management; Describe basic management of –Constipation, Delirium, Dyspnea Appreciate the principles of symptom management.

4. Cancer Care Ontario Guidelines www.cancercare.on.ca Palliative care tools Symptom management tools

5. Objective 2: Review from yesterday Assess – rectal exam Treat underlying causes Treat symptoms –pharmacological and non-pharmacological Monitor Educate

6. Objective 3: Constipation Huge burden to patients Uncomfortable, AND Makes them stop using opioids

7. Constipation: Definition Infrequent, hard stools, difficult to pass Feeling of incomplete evacuation Not just infrequency

8. Multiple causes: we know these! Immobility Disease Neurologic abnormalities Metabolic abnormalities (hypercalcemia) Decreased intake Medications (OPIOIDS, anticholinergics) Weakness Physical surroundings

9. Again, to manage – follow the steps Assess – rectal exam Treat underlying causes Treat symptoms –pharmacological and non-pharmacological Monitor Educate

10. Management: Many products Know the classes of laxatives to use –Stimulant (senna) –Lubricant (mineral oil) –Osmotic (lactulose) –Opioid antagonist (methylnaltraxone) Usually don’t recommend: –Fibre or docusate Create a protocol for your practice

11. Set up regular dosing of laxatives: –Sennosides or bisacodyl: 2–4 tablets at bedtime to begin plus –Lactulose 30 mL at bedtime or –PEG 3350 powder 17 g once or twice daily Monitor daily. If no bowel movement by day 2: –Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG 3350 to 30 mL twice daily If no bowel movement by day 3: –Perform rectal examination If stool in rectum: –Use phosphate enema or bisacodyl suppository If no stool in rectum and no contraindication: –Give oil enema followed by saline or tap water enema to clear Increase regular laxatives If problems continue: –Do flat-plate radiograph of abdomen –Switch stimulant laxative –Use regular enemas

12. Set up regular dosing of laxatives: –Sennosides or bisacodyl: 2–4 tablets at bedtime to begin plus –Lactulose 30 mL at bedtime or –PEG 3350 powder 17 g once or twice daily Monitor daily. If no bowel movement by day 2: –Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG 3350 to 30 mL twice daily If no bowel movement by day 3: –Perform rectal examination If stool in rectum: –Use phosphate enema or bisacodyl suppository If no stool in rectum and no contraindication: –Give oil enema followed by saline or tap water enema to clear Increase regular laxatives If problems continue: –Do flat-plate radiograph of abdomen – Rule out Bowel obstruction –Switch stimulant laxative –Use regular enemas

13. Constipation Pearls! Prevent!!! If not, treat aggressively Myth: he’s not eating… Regular laxatives if regular opioids –Easier to decrease laxatives

14. Dyspnea: Frightening symptom Often linked with anxiety, fear Need lots of education and support for patient with severe dyspnea

15. Prevalence of dyspnea 50% - 70% of all cancer patients 60% of patients with NSCLC Worsens as disease progresses Prognostic indicator –When patients are dysnpeic at rest, prognosis is often in the range of weeks

16. Etiology Multifactorial: Dudgeon, Lertzman Dyspnea in the advanced cancer patient, JPSM 1998 Oct;16(4) Reviewed 100 pts to determine etiology of dyspnea; Average number of potential causes = 5

17. Etiology: many many causes From the Tumour itself; Compression Obstruction Carcinomatosis Other Card/Resp Dx COPD CHF Indirectly from tumour: Muscle weakness Anemia Thromboembolic disease Effusions: pleural, pericardial, peritoneal Infection

18. Again, to manage – follow the steps Assess: to diagnose –Tachypnea is not dyspnea Reverse when you can Treat the symptoms Monitor Educate

19. Treat underlying cause if possible: Antibiotics Drain effusion: +/- Tenchkoff catheter Radiotherapy Stents Transfusions

20. Non-pharmacological Education ++ Energy Conservation Breathing techniques Muscle strengthening Cool air/fan Positioning Relaxation exercises

21. Pharmacological Opioids are mainstay Methyltrimeprazine Anxiolytics Steroids Inhalers/diuretics Secretion management at EOL Trial of oxygen

22. What about respiration compromise? 11 studies looked for evidence of respiratory compromise – no clinically relevant compromise found Again, related to opioid naive

23. Opioid dosages Opioid-naïve patients, mild dyspnea –codeine 30 mg q 4 hr –morphine 2.5 mg q 4 hr Opioid-naïve patients, moderate - severe –morphine 2.5 - 5.0 mg q 4 hr (or equivalent) –titrate 25 - 50% every 24 hrs –in COPD, start low and go slower

24. Opioid dosages Opioid tolerant patients –titrate baseline dose by 25 - 50 %

25. Anxiolytics: if anxiety a component Lorazepam 1 – 2 mg sl q 8 hrs prn Clonazpam 0.25 - 2.0 mg q 12 hr Midazolam 0.5 - 1.0 mg s/c or iv q 20 mins prn

26. Steroids Dexamethasone 4 – 16 mg daily Can give in one dose in the morning, rather than qid

27. Dyspnea summary: Tachypnea is not dyspnea Reverse when you can Opioids are mainstay of medical therapy Use non-pharmacological measures when you can

28. Delirium Palliative care emergency! A delirious patient cannot express their symptoms; Distressing for patient and family Remember: –Hyperactive –Hypoactive

29. Patient’s remember their delirium 50% of patients remember the experience – It is frightening for them

30. To manage – follow the steps Assess: to diagnose –Don’t forget to do physical exam Reverse when you can Treat the symptoms Monitor Educate

31. Reverse when that is the goal Hydration Opioid rotation Bisphosponates Stop medications if possible

32. Non-pharmacologic measures: Quiet room Decrease stimulation Light Visible reminders of time and date Verbal orientation of patient

33. But most importantly: TREAT IT Don’t leave patient untreated while attempting to reverse: First line: –Haloperidol 0.5 mg bid plus breakthrough –Risperidone 0.5 mg bid plus breakthrough –Olanzipine 2.5 mg bid plus breakthrough –If severely agitated, we use Methyltrimeprazine

34. Delirium summary: Prevent it when possible –PCUs may use daily screening tool (CAM) Reverse when possible Treat always Counsel patient after, if needed

35. SUMMARY Many symptoms Don’t be overwhelmed Use the model Use the resources out there!

36. Opioids treat symptom of dyspnea Cochrane review Mechanism unclear Systemic naloxone increases dyspnea Opioid receptors in tracheobronchial tree and alveolar walls But, no clear role for nebulized though