PATIENT CASE

Module 5

Date of preparation: June 2015 HQ/EFF/15/0024h

Multidisciplinary team management of a difficult case of pancreatic cancer painDr Juan Manuel Núñez OlartePalliative care specialistPalliative Care Unit (PCU),Hospital General Universitario Gregorio Marañón, Madrid, Spain

Patient referred by medical oncologist to PCU’s Outpatient Clinic (OC) for Early Palliative Care (EPC)

Patient history on arrival OC on 5/2013

49 years oldMaleRetired publicist, sportsman, very conflictive divorceFrequent cannabis consumptionNeuroendocrine, supposedly non-functioning, pancreatic cancer with liver metastasis tx with surgery, radiofrequency, embolisation and now chemotherapy – partial response• Irritable bowel syndrome • Everolimus, low molecular weight heparin, megestrol

7/2011 starts with pain in upper abdomen 6/2012 celiac plexus lymph nodes in CT scanHas been on oral morphine, oxycodone/naloxone, pregabalin, benzodiacepine

Current pain/illnesses

Visceral pain in upper abdomen, myofascial spinal pain in paravertebral muscles, colic abdominal pain with defecation – pain unrelieved for two years in spite of opioid titration by medical oncologist

Problems associated with pain: fatigue, constipation, depression secondary to pain (assessed by psycho-oncology), insomnia

Current medication: morphine 30 mg bid, morphine 20 mg PRN

Specialists previously seen regarding pain management: psycho-oncologist (emotionally mediated pain?)

Clinical examination and pain assessment

Physical examination: surgical abdominal scars with secondary hernia, mild contraction of spinal muscles

Blood pressure: normal

Cardiovascular examination: normal

Sensory examination: normal

Screening tool: • Davies algorithm for breakthrough pain (BTP) shows unrelieved basal pain• Mini-mental state examination - normal

Clinical judgment

Retroperitoneal celiac plexus pain NxIiPpAaCo – basal NVS score 4/10 with frequent crisis of BTP 8/10

Muscle spasm spinal pain NcIiPpAaCo – constant basal pain NVS score 5/10

Colicky abdominal pain NcIiPpAaCo – only BTP 7/10 related to defecation with no perceived response to opioids

Diagnoses associated to chronic pain:• Depressive disorder• Hypogonadism• Adrenal insufficiency• Vitamin D deficiency

Therapeutic approach

Background pain meds: oxycodone/naloxone titrated to 40 mg q8h, sustained release oxycodone titrated to 20 mg q8h, diazepam 5 mg q12h, pregabalin titrated to 300 mg q12hBTcP meds: oxycodone 40 mg q4h PRN for retroperitoneal crisis, dipirone 500-1000 mg q6h PRN for colic crisis, diazepam 5 mg q12h PRN for muscle spasm crisis

Other meds: low weight molecular heparin, hydroxyzine, prednisone, fludrocortisone, proton pump inhibitor, vitamin DGood pain control in 3 weeks – unexpected delay due to reversal of analgesia with high doses of oxycodone/naloxone

Follow-up

Minimum of monthly visit to our OC for EPC

Opioid-induced constipation becomes a major problem: laxatives, rectal measures, methylnaltrexone SC

Regular follow-up in medical oncology, endocrinology, haematology, psycho-oncology, surgery

Sympathetically mediated retroperitoneal BTP crisis triggered by emotional/ family problems very difficult to manage

3/2014 Endocrinologist requests steroid discontinuation

6/2014 in spite of slow reduction patient becomes very symptomatic with steroid psychosis treated effectively with duloxetine

Follow-up

7/2014 starts loosing weight after steroid d/c with no evidence of tumour progression – Nutrition consultation8/2014 autonomic dysfunction disclosed in our clinic, good analgesia allows opioid reduction10/2014 incidental pulmonary embolism11/2014 starts again with gradual pain crescendo, weight loss, loss of function – tumour stabilised with no progression – low dose prednisone reintroduced in our clinic1/2015 CT guided celiac diagnostic plexus block performed with partial response as relates to analgesia and huge increase in peristaltic movements2/2015 CT guided superior hypogastric diagnostic plexus block discussed in pain clinic

Follow-up

2/2015 admitted to our PCU as an EPC patient for pain and cachexia management – no DNR code in place, in fact just the opposite – patient responds to a combination of opioid rotation to methadone + octreotide + prednisone3/2015 regular follow-up by medical oncology, neuro-endocrinology, haematology, psycho-oncology, nutrition, pain clinic, surgery and early palliative care4/2015 PC MDT involved in family conflict – social worker, liaison psychiatrist5/2015 pain well controlled – new tx with prucalopride trial for constipation, bisphosphonates for osteoporosis associated to hypogonadism and steroid treatmentMonthly EKG in our clinic checking for QTc prolongation

Conclusions

Cancer pain management in long cancer survivors can be extremely complex to manageCollaboration between palliative care specialist and pain specialist was beneficial for the proper therapeutic choiceMDT management is the only valid option for very difficult cancer pain cases

Thank you