What are the recommendations for pain control in a palliative patient with colon cancer metastasized to the kidneys and bone, beyond hydromorphone (HydroMORphone)?

From the Guidelines

For pain control in a palliative patient with metastatic colon cancer to the kidneys and bone, beyond hydromorphone, a multimodal approach is recommended, prioritizing morphine as the first-line opioid, as per the ESMO clinical practice guidelines 1.

Key Considerations

• The patient's renal impairment due to metastatic disease to the kidneys necessitates careful opioid selection, with morphine, hydromorphone, hydrocodone, oxymorphone, and codeine to be used with caution 1.
• Buprenorphine may be considered for patients with renal impairment, as it is mainly excreted in the stool, reducing the risk of neurologic toxicity 1.
• Methadone can be an effective alternative for patients who do not respond to other opioids, but its use requires careful attention due to marked inter-individual differences in plasma half-life 1.

Adjuvant Therapies

• Gabapentin (starting at 100-300mg three times daily) or pregabalin (starting at 25-75mg twice daily) can be added for neuropathic pain components.
• NSAIDs like celecoxib (200mg twice daily) can target inflammatory pain if renal function permits.
• Bisphosphonates such as zoledronic acid (4mg IV every 3-4 weeks) or denosumab (120mg subcutaneously every 4 weeks) may provide relief for bone pain.
• Radiation therapy is highly effective for localized bone pain, typically delivered in 1-10 fractions depending on the patient's prognosis.
• Corticosteroids like dexamethasone (4-8mg daily) can reduce inflammation around tumors and improve pain control.

Breakthrough Pain Management

• Immediate-release opioids at 10-15% of the total daily opioid dose can be used for breakthrough pain.
• Non-pharmacological approaches, including heat/cold therapy, physical therapy, and psychological interventions, should complement medication management.

Regular Reassessment

• Regular reassessment of pain control is essential, with dose adjustments based on response and side effects.
• This multimodal approach targets different pain mechanisms simultaneously, providing more effective relief while potentially reducing opioid requirements and associated side effects, as recommended by the NCCN clinical practice guidelines 1.

From the Research

Pain Control Recommendations

Beyond hydromorphone, the following options can be considered for pain control in a palliative patient with colon cancer metastasized to the kidneys and bone:

• Morphine: As mentioned in the study 2, morphine may be compared with hydromorphone for cancer pain, with no clear evidence of a difference in pain intensity.
• Oxycodone: The study 2 also compared hydromorphone with oxycodone, finding no clear evidence of a difference in pain intensity.
• Fentanyl: Hydromorphone was compared with fentanyl in one study 2, with no clear evidence of a difference in pain intensity at 60 minutes.

Multidisciplinary Approach

A multidisciplinary approach to pain management is recommended, including:

• Collaboration between healthcare team members to manage pain and other symptoms 3
• Providing comfort care and offering psychological, spiritual, and social support 3
• Assessing the patient's spiritual needs and providing spiritual care for a good end, a good farewell, and a good life 3

Symptom Management

In addition to pain control, symptom management is crucial in palliative care, including:

• Management of fatigue, anorexia, distress, and insomnia, as mentioned in the study 4
• Use of medications such as ibuprofen, incadronate disodium, and oxycodone hydrochloride sustained-release tablets to manage symptoms 4

Challenges and Facilitators

Challenges in providing palliative care include:

• Professional staff shortage, affecting the quality of care 3 Facilitators include:
• Multidisciplinary teamwork, which greatly improves the patient's overall care experience 3
• Intensive communication training to improve nurses' communication skills and ensure effective communication with patients and their families 3