Professional Documents
Culture Documents
Nyeri Kanker
Nyeri merupakan :
utama pasien-pasien kanker :
selama terapi, dan juga pada
penyakit lanjut & terminal
Simptom untuk melalukan evaluasi terapi
Konsekuensi tersering yang sangat ditakutkan
pasien
Simptom
% Patients (n=275)
0
10
20
30
40
50
60
70
80
90
% Patients
Leukemia
0
10
20
30
40
50
60
70
80
90
Keseluruhan
Mortalitas
Nyeri kanker
Penyebab kematian
terbanyak di dunia
nomor
Nyeri Organik
Nyeri
Dimensi
Psikologis
Afek Motivasi
Evaluasi Kognitif
MANAJEMEN NYERI / PPKC
The meaning of pain
TOTAL PAIN
BIOPSYCHOSOCIOCULTUROSPIRITUAL
MANAJEMEN NYERI / PPKC
WHO 1986
Symptoms of debility
Non-cancer pathology
Side-effects of therapy
Cancer
SOMATIC SOURCE
TOTAL
DEPRESSION
PAIN
ANGER
Delay in diagnosis
Unavailable doctors
Irritability
ANXIETY
Disfigurement
Bureaucratic bungling
Therapeutic failure
Fear of pain
Family finances
Fear of death
Spiritual unrest
Nyeri Kanker
Dapat dibagi 2 kategori :
1. Nyeri organik
2. Nyeri psikologis
Nyeri organik
A. Nyeri Nociceptif :
Nyeri somatik
(kulit, otot, jaringan ikat)
Nyeri visceral
(organ dalam torak dan abdomen)
B. Nyeri non nociceptif:
Nyeri neuropatik(nyeri deaferensiasi) /
kerusakan saraf perifer atau saraf pusat
MANAJEMEN NYERI / PPKC
NYERI NOSISEPTIF
NOSISEPTIF
dapat di bagi :
NYERI SOMATIK
NYERI VISCERAL
1. NYERI SOMATIK
konstan
tajam, perih
lokasi dapat ditunjuk
Mekanisme:
aktivasi nosiseptor
pelepasan mediator nyeri ( terutama PG)
Contoh:
metastasis tulang
tumor jaringan lunak
Penanganan:
Aspirin
Acetaminophen
NSAID (COX1 or COX2 inhibitor)
MANAJEMEN NYERI / PPKC
Nyeri Nocicepti
Nociceptiff
Nyeri Somatik
2. NYERI VISCERAL
konstan
nyeri dalam atau tumpul
lokasi sulit di tunjuk
diikuti mual dan muntah
kadang nyeri di alihkan ke kulit
kolik & kram
Mekanisme:
Aktivasi nosiseptor
Contoh:
kanker pankreas
metastasis kanker hati/paru ke tulang bahu
Manajemen:
Opioid (MS contin)
Blok saraf (e.g celiac plexus block)
MANAJEMEN NYERI / PPKC
Nyeri Nociceptif
Nyeri Visceral
Iritasi
Iritasi permukaan mukosa dan serosa
organ viscera
Torsi dan tertarikya mesenterium
organ viscera
Distensi atau kontraksi rongga usus
usus..
Tertekannya organ viscera
Nyeri Neuropatik
Neuropatik
Kerusakan jalur saraf
Respon tidak normal pada stimulus
yang normal
Akibat kerusakan saraf perifer & sentral
1.
2.
3.
Pathophysiologic classification:
Temporal classification:
- Acute
- Breakthrough
- Chronic
Severity-based classification:
- Mild
- Moderate
- Severe
MANAJEMEN NYERI / PPKC
Somatic Pain:
Visceral Pain:
Nerve Compression:
Deafferentation
Nerve Injury:
Sympathetically
Mediated:
Kemoterapi:
Polineuropati
Nekrosis tulang
Pseudorhematoid steroid
Mucositis
Radiasi:
Fibrosis akibat radiasi pleksus brachial dan pleksus
lumbosacral
Mielopati akibat radiasi
Radiasi yang mencetuskan tumor saraf perifer
Mucositis
MANAJEMEN NYERI / PPKC
Nekrosis tulang akibat radiasi
PALLIATIVE CARE
World Health Organization Definition:
Palliative care is an approach that improves the
quality of life of patients and their families facing the
problem
associated
with
life-threatening
illness,
PRINSIP DASAR
Analgetik
Analge
tik diberikan regularly
Ada akses untuk obat analgetik
Eskalasi potensi analgesic
analgesic sesuai dengan
analgesic ladder
Obat yang sesuai untuk breakthrough pain
Obat untuk mengatasi efek samping
Monitoring pasien secara berkala
MANAJEMEN NYERI / PPKC
Opioids
Infrequent dosing
Toxicity
Effect
Analgesia
Pain
Time
MANAJEMEN NYERI / PPKC
Opioids
Adequate dosing
Toxicity
Analgesia
Pain
Time
MANAJEMEN NYERI / PPKC
10
Worst
possible
pain
No
pain
0
No
pain
2
Mild
pain
Moderate
pain
Faces Scale
10
Worst
possible pain
How to apply
THREE STEP LADDER ANALGESIC
As much as possible, depend on patients
condition, drugs should be given by
by::
the patients him/herself
the mouth/oral
the clock (06, 10, 14, 18, 22, 02)
the ladder
Started with step one, two than three
MANAJEMEN NYERI / PPKC
2.Moderate
Codeine*
1.Mild
Hydrocodone
Oxycodone
ASA*
Acetaminophen*
NSAIDs*
Adjuvants*
Dihydrocodeine
Tramadol*
Adjuvants*
MANAJEMEN NYERI / PPKC
Hydromorphone
Methadone
Levorphanol
Fentanyl*
Oxycodone
Adjuvants*
Level I Analgesics
Paracetamol::
Paracetamol
Simplest and safest analgesic
Mechanism of action not fully elucidated
Central effect
(chemotherapy
(chemotherapy--induced) neuropathy
Non-steroidal antiNonanti-inflammatory
drugs:
Very diverse group
Main mechanism of action:
Reduction PG synthesis
Malignant bone pain
Ceiling analgesic effect
Opioid dosedose-sparing MANAJEMEN
effectNYERI / PPKC
No reduction in side effects
Level II Analgesics
Codeine:
10
Weak analgesic
K i (M )
Tramadol:
0,01
0,001
ol
ad
in
am
Tr
e
in
Verbale Beoordelingsschaal
Ti
l id
Co
de
Pr
op
ir a
e
in
yfe
Pe
ox
De
xt
ro
p
ro
p
th
id
cin
ne
zo
do
nt
a
Pe
fi n
e
ha
M
et
em
to
b
or
ne
yl
i do
an
nt
Fe
Ke
Bu
pr
e
no
r fi
ne
0,0001
Tilidine::
Tilidine
Weak opioidopioid-like activity
Buprenorphine:
Hydromorphone:
5x potent as morphine
Fentanyl:
Hydromorphone
Morphine
Oxycodone
Fentanyl
Oxycodone:
-opioid receptor
Methadon:
Racemic mix
NMDA-antagonist
NMDA-receptor agonist
Dosage
Comments
Acetaminophen
Ibuprofen
Naproxen
Diclofenac
MANAJEMEN
NYERI / PPKC
Note: Increasing the dose of nonopioids beyond the
recommended
therapeutic level produces a ceiling effect
(i.e., there is no additional analgesia but there are major increases in toxicity and side effects).
Symptom control
Tricyclic antidepressants
Antiepileptics
Ketamine
Neuropathic pain
Corticosteroids
Benzodiazepines
Baclofen
Buscopan
Muscle spasm
Bisphosphonates
Bone pain
Drug, Dosage
Indications
Amitriptyline:
- Initial dose 0.2-0.5 mg/kg PO
- Titrate upward by 0.25 mg/kg
every 2-3 days
- Maintenance: 0.2-3 mg/kg
Alternatives: nortriptyline,
doxepin, or imipramine
Anticonvulsants
Gabapentin:
- Initial dose 5 mg/kg/day PO
- Titrate upward over 3-7 days
- Maintenance: 15-50 mg/kg/day
PO divided TID
Neuropathic pain,
especially shooting,
stabbing pain.
Carbamazepine:
Antihistamines
Comments
Opioid-induced
pruritus, anxiety,
nausea
Drug, Dosage
Sedatives,
hypnotics,
anxiolytics
Prednisone, prednisolone,
and dexamethasone dosage
Headache from
increased intracranial
pressure, spinal, or
nerve compression;
widespread metastases
Opioid-induced
somnolence
Potentiation of opioid
analgesia
Corticosteroids
Indications
Dexamethasone:
- Initial dose: 0.2 mg/kg IV.
- Dose limit 10 mg.
- Subsequent dose: 0.3 mg/kg/
day IV divided every 6 h
Psychostimulants
Dextroamphetamine,Methyl
phenidate: 0.1-0.2 mg/kg BID.
Escalate to 0.3-0.5 mg/kg as
needed
Comments
Equianalgesic
dosage
(parenteral)
Starting dosage IV
IV:PO
ratio
Starting dosage
PO/Transdermal
Duration of
Action
Morphine
10 mg
1:3
3-4 h
Hydromorphone
1.5 mg
1:5
2-4 h
Codeine
120 mg
Not recommended
3-4 h
Oxycodone
5-10 mg
Not recommended
3-4 h
Meperidine
75 mg
1-3 h
Fentanyl
100 g
1-2 g/kg/h as
continuous infusion
Methadone
10 mg
1:4
1:2
25 g patch
72 h (patch)
12-50 h
Equianalgesic
dosage
(parenteral)
Starting dosage IV
IV:PO
ratio
Controlledrelease
morphine
Controlledrelease
hydromorpho
ne
Controlledrelease
codeine
3 mg/kg every 12 h
Controlledrelease
oxycodone
Starting dosage
PO/Transdermal
Duration of
Action
STRONG OPIOIDS
Most commonly use:
Morphine*
Hydromorphone
Transdermal fentanyl (Duragesic
(Duragesic)*
)*
Oxycodone
Methadone
DO NOT use Meperidine (Demerol) longlong-term
active metabolite normeperidine seizures
MANAJEMEN NYERI / PPKC
Brand
Dosing Interval
MS Contin
8-12 hrs
Oramorph-SR
8-12 hrs
Kadian
12-24 hrs
Avinza
24 hrs
Oxycodone
OxyContin
8-12 hrs
Oxymorphone
Opana ER
12 hrs
Fentanyl
Duragesic
48-72 hrs
Methadone
6-12 hrs
MANAJEMEN NYERI / PPKC
Opioid Resistance
limiting side effects
Small group of patients
Pathophysiology of true
resistance ?
Downregulation of number -receptors:
Peripheral nerve damage
Long--term use of opioids
Long
Cholecystokinin (CCK):
Control of opioid sensitivity
Cancer syndromes
DeDe-activation of opioid
opioid--receptors:
GURK--receptor activation
GURK
Inhibition of -receptor
MANAJEMEN NYERI / PPKC
Equianalgesic ORAL
Equianalgesic IV
Codeine
200 mg
130 mg
Hydrocodone
30 mg
---
Morphine
30 mg
10 mg
Hydromorphone
7.5 mg
1.5 mg
Oxycodone
20 mg
---
(patch ~ morphine)
Meperidine
300 mg
75 mg
Methadone
10 mg ACUTE
5 mg ACUTE
Fentanyl
Opioid--Induced Neurotoxicity
Opioid
(OIN)
Neuropsychiatric syndrome
Cognitive dysfunction
Delirium
Hallucinations
Myoclonus/seizures
Hyperalgesia//allodynia
Hyperalgesia
MANAJEMEN NYERI / PPKC
OIN: Treatment
Opioid rotation
Reduce opioid dose
Hydration
Circadian modulation
Psychostimulants
Other Rx
MANAJEMEN NYERI / PPKC
Opioid Rotation
Metabolites cause OIN
Change to another opioid analgesic
25 - 50% dose reduction
Morphine/hydromorphone
Morphine/
hydromorphone/oxycodone
/oxycodone
Second line agents:
- fentanyl/
fentanyl/sufentanil
sufentanil
- methadone
MANAJEMEN NYERI / PPKC
Cancer Pain
Breakthrough Pain:
Incidental pain
Severe transitory increase in pain on
baseline of moderate intensity or less
Caused by movement, positioning,
cough, wound dressing, etc
Often associated with bony metastases
Portenoy
R. Sem Onc, 1997;24:S16-7-S16-12
MANAJEMEN NYERI / PPKC
Components of ModerateModerate-to
to-Severe Chronic Cancer Pain
Around-the-Clock
Medication
Breakthrough
Pain
Breakthrough Pain
Ideal Agent:
Agent:
Potent, pure opioid agonist
Potent,
Rapid onset
Early peak effect
Short duration
Easily administered
Sublingual/Transmucosa
Sublingual/
Transmucosa routes
advantageous
MANAJEMEN NYERI / PPKC
Breakthrough Pain
Medication type
Fentanyl
Fentanyl
Fentanyl
Fentanyl
Sublingual Dose
12.5 g
25.0 g
50.0 g
100.0 g
SUMMARY:
1. Pain is common problem and a major symptom of
cancer patient.
2. Pain is one at most feared aspect and can cause
to suicide.
3. Cancer pain can be organic or psychological pain.
4. Organic pain may be somatic,
neuropathic pain or combined.
visceral
or
Trade Name
Strength mg
Dose by pill
Aspirin +
caffeine +
dihydrocodeine
Synalgos
356.4+30+16
1-2 q4 hr
Moderate to
moderate
severe pain
Aspirin +
carisoprodol +
codeine
Soma
Compound
w/codeine
325+200+16
1-2 TID-QID
(6)
Painful muscle
spasm
Aspirin +
codeine
Empirin w/
codeine #3
Empirin w/
codeine #4
325+30
1-2 q4 hr
325+60
1 q4 hr
Mild to
moderate
pain
LortabASA
500+5
1 q4 hr
Moderate
severe
acute pain
Aspirin +
hydrocodone
Indication
Comments