Palliative Crae in Cervical Cancer and How do Pharmacist must know

1. PALIATIVE CARE IN CERVICAL CASE UPF POSA RAWAT JALAN RSU DR SOETOMO SURABAYA

2. KASUS PASIEN PALIATIVE Namapasien Mrs. X (39 tahun) Dx : Ca Cervix stad III B Terapi symptom : Relief Nyeri R/Codifam Codein Amitrip

3. Cervix Lower part of the uterus Connects the body of the uterus to the vagina (birth canal) Source: American Cancer Society

5. The HPV detected today could have been acquired years ago

7. What are the symptoms of cervical cancer? Abnormal bleeding Between periods With intercourse After menopause Unusual vaginal discharge Other symptoms Leg pain Pelvic pain Bleeding from the rectum or bladder Some women have no symptoms

8. Who is at risk? Women who have ever had sex Women who have had more than one partner Women whose partner (s) has had more than one sexual partner Women who have had a sexually-transmitted disease

9. Signs and Symptoms Vaginal bleeding Menstrual bleeding is longer and heavier than usual Bleeding after menopause or increased vaginal discharge Bleeding following intercourse or pelvic exam Pain during intercourse Source: American Cancer Society

10. Risk Factors Human papillomavirus infection (HPV) – Primary factor HPV 16, HPV 18, HPV 31, HPV 33, HPV 45 50% are caused by HPV 16 AND 18 Sexual behavior Smoking HIV infection Chlamydia infection Diet Oral contraceptives Multiple pregnancies Low socioeconomic status Diethylstilbestrol (DES) Family history Source: American Cancer Society

11. Treatment Ca Cervix Surgery Preinvasive cervical cancer Cryosurgery Laser surgery Conization Invasive cervical cancer Simple hysterectomy Removal of the body of the uterus and cervix. Radical hysterectomy and pelvic lymph node dissection Removal of entire uterus, surrounding tissue, upper part of the vagina, and lymph nodes from the cervix. Radiation Chemotherapy Paliative Care Source: American Cancer Society

12. 3 By the 2 Clock 1 W.H.O. ANALGESIC LADDER Strong opioid +/- adjuvant Weak opioid +/- adjuvant Pain persists or increases Non-opioid +/- adjuvant

13. Non-Pharmacological Pain Management Acupuncture Cognitive/behavioral therapy Meditation/relaxation Guided imagery TENS Therapeutic massage Others…

14. Massage– muscle tension, headaches, anxious patient Heat & cold applications – muscle spasm Distraction– periodic or procedural pain Transcutaneous Electrical NerveStimulation (TENs) – musculosketal problems Aromatherapy Complimentary and Alternative therapies Nerve block Non-pharmacological methods of pain relief

15. Pain Relief Neuropathic Pain TCAD, Anticonvulsants, topicals (Capsaicin) , Baclofen Inflammatory Pain Steroids, NSAIDS use cautiously, opioids Bone Metastasis Pamidronate, Calicitonin, opioids Muscle Spasms Baclofen, Benzodiazepines

16. Step I Acetaminophen up to 4 gm/day, ASA up to 4 gm/d NSAID use cautiously for persistent pain Step II Tramadol 50 mg max 8 tabs divided q 6h Oxycodone 5 mg max 12 tabs divided q 6h Morphine 5 mg no maximum dose q 4 hour Persistent Pain

17. Step III Calculate 24 h opioid need and convert to long acting bid form Use short acting for breakthrough Barriers to maximal pain relief from doctors and patients Ethical precedent for using as much as needed to alleviate suffering Persistent Pain

20. morphine

21. Hydromorphone (Dilaudid ®)

22. transdermalfentanyl (Duragesic®)

23. oxycodone

24. Methadone

25. DO NOT use meperidine (Demerolâ) long-term

27. cross-tolerance unpredictable, especially in:

28. high doses

29. long-term use

31. Opioid Side Effects Constipation – need proactive laxative use Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol) Urinary retention Itch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great success Dry mouth Respiratory depression – uncommon when titrated in response to symptom Drug interactions Neurotoxicity (OIN):delirium, myoclonus® seizures

32. Management of Symptoms Try to prevent symptoms if possible use laxatives with opioids give an anti-emetic when starting morphine review and often stop after 3-4 days give anti-emetics before and during chemotherapy encourage good mouth care, especially in dying patients sips of water, moisten mouth, anti-fungal agent

34. Vestibular Antihistamines

35. Chemoreceptor Dopamine Antagonist

36. Gastric Irritation Feeds, stop NSAIDS

37. Gut Motility Metaclopromide

38. Ascites Diuretics

39. Pain or anxiety Treat accordingly Nausea and Vomiting

40. Physical and/or psychological Morphine Oxygen Fan in Room, Fresh Air Secretions Control with anticholinergics and suctioning Address fears, anxiety, spiritual needs Relaxation, distraction, Dyspnea

41. Sources include: fear, pain, psychological and spiritual distress Treatment : Anxiolytics Human Contact Address fears Setting affairs into order Anxiety

42. Target behavior and seek causes if possible Decrease external stimuli Use Music, Prayer Agitation as a form of communication As part of delirium very near end of life Haldol, Anxiolytics Agitation

43. Target behavior and seek causes if possible Decrease external stimuli Use Music, Prayer Agitation as a form of communication As part of delirium very near end of life Haldol, Anxiolytics Agitation

44. Combat constipation of narcotics, avoid impaction Careful skin care, positioning If diarrhea use anticholinergics Scheduled voids , disposable pads, Foley’s urine catheter? Manage odors Bowel and Bladder

46. Delays the inevitable

47. Consider limited trial and withdrawal if no evident benefitNutrition and Hydration

48. Skin Care and Pruritis Pruritis Consider xerosis, uremia, hypercalcemia, medication side effects, delirium Hygiene and positioning Lotions Cool moist compresses Antihistamines

49. Shock and denial Anger Bargaining Depression Acceptance Reaction to death or Impending death

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