Open Access Open Access  Restricted Access Subscription or Fee Access

Managing breakthrough pain for advanced malignancy in elderly patients: A real challenge

Deepti Ahuja, MD, Nandan Choudhary, MD, Vinod Kumar, MD, Nishkarsh Gupta, MD, Sachidanand Jee Bharati, DM

Abstract


Pain management in advanced cancer patients using opioids like morphine is challenging due to presence of predisposing factors like renal insufficiency, hepatic insufficiency, hypoproteinemia, hypoalbuminemia, and anemia that can easily precipitate inadvertent toxic effects. We report a case morphine toxicity in an elderly patient of lung cancer with concomitant presence of chronic obstructive pulmonary disease (COPD) and recent onset renal impairment. Opioid analgesic overdose is a lethal but at the same time, a preventable and treatable condition. We managed the case using naloxone infusion. However, we emphasize early anticipation and recognition of predisposing factors followed by timely intervention to manage this life-threatening condition.


Keywords


elderly, lung cancer, COPD, renal impairment, hypoproteinemia, opioid, toxicity, naloxone

Full Text:

PDF

References


World Health Organization: Cancer pain relief. Geneva, Switzerland: World Health Organization, 1986.

van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, et al.: Update on prevalence of pain in patients with cancer: Systematic review and meta-analysis. J Pain Symptom Manag. 2016; 51(6): 1070-1090.

Mandala M, Moro C, Labianca R, et al.: Optimizing use of opiates in the management of cancer pain. Ther Clin Risk Manag. 2006; 2: 447-453.

Regnard C, Pelham A: Severe respiratory depression and sedation with transdermal fentanyl: Four case studies. Palliat Med. 2003; 17: 714-716.

Upadhyay S, Jain R, Chauhan H, et al.: Oral morphine overdose in a cancer patient antagonized by prolonged naloxone infusion. Am J Hosp Palliat Care. 2008; 25(5): 401-405.

Tarumi Y, Pereira J, Watanabe S: Methadone and fluconazole: Respiratory depression by drug interaction. J Pain Symptom Manage. 2002; 23(2): 148-153.

Hunt G, Bruera E: Respiratory depression in a patient receiving oral methadone for cancer pain. J Pain Symptom Manage. 1995; 10(5): 401-404.

Andersen G, Christrup L, Sjogren P: Relationships among morphine metabolism, pain and side effects during long-term treatment: An update. J Pain Symptom Manag. 2003; 25(1): 74-91.

Davis MP, Srivastava M: Demographics, assessment and management of pain in the elderly. Drugs Aging. 2003; 20: 23-57.

Kumar V, Garg R, Gupta N, et al.: Cautious use and optimal dose of morphine for relieving malignant pain in a complex patient with multiple comorbidities. BMJ Case Rep. 2016; 2016: bcr2016217174.

Steynor M, MacDuff A: Always consider the possibility of opioid induced respiratory depression in patients presenting with hypercapnic respiratory failure who fail to improve as expected with appropriate therapy. Case Rep Crit Care. 2015; 2015: 562319.

Howlett C, Gonzalez R, Yerram P, et al.: Use of naloxone for reversal of life-threatening opioid toxicity in cancer-related pain. J Oncol Pharm Pract. 2016; 22(1): 114-120.

Launay-Vacher V, Oudard S, Janus N, et al.: Prevalence of renal insufficiency in cancer patients and implications for anticancer drug management: The renal insufficiency and anticancer medications (IRMA) study. Cancer 2007; 110: 1376-1384.

Sande TA, Laird BJA, Fallon MT: The use of opioids in cancer patients with renal impairment--A systematic review. Support Care Cancer. 2017; 25(2): 661-675.




DOI: https://doi.org/10.5055/jom.2020.0571

Refbacks

  • There are currently no refbacks.