R J Crossno, MD 1 - Texas & New Mexico Hospice ...txnmhospice.org/docs/2015Conference/A-1(Crossno)Non-pain_Sympto… · R J Crossno, MD 1 TXNMHO / TAPM Annual ... R J Crossno, MD

Non-Pain Symptom Management March 2012

R J Crossno, MD 1

TXNMHO / TAPM Annual Convention

March 28 2015

• Ronald J Crossno, MD FAAHPM

Chief Medical Officer, Kindred at Home

(formerly Gentiva)

[email protected]

• Disclosures

No relevant financial disclosures

Off-Label indication is entered on slides as “OL”

• Identify common non-pain symptoms

encountered in the hospice setting, including

dyspnea, nausea, anxiety, and fatigue

• Describe the choice of appropriate therapeutic

interventions to address these symptoms


R J Crossno, MD 2

• 70-yo female living at home

• Diagnoses

• COPD, CAD, CHF, PVD

• Continued tobacco use

• Functional

• PPS 50% / cognitively intact (with oxygen on)

• Structural

• Dyspnea with any exertion & sometimes at rest rated up to 7 on the Borg scale

• Occasional angina; 2+ pedal edema; BMI = 17; SaO2 = 84% on room air

• Current COPD meds / txs include

• Oxygen @ 2L/m, prn

• Duoneb® treatments every 4h as needed

• Xopenex® neb twice daily

• Advair® 1 inh twice daily

• Serevent® 1 inh twice daily

• Spiriva® 1 inh twice daily

• Combivent® MDI 2 puffs twice daily

• Singulair® daily

• What are your thoughts about these?

• Current cardiac meds

• Digoxin 0.25mg daily

• Lisinopril (Prinivil®) 40mg daily

• Carvedilol (Coreg®)12.5mg twice daily

• Aspirin 325mg twice daily

• Valsartan ER (Diovan®) 160mg daily

• Isosorbide mononitrate (Imdur®) 60mg daily

• Furosemide (Lasix®) 80mg daily

• What are your thoughts about these?


R J Crossno, MD 3

• Central & peripheral chemoreceptors

• Some report severe dyspnea despite normal ABGs

• Some patients with severely abnormal ABGs are not burdened by breathlessness

• Mechanical receptors in chest wall & respiratory muscles • Sense airflow obstruction and low lung volumes

• Vagal receptors in the airways & lungs • Sense airflow obstruction and low lung volumes

• Extra-thoracic receptors on the face & in the CNS

• Persistent dyspnea despite maximal medical

management of the underlying disease

• Breathlessness is defined by the patient

• Symptom distress is defined by the patient

• Independent of underlying etiology

• Therapies are general (global), not disease-specific

Abernethy AP, et al BMJ 2003;327(7414):523-528


R J Crossno, MD 4

• Focus on identifying and addressing underlying

cause if possible

• Focus on

• What dyspnea means to the resident in relationship to their

underlying illness

• Its effect on activities of daily living

• Concerns regarding possible treatment modalities, such as

opioids or oxygen.

• Focus on psychological and spiritual distress

TOTAL

DYSPNEA Psychological Social

Spiritual

Physical

• Improved sensation of breathlessness

• Based on 9 crossover trials mainly in COPD patients.

• Central and peripheral action

• Relief not related to respiratory rate

• No significant change in O2 sats

• Survival time is unrelated to opioid administration

• Low doses are proven safe

• Higher dose opioids may ↑ mortality risk

• Nebulized opioids are no better than placebo

• No ethical or professional barriers J Pain Symptom Manage 1999;17(4):256-65.

BMJ 2003;327(7414):523-8.

BMJ 2014;348:g445.


R J Crossno, MD 5

• Not really effective

• Recent Cochrane review encompassing 200 individuals with advanced cancer or COPD

• no beneficial effect on the relief of dyspnea in patients

• slight, nonsignificant trend toward benefit

• Do ↑ mortality rates!

•Consider as a second-line or third-line treatment for refractory dyspnea associated with anxiety

BMJ 2014;348:g445.

• Potent symbol of medical care

• Expensive

• Fan may do just as well

• RCT of O2 vs room air

• Randomized, double-blind, multicenter trial

• Non-hypoxic residents with life-limiting illness

• Oxygen delivery compared with room air by NC

• No additional symptomatic benefit for relief of refractory

dyspnea

Lancet 2010;376(9743):784–93.

• Fan

• Breathlessness Clinics

• Psychosocial support to alleviate anxiety/distress

• Positioning and pursed lip breathing

• Relaxation techniques

• (e.g. massage, guided imagery)

• Discuss symptom management with family to alleviate

concerns

• (e.g., opioids at low doses do not hasten death)


R J Crossno, MD 6

From Dyspnea Review for the Palliative Care Professional: Treatment Goals and Therapeutic Options, J Pall Med, 15(1), 106-114.

• Her medications were reviewed

• Non-beneficial medications were discontinued

• Duplicative medications were eliminated / consolidated

• Meds for symptoms started upon hospice admission

• Morphine 5mg q 4h prn dyspnea was started and titrated as needed

• Oxygen started at 1.5L/m continuously

• Nitroglycerin 0.4mg SL q 5m prn angina, max 3/h

• APAP 650mg every 4h prn minor/musculoskeletal pain

• Non-pharmacologic measures

• Fan in room

• Hospice aides to help with ADLs

• SCC and SW to help assess/counsel regarding anxiety-inducing concerns

• Optimize disease-directed treatments

• Opioids are the mainstay of dyspnea management when other,

definitive treatments are no longer effective

• Oxygen may help for dyspnea associated with hypoxemia

• Non-pharmacologic techniques are always worth trying

• Goals of care must be considered

• Never assume that interventions are always benign

• Sometimes our treatments may hasten death

• Try to anticipate what has a reasonable likelihood of

happening, such as a respiratory crisis with severe pulmonary

disease

• Ensure there is a plan in place to manage such crises


R J Crossno, MD 7

• 31-yo M financial consultant

• Diagnoses

• HIV-AIDS, Visceral Kaposi’s sarcoma, wasting syndrome

• Function

• PPS = 40% / FAST = 4

• Structural

• BMI = 17

• c/o pain, currently controlled with oxycodone

• c/o nausea, uncontrolled with meds; last BM 2 days ago with

normal bowel sounds

• Has been unable to take HAART meds due to the

gastrointestinal upset

• Current “GI” meds include

• Promethazine 25mg every 4h prn

• Prochlorperazine 10mg every 6h prn

• Ondansetron 8mg every 4h prn

• Other meds

• Oxycodone ER 80mg every 12h

• Oxycodone conc. 10mg every 2h prn BTP

• Lorazepam 1mg 3x daily and every 4h prn

• Key Anatomic Sites

• Important Receptors

• Evaluation

• Management


R J Crossno, MD 8

From Basic & Clinical Pharmacology, 11th Ed (Fig 62-6), by Katzung BG, Masters SB, Trevor AJ, 2008, Philadelphia,

PA: McGraw-Hill. http://www.accessmedicine.com.

• Muscarinic Acetylcholine M1

• Vestibular

• Dopamine D2

• CTZ

• Histamine H1

• Vestibular and Vomiting Center (VC)

• 5-Hydroxytryptamine 5-HT3 (serotonin)

• GI, Chemoreceptor Trigger Zone (CTZ), VC

• Neurokinin 1 (a.k.a. Substance P)

• CTZ, VC

• Toxins

• Metabolic Derangement

• Enteral Dysfunction

–Hypo-kinetic

–Obstructive

• Vestibular Dysfunction

• Cortical


R J Crossno, MD 9

• Toxins

–Drugs

–Other Exposures

• Metabolic Derangement

–Uremia

–Hepatic Dysfunction

–Hypercalcemia

• Enteric Dysfunction

–Bowel Pattern, Pain

–Change in symptoms with vomiting

–Constipation!

• Vestibular Dysfunction

–Vertigo

• Cortical

–Anxiety

–Focal symptoms, headache etc.

• Vitals and Volume Status

• Abdominal Exam

–Distention

–Hyper or Hypo-active bowel sounds

–Abnormal Masses, Ascites etc.

–Tenderness

• Neurologic Exam

• Rectal Exam (!!!)


R J Crossno, MD 10

• Renal Function

• Liver Function Tests

• Calcium

• Obstruction Series

• MRI or CT of Brain

*Appropriate to Goals and Patient’s Condition

Etiology Management

Vestibular H1 or M1 blockade

CNS Disease Corticosteroids

Constipation Stimulant laxative

Impaired GI motility Prokinetic agent

Anxiety Anxiolytics

Post-chemo 5-HT3 or NK-1 blockade

General D2 blockade

• Vestibular (H1 or M1 Blockade)

• MeclizineOL 25 to 50 mg PO TID

• Scopolamine via Patch, IV or SC

• CNS Disease

• Dexamethasone 8 to 16 mg PO, IV, SC

• Constipation

• Senna 2 tabs PO one to three times/day

• Methylnaltrexone 8 to 12 mg SC QOD for refractory cases

• Impaired GI motility (Prokinetic Agents)

• Metoclopramide 10 mg PO/IV AC TID + HS


R J Crossno, MD 11

•Anxiety (Anxiolytics)

• LorazepamOL 0.5 to 2 mg PO/IV Q 4-6 hours

• Post Chemo (5-HT3 and NK1)

• Ondansetron - variable dosing (4 to 32 mg)

• Granisetron 1 mg PO Q 12 hours

• Aprepitant 125mg day 1, then 80 mg day 2, 3

•General (D2 Blockade)

• HaloperidolOL 0.5 to 1 mg PO, IV, SC

• Prochlorperazine 5 to 10 mg PO QID or 25 mg PR BID

• Frequent, small feedings

• Remove foods with unpleasant smells or visual

appearance

• Serve meals in pleasant, comfortable surroundings

• Consider “alternative” therapies

• Guided imagery has the most data showing efficacy

• He is admitted to hospice

• Exam fails to reveal acute findings other than some

constipation and general nausea

• Routine meds are started to help manage nausea

• Senna 2 po BID

• Haloperidol 1mg po BID

• Ondansetron is continued for prn usage

• These medications plus guided imagery are effective

for nausea management


R J Crossno, MD 12

• Always rule-out impaction as a cause for nausea

• Be familiar with etiologies of nausea and use of

various medications to cover different neuroreceptors

involved in mediating nausea

• Combining meds that block other involved receptors may be

needed

• Nonpharmacologic treatments may be helpful

• Topical gels for nausea are no more effective than

placebo

• There are virtually no detectable blood levels of these drugs

when administered topically

• 65-yo F former housekeeper living with her daughter

• Diagnosis

• ASHD, CHF

• Ongoing tobacco use

• Drinks 2 glasses of wine daily

• Functional

• PPS 50% / cognitively intact

• Structural

• BMI 35; NYHA IV

• At hospice admission, she c/o anxiety “all the time”

• Besides being on appropriate cardiac meds, she is

taking

• Morphine for refractory pain is effective

• Lorazepam (Ativan®) 0.5mg TID routinely for anxiety

• What else do you need to know?

• What would you consider suggesting for management?


R J Crossno, MD 13

• Most common anxiety-related diagnoses

• Generalized Anxiety Disorder (GAD)

• Anxiety Secondary to a Medical Condition

• Medications that can cause or exacerbate anxiety

• Caffeine

• Steroids

• Nicotine

• Antidepressants, antipsychotics, stimulants

• Phenylephrine (Sudafed)

• Synthroid over-replacement

• Symptoms are common and distressing

• Significant anxiety symptoms 25-70%

• Subsyndromal PTSD 20-80%

• Often presents with somatic symptoms

• Tension or restlessness

• Jitteriness or autonomic hyperactivity

• Hypervigilance

• Insomnia

• Distractibility

• Worry, apprehension, rumination

• Shortness of breath

• Need to evaluate carefully for medical causes such as pain and

dyspnea

• Often looks like GAD but can include panic attacks

• Actual underlying anxiety disorder

• Fear of death and the dying process

• Spiritual or existential concerns

• Chronic coping or personality style

• Medication side effects (akathisia from anti-emetics)

• Undertreated symptoms (pain, dyspnea, sepsis)

• Withdrawal states (sedatives, opioids)

• Delirium

• Anticipatory response to repeated aversive treatment (chemo)


R J Crossno, MD 14

• Explore fears/concerns in non-judgmental fashion

• Listen, acknowledge, normalize, remain available

• Reassurance not usually effective

• Can make highly anxious pts more anxious

• Supportive-expressive therapy

• Aims to reduce symptoms & maintain coping (not cure)

• Consider psychiatric referral

• Music Therapy

• Relaxation/ Guided Imagery/ Hypnosis

• Mindfulness Based Stress Reduction (MBSR)

• Psychotherapy

• Cognitive behavioral therapy

• Interpersonal therapy (IPT) grief work

Antidepressants if life expectancy >8 weeks • SSRI’s

• Sertraline (Zoloft®) 25-200 mg qd

• CitalopramOL (Celexa®) 10-40 mg qd

• Escitalopram (Lexapro®) 5-20mg qd

• MirtazapineOL (Remeron®) • Also helps with sleep and appetite

• Antidepressants to avoid • Paroxetine (Paxil®): anti-cholinergic and withdrawal

• Venlafaxine (Effexor®): withdrawal

• Bupropion (Wellbutrin®): seizure risk

• Start low and go slow to avoid increasing anxiety


R J Crossno, MD 15

• Benzodiazepines: drugs of choice at EOL • Lorazepam (Ativan®) 0.5-2 mg q4-6hrs prn

• Alprazolam (Xanax®) 0.25-0.5 mg q4-6hrs prn

• Clonazepam (Klonopin®) for long-acting coverage

• Can cause sedation, confusion, tolerance, abuse, disinhibition, gait instability, falls, and increased risk of death

• TrazodoneOL • Sedating but can be given in low doses during the day

(12.5-50 mg q4hrs prn)

• Buspirone (BuSpar®)

• Should be scheduled, takes at least 4-6 weeks to see an effect

(7.5-10 mg BID-TID)

Consider antipsychotics •More sedating • ChlorpromazineOL (Thorazine) 12.5-50 mg q4hrs prn

• OlanzapineOL (Zyprexa) 2.5-5 mg q 4hrs prn

• QuetiapineOL (Seroquel) 12.5-50 mg q4hrs prn

• Less sedating • HaloperidolOL (Haldol) 0.5-2 mg q4hrs prn

• RisperidoneOL (Risperdal) 0.25-1 mg q4hrs prn

• Already on a benzodiazepine

• Sertraline 50mg daily is prescribed

• Encourage moderation of alcohol & tobacco intake

• Educate about

• Interactions between benzodiazepines and alcohol

• Adverse effects of alcohol and tobacco on anxiety

• Involve rest of IDG to offer possible non-pharmacological interventions

• Over the next 3 weeks, anxiety levels greatly improve


R J Crossno, MD 16

• Anxiety is a distressing symptom

• Benzodiazepines remains the drug of choice in EOL

care

• But management involves more than just benzodiazepines

• SSRIs are very effective in managing anxiety if sufficient time

for them to work

• Always consider

• Other modifiable causes of anxiety

• Offering non-pharmacological management

• 61 yo F librarian

• Diagnoses

• Breast cancer – originally dx 8 yr ago

• Recurrent now with multiple bone mets

• Functional

• PPS 60% / cognitively intact

• Structural

• Several bone mets with pain better now, controlled with opioids and recent radiation therapy

• BMI 24, working 2 ½-days a week

• Oncologist referred to hospice

• One month after hospice admission, the patient begins to complain of increasing fatigue

• She wants to know what she can do for this

• She’s been reading about various things on the internet

• What do you recommend to her


R J Crossno, MD 17

• Most common symptom in palliative care patients with

cancer or other serious and/or life-threatening illness

• Definition

• Cancer-related fatigue is an

unusual, persistent, subjective

sense of tiredness related to

cancer or cancer treatment,

despite adequate rest, that

interferes with usual functioning

NCCN Guidelines

• Multiple scales for research use

• None in common practical use except linear analog

scale

• Cut off for clinically significant fatigue

• No clearly defined demarcation

• Most suggest > 4 or 5 on a 1-10 scale


R J Crossno, MD 18

• Considered a multidimensional syndrome, often with

multiple contributors, including

• Severity of psychological Sx’s (e.g. anxiety / depression)

• Pain

• Sleep disturbances

• Dyspnea

• Anorexia

• Anemia

• Opioid use

• Various neuromodulators (cytokine dysregulation, HPA

dysregulation, autonomic failure, drug interactions)

• Anemia – transfusions and erythropoetic agents

• Deconditioning – exercise

• Depression – antidepressants

• Infections – antibiotics

• Dehydration – fluids

• Hypoxemia – oxygen therapy

• Insomnia – sleep hygiene

• Pain – pain management (e.g. opioids)

• Metabolic / endocrine disorders – correct problem

• CorticosteroidsOL

• Megestrol acetateOL

• ThalidomideOL

• MethylphenidateOL

• ModafinilOL

• MelatoninOL

• L-carnitineOL

• Counseling

• Physical and occupational therapy


R J Crossno, MD 19

• Optimal dose and duration: unknown

• Mechanism: multiple proposed, but unknown

• Duration of benefit: unknown

• Still recommended as first-line if no contraindications

• Suggested dose: dexamethasone 8mg/d x 2 weeks

• Opioid-induced sedation

• Level 1 evidence for use in this

• Depression

• Hypoactive delirium

• Fatigue

• Some evidence for benefit and some showing no benefit

• Dose unclear, but suggest starting methylphenidate 5mg

morning, then add 5mg mid-day

• Also – no benefit with paroxetine or donepezil

• Evidence in literature for efficacy in managing CRF:

• Cognitive behavioral therapy

• Education

• Stress management groups

• Coping strategies training

• Availability may be limited for hospice patients with

advanced disease

• Counseling of family to better understand what is

happening also shown to have benefit


R J Crossno, MD 20

• She and her family are educated regarding Cancer Related

Fatigue (CRF)

• She is started dexamethasone 8mg q am

• Sleep hygiene techniques are reviewed

• Zolpidem 5mg at bedtime, if unable to fall asleep within 20 minutes, is

made available if needed

• She declines other psychological interventions at this time

• Fatigue is a very common symptoms

• May cause distress for our patients

• Education remains a mainstay of management

• Pharmacologic interventions have limited efficacy, but

end up often being tried

• Know the facts regarding pharmacologic efficacy

Documents

R J Crossno, MD 1 - Texas & New Mexico Hospice ...txnmhospice.org/docs/2015Conference/A-1(Crossno)Non-pain_Sympto… · R J Crossno, MD 1 TXNMHO / TAPM Annual ... R J Crossno, MD