Page 38 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)
• Titration
Early assessment and dose titration must be carried out in all patients
initiated on opioids. Dose titration can be done as early as 24 hours
after initiation. A dose increment may be necessary when a patient
reports persistent pain, or needs to take multiple doses for breakthrough
pain (>3 doses) throughout the day, while a dose reduction may be
warranted if there are intolerable side effects.
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25 - 50% of the total daily dose, taking into consideration patient factors
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such as organ function, frailty and co-morbidities. However, if the
patient persistently requires many rescue doses despite increasing
ATC medication, other pain conditions need to be considered and
further assistance from specialist is required.

Options of titration:
{ Calculate the total daily dose of 4-hourly opioid + dose of opioids
taken for breakthrough pain over the last 24 hours (Limit to 50%
dose increment within 24 hours. If >50% increment is needed, to
consult specialist.)
OR
{ Increase opioid daily dose (25 - 50% of the daily dose) for patient
who takes no rescue doses but still has uncontrolled pain

Example 1:
To determine the new dose of opioids, the total daily dose of opioid is
calculated (4-hourly opioid added with the total dose of opioids taken
for breakthrough pain over the last 24 hours). This is divided by 6 to
give the new regular 4-hourly doses.

Patient is on aqueous morphine 5 mg 4-hourly and takes 3 extra rescue
doses.
Total 24h morphine = (5 mg x 6) + (5 mg x 3) = 45 mg/24h
New 4-hourly dose: 45 mg/6 = 7.5 mg (rounded down to nearest mg)
Prescription: aqueous morphine 7 mg 4-hourly and 7 mg PRN

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