Page 48 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)
Management strategies include awareness and recognition of the
AEs, symptomatic management of individual AEs and adjustment of
opioid dosages, including dose reduction and opioid switching. Refer
to $SSHQGL[ D for 6XJJHVWHG 0HGLFDWLRQ 'RVDJHV DQG $GYHUVH
(YHQWV LQ $GXOWV The management of the side effects is discussed
below.
• Constipation
{ Constipation is the commonest reported AE with a 25% incidence
rate. 53, level I
{ &RQFXUUHQW SURSK\OD[LV IRU FRQVWLSDWLRQ H J VWLPXODQWV DQG
VRIWHQLQJ OD[DWLYHV LV UHFRPPHQGHG IRU DOO SDWLHQWV RQ UHJXODU
opioid therapy. 9
{ The rate of constipation is lower for fentanyl than morphine. 54,
level I Thus, fentanyl can be considered as an alternative in severe
morphine-induced constipation. 9
• Nausea and vomiting
{ Nausea occurs in 21% while vomiting in 13% of patients on opioid
therapy. 53, level I
{ These AEs are temporary and tolerance commonly develops in 5
-10 days after initiation of opioids. 9
{ Anti-emetics e.g. metoclopramide, haloperidol and prochlorperazine
can be used to treat these AEs. 9
• Dry mouth
{ The incidences of dry mouth are variable, ranging from 17% 53, level I
to 94%. 54, level I
{ It is particularly important, as patients on opioid therapy rated the
symptom as moderate to severe. 54, level I Non-pharmacological
measures e.g. oral hygiene, sugar-free chewing gum/candies,
and saliva stimulant mouth spray/gel can be offered to patients to
improve their symptoms.
‡ 6HGDWLRQ DQG GURZVLQHVV
{ 6HGDWLRQ FDQ RFFXU DW WKH LQLWLDWLRQ RI RSLRLG WKHUDS\ DQG WHQGV WR
resolve within a week. 9
{ 6RPQROHQFH LV UHSRUWHG LQ RI SDWLHQWV 53, level I and drowsiness
LQ XS WR ZLWK WKH UDWH RI GURZVLQHVV KLJKHU LQ R[\FRGRQH
compared with other opioids, even where low doses are used. 54, level I
{ In many patients, symptoms are brief and patient education
LV VXI¿FLHQW )RU SDWLHQWV ZLWK FR PRUELGLWLHV PHWDEROLF
encephalopathy, dementia) and on concomitant sedation use,
9
prolonged sedation may occur.
{ Management strategies include dose reduction, titration using the
9
lowest effective dose, and opioid switching. Methylphenidate and
other psychostimulant drugs can be considered if necessary. 9; 40
‡ 'HOLULXP DQG QHXURWR[LFLW\ LQFOXGLQJ FRQIXVLRQ DQG P\RFORQXV
{ Transient mild cognitive impairment may occur upon opioid initiation
and usually resolves within 1 - 2 weeks. 9

30

e-cpg inside text-Cancer pain-25/5/24.indd 30 09/08/2024 12:09 AM