Pain management is an integral part of the care of a cancer patient. The risk factors during pain management of patients with hematologic malignancies are above all thrombocytopenia, bleeding or hepatic and renal toxicity during chemotherapy and hematopoietic stem cell transplantation.
CAUSES OF PAIN
Therefore due to the abovementioned factors, weak and strong opioids in particular and less so nonsteroidal anti-inflammatory drugs are administered to these patients to manage cancer pain. A patient with blood cancer regularly suffers pain of varying intensity. For some patients, particularly children and sensitive individuals, regular collection of blood could be painful, which can be resolved with the timely local application of cream containing Lidocaine and Prilocaine before collection.
A specifically painful procedure is bone marrow collection when local anaesthesia (Trimecaine, Articaine) needs to be used. Patients with multiple myeloma (with skeletal pain) also need opioid premedication to provide relief from breakthrough pain during the procedure (Morphine, Pethidine, and possibly Fentanyl in the form of transbuccal or sublingual tablets or a nasal spray). The same analgesic measures also apply to the insertion of central venous catheters and port catheters. Besides invasive procedures, the source of pain also tends to be the actual cancer treatment and its complications. Painful toxic-inflammatory mucositis of the oral cavity, pharynx and other parts of the digestive system can also accompany intensive high-dose chemotherapy and autologous or allogeneic stem cell transplantation or intensive treatment of acute leukaemia with high-dose Cytarabine and Anthracycline.
Equally painful are also the affected mucous membranes as part of the graft reacting against the host after allogeneic stem cell transplantation. Patients with multiple myeloma treated with Bortezomib and Thalidomide typically develop neuropathic pain of the lower extremities. Treatment with Vincristine tends to be accompanied by paresthesia of the fingers of the hands and soles of the feet. An accompanying symptom of repair or activation of hematopoiesis, especially when using the growth factors of granulopoiesis (Filgrastim, Pegfilgrastim, Lipegfilgrastim), can be skeletal pain of the pelvis, spine, myalgia and arthralgia. The basic problem due to its intensity and duration is pain from the actual malignancy (effect on the body skeleton, infiltration and compression of the spinal nerve roots).
THERAPEUTIC MODALITY
Every form of pain always requires an individual approach. Recommended procedures for the pharmacotherapy of cancer pain using the WHO three-step analgesic ladder are used to manage pain. According to this ladder the treatment of first choice are non-steroidal anti-inflammatory drugs. Obviously the risk of bleeding needs to be considered when using these drugs during simultaneous relatively common thrombocytopenia or in case when after stimulation by the growth factor of granulopoiesis it is planned to collect peripheral stem cells. Here, the alternative can be Paracetamol, Tramadol, or a combination of both.
Hepatic, renal and gastrointestinal toxicity also need to be considered when using non-steroidal anti-inflammatory drugs, as well as their antipyretic effects, which can suppress fevers that in blood cancer are considered a major symptom of the ongoing – often asymptomatic – systemic infection of patients with severe neutropenia. Tramadol can be used for more severe pain caused by a malignancy, graft reaction against the host or in oral mucositis, morphine can also be administered in severe cases depending on the current need subcutaneously (intramuscular injection is contraindicated due to frequently present thrombocytopenia: < 50 × 109/l) or in continuous intravenous injection by linear dosers, or as part of the patient-controlled analgesia (PCA) strategy.
An alternative to the administration of morphine, with minimum adverse effects, are the transdermal forms of Fentanyl and Buprenorphine. However, the limitations of transdermal application have a slow onset of action and the dose cannot be adjusted as quickly as is required, especially for breakthrough pain. In such cases faster acting forms of Fentanyl (buccal or sublingual tablets or a nasal spray) can be used. At the start of opioid treatment preventive administration of the antiemetic/prokinetic of Metaclopramide and Lactulose syrup to reduce the risk of constipation is recommended. Increased caution is necessary when using opioids especially in patients receiving neurotoxic treatment or patients with conditions increasing the risk of reducing peristalsis (multiple myeloma, Bortezomib, Thalidomide, Vincristine). In these cases there is the risk of significant constipation and even paralytic ileus. Accelerated absorption of a transdermally administered opioid needs to be considered in patients with feverish conditions and simultaneous neutropenia. Coanalgesics from the class of antidepressants and antiepileptic drugs can also be indicated in pain management. Gabapentin can be administered preferably for peripheral neuropathic pain, whereas Butylscopolamine or a combination of Metamizole with Pitofenone is used for spasmolytic effects.
CONCLUSION
Pain management is an integral part of the care of patients with hematologic malignancies. It is essential that it is chosen individually while opioids play a central role because of their effect, good tolerance and zero hematologic toxicity.
Source: Vokurka S. Léčba bolesti u pacientů s hematologickou malignitou. Acta Medicinae 2016; 5 (Suppl.): 36–37. Published on https://www.prolekare.cz/tema/lecba-bolesti-v-onkologii/detail/ovlivneni-bolesti-u-hematoonkologickych-pacientu-8615.
