Cancer associated pain

 Brief pain inventory:

BPI

Assess pain at every visit. Rate the pain ( worst, best, current, average). How does it interfere with ADL and social life?

Create a personalized treatment plan

Create a monitoring plan.

Duloxetine is the only adjunct agent with data supporting treatment of chemotherapy induced neuropathy. However a recent BMJ article challenges this.

Consult an interventional pain specialist if considering nerve blocks, trigger point injections, cryoablation, radiation ( rad onc).

Calculate total daily opioid use= convert to long acting form. Then calculate 10-20percent of this and give another prescription for breakthrough pain.

If patient needs more than 4 breakthrough pain medication dose, then pain is typically not controlled.

If pain is controlled and you want to taper the opioids:

1. If patient has been on it for over a year, taper by 10 percent per month

2. If patient has been on opiates for weeks to months, taper by 10% per week

Specific types of cancer related pain

Bone pain: Is this an oncologic emergency? If not ok to use NSAID, Acetaminophen, steroids and topical agents ( voltaren) along with opiates

Neuropathic pain: antidepressants, anticonvulsants, topical patches ( lidocaine)

Bowel obstruction pain: opiates ok

Mucositis/Esophagitis/ stomatitis pain: opiates, non opiates, gabapentin

Myeloma associated Kidney disorders

 Renal dysfunction ie lower creatinine clearance seen in 50% patients at presentation for MM ( anemia is seen in 75%).

Significance in prognosis: critically important prognostic factor is improvement in renal dysfunction with induction treatment and predicts improved survival even before response to systemic therapy is otherwise assessed.

Monoclonal plasma cell disorders are a spectrum of diseases that includes premalignant MGUS, solitary plasmacytoma, Ig-mediated amyloidosis (AL amyloidosis), and both asymptomatic and symptomatic MM

Range of myeloma associated renal dysfunction: Ig-dependent and -independent categories

Three distinct syndromes account for most cases of Ig-mediated kidney disease

1. Amyloidosis ( proteinuria, low Bp, cardiac dysfunction): monoclonal light chains and other proteins together form β-pleated sheets in the glomeruli

2. Cast nephropathy: casts and crystals composed of filtered monoclonal Ig and other urinary proteins obstruct distal renal tubules, often precipitously, and typically incite an accompanying tubulointerstitial nephritis.  Hypercalcemia, sepsis, vol depletion worsens this. Subtype of myeloma commonly associated Ig D myeloma

3. Monoclonal Ig G deposition disease ( may present with microscopic hematuria, elevated BP)intact or fragmented light chains, heavy chains, or both deposit along glomerular and/or tubular basement membranes

Pearls: Ig A myeloma has been described with Henoch Schonlein purpura ( HSP) although this is rare.

Ig-independent mechanisms:

•  volume depletion
•  sepsis
•  pyelonephritis
•  hypercalcemia, uric acid nephropathy, rhabdomyolysis
•  direct renal parenchymal invasion by plasma cells
•  Drugs:nonsteroidal anti-inflammatory drugs, and renin-angiotensin system inhibitors , zoledronic acid and pamidronate.

What is the commonest cause of renal injury? ANS:ATN due to light chains

Light chain myeloma ( 20% of all myeloma) 40-60% with renal injury

Ig D -100% develop renal injury 

Reference: Blood journal 2010