By Carla Alexander, 4th Year Pharmacy Student March 15, 2011 Pain management in the elderly differs from that for younger people: Clinical manifestations are often complex and multifactorial Underreport pain Concurrent illnesses make pain evaluation and treatment more difficult More likely to experience medication-related side effects and have higher potential for complications However, despite these challenges, pain can usually be effectively managed in this age group. Elderly may see an increased sensitivity to analgesics ◦ ◦ ◦ ◦ Start low and go slow Reassess pain scale frequently Monitor side effects Consider renal and hepatic function as well as concurrent medications Pain is dynamic ◦ Consider IR dosing as well as scheduled ◦ Treatment should be tailored to the level of pain Relaxation, refocus Physical Manipulation (physiotherapy) Thermal therapy (heating pad, ice packs) Physical Stimulation (massage) Behavioural (support groups) High alert medications ◦ Heightened risk of causing significant harm if used in error Morphine and Hydromorphone (Dilaudid) are the most frequent high alert medications to cause patient harm. ◦ Dilaudid is 5x more potent than morphine Serious adverse events over-sedation, respiratory depression, seizures, myoclonus, death. Note: not to be used for neuropathic pain Step #1: Non-opioid such as acetaminophen, NSAID Step#2: Opioid such as codeine, oxycodone, tramadol (in combination with acetaminophen) Percocet (oxycodone + acet.) Tramacet (tramadol + acet.) T#2, T#3 (codeine + acet.) Step#3: Opioid such as Morphine, oxycodone, hydromorphone, fentanyl, methadone (used as monotherapy) Note: ◦ Steps 1 and 2 have a ceiling dose due to the combination with non-opioids (example: acetaminophen (4g/day)). ◦ Step 3 has no ceiling dose ◦ Must be on at least 60mg oral morphine equivalents for one week before started on fentanyl. ◦ Adjunct treatment include: NSAIDS, antidepressants, anticonvulsants, dexamethasone Mild-to-Moderate Pain Severe Pain First Line codeine or tramadol morphine, oxycodone or hydromorphone Second Line morphine, oxycodone or hydromorphone fentanyl Third Line methadone Note: trial non-opioid options first (acetaminophen, NSAID) Immediate Release (IR) ◦ Duration 4-6 hrs ◦ Used for acute pain “breakthrough” pain or when initiating someone on chronic therapy Sustained Release (SR) ◦ Usually lasts for 12 hrs ◦ Up to 72 hrs for fentanyl patches ◦ Unique once daily formulations Morphine, hydromorphone, tramadol More consistent pain relief More convenient for the patient ◦ Dosing OD or BID Do not crush, chew or dissolve SR products ◦ Can lead to rapid absorption of the entire 12-24hr dose leading to sedation, respiratory depression and potentially fatal dose. 1/10th the potency of morphine ◦ 200mg po codeine = 20mg po morphine Increased risk of constipation & GI upset Lower risk of overdose & addiction Converted to morphine through CYP 2D6 metabolism in our body. ◦ Some people are rapid metabolizers, therefore increased side effects because can convert faster ◦ Some people do not have CYP 2D6 therefore no metabolism takes place, no morphine formed, no pain relief. Combination products with non-opioids ◦ Acetaminophen (ex. T#1, #2, #3)- watch ceiling dose of 4g/day of acetaminophen when dosing 3g/day limit with elderly? ◦ Combination products also contain caffeine IR: tablets, syrup, injectable (IM) SR: tablets, can be halved on score line but patients must swallow half tablet intact Exception: 50mg tablet cannot be halved EDS criteria discussed later Lower risk of addiction & abuse Increased risk of seizures and nausea ◦ Watch for patients with history of seizure or on concurrent medications that lower seizure threshold Combination products ◦ Tramacet (tramadol 37.5mg + acet. 325mg) max 8 tabs/day ◦ IR: tablets- BID to QID ◦ SR: tablets- daily ◦ Note: none of the products are covered by SK Drug Plan 2x more potent than morphine ◦ 10mg oxycodone po = 20mg morphine po Equianalgesia with chronic dosing Used for mild to moderate pain when in combination with non-opioid Used for severe pain when used as single agent Increased risk of abuse potential Combination products (not on SK formulary) ◦ Percocet (acet. 325mg + oxycodone 5mg) IR: tablets, suppository SR: tablets (oxycontin) No parenteral formulation available (not on SK formulary) Used as a standard for comparing potency Available as: ◦ IR: tablets, solution, suppository, injectable ◦ SR: tablets, may be given rectally ◦ Unique SR: 24 hr coverage Kadian capsules- not interchangeable with other SR products Should not be started in opioid naïve patients 5x more potent than morphine Available as: ◦ IR: tablet, liquid, suppository, injectable ◦ SR: capsule ◦ Unique SR: 24hr coverage Tablet Not listed in SK formulary Potency is variable ◦ The higher the dose of the original opioid, the more potent the methadone is. Used for moderate to severe chronic pain as well as opioid addiction Long acting and complicated dosing ◦ Duration of pain relief: initially 4-8 hrs, increases to 24-48 hrs with repeated doses ◦ Takes 3-5 days to reach plasma steady state Peak respiratory depressant effects occur later, and persist longer than its peak analgesic effects Risk of QT prolongation Many drug interactions Available as: ◦ Tablets, oral solution, powder (all which can be administered rectally) Continue to be inappropriately prescribed, dispensed and administered to opioid naïve patients with acute pain. Indicated for the management of persistent, moderate to severe chronic pain that can not be managed by other opioids. Only to be used in patients: ◦ who require continuous around the clock opioid analgesia for extended periods of time. ◦ who are already receiving opioid therapy at a total daily dose of at least 60mg/day morphine equivalents for a minimun of 7 days (no longer considered opioid naïve). 100x more potent than morphine! ◦ 100mg po morphine/day = 25mcg fentanyl patch Available as ◦ Duragesic MAT and generic duragesic Required EDS for SK drug plan (later discussed) ◦ Parenteral solution (not on SK formulary) Less constipation, nausea, vomiting and itchiness compared to morphine Very effective Convenient dosing schedule (every 72 hrs) No ceiling dose Opioid naïve patients ◦ Need to be on at least 60mg of morphine equivalents per day for a week or longer before initiating fentanyl patch. Acute pain management ◦ Takes 12-24hrs for analgesia to take effect Unstable or poorly controlled pain ◦ Pain controlled for at least 48 hrs Not appropriate for patients with: ◦ Fever- heat activated absorptive system ◦ Diaphoresis- difficult to adhere ◦ Cachexia- lipophilic drug, won’t absorb ◦ Morbid obesity- increased absorption, lose patch ◦ Ascites Continuous delivery of opioid for 72 hrs ◦ Breakthrough” doses may still be required Blood levels reach steady state between 1224 hrs Absorption is: ◦ 47% complete after 24hrs ◦ 88% complete after 48hrs ◦ 94% complete after 72hrs Therefore a used patch contains residual drug Apply patch to a non-hairy area on chest, back, flank or upper arm ◦ Avoid areas of excessive movement ◦ If necessary, clip hair as close to skin as possible ◦ Do not shave as this irritates skin and increases absorption If patch falls off, discard it and put a new patch on at a different site. If the gel contacts your skin, wash with water. Do not use soap as it can increase the drug’s ability to go through the skin Remove patch after 3 days New patch should be applied to different site Avoid sources of heat (hot tub, waterbeds, electric blankets) Disposal: ◦ Fold sticky sides together and flush down toilet or discard in safe place (sharps container) Recommended to not cut as this will disrupt the reservoir membrane and the entire dose will be available immediately. Future: Duragesic-MAT patches may be cut, check with pharmacy first! If only need ½ strength of patch use an occlusive barrier to cover half. Pain Medication Elderly Dosing Considerations Acetaminophen Clcr 10-50ml/min: administer q6hrs; if Clcr <10ml/min: administer q8hrs. Ibuprofen NSAIDS can compromise existing renal function especially when Clcr is <30ml/min. Be aware of comorbidities: GERD/PUD, GI bleed, Asthma, Renal failure, Heart failure. Codeine Clcr 10-50ml/min: administer 75% of dose; if Clcr <10ml/min: administer 50% of dose. Tramadol Elderly >65 yrs old use with caution and initiate at the lower end of dosing range. Elderly >75 years old, do not exceed 300mg/day for IR formulation and use with great caution. •IR formulation: Clcr <30ml/min: administer 50100mg dose q12rs (max 200mg/day). •ER formulation: should not be used in patients with Clcr<30ml/min because experience more adverse effects: constipation, fatigue, weakness, postural hypotension, dyspepsia. Pain Medication Elderly Dosing Considerations Morphine Clcr 10-50ml/min: administer 75% or normal dose; if Clcr <10ml/min: administer 50% of normal dose. Oxycodone serum concentrations increase ~50% in patients with Clcr <60ml/min, adjust dose based on clinical situation. Hydromorphone Moderate renal impairment: start with a reduced dose and monitor closely. Severe renal impairment: consider use of an alternate analgesic with better dosing flexibility. Methadone Clcr <10-ml/min: administer 50-75% of normal dose. Because of its long half life and risk of accumulation, methadone is difficult to titrate and is not considered a drug of first choice. Fentanyl Elderly have been found to be twice as sensitive as younger patients to the effects of Fentanyl. A wide range of doses may be used. No renal adjustment necessary. Potency varies by agent and route Oral/rectal doses ≠ parenteral doses (IM, SC, IV) Parenteral route is 2x more potent than oral/rectal route morphine 5mg po = morphine 2.5mg SC Onset 30-60mins Advantages: Preferred and easier to administer Maintain patient independence Portable Less expensive Disadvantages: Caution with patients suffering form vomiting, difficulty swallowing or pain with swallowing IR formulations can be crushed SR formulation CANNOT be crushed ◦ Open capsule and sprinkle contents onto small amount of soft, cold food. ◦ Ensure patient does not chew the spheres ◦ Take within 30mins of sprinkling ◦ Mouth should be rinsed to ensure all medication has been swallowed Or switch formulation/route/opioid Suppository, oral solution, injectable Onset varies depending on opioid Use concentrated parenteral formulations Advantages: Rapid onset of action Disadvantages: Maximum of 2ml Must retain volume in mouth for 10-15mins Not all meds have good transmuscosal absorption (morphine) Thrush, mucositis & dry mouth may impact absorption Onset similar to oral Advantages: Used if unable to swallow pills Can administer controlled release oral opioids rectally Disadvantages: Not easy to administer Patients feel uncomfortable Limited commercial preparations Avoid in patients with diarrhea, colostomy, hemorrhoids Suppositories may be expelled before absorbed High degree of inter-individual absorption variability Not recommended due to: Painful, unreliable absorption Nerve injury, sterile abscess formation and muscle/soft tissue fibrosis with chronic injections 30-60min lag time until peak effect Subcutaneous Intravenous Transdermal Topical Nebulized Patient controlled analgesia (PCA) Etc. Defn: transient pain not controlled by around-the-clock analgesia Use immediate release products Used the same opioid for both scheduled and prn, when possible Exception: fentanyl patch 1. Idiopathic unpredictable, unknown cause 2. End of dose failure pain at the end of a scheduled interval 3. Incident pain Secondary to stimulus Nausea/vomiting Constipation Laxative should always be used when on opioid Dizziness/orthostatic hypotension Respiratory depression Urinary Retention Improves within 1 week Delirium/confusion Usually resolves in 3-4 days Sedation Tolerance develops in 2-4 days Pruritis Dry mouth Codeine, controlled release tablet, 50mg, 100mg, 150mg, 200mg For treatment of : (a) Palliative and chronic pain patients as an alternative to ASA/codeine combination products or acetaminophen/codeine combination products. (b) Palliative and chronic pain patients as an alternative to regular release tablet when large doses are required. In non-palliative patients, coverage will only be approved for a 6 month course of therapy, subject to review. *Fentanyl Patch For treatment of patients: (a) Intolerant to, or unable to take, oral sustained-release strong opioids. (b) As an alternative to subcutaneous narcotic infusion therapy. *These brands of products have been approved as interchangeable. Lecture Notes Pharmacy 557 Saskatchewan Formulary RX Files Exceptional Drug Status Program American Geriatrics Society Therapeutic Choices, 5th edition Questions?