P Sylvester MBBS D Narinesingh MBBS MMed FCRad

P Sylvester (MBBS), D Narinesingh (MBBS , MMed , FCRad. Onc) THE PATIENT WITH METASTATIC BONE PAIN: A PRACTICAL EVIDENCED BASED APPROACH

Case 50 year old female Metastatic Left Breast cancer Solitary Liver metastases ER+ PR+ HER 2+ Performance status (PS) = 2 Severe lower back pain Numerical pain score = 8 Bone scan and MRI revealed bone metastases to vertebra L 5

WHO Analgesic Ladder Bone Pain BMA Radiotherapy

Bone pain Affects quality of life (Mental + Physical) Nociceptive somatic pain Assessment of pain by : 0 -10 Numeric pain scale Faces pain rating scale Three intensities: Mild pain(1 -3); Moderate(4 -6); Severe (7 -10) Psychosocial support and Patient education NCCN guidelines Version 1. 2012 , Adult Cancer Pain

WHO Analgesic Ladder http: //pharmacologycorner. com/wp-content/uploads/2009/03/image. png

Commonly Selected Analgesics Non opiod Acetaminophen Ibuprofen Diclofenac Arcoxia/ Celebrex Combined ( Weak Opioid + Non opioid) Panadeine Tramacet Opioids Morphine sulphate oral Morphine parenteral Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v 257 -v 260, 2010

Opioid Scheduling and titration Goal Rapid pain relief Initial dose regime 5 -7. 5 mg sc q 4 hr “Breakthrough dose” transient exacerbations of pain = 10 -15% of total daily dose Revision of analgesic regime more than 4 “breakthrough” doses per day are administered dose titration Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v 257 -v 260, 2010

Co analgesics for neuropathic pain Antiepileptic Carbamazepine Pregabalin Antidepressant Fluoxetine Amitryptiline Neuroleptic Haloperidol Chlorpromazine Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v 257 -v 260, 2010

Bone modifying agents (BMA’s) [1] Adjunctive therapy for pain control Zoledronic acid/Donesumab superior in terms of delaying SRE[2] Calcium and Vitamin D supplementation Monitor creatinine clearance for intravenous bisphonates Monitor calcium levels Dental exam and preventive dentistry before using a BMA [1]Van Poznak CH, Temin S, Yee GC, et al: American Society of Clinical Oncology Executive Summary of the Clinical Practice Guideline Update on the role of Bone-Modifying Agents in Metastatic Breast Cancer. J Clin Oncol 29: 1221 -1227, 2011 [2] Stopeck A, et al. J Clin Oncol. 2010; 28: 5132 -5139.

Palliative radiotherapy Specific and Critical efficacy in pain relief[1] Clinical mark up Areas of maximal pain intensity Whole pelvis radiation Radiation to spine Doses (tailored to Performance Status) 8 Gy in 1# / 30 Gy in 10# / 20 Gy in 5# Studies show 8 Gy in 1# = 30 Gy in 10# [2] Bone targeted radioisotopes E. g. Strontium-89 [1] Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v 257 -v 260, 2010 [2] Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst. 2005; 97: 798 -804.

Case Management Initial Bone Pain Management Zoledronic acid 4 mg iv q 4 weeks Oral Morphine Mild relief after initial management Also developed BL Lower limb paresthesiae 2 o tumor infiltration Palliative RT to L 5 (30 Gy in 10#) Had good pain relief after RT Now on Pregabalin After one year of BMA therapy ○ Pain score = 1 ○ PS = 0

IN SUMMARY Mild to Moderate • Non opioids ± weak opioids • Zoledronic acid Severe • Opioids • Zoledronic acid Refractory pain • Palliative RT • Reassess pain