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Terminal Pancreatic Cancer.

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Hi, someone close to me has terminal pancreatic cancer and only a few months to live. The focus now is making them comfortable. The person seems to be in continual great pain. There must be a way to manage the pain more effectively. They are at home and have elected not to have radiation or chemotherapy. Also, IV and injectable medication is not an option. She is currently taking dihydrocodeine with paracetamol. It does not seem to be very effective. It there a tablet or suppository that is more powerful than this that will better control their pain? I am currently visiting this person in China and am having difficulty communicating my concerns to others. Any help would be appreciated. Thank you

Category: Oncologist

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Category: Hematologist
 30 Doctors Online

Hello and thankyou for approaching DoctorSpring with your query.
Sorry to hear about your friend. I understand these are tough times for you'll.

I have gone through your question. There is no reason your friend should gone through this pain with the recent advances in medicine.
I am not sure why intravenous injections are not being considered. My honest opinion would be that the patient should receive morphine or pethidine injectables.
If that is not an option, patient can take a oral pain relief combination with a stronger NSAID like diclofenac or aceclofenac , with morphine, and a benzodiazepine tablet like diazepam and lorazepam. The benzodiazepine tablet will have a sedation effect on the patient. You will require a prescription for the above medications.
So in short a NSAID + morphine + a benzodiazepine combination of tablets.

Dihydrocodeine plus paracetamol are milder painkillers and will not be effective in controlling pain in terminally ill patients.

I am not sure how the prescription system works in China, but it should not be difficult to get a prescription from a primary physician for terminally ill patients.
Morphine will be required to be started in low doses, start with 15mg 4 hourly before or after food. The dose will have to be gradually increased. Prescriptions will be required.

I will leave this consult open so you can get back to me anytime. You can discuss with the treating doctor too what options are available and I will help you.
I hope this has helped.
Thankyou
Thankyou


Patient replied :

Thank you for your reply. Your information is very helpful to me.

Tomorrow i meet with the head family member and a doctor.

I have a few questions for you that will help me prepare for the meeting:

1) Is oxycodone (Opana ER) the best oral painkiller for this situation? What about HYDROMORPHONE (Dilaudid). Is there one I am not mentioning? According to my reading, both drugs are more powerful than morphine alone. Please advise for the best drug for pain in this situation. You already mentioned morphine. I was wondering if either mentioned drug was a more specific example of a morphine derivative?

I read about ZOHYDRO. It is a new drug approved in the US. It is supposed to be very strong. I do not know if it is available in China yet.

2) from my understanding, the patient was very nauseous taking another painkiller. I do not know which one. So they switched to Dihydrocodeine plus paracetamol, which you said was not strong enough. You mention phenergan and zofran as drugs that help with nausea. Can these drugs be used with Dihydrocodeine plus paracetamol, or oxycodone, or HYDROMORPHONE? If they do not work with these drugs, are there nausea drugs that will work with these painkillers?

3) Another side effect of Dihydrocodeine plus paracetamol that the patient is experiencing is much itching all over her skin. She has scratched many cuts into her skin scratching. Is there a drug to help this side effect of itching?

4) the reading on oxycodone said the patient may suffer depression. Is there an antidepressant that will work with these drugs okay?

5) another major side effect is constipation. Which laxative do you recommend in this situation?

6) the last major side effect the patient has is insomnia. You mentioned benzodiazepine will have a sedation effect. Can benzodiazepine just be given at night to help sleep? I do not want her to be unconscious all day as well so she can talk with people. Are there other recommendations for a sleep aid? Maybe if the other side effects and pain are controlled, she will sleep better.

7) Some people have had success in decreasing their pain by using anti-seizure medication like topomax (topamax) or lyrica. Do you recommend any of these in this situation?

8) antidepressants can have a positive effect. Amitryptiline is an old standby for chronic pain sufferers. Do you recommend any of these in this situation?

9) one surgical procedure for pain is a nerve block where alcohol is injected into
The relevant nerves to deaden them, or the nerves are actually cut. What is your
Opinion for doing this in this situation? 11) another side effect/symptom is lips she has a lot of fluid retention in the abdomen. Is there anything to be done for this?

I think these are my questions for tomorrow. Thank you very much for your help. I an having difficulty communicating my concerns to others. Your information will help me organize my questions better.

Thank you,

Kent




1. Any potent opioid will do good in this case. There is no evidence to say Oxycodone is the best pain killer. Opioids are the best choice. Any of the above medications can be chosen. Potency has no significant practical value. (Rather than potency it is 'equivalent value'. This not to be confused with potency). I suggested morphine because it is the most commonly used (and effective for most individuals). And unlike many other drugs Morphine has an IV and oral form. So switching is also easy. If I have to suggest any other option among opioids that would be transdermal fentanyl patches. Please discuss this with your doctor.

2. Yes these drugs will work with opioid painkillers. Nausea and vomiting are known side effects/ infact with IV opioids patient will need to take anti emetic injections also

3. The itching could be due to obstruction of the bile duct resulting in obstructive jaundice. Cholestyramine and Ursodeoxycholic acid are two medical options. Surgical options can be considered in discussion with your Doctor

4. SSRI antidepressants can be used. But this need not be used at first stage. It is important to have a realistic approach to pain management. There are going to be many side effects from pain management. So a treatment over treatment is not recommended. The aim here is to avoid physical pain and stress, which will take care of the mental health in most cases.

5. High fibre diet - mainstay. Treatment options include prophylactic laxative regimen that might include a stool softener and contact cathartic (eg, docusate 100 mg orally twice daily and senna two tablets at bedtime) or daily administration of an osmotic laxative (eg, lactulose 30 ml daily or polyethylene glycol two tablespoons daily)

6. Pain control will improve sleep. Benzodiazepine will help too and it can be taken night only.

7,8,9 - Not as first line. Opioids are the first line and it should take care of the pain in most cases. Start opioids and asses response. Increase dose if not working.

10. Fluid can be easily drained. This is important for patient comfort. Your GP can easily drain this using a needle and drain.

Thank you

8.


Patient replied :

Thank you very much for your help. The meeting went well today with the family and doctor. It seems the big problem is obtaining morphine based drugs here in China. They are strictly controlled. Also, some of the other medications may not be easily available either. They understand the issues better now, and will try to get the medications you suggested.

The other obstacle is the patient. Everything would be easier if she was willing to stay at the hospital longer. Her mother had this disease as well. So, the patient saw how much the mother suffered in the hospital, and she does not want to go through the same thing.

I am trying to talk with her and tell her if she stays at the hospital a few days to set up the treatment regimen you described, she can then go home and use this treatment regimen at home. She will then be much more comfortable at home.

If it is okay, I will leave this discussion open for now if there are a few more questions to ask you. You have done much already. If I must pay another fee to keep talking with you, please let me know how I can pay it to continue this conversation.

Thank you very much,

Kent


Hello Kent,

Opioids are regulated world over. So you will need your Doctor's help in this regard.
Patient compliance is very important. You can motivate her for the treatment. But remember it is always important to give patients wishes first priority if she is thinking clearly. Many patients at end stage diseases prefer to bear some pain rather than be troubled from sedation and undesirable side effects.

A hospital visit for Palliative care is not really necessary. (but it depends on the country). There are home palliative care team which can set up the treatment.

I think you can ask 3 followups. After that I think the consult will disappear from dashboard. Please contact [email protected] for assistance regarding this. They know better.

Hope this helps
Thank you


Patient replied :

Thank you for your help. She passed away. So this question can be closed.


I am sorry to hear that. My sincere condolences to you.


Dr. Prasad Eswaran
Category: Hematologist
Experience: 
Doctorate in Medicine (Fellowship in Oncology), DM,  Madras Medical College & Govt. General Hospital, Chennai, India.

Doctor of Medicine (Residency in Radiation Oncology) , MD, Christian Medical College, Vellore, Tamilnadu, India, 2004-06.

Diploma in Medical Radiology & Therapy (Residency in Radiation Oncology), D.M.R.T, Madras Medical College & Govt. General Hospital, Chennai, India, 2004-06.

Bachelor of Medicine & Bachelor of Surgery - M.B.B.S, Govt. Stanley Medical College & Hospital, Chennai, India, 1998-2004.
Dr. Prasad Eswaran and 4 other Medical Specialists are ready to help you

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