Page 369 Guide to Pain Management in Low-Resource Settings

Drug Profi les, Doses, and Side Eff ects 357

Because tricyclic antidepressants may impair the problem). Always identify and treat the underlying
liver function, it is advisable to check the liver enzymes cause along with giving symptomatic treatment with
regularly (e.g., once a month for 3 months and than neuroleptics (titrate in increments of 2.5 mg to eff ect
once every 3 months). Before initiating tricyclic antide- with haloperidol with a “normal” daily dose of 2.5 to 5
pressant medication, check the ECG for major AV node mg t.i.d.). In advanced cancer patients, delirium may
irregularities and polytope extrasystoles. also be a sign of reaching the terminal stage (“terminal
Up to 20% of cancer patients develop episodes disorientation”). Even at the fi nal stage of illness, deliri-
of depression, and in this case antidepressants with the um should be treated, to reduce the stress of the patient
lowest side eff ects should be used (SNRIs and SSRIs). and family.
Neuroleptics (like benzodiazepines) have no an-
Steroids algesic effi cacy and therefore should never be used for

Steroids are widely used in cancer pain therapy, es- the indication of pain. Pain needs analgesics and not se-
pecially in patients with an advanced stage of disease. dation, with the exception of terminal sedation, when all
Th ese agents reduce perineural edema and may inhib- available alternatives for pain control fail.
it spontaneous activity in excitable, damaged nerves Note also that neuroleptics are potent blockers
due to cancerous infi ltration or compression of nerval of D receptors in the dopamine pathways of the brain.
2
structures. Because of their anti-infl ammatory eff ects, Th erefore, they have direct eff ects on opioid-induced
steroids may be also used in chronic infl ammatory dis- nausea and are very valuable antiemetics (a dose of 0.5
eases, such as rheumatoid arthritis. In cancer patients to 1 mg of haloperidol t.i.d. is suffi cient for that purpose
the drug of choice is dexamethasone, which provides and is without psychomimetic eff ects).
only glucocorticoid properties, causing less fl uid reten- Other neuroleptics that may be available in-
tion and potassium loss as compared to hydrocortisone clude thioridazine (25 to 50 mg daily), chlorpromazine,
or prednisolone. Th ere is no evidence-based dosing and levopromazine. Th ey all have a low neuroleptic po-
scheme, but in acute pain exacerbation because of mas- tency, but a good sedating eff ect, and therefore may be
sive cancer progression, a common approach would be used as sleeping pills in cancer patients. Th e new “atypi-
to use a loading dose of approximately 24 mg the fi rst cal” neuroleptics such as olanzapine or risperidone are
day and then reduce the dose subsequently over the fol- not the fi rst choice for cancer patients and should be re-
lowing days to a maintenance dose of 2 mg daily. served for patients with psychiatric disorders.
Side eff ects can prove to be benefi cial for the Antipsychotics are associated with a wide range
patient, such as euphoria and an increased appetite in of side eff ects. Extrapyramidal reactions include acute
cachectic patients. “Negative” uncommon side eff ects dystonia, tardive dyskinesia, and Parkinson-like symp-
may include psychotic episodes and myopathies. Other toms (rigidity and tremor) due to blockage of dopamine
typical side eff ects such as osteoporosis, skin thinning, receptors. Tachycardia, prolonged QT interval, hypo-
diabetes, and adrenal suppression are of less importance tension, impotence, lethargy, seizures, and nightmares
in the target patient with limited life expectancy. To lim- are possible. Another serious side eff ect is neuroleptic
it the risk of gastric ulcers, do not combine NSAIDs and malignant syndrome. In this case the temperature regu-
steroids, and do not use steroids unless critical in the lation centers fail, resulting in a medical emergency, as
noncancer patient. the patient’s temperature suddenly increases to danger-
ous levels. Most of the above-mentioned side eff ects are
Neuroleptics
fortunately rare and not of relevance in the period of the
Neuroleptics are psychoactive drugs that are commonly end of life.
used to treat psychotic episodes and nausea. Patients
with advanced cancer often suff er from delirium. Do Benzodiazepines
not underestimate the distress for the patient and family Benzodiazepines are a group of drugs with varying
in the presence of delirium. Try to identify the reason sedative, anxiolytic, anticonvulsant, and muscle relax-
for the delirium. Most of the time it is the fi rst sign of ant properties. Th e main indication for these drugs in
infection, renal failure, dehydration, or electrolyte im- pain management and the palliative care management
balances. In rare instances, it may also be a side eff ect of is the treatment of anxiety and intractable dyspnea.
opioid therapy (in which case, opioid rotation will solve Do not hesitate to prescribe these drugs for terminal