Page 64 Guide to Pain Management in Low-Resource Settings

52 Lukas Radbruch and Julia Downing

Table 1
Th e essence of symptom control:
fi rst-line medication for predominant symptoms
Medication Dosage Drug Class Comments
Dyspnea
Morphine As required, or 10–30 Opioid (μ-agonist) AE: constipation, nausea, sedation,
mg/d initially p.o., titrate cognitive impairment
to eff ect; maximum dosage
may exceed 600 mg/d
Hydromorphone As required, or 4–8 mg/d Opioid (μ-agonist) AE: constipation, nausea, sedation,
initially p.o., titrate to cognitive impairment
eff ect, maximum dosage
may exceed 100 mg/d
Lorazepam As required, or 1–5 mg/d Benzodiazepine Cumulation with repeated use
sublingual
Respiratory Tract Secretions
Hyoscine butylbromide (butyl- As required, 20–40 mg s.c. Antimuscarinergic drug (periph- No antiemetic eff ect
scopolamine) (4-hourly) eral action)
Hyoscine hydrobromide As required, 400 μg s.c. Antimuscarinergic drug (central Antiemetic eff ect;
(scopolamine) and peripheral action) AE: sedation
Nausea and Vomiting
Metoclopramide 30 mg/d; high dose: up to 5-HT antagonist Extrapyramidal AE; do not use in pa-
4
180 mg/d tients with gastrointestinal obstruction!
Haloperidol 2 mg/d up to 5 mg/d Neuroleptic drug Extrapyramidal AE

Constipation
Macrogol 1 bag orally
Sodium picosulfate 10–40 drops orally
Octreotide 0.3–0.6 mg/d s.c. Reduces gastrointestinal secretions
eff ectively, indicated for patients with
gastrointestinal obstruction
Methylnaltrexone 0.8–1.2 mg/d Opioid antagonist (peripheral Eff ective for opioid-induced constipa-
action) tion
Fatigue, Weakness
Dexamethasone 12–24 mg/d initially, Corticosteroid Gastric ulcers, hallucinations, night-
stepwise reduction after a mares, weight gain, only eff ective for a
couple of days restricted time period
Anxiety
Lorazepam 1–5 mg/d Benzodiazepine AE: paradoxical eff ects
Mirtazapine 15 mg initially, stepwise Antidepressant (SNRI) Also eff ective for treatment of panic at-
increase after 2–3 weeks tacks, pruritus; AE: sedation, increased
up to 45 mg/d appetite, liver dysfunction

Depression
Mirtazapine 15 mg initially, stepwise Antidepressant (SNRI) Also eff ective for treatment of anxiety,
increase after 2–3 weeks panic attacks, pruritus; AE: sedation,
up to 45 mg/d increased appetite, liver dysfunction
Methylphenidate 5 mg in the morning ini- Stimulant AE: agitation, restlessness, extrapyra-
tially, stepwise increase to midal eff ects, tachycardia, arrhythmia
30 (40) mg/d
Agitation, Confusion
Haloperidol 2 × 1 mg, up to 20 mg/d Neuroleptic drug AE: extrapyramidal eff ects
Levomepromazine (metho- 25–50 mg, up to 200 mg/d Neuroleptic drug AE: sedation, anticholinergic eff ects
trimeprazine)
Abbreviations: AE = adverse eff ect; SNRI = serotonin norepinephrine reuptake inhibitor.