PALLIA NOTES

Categories of Cancer pain

Type of Pain Examples Mechanisms

Nociceptive Somatic Pain  Neoplastic invasion of Activation of nociceptors
the bone, joint, muscle
or connective tissue
Nociceptive Visceral Pain  Obstruction, infiltration Activation of nociceptors
or compression of
visceral organs
Neuropathic Pain  Neoplastic infiltration or Ectopic discharge within the
compression of nerve, nervous system
plexus, or roots

Agent Mechanism of Action Titration

Paracetamol  Weak prostaglandin 2-4 g/day
inhibitor
 Primarily metabolized in
the liver
NSAID  Inhibit cyclooxygenase 1. Ibuprofen 400mg tds
inhibitor 1 & 2 2. Naproxen 250, 500mg
 Antipyretic and anti- BID
inflammatory 3. Diclofenac 50 bd-tds
(Supp: 25, 50 mg tds)
COX 2 Inhibitors  Anti-inflammatory  Celecoxib 200mg bd
 Decreased risk of peptic  Etoricoxib 60, 120 mg
ulceration OD
WHO STEP 1 Medication
 Agent Mechanism of Action Titration
Tramadol  Weak u-opioid receptor 25, 50 mg tds
agonist (max 400mg/day)
 Releases serotonin
 Inhibits noradrenaline
reuptake
Codeine Phosphate  2 10% will be 30mg bd, q4H
biotransformed to (max q4H)
Morphine
WHO Step 2 Medications

WHO Step 3 Medications

Agent Mechanism of Action Titration

Morphine solution u-opioid receptor agonists 2-5mg q 4H
Oxycodone / Oxynorm u-opioid, k-opioid agonists 5 mg q4H
Methadone u-opioid, &-opioid agonist Specialist review
NMDA receptor antagonist

Controlled Release

Morphine sulfate u-opioid agonist 10mg q 12h

Oxycontin u-opioid agonist 10mg q 12H
Transdermal Fentanyl u-opiod agonist 12mcg/hr
Q72H

Adjuvant Analgesics

Agent Mechanism of Action Titration

TCAs  Na channel blockers  Nortriptylline 10-100
 Inhibits reuptake of mg OD
serotonin and  Amitriptyline 10-75mg
norepinephrine OD
SNRIs  Inhibits reuptake of  Duloxetine 30-60 mg
serotonin and OD
norepinephrine  Venflaxine 37.5 mg OD-
BID
Antidepressants