A 57-year-old man with prostate cancer comes to the office due to progressive lower back pain. He rates the pain as 7 on a scale of 0-10. The patient has been taking nonsteroidal anti-inflammatory drugs and acetaminophen, which are no longer providing pain relief. He has had no lower extremity weakness or numbness, falls, or urinary or fecal incontinence. The patient was diagnosed with prostate cancer 3 years ago and was recently found to have multifocal bone metastases. He takes leuprolide and zoledronic acid.
Temperature is 37.2 C (99 F), blood pressure is 150/90 mm Hg, and pulse is 98/min. Examination shows tenderness to percussion along his lower spine. The abdomen is soft and nontender. Rectal examination reveals an enlarged and firm prostate and normal rectal tone. Lower extremity motor power, deep tendon reflexes, and sensation are normal.
Laboratory results are as follows:
Imaging studies show multiple osteoblastic lesions in the thoracic and lumbar spine without evidence of compression fractures.
Which of the following is the best next step in management of this patient's pain?

Question

A 57-year-old man with prostate cancer comes to the office due to progressive lower back pain.  He rates the pain as 7 on a scale of 0-10.  The patient has been taking nonsteroidal anti-inflammatory drugs and acetaminophen, which are no longer providing pain relief.  He has had no lower extremity weakness or numbness, falls, or urinary or fecal incontinence.  The patient was diagnosed with prostate cancer 3 years ago and was recently found to have multifocal bone metastases.  He takes leuprolide and zoledronic acid.
Temperature is 37.2 C (99 F), blood pressure is 150/90 mm Hg, and pulse is 98/min.  Examination shows tenderness to percussion along his lower spine.  The abdomen is soft and nontender.  Rectal examination reveals an enlarged and firm prostate and normal rectal tone.  Lower extremity motor power, deep tendon reflexes, and sensation are normal.
Laboratory results are as follows:
 Imaging studies show multiple osteoblastic lesions in the thoracic and lumbar spine without evidence of compression fractures.
Which of the following is the best next step in management of this patient's pain?

Quizplus · Accepted Answer

11ec193a_982f_a711_853d_09f541fdf3cd_MD0002_00 The World Health Organization's 3-step pain ladder offers a useful framework for the pharmacologic management of cancer-related pain. The ladder process begins with a trial of nonopioid analgesics (eg, nonsteroidal anti-inflammatory drugs, acetaminophen). If the pain is inadequately relieved by maximal doses of nonopioids, a weak opioid should be added. If the weak opioid is still unable to control the pain, it should be switched to a strong opioid (eg, morphine). However, if the initial presentation is severe pain, this stepping process should be skipped and a strong opioid should be started immediately. The most appropriate management for this patient in severe pain (≥7/10) is prompt initiation of a short-acting strong opioid, such as oral morphine. When pain control is adequate with a short-acting opioid, the cumulative dose of the short-acting opioid can be used to calculate the effective dose for a long-acting opioid such as transdermal fentanyl (Choice B). Even after starting long-acting opioids, a short-acting opioid should still be prescribed for breakthrough pain. Long-acting opioids have long half-lives, making it difficult to quickly titrate the dose while maintaining adequate pain control; therefore, they should not be used as initial therapy in patients with severe pain. (Choice A) Although systemic chemotherapy (eg, docetaxel plus prednisone) may be helpful in treating bone pain when initial androgen withdrawal therapy is no longer effective, it may take days or weeks to take effect and this patient requires immediate pain relief. (Choice C) Leuprolide, a GnRH agonist, needs to be continued indefinitely in metastatic prostate cancer to maintain suppression of testicular androgen production and prevent worsening disease progression. (Choice D) Methadone is a strong opioid with a complex and unpredictable half-life (ranging from 12 hours to 1 week). It is second-line agent that often requires the help of a consultant for safe use. Educational objective: The 3-step pain relief ladder process begins with nonopioid drugs. Patients who have insufficient pain control should be started on a weak opioid. If the weak opioid is unable to control the pain, it should be switched to a strong opioid (eg, morphine). However, patients with severe pain require initial therapy with a short-acting, strong opioid. __________ References: WHO cancer pain relief programme. (http://www.ncbi.nlm.nih.gov/pubmed/2454740) The appropriate treatment of chronic pain. (http://www.ncbi.nlm.nih.gov/pubmed/22356221)

A 57-Year-Old Man with Prostate Cancer Comes to the Office