A 71-year-old man with metastatic prostate cancer comes to the office due to progressively worsening back pain. The patient reports pain of 5 on a 10-point scale. The pain is notably worse with movement and limits his activity. He reports no lower extremity weakness or numbness and no bladder or bowel dysfunction. He is taking ibuprofen 3 or 4 times a day, and his pain is not controlled. The patient takes androgen deprivation therapy and has also received palliative radiotherapy for multiple lumbar spine metastases recently. Temperature is 37 C (98.6 F), blood pressure is 140/86 mm Hg, and pulse is 88/min. Lower extremity motor strength, deep tendon reflexes, and sensation are normal. Which of the following is the most appropriate initial therapy for this patient's pain?

Question

A 71-year-old man with metastatic prostate cancer comes to the office due to progressively worsening back pain.  The patient reports pain of 5 on a 10-point scale.  The pain is notably worse with movement and limits his activity.  He reports no lower extremity weakness or numbness and no bladder or bowel dysfunction.  He is taking ibuprofen 3 or 4 times a day, and his pain is not controlled.  The patient takes androgen deprivation therapy and has also received palliative radiotherapy for multiple lumbar spine metastases recently.  Temperature is 37 C (98.6 F), blood pressure is 140/86 mm Hg, and pulse is 88/min.  Lower extremity motor strength, deep tendon reflexes, and sensation are normal.  Which of the following is the most appropriate initial therapy for this patient's pain?

Quizplus · Accepted Answer

11ec25c8_d47f_1d3f_bc81_991d22de169c_MD0003_00 This patient has bone metastases with progressive pain despite specific cancer-directed treatment (ie, androgen deprivation therapy, radiotherapy). Mild cancer-related pain can usually be managed with nonopioid analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]). However, if nonopioid interventions are ineffective, as in this patient with moderate to severe (eg, >4/10) pain limiting activity despite NSAIDs, short-acting opioids (eg, oxycodone, morphine) should be offered. Short-acting opioids are safe and well tolerated when taken as directed, and the dose and schedule can be easily adjusted to the patient's pain pattern. Once short-acting opioids have been started, if the patient's pain requires frequent dosing or if bedtime doses do not provide adequate relief through the night, conversion to long-acting opioids can improve convenience (eg, less frequent dosing) and help stabilize pain control (eg, steady drug levels). Options include extended-release morphine and transdermal fentanyl. However, due to the risk of respiratory depression, patients not receiving opioids should generally not be started on long-acting opioids initially (Choice E). Rather, they should have a trial of short-acting opioids that can be readily titrated and then converted to a long-acting opioid dose that can be safely tolerated. This approach provides adequate analgesia while avoiding the risk of "overshoot" from the accumulation of long-acting opioids prior to reaching their steady state. Even after transition to a long-acting formulation, short-acting opioids should still be available for rescue treatment of breakthrough pain. (Choice B) Naproxen has a longer duration of action than ibuprofen and can be used in patients who require frequent dosing. Switching from one NSAID to another can be considered for patients with mild pain, but this patient's activity-limiting pain warrants a trial of opioids. (Choice C) Systemic glucocorticoids (eg, dexamethasone) are used urgently for the treatment of malignant neurologic compromise (eg, spinal cord compression). They are also sometimes used as adjunctive therapy in patients who have bone pain without neurologic deficits if there is incomplete improvement on opioid therapy alone. (Choice D) Topical capsaicin is useful for mild to moderate joint and neuropathic pain (eg, postherpetic neuralgia); it is unlikely to relieve metastatic bone pain. Educational objective: Mild cancer-related pain can usually be managed with nonopioid analgesics. However, if initial interventions are not effective, intermittent doses of short-acting opioids should be offered. If the pain requires frequent dosing or if bedtime dosing does not provide relief through the night, then conversion to a long-acting opioid is helpful. References: Oral morphine for cancer pain. (http://www.ncbi.nlm.nih.gov/pubmed/27105021) Optimal pain management for patients with cancer in the modern era. (http://www.ncbi.nlm.nih.gov/pubmed/29603142)

A 71-Year-Old Man with Metastatic Prostate Cancer Comes to the Office