Panel recommends consideration of several factors when selecting intrathecal drug treatment for patients with cancer pain.
A distinguished panel of pain management clinicians recently released consensus guidelines intended to “assist clinicians in identifying the candidacy of patients with cancer-related pain and end of life diseases causing pain that may benefit from intrathecal drug delivery.”
Noting that clinical trials have shown that “intrathecal drug delivery is a viable treatment strategy for both neuropathic and nociceptive pain in the cancer population” that can produce “improved pain relief and decreased adverse effects… compared with conventional medical management alone,” the authors of these guidelines caution readers that “Proper patient selection, implantation technique, maintenance, and continued vigilance are paramount to reduce predictable iatrogenic complications and ensure success” when using intrathecal (IT) drug delivery systems to treat patients for pain. To help guide physicians in making the proper assessments and IT drug treatment choices for patients suffering from cancer-related pain, an expert panel evaluated the available data supporting various measures and interventions and created these guidelines, supported by explanations of the evidence backing their recommendations for “clinically relevant management decisions.”
Regarding the prevalence, impact, and need for better treatment for cancer- and non-cancer related pain, the authors reported:
IT drug therapy can “effectively reduce neuropathic and mixed neuropathic-nociceptive pain in cancer patients, while relieving drug-related toxicities and minimizing the need for supplementary systemic opioids.” Adverse effects associated with IT drug therapy include “opioid-induced hyperalgesia, hypotension, sedation, respiratory depression, inflammatory mass, hypogonadotropic hypogonadism, and immunologic compromise.” Other dangers associated with this approach to pain management include increased mortality risk from rapid and improperly monitored dose escalation. To guard against adverse events, the panel recommended that “therapy be initiated at low doses, with slow titration upward, as necessary, based on patient response.”
Recommendations for selecting patients for treatment with IT drug therapy include:
Because it “may be difficult to overstate” the role played by psychological factors and emotional stresses in patients’ response to pain and pain treatment, clinicians should consider conducting a pre-implantation psychological evaluation of patients suffering with cancer-related pain based on the status of the patient’s disease. The authors identify three levels of need:
Although IT drug therapy trials prior to permanent device implantation can be used to “determine patient response to therapy and establish a baseline measurement from which potential improvement can be assessed,” research has not yet established “a direct correlation between a patient’s response during an IT trial and subsequent effects of therapy.” Thus, the panel reminds that “it is up to the implanting clinician to weigh the benefits and limitations of each trialing method and decide which technique—if any—is best suited for the patient.” The panel also recommends against the use of mandatory IT drug trials, especially for patients near the end of life.
In the conclusion to these recommendations, the authors wrote that although there has been “relatively limited application of this treatment modality,” IT therapy can “significantly help cancer patients with severe pain.” The authors recommend that clinicians seeking to optimize outcomes with IT drug therapy should ensure “careful consideration of the patient’s medical comorbidities and prior therapies, communication with the oncologist, proper psychological evaluation, and appropriate trialing technique.”
The complete text of “Comprehensive Consensus Based Guidelines on Intrathecal Drug Delivery Systems in the Treatment of Pain Caused by Cancer Pain,” published in the May/June 2011 issue of Pain Physician, is available online.