THE NEW ENGLAND JOURNAL OF MEDICINE
Mild-to-moderate pain
1000 mg orally or rectally 3–4 times a day
Do not exceed 4 g per day. Use this agent with caution in the treatment of patients with liver disease.
800 mg orally 3–4 times a day
30 mg (with or without 325 mg acetaminophen) orally every 3–4 hr as needed
Do not exceed 360 mg per day.
5 mg (with or without 325 mg acetaminophen) orally every 3–4 hr as needed
If analgesia is inadequate with initial treatment, adjust the dosage to 10 mg orally every 3–4 hr as needed; for further management, see treatment for moderate-to-severe pain.
Moderate-to-severe pain in patients not currently receiving opioids
Oral: 5–15 mg every 30–60 min as needed
Intravenous: 2–5 mg every 15–30 min as needed
Oral: 2–4 mg every 30 min as needed
Intravenous: 0.4–0.8 mg every 15–30 min as needed
For both morphine and hydromorphone:
If analgesia is inadequate with initial treatment, increase the bolus dose by 25–50% for moderate pain or by 50–100% for severe pain.
If the level of analgesia is acceptable, administer continuous infusion (equal to the total daily opioid dose) over 24 hr, with a breakthrough dose every hour equivalent to 10–20% of the total 24-hr opioid dose. If the current drug causes unacceptable side effects to the patient, administer an equianalgesic dose of a different opioid.
Moderate-to-severe pain in patients currently receiving opioids
Bolus dose (up to 10–20% of total opioid taken in the previous 24 hr) every 15–60 min as needed
If previously satisfactory analgesia becomes inadequate, increase the basal and bolus dose by 25–50% for moderate pain or by 50–100% for severe pain.
For daily follow-up, calculate the total 24-hr dose received (basal plus breakthrough) and adjust the basal rate to equal this 24-hr opioid amount; adjust the bolus dose to 10–20% of this 24-hr total. If the current drug causes unacceptable side effects to the patient, administer an equianalgesic dose of a different opioid.
Neuropathic pain
Adjust dose until analgesia has been achieved (as described above for moderate-to-severe pain)
For example, 4–16 mg of dexamethasone intravenously daily
Consider especially for acute neurologic injury, such as nerve or spinal cord compression from a tumor.
Consider especially when allodynia is present.
If survival for more than a few days is anticipated, consider adding one of these agents immediately.
Dyspnea
Oral: 5–10 mg every 30 min as needed until patient is comfortable
Intravenous: 2–4 mg every 30 min to 1 hr as needed until patient is comfortable
For patients already receiving opioids, increase the dose by 25–50%
For dose adjustments, follow the guidelines for treating moderate-to-severe pain.
Adjust to achieve satisfactory oxygen saturation and subjective relief of dyspnea
Should be used only for patients with low oxygen saturation; oxygen delivered by a high-flow nasal cannula may be useful for patients with low oxygen saturation, as long as it does not cause discomfort for the patient.
Use if consistent with patient’s goals, as long as it does not cause discomfort for the patient, and if it is subjectively helpful.
Approaches include psychosocial support, relaxation and breathing training, facial cooling with a fan, keeping windows open for ventilation, keeping the ambient room temperature low, humidifying the air, and keeping the head of the bed elevated.
Cough
30 mg orally every 4–6 hr as needed
Codeine is available in various liquid formulations, often with additional medications, or as a tablet.
Oral: 5–10 mg every 60 min as needed until patient is comfortable
Intravenous: 2–4 mg every 30 min to 1 hr as needed
For dose adjustments, follow the guidelines for treating moderate-to-severe pain.
Xerostomia
5–10 mg orally 3 times daily (not to exceed 30 mg/day)
Evidence of pharmacologic effectiveness is minimal. This method requires that the patient be able to take medication by mouth.
Approaches include the use of antimicrobial mouthwashes, saliva substitutes, oral hydration, mouth swabs, sugarless gum, lip balm, or a humidifier.
Excessive oral–pharyngeal secretions (“death rattle”)
Intravenous or subcutaneous: 0.2 mg every 4 hr as needed, not to exceed 4 doses per day
Oral: 0.5 mg 3 times per day
There is insufficient evidence to support the use of anticholinergic agents.
Family members and staff should be reassured about the low probability that the patient will have discomfort as a result of the secretions and should be counseled about the potential side effects of treatment.
Nausea and vomiting
Caused by bowel obstruction
If the patient has complete bowel obstruction, avoid prokinetic drugs.
100–200 μg subcutaneously 3 times per day (or 100–600 μg per day in an intravenous or subcutaneous infusion)
Although this treatment is commonly administered, studies have shown conflicting results regarding its usefulness.
4–8 mg orally or intravenously every day (up to 16 mg per day)
Caused by gastroparesis
10–20 mg orally or intravenously every 4–6 hr (up to 100 mg per day)
Caused by increased intracranial pressure
4–8 mg orally or intravenously once a day (up to 16 mg per day)
Caused by medications, uremia, toxins, or other unspecified or multiple factors
10–20 mg orally or intravenously every 4–6 hr (up to 100 mg total daily dose)
Oral: 1.5–5 mg 2–3 times per day
Intravenous: 0.5–2 mg every 8 hr
8 mg orally every 8 hr as needed
4–8 mg orally or intravenously once a day (up to 16 mg per day) Dexamethasone is usually combined with other antiemetics.
Constipation
Check for fecal impaction.
2–4 tablets (8.6 mg sennosides per tablet) or 1–2 tablets (15 mg sennosides per tablet) as a single daily dose or in two divided doses each day (not to exceed 100 mg per day)
10-mg rectal suppository once daily as needed
17 g orally once daily as needed
For patients weighing 38 to <62 kg: 8-mg dose subcutaneously every other day
For patients weighing 62 to 114 kg: 12-mg dose subcutaneously every other day
For patients weighing <38 kg or >114 kg: 0.15 mg/kg subcutaneously every other day
Anorexia
2–4 mg orally or intravenously once a day
Counsel the patient and family about the limited long-term value of treatment.
Fever
Cooling blankets, ice packs, and sponging may be helpful; in some cases, however, the patient may find them troublesome.
650–1000 mg orally, rectally, or intravenously every 4–6 hr as needed (maximum dose, 4 g per day)
250–500 mg orally twice daily Naproxen may be of particular benefit in the treatment of neoplastic fevers.
Anxiety and insomnia
0.25–2 mg orally, intravenously, or subcutaneously every 4–6 hr as needed; dose may be increased to 5 mg
Psychosocial interventions may be helpful. Sedation may increase the risk of falls.
Delirium
0.5–1 mg orally or intravenously every hour as needed; when symptoms have been relieved, give the total daily requirement in 3 or 4 divided doses per day
If symptoms are refractory, consider a trial of another antipsychotic agent, instead of or in addition to haloperidol. If agitation is refractory to treatment, consider the addition of a benzodiazepine, with careful monitoring.
IKA SYAMSUL HUDA MZ