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Case 1
A 67-year-old man with multiple myeloma and associated chronic renal failure, had severe neck pain and weakness in both arms. An MRI scan revealed that there were no deposits or spinal cord compression. He had surgery for carpal tunnel decompression, which gave him some relief, but his neck pain was still a problem. He was initially prescribed prolonged release morphine 150 mg once-daily, which gave good pain relief, but he developed hallucinations, and continuous nausea and vomiting. He was switched to Palladone® SR capsules 10 mg 12-hourly with concomitant levomepromazine for the nausea. His pain control improved and he had no hallucinations. His pain was controlled until his death six weeks later.
Case 2
A 68-year-old man with renal cell carcinoma, was referred to a day hospice with severe bone and loin pain. He had never tolerated morphine, so he was initially prescribed fentanyl patches and immediate release oxycodone, which controlled his pain. However, the patches were failing to adhere properly, so he was switched to prolonged release oxycodone, which was also effective. Although his pain control remained stable for several months, he eventually became drowsy, and he experienced tremors and vivid dreams. He was unwilling to receive fentanyl patches again, so he was admitted to the hospice for close monitoring while alfentanil was started. Within 48 hours of receiving s.c. alfentanil, his side effects improved. He was happy to use a syringe driver, but this route of administration is not appropriate for providing breakthrough medication. He refused to receive transmucosal fentanyl, so he was prescribed Palladone® capsules 7.8 mg as required. By using between two and three doses per day, he experienced good pain relief with no adverse effects. He was discharged home and, with slight increases in his dose over the next three weeks, he remained pain-free until his death two months later.
Case 3
A 48-year-old man with adenocarcinoma of the prostate, had been effectively maintained on prolonged release morphine. However, when he developed renal impairment, he began to suffer drowsiness due to accumulation of morphine metabolites, and prolonged release morphine was also no longer controlling his pain. He was switched to Palladone® SR capsules 8 mg 12-hourly and became more alert within 24 hours. Over the next week, his dose was titrated to 20 mg 12-hourly at which he was pain-free and had no drowsiness. After six weeks, he suffered a kidney infection, during which he needed i.v. antibiotics and i.v. hydromorphone. However, once the infection had cleared, he was re-established on his previous dose of Palladone® SR capsules. He remained pain-free with Palladone® SR capsules for 2.5 years. During this time, despite an increase in dose to 64 mg 12-hourly, he did not suffer drowsiness.
Case 4
A 67-year-old man with carcinoma of the rectum, extensive metastases and bilateral hydronephrosis, was referred for pain control. In addition to renal failure, he was suffering myoclonus and drowsiness, and was in low spirits. He was receiving prolonged release morphine 50 mg 12-hourly, but he refused to take immediate release morphine because it increased his drowsiness. He was unsuitable for treatment with an NSAID because of his renal failure, so he was prescribed Palladone® SR capsules 2 mg 12-hourly and Palladone® capsules 1.3 mg as required. Within two days, he was alert and his myoclonus had gone. His dose of Palladone® SR capsules was titrated over four days to 6 mg 12-hourly with Palladone® capsules 3.9 mg as required. He was discharged home pain-free and able to look after himself, and was very happy to be free of the side effects.
Case 5
A 75-year-old man with carcinoma of the bladder and liver metastases, was admitted to hospital with increased confusion, severe back pain and hallucinations. He had been receiving prolonged release morphine 30 mg 12-hourly plus immediate release morphine 10 – 20 mg as required. Blood test results showed that he had renal impairment. His renal function continued to deteriorate, and he became fidgety and agitated. He was referred to the palliative care team who discontinued his morphine and switched him to Palladone® SR capsules 4 mg 12-hourly plus Palladone® capsules 1.3 mg as required, and regular paracetamol and laxatives. The day after the switch, his cognitive function was improved and he was alert. He continued to have good pain control until he was no longer able to tolerate oral medication.
Case 6
An 84-year-old man with myeloma, was admitted to a hospice with a history of hip and knee pain. He had been prescribed 30 mg prolonged release morphine 12-hourly by his GP, but his pain was not controlled and he had taken immediate release morphine to improve the situation. He was now excessively drowsy and nauseated, and he had lost his mobility. The hospice staff discontinued his morphine and prescribed Co-codamol, but he was in severe pain. Because his blood test results showed signs of renal impairment, he was prescribed Palladone® capsules 1.3 mg as required for breakthrough pain. Over the next few days, he became more alert and his nausea resolved. The haematologist felt that his clinical signs and symptoms were indicative of active myeloma, so he received a 4-day course of dexamethasone. With his improved pain control, he became more mobile and was able to return home to his wife, where he continued to take Palladone® capsules for breakthrough pain.
To view case studies 1 to 4, please click here
To view case studies 5 to 8, please click here