Management of predictable pain using fentanyl pectin nasal spray in patients undergoing radiotherapy
A 32-year-old man who had a rectal adenocarcinoma with lamina propria invasion (T2N0M0) was referred for combined preoperative therapy with sensitizing capecitabine and intensity-modulated radiation therapy/tomotherapy (cumulative radiation dose of 4,500 cGy over 25 fractions).\nHis initial pain assessment revealed persistent rectal and low abdominal cramping rated 5/10 occurring 3–4 times each day and lasting 20–30 minutes. The patient also reported pain during defecation without narcotics (7/10). Hydrocodone/acetaminophen (10/325 mg four times daily) reduced his defecation pain to 4/10 and cramping abdominal pain to 2/10. During week 2, the hydrocodone/acetaminophen was increased (two tablets of 10/325 mg every 6 hours) and a fentanyl transdermal patch was added (25 μg every 72 hours). Because the patient reported nausea within 12 hours of applying the fentanyl patch, ondansetron and lorazepam were prescribed with benefit. During week 4, he reported increased pain with defecation (8/10); in addition, he had a BTPc episode that woke him in the middle of the night (5/10). The dose of the fentanyl patch was increased (50 μg every 72 hours), and the hydrocodone/acetaminophen was replaced by FPNS (100 μg 20 minutes before defecation). This adjustment reduced pain associated with defecation from 5/10 to a manageable 3/10. Additionally, the night-time pain was reduced from 5/10 to 2/10, which allowed the patient to return to sleep and to remain asleep until morning.\nDuring week 5, the FPNS dose was increased to 200 μg as the patient developed radiotherapy-associated rectal and perineal irritation. FPNS reduced the pain from 6/10 to 2/10. The patient continued to complain of nausea (grade II) and the ondansetron was replaced by granisetron transdermal patch that reduced the nausea to grade I. In week 6, the FPNS dose was further increased (400 μg 20 minutes before defecation) which eased the pain associated with defecation to 2/10.\nOn completion of 25 radiotherapy sessions without interruption, the patient required a further increase in the dosage of the fentanyl patch (75 μg every 48 hours) because of persistent background pain of 5/10; but by 2 weeks after completing therapy, the fentanyl patch dosage was reduced (first to 50 μg and then to 25 μg every 72 hours). The FPNS was reduced (200 μg, 20 minutes before defecation and during the night if needed). FPNS was discontinued 4 weeks after therapy and the patient was switched back to hydrocodone/acetaminophen (10/325 mg, up to two tablets every 6 hours) for up to one week prior to discontinuing all narcotics.