Management of predictable pain using fentanyl pectin nasal spray in patients undergoing radiotherapy
An 84-year-old man with a minimally invasive, multifocal, low-grade esophageal adenocarcinoma invading into the sub-mucosa was referred for concurrent sensitizing capecitabine chemotherapy with intensity-modulated radiation therapy/tomotherapy (5,500 cGy over 30 fractions). His medical history included prostate cancer treated with radiation therapy and long-standing but controlled Parkinson’s disease.\nUpon referral, the patient reported a long history of low back pain (4/10) when walking and when lying down. His background analgesia was hydrocodone/acetaminophen (5/500 mg twice a day) plus a fentanyl transdermal patch (initially 12 μg, and then 25 μg every 72 hours). Because of this pain and the associated Parkinson’s disease, he was reluctant to accept the course of radiotherapy. The radiotherapy team suggested a trial of FPNS (100 μg given 20 minutes before each session) which managed his discomfort during the 40-minute planning session (3/10). The patient requested better pain control, and the FPNS dose was increased (200 μg 20 minutes before radiation) and further reduced the pain to 2/10, which the patient deemed acceptable. In week 3, he developed odynophagia (5/10) which was reduced to 2/10 by FPNS (200 μg 20 minutes before meals). The patient also experienced reduced rigidity from his neurologic Parkinson’s disorder, with improved movement and mobility and decreased pain and anxiety during transfer from wheelchair to treatment table.\nThe patient completed all 30 radiotherapy sessions without interruption due to pain; he did have a single interruption related to fatigue associated with his Parkinson’s disease. Two weeks after completion of radiotherapy, the fentanyl patches were discontinued and the FPNS dose was reduced (100 μg 20 minutes before meals). The FPNS was discontinued 4 weeks after completion of therapy.