Management of predictable pain using fentanyl pectin nasal spray in patients undergoing radiotherapy
A 66-year-old woman, post-Whipple surgery for a moderately to poorly differentiated adenocarcinoma of the head of the pancreas with both lymphovascular and perineural invasion (T3N0M0), was referred for combined sensitizing chemotherapy with intensity-modulated radiation therapy/tomotherapy (5,040 cGy over 28 fractions) because her CA-19-9 rose from 4.9 to 581 U/mL (normal range, 0–35 U/mL).\nOn referral, the patient complained of diffuse low abdominal pain (7/10). Hydromorphone hydrochloride (2 mg every 12 hours) plus hydrocodone/acetaminophen (7.5/500 mg, two tablets every 4–6 hours) reduced the pain to 5/10. During radiation simulation planning, she complained of abdominal and low back pain while lying on the table (6/10), which persisted for the 40-minute duration of the simulation process. The hydromorphone hydrochloride was discontinued, and FPNS was started (100 μg 20 minutes before radiotherapy sessions) and reduced her pain on the table to 2/10. In addition, the patient used FPNS prior to her evening meal to prevent mucositis-associated pain (5/10) and once at night when she would awaken with abdominal pain (7/10). Her mucositis-associated pain was reduced from 5/10 to 2/10. Her night-time pain was reduced to 3/10, allowing her to return to sleep, which had not been the situation previously. This regimen allowed the patient to complete her 28 planned radiotherapy sessions without interruption.\nThe patient represented 13 months later when she was referred for stereotactic body radiation (4,000 cGy in five fractions) because of asymptomatic lung metastases. At that time, her abdominal pain was controlled with intermittent use of hydrocodone/acetaminophen (7.5/500 mg) plus FPNS (100 μg as needed, typically once a day and once at night). This regimen controlled her abdominal pain (3/10) on most occasions.\nAfter the first radiation treatment to the left lung lesion, the patient experienced stabbing left anterior upper chest pain (7/10); chest computed tomography revealed mediastinal and esophageal compression. A fentanyl transdermal patch was prescribed (25 μg every 72 hours) and the frequency of FPNS (100 μg) was increased to three times a day plus once at night. The patient reported a reduction in her chest pain from 7/10 to 4/10, with alleviation of pain for between 1.5 and 2 hours. Increasing the FPNS dose (200 μg) provided greater pain relief (2/10).\nAfter completion of stereotactic body radiation, she discontinued the fentanyl patch after 10 days and the FPNS after 12 days. The patient remained on hydrocodone/acetaminophen (7.5/500 mg, once or twice a day) for slight (3/10) odynophagia.