Journal of Pharmacy Practice

Pain, by definition, is a subjective phenomenon. The subjective component in chronic pain due to cancer is very important. Opioid analgesics are the mainstay of treatment for cancer pain. Their use should be optimized to provide adequate pain relief. Optimal use includes understanding the concepts of tolerance, physical dependence, and psychological dependence. None of these should limit or inhibit pain management. Optimal use also includes familiarity with the clinical use of opioids. Regular use is generally preferred over “prn” use. Increased parenteral versus oral effectiveness of opioids, secondary to a high first-pass effect, is an important consideration when routes of administration must be altered. Familiarity with approximate equianalgesic doses allows for conversion from one opioid to another. Such conversion might help increase the convenience, increase the efficacy, or decrease the adverse effects of an opioid regimen. Knowledge of durations of action of opioids helps in the selection of dosing intervals to facilitate continuous pain relief. Morphine is the most common opioid chosen for cancer pain management, but others may be equally effective. Follow-up assessments with subsequent alterations are as important as the initial selection of drug, dose, and dosing interval. Adjuvant analgesics, such as nonsteroidal antiinflammatory drugs, anticonvulsants, or antidepressants, may enhance pain relief, especially in certain pain syndromes (eg, metastatic bone pain, neuropathic pain). These agents are usually used in addition to opioids.

Nausea and vomiting (N/V) are well-recognized and potentially serious complications of cancer chemotherapy that can significantly impact therapeutic outcomes and overall quality of life. As the management of cancer patients moves to the outpatient setting, therapeutic strategies for N/V control must be adapted accordingly. The purpose of this article is to provide an overview of the pathophysiology and basic principles of N/V management and the available antiemetic agents, with an emphasis on applications in outpatient oncology. Development of antiemetic guidelines promotes selection of appropriate antiemetics to maximize N/V control, while minimizing associated cost. Use of oral antiemetics when possible also significantly reduces the cost of N/V management, without compromising therapeutic efficacy. In addition to designing an appropriate treatment regimen, measures for the early evaluation of N/V outcomes must also be instituted. Pharmacists can have an important role in ensuring optimal control of N/V in cancer patients.

Not since the introduction of doxorubicin has a drug been as exciting and promising as paclitaxel for the treatment of breast cancer. Currently, the only approved use of paclitaxel in breast cancer is the metastatic setting. Paclitaxel is being studied in the adjuvant setting to assess its relative efficacy and to theoretically increase the chances of killing all micrometastases with alternate therapy with a different mechanism of cytotoxic activity. The optimal dose and schedule of administration have not been identified. Toxicities differ depending on dose and schedule, and treatment and prevention strategies for these toxicities are discussed. Continuous infusion administration can be accomplished with the use of ambulatory infusion devices. Issues of central venous access, use of premedications, use of granulocyte colony-stimulating factor (G-CSF), and dosages and schedule of paclitaxel will be discussed in relation to ambulatory paclitaxel administration. Special circumstances that require inpatient administration or special monitoring are also discussed.

The adult autologous bone marrow transplant (ABMT) program at Duke University Medical Center has developed an innovative outpatient approach to managing patients with solid tumors with ABMT during their postchemotherapy period of myelosuppression and recovery. The use of colony-stimulating factors in combination with peripheral blood progenitor cells (PBPCs) and bone marrow for hematologic support plus implementation of prophylactic antibiotics with sequential once-daily empiric antibiotic modification regimen were key to the success of this approach. This program reduces the duration of hospitalization, and thus the costs associated with a traditionally complex and difficult therapy. More than 400 patients have been treated in the outpatient setting since May 1992. Patients are initially admitted for 5 days of hospitalization to receive combination high-dose chemotherapy with continuous hydration and antiemetic support. Twenty-four hours after completion of chemotherapy, patients are discharged on oral prophylactic antibiotics, electrolyte supplements, and antiemetic agents. Close to half of the patients are readmitted to the inpatient unit during their period of ambulatory supportive care. Continuous provision of drug therapy and clinical pharmacy services require ongoing communication between pharmacy and both outpatient and inpatient personnel. Months of planning with nurse, physician, and pharmacist input were required to develop a program that meets the changing needs of patients undergoing a complex and potentially toxic therapy. Reliable 7-day pharmaceutical services was one of the essential components required for operation of such an outpatient program. This article reviews the basic principles and procedures used in treating patients in the Duke Outpatient ABMT program, with a focus on the complexity of supportive care issues that occur in the ambulatory setting, and the development of integrated pharmacy services for the program will be discussed.

Provision of home chemotherapy to pediatric oncology patients offers substantial advantages to children and their families, including improved scheduling and continuity of care and decreased disruption of the family unit. These advantages may positively impact upon both parental anxiety and quality of life for these children and their families. Establishing and maintaining a successful home chemotherapy program is a complex task, requiring a detailed orientation program along with an interdisciplinary team approach, a successful communication network, and close patient follow-up. Home chemotherapy delivery offers a unique practice setting with many professional growth opportunities for clinicians. A home chemotherapy program may also result in substantial monetary savings to patients and third-party payors, especially for protocols that require several days of inpatient admission to deliver.