75 mcg/hr 75 mg po morphine/day 225 mg po

fentanyl patch 25 mcg/hr fentanyl patch morphine/day

MS Contin 75 mg q12h with 15-30mg MS IR prn

 Patient: MR. S, 55 year old
HISTORY OF ILLNESS :
• He was refered from Neurologist in Oct 2013 due to severe
low back pain and weakness and cramp in both low
extremities since three days before.
• Patient already experienced LBP since mid July 2013
• PE: Showed within (N) limits, EXCEPT
Lower Extremities : significant decreasing ROM , pain (++)
PAIN assessment: VAS 7- 9; sometimes the pain getting
stronger; CAN’T HARDLY MOVE BECAUSE OF THE PAIN
IN THE LOWER BACK
 LABORATORY Result: 17 OCT, 2013
• Hb : 8,3 gr/dl Ht: 31 % • Ureum : 26 mg/dl
• ESR : 26 / hr • Creatinine : 1,0 mg/dl
• WBC : 7900 / uL • Glucose random : 97 mg/dl
0 / 1 / 5 / 52 / 38 / 4 • Calcium : 8,3 mg/dl
• Plt’s : 196.000 / uL • SGPT : 18 U/L
• Protein total : 13,8 gr/dl • SGOT : 23 U/L
• Albumin: 2,6 gr/dl • BMP : plasmocyte 64 %
• Globulin : 11,2 gr/dl
Patient’s Diagnosis :
• Severe LBP ( VAS 8 – 9)
• Multiple Myeloma stage IIIA ( Durie Salmon )
Please classify this patient ‘s pain type:
A. Nociceptive pain
B. Neuropathic pain
C. Mixed pain
D. Mechanic / Traumatic pain
E. A and D
F. All of the above
 Type of tumor influences
metastatic bone disease

Adapted from Mundy G. Nature reviews cancer 2. 584-593. 2002

What type of analgesic drug would you
prescribe for the patient’s pain?
A. Paracetamol + NSAID/Coxib
B. NSAID/Coxib + Weak Opioid
C. NSAID/Coxib + Strong Opioid
D. Paracetamol + Weak Opioid
E. Paracetamol + Strong Opioid
How will you initiate treatment with
Strong Opioid?
A. Start with oral short acting strong opioid
B. Start with oral long acting strong opioid
C. Start with IV (intravenous) strong opioid
D. A and C correct
E. A and B correct
How will you perform the titration for
this opioid naive patient?
A. With slow titration
B. With rapid titration
C. Both of the above
D. None of the above
When and how will you convert to oral
long acting strong opioid?
A. I will continue with short acting strong opioid
for as long as possible/needed
B. I will convert to oral long acting strong opiod
after 24 hours reach effective pain control
C. I will convert to oral long acting strong opiod
after 48 hours reach effective pain control
D. I will move to patch strong opioid as soon as
patient’s reach effective pain control
Patient’s Therapy ….
Therapy :
1. Morphin sulfat IV 2,5 mg 
cont. IV10 mg (D1-2) 20 mg
(D3)
VAS: 3 – 4 (in static
condition)
Then convert to oral long acting
Morphine 2dd 25 mg ( D4 )
2. Ketorolac 30 mg ; 2-3dd
3. Zoledronic acid 4 mg/ 4 weeks

Patient was informed about

his condition and that, he
will need an orthopaedic
intervention for internal fixation for
stabilization and decompression
d

d
What will be side effect that are fairly
common with strong opioid?
A. Nausea and vomiting
B. Constipation
C. Pruritus
D. Delirium
E. All the above are correct
After 4 days of treatment, patients
start to experience constipation. What
will you do?
A. Lower the dose of strong opiod
B. Prescribe prophylactic medication
C. Maintain adequate fluid intake
D. Maintain adequate dietary fiber
E. B,C and D are correct
F. All the above are correct
Patient’s Therapy ….

ORTHOPAEDIC SURGERY
WAS DONE ON LATE
OCT 2013, followed by:
• Radiotherapy
• Chemotherapy
(Thalidomide) +
Bortezomib

Patient start to
complain about
burning, numbness
and pain in the
hands.
What will be adjuvant therapy you
prescribe for the patient?
A. Anti-depressant
B. Anti-convulsant
C. NSAID
D. Topical agent, such as Diclofenac gel
E. Others
MRI ( 28-10-13 )
( Cont. MRI )
X-ray of Thoraco lumbal : 7-12-13
X-ray of Thoraco Lumbal: 10-01-14
X-ray of Thoraco lumbal: 18-01-14
•Patient’s pain was well controlled.
The VAS was 2 – 3, except the
hyperesthesia and paresthesia on
both hands
•On March 2014, patients went to
Meccah for Haaj.