SUCCESSFUL MANAGEMENT OF TOTAL PAIN FOR A LADY WITH ASTROCYTOMA.

Background & Aims

A thirty years old lady had her first seizure at the end of first trimester of pregnancy. She delivered a healthy baby by caesarean section at nine months. She developed postpartum severe frontal headaches and raised intracranial pressure with hydrocephalus. This was treated with a ventriculoperitoneal (VP) shunt one month later. The biopsy showed a multifocal anaplastic astrocytoma (WHO grade 3) in the left frontal lobe and the insula.
She was planned for radiotherapy and chemotherapy but due to rapid progression, increased brain swelling on interval scans and general decline treatment was never commenced. Plan of care was to transfer from the hospital to a hospice for specialist symptom control in relation to severe headaches, personality changes and fluctuating Glasgow Coma Scale (GCS) scores. One month after the hospice admission her condition declined. It was agreed to transfer her from England to her family in Ireland for end of life care.

Methods

Specialist community palliative care team assessment.
Main symptoms: headaches, weight gain, seizures, personality changes, lower limb oedema, family issues, treatment options.
Actions:
Headaches: Switching Morphine Sulphate slow release 120 mg/day to Oxycodone in decreasing doses.
Decreasing dexamethasone.
Weight gain: from 52 kg up to 115 kg started to reduce by introducing Semaglutide 0.25 mg SC weekly.
Seizures + Personality changes:
Switching Levetiracetam to Na-valproate maximum dose of 2400 mg / day and introducing a second anticonvulsive drug i.g. Lacosamide.
Lower limb oedema: weaning of diuretics.
Family issues: family meetings, social work input, regular home visits and outpatient’s reviews.
Oncology review: to assess further treatment options.
Backup plan to the community team: hospital admission for deterioration, infection control and respite of family.
Art therapy: painting twice weekly.

Results

Headaches: no regular opioids required after 2 months. Currently PRN Paracetamol 1 g PO, Oxycodone 2 mg PO
Loosing weight (currently 20 kg): feeling better under Semaglutide 0.25 mg SC weekly. Self-esteem improved regarding body image.
Seizures + Personality changes: Seizures are settled, personality changes have disappeared. She is able to hold meaningful conversations, take decisions and mobilize more independently.
Urinary incontinence has decreased.
Currently on Na-valproate 2400 mg / 24h continuous subcutaneous infusion (CSCI) + Lacosamide 100 mg BD PO.
Lower limb oedema: improved, diuretics stopped.
Oncology review: after reimaging no further treatment options offered.
Family issues: ongoing with regular support, able to engage and bond with her baby and family.
After one hospital admission she is back home.

Conclusions

In addressing her total pain (1) and her uncontrolled frontal brain hyperactivity she stabilized. She tolerates her anti-epileptic therapy which also covers now the behavioural and vegetative aspects. The frontal headaches most likely represented her total pain represented initially by the raised intracranial pressure and poor prognosis. The frontal headaches have subsided switching from morphine which has a neuroexcitatory morphine-3-glucuronide metabolite (2) to oxycodone allowing the brain function to majorly improve. She now requires no regular opioid therapy.
She was in a situation where she could not understand and cope in a constructive way the complexity of her condition. Relieving the headaches has allowed us to support her to manage and nurture her own resources. She has regained a certain independence and is facing her extremely difficult situation in a very serene and constructive way at home with her family.

References

(1) Ong CK, Forbes D. Embracing Cicely Saunders’s concept of total pain. BMJ. 2005 Sep 10;331(7516):576. doi: 10.1136/bmj.331.7516.576-d. PMID: 16150775; PMCID: PMC1200625.
(2) Gabel F, Hovhannisyan V, Berkati AK, Goumon Y. Morphine-3-Glucuronide, Physiology and Behavior. Front Mol Neurosci. 2022 May 12;15:882443. doi: 10.3389/fnmol.2022.882443. PMID: 35645730; PMCID: PMC9134088.

Presenting Author