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Mindy, I agree that their should be a streamlined practice for how we are instructing patient’s to use Claritin and NSAIDS. I also have seen providers tell patients to start taking Claritin the day before and 3 days after their neulasta OBI or neulasta shot is injected. In my practice I see that the solid tumor clinics are better at educating their patients about the possibility of bone pain r/t GCSF than the hematological clinics. This may be attributed to the prevalence of bone mets in the solid tumor population, but I am not for certain. I have also seen providers tell patients to just take Claritin the day of the injection. For heme patients in HTC patients who are getting high dose nuepogen for multiple days in a row, prior to mobilization for stem cell transplant, they tell their patients to take Claritin daily while receiving the neupogen injections. In both the heme population and solid tumor population, I have had patients that have received no education regarding the possibility of bone pain from GCSF.
Mindy, I agree that we should pre-educate our patients on the possible side effects and ways to reduce them. I have seen too many patients that come in for their next Chemo and had pain the last OBI but thought it was just “normal” so they didn’t reach out or try to reduce the effects. I notice though that our older patient population seems to just “deal with it” pain because they are already in some type of arthritic pain.
Megan, I agree that each doctor has their own way of doing things. As a float, I sometimes suggest things that the pt’s particular doctor does not recommend. But I also find it as an educational opportunity. If I see something in one clinic that works & take it to another clinic that seems to be struggling finding a good solution. The Claritin, I learned about in the BSH chemo infusion clinic and I have recommended it in 5 infusion and Morehouse infusion clinics.
Kasey Karafa Ambulatory JCRU RN
ACUTE BONE PAIN- An analysis of symptom management interventions after administration of granulocyte-colony-stimulating factors for myelosupression.
1)What was the knowledge gained from the article?
This study suggests that nonpharmacologic interventions were perceived by patients as an effective primary or adjunct intervention in managing bone pain from G-CSF. I have not seen these type of recommendations given as a standard of practice at the James.
2)Will the research/information in this article change or influence your practice? If so how?
I will be apt to recommend both pharmacological and non pharmacological interventions for bone pain. Suggesting stretching, walking, yoga, and heat to help ease bone pain associated with G-CSF, not just educating on Claritin and NSAIDS. Also the education of the possibility of bone pain needs to be addressed with all patient’s on treatment with G-CSF, not assuming that they received information from their doctor prior to the start of treatment.
3)What other questions does the article raise about current practice?
It shows the inconsistency in treatment regimens/ recommendations used to treat/ prevent bone pain associated with G-CS, and the lack of EBP done on this subject.
Abby,
I enjoyed reading your post. I also too wonder if the older population has come more accustomed to pain and management of pain without pharmacological intervention. It does see that the younger patients I deal with are experiencing more difficulties with bone pain.
Megan
Kasey,
I too agree with you that there are some major inconsistencies with management of bone pain at the James. I have yet to get a definitive answer as to management and I feel like physicians have different recommendations. I would like to see some general education for nurses to follow or a logarithm to follow in order to manage this better!
Megan
Mindy- I think a smart phrase for each med/onc group would be helpful. I find even at the breast center the physicians have different approaches to treating bone pain. It would be nice to hear the physicians rationale for their treatment decision.
Megan, Have you you found through your career the culture in medicine has changed in regards to pain?
I recall when I started nursing I was told pain is the fifth vial sign and pain is subjective to whatever the patient reports.
I think that we are just beginning to change this culture especially by now asking each patient’s tolerable pain level is.
Hi! This is Holly Smith from Ambulatory JCRU
1. Knowledge gained: I, as many of you have stated, found it interesting that younger people reported more pain after G-CSF. Although, it makes sense in that if older patients have less red marrow and more fatty marrow (go figure) that pain caused by bone marrow expansion might be reduced in that population. Although, I would have thought older patients would have more pain than younger. It make sense that a history of bone pain makes a patient more likely to have bone pain after G-CSF.2.Change/influence to practice: I plan to focus on the alternative therapies when doing teaching in hopes that it will help alleviate the pain associated with G-CSF. It seems from these articles that incorporating multiple modalities and even prophylaxis can make a difference in pain level. On a side note, sometimes just having a little control (i.e stretching/walking) gives patients perceived pain relief.
3. Questions about current practice: This issue is clearly not a one size fits all and it needs deeper study and on a larger scale. It would be interesting to see how different combinations of alternative therapies and medications would fair. Prescribing shouldn’t always be first line for pain, especially if is not moderate to severe. An example is if a patient has surgery, they should expect to have some pain. We may want to spend more time educating patients on acceptable levels of pain, as well as stretching, meditation, essential oils, and medications.
4.Agree/disagree: I agree that this is important to control pain so that patients can complete/tolerate therapy. I also agree more studies need to be done on specific combination treatments for G-CSF related pain.
Abby,
I wondered too if older patients are so used to aching joints and bones that it is more tolerable or doesn’t stand out as much!!! I think, too, in some cases, life experience can reduce the anxiety of the unknown, thus decreasing pain.
HollyKasey,
I agree that there isn’t alternative therapy as a standard of practice for G-CSF pain. Maybe if more studies were done to validate the effectiveness, alternative therapies would become standard.
HollyHi, my name is Melissa Van Meter and I am one of the JCRU nurses. Thank you Holly Smith for sending me the link to this Journal Club. I really enjoyed these two articles and think they are very relevant to our patient population.
Questions
1. What was the knowledge gained from the article?
I learned that the reported incidence of bone pain was greater in the under 65 year old group of people and that many patients are unaware of this possible side effect of G-CSF’s. I think it is interesting that the younger patients are more likely to experience bone pain or at least more willing to self report it. I wonder if over 65 year old population ever attribute pain they experience to other problems they may have like arthritis ect.
2. Will this article info change or influence your practice? If so how?
Yes, now that I am aware that the incidence is less in the older population I will ask them more exploring questions when they complain of pain in clinic and make sure they understand the difference and that these growth factors can cause acute pain that could be masked in their chronic pain so they can understand the difference.
3. What other questions does the article raise about current practice?
The articles raised questions about the what the best standard of care is for prevention and treatment weather Nsaud’s like Naproxen, opioids, Loratadine and or other non-pharmacological interventions are the best for treatment. I don’t think there is enough information to say which method works best but it would be nice to develop a first line second line tier type of recommendations for this type of pain.
4. Do you agree/disagree with the conclusion of the Author, why?
I agree with the conclusions, over all we need more information. The sample sizes they were able to work with were relatively small and we need to do more studies with more patients in the outpatient setting and compare the available treatments to see which interventions work the best.Kasey,
I agree, these articles made it clear all the variation in practice that’s out there so I will also keep that in mind when educating patients. It will be interesting to see what comes from this. Maybe a patient handout? They probably need to research it more first. 🙂
Melissa
Holly,
I agree they need more studies and it seems that one of the limitations was that more of it is done out-patient than in-patient. I wonder if the research department will be taking a closer look at our outpatients do better assess what treatments work best?
Melissa
Hi everyone! Great discussion. I agree a smartphrase would be great. It would be nice if we had more consistency across all of our areas. This is Renee Shalvoy.
Lynne Brophy recently did a journal club on using weighted blankets to comfort patients. She is repeating this on March 11th via Zoom. Send me an email if any of you would like the link. The other option is we could use those articles for our next online club, sounds like a really interesting topic. What do you all think?
Renee
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