MOH KS management guidelines

Jane BatesTiyanjane Clinic, QECH

October 2009

Criteria for vincristine

Tested for HIV

advanced and / or progressive disease (check FBC)- consider vincristine

Clinical diagnosis of KS

On ARVs for at least 3 months

improving and / or stable disease - hold vincristine

High priority Medium Priority consider continue ARVSmay start before unilat or biilat. leg if exclusions 3 months ARVs completed KS limiting function apply confirmed or suspected oral lesions Pulmonary KS rapidly progressive maintain pain anddisease Involving face symptom control

ExclusionsAbsolute • severe peripheral neuropathy • unable to travel – financial or physical constraints• Hb < 8, platelet < 150• severe liver disturbance/diseaseRelative • near to another hospital site delivering

chemotherapy• minimal disease

2mg × six doses weeklySix week review If ‘no effect’, side effects and /or

limited stable disease - discontinueIf ‘good effect’, minimal side

effects and residual disease – continue

2mg × six doses fortnightly Review (as for six week review)2mg × six doses monthlyReview at end of schedule+ Review 3 months post treatment

Initial assessment visit

Pain and symptom control

• Assess and treat pain according to WHO analgesic ladder

• Salicylic acid cream/antihistamines for itching• Crushed metronidazole to reduce smell• potassium permanganate soaks to dry excess

oozing• Wound care, nutrition assessment and advice

WHO 3-stepLadder

1 mild1 mild

2 moderate2 moderate

3 severe3 severe

Morphine

± step 1 and/or Adjuvants

Morphine

± step 1 and/or Adjuvants

A/Codeine

A/Dihydrocodeine

Tramadol

± step 1 and/or Adjuvants

A/Codeine

A/Dihydrocodeine

Tramadol

± step 1 and/or Adjuvants

Aspirin

Paracetemol

NSAIDs

± Adjuvants

Aspirin

Paracetemol

NSAIDs

± Adjuvants

Drug type Drug name Dosage

(max daily dose)

Non opioids Paracetamol

Indomethacin

Aspirin

Brufen

1g qds (4g)

50mg tds (200mg)

300-900mg qds (4g)

400mg tds (2.4g)

Weak opioids Codeine

Dihydrocodeine

Compound preps

tramadol

30-60mg 4 hrly (240mg)

30mg 4-6 hrly (360mg)

2 tablets qds

50mg tds (400mg)

Strong opioids

Note : Pethidine is no longer recommended for treatment of chronic pain

Morphine Oral morphine solution, start at 2.5-5mg 4 hrly

MST, calculate according to need of oral solution (or start 10mg bd)

Other issues to consider

• This treatment regime is not curative• Patients/guardians need counselling about nature of

disease to assist with having realistic expectations• A major part of management is managing expectations

of patients, so information needs to be clear, consistent and honest

• At Tiyanjane we use a Chichewa information sheet for literate patients (double side A4) which you can have a copy of. If its of use photocopy and give out.

• If vincristine is not helping don’t continue it, aim for patient comfort and quality of life