Dr. Jana Pilkey MD, FRCPC Internal Medicine, Palliative Medicine

1. Have the ‘Lytes Gone Out?Electrolyte and Metabolic Abnormality Management In Palliative Care – A case based discussion Dr. Jana Pilkey MD, FRCPC Internal Medicine, Palliative Medicine Assistant Professor University of Manitoba

2. Objectives • To list symptoms & treatments for hypercalcemia • To gain approach to treatment of hyponatremia and hypernatremia • To list symptoms & prevention of refeeding syndrome • To list symptoms & treatment of hypomagnesemia • To understand differences in the management of diabetes in the palliative patient • To understand ethical issues of treatment

3. Case 1 • Mr. B. was a 42 year old man • Morbidly obese – weight around 500 lbs • Diagnosed with locally invasive squamous cell penile cancer • Underwent penectomy 2006 • Referred to palliative care

4. Case 1 • Unable to ambulate • Multiple perineal wounds • Profound leg and scrotal edema • Calcium 4.02 (corrected)

5. Hypercalcemia • 30% of patients with cancer • 50% die within 30 days • Most common cancers: • squamous cell • breast • renal • MM • lymphomas

6. Hypercalcemia • Causes: • Osteolytic effects of bony mets • Humoral – secretion of a PTHrP • 1,25 (OH)2D – secreting lymphomas • Ectopic secretion of PTH (very rare)

7. Clinical Symptoms • Bones – bony pain • Stones - (Renal) – dehydration, polyuria, thirst/polydipsia, renal calculi • Moans – sedation, delirium, coma • Groans – anorexia, nausea, vomiting, abd pain

8. Diagnosis • Total serum calcium (corrected for albumin) • Ionized calcium • If treating must monitor: • Renal function • phosphate • magnesium • potassium

9. How to Treat • Antineoplastics - key to maintenance • Fluids – Saline hydration and loop diuretics • Bisphosphonates • Decreases bone resorption • Full efficacy in 2-7 days • Lasts 1-3 weeks. • Calcitonin • subcut 4U/kg q 12 hours, • works immediately • tachyphylaxis within a few days (Siddiqui, J Pall Med 2010)

10. Should I Treat? • Ethical Issue • Must take into account: • patients goals • ability to palliate/treat • “good death”

11. Case 1 • Initially responded to pamidronate • Time between treatments getting shorter • Switched to IV zolendronate • Tried 4 and then 8 mg doses • Continued to decline • Died at home

13. Hyponatremia (Verbalis, Am J Med, 2007)

14. Hyponatremia • Assuming Hypotonicity if they are: • Wet – dry them (diuretics) • Dry – wet them (fluids) • Neither – fluid restrict them

15. Hyponatremia • Most often happened gradually • Must be very careful to not over correct • Is correction appropriate in palliative care?

16. Hypernatremia • Always Hypertonic • Most often Hypovolemic in palliative care • Should palliative patients be treated with fluids?

17. Fluids in Palliative Care When might it not be appropriate: Close to dying Gross edema Prone to pulmonary edema • When might it be appropriate: • Patient unable to take orally & not close to dying • Goal to prolong life • Treat a cause of delirium

18. Fluids in Palliative Care • Oral • Enteral feeding tube • Intravenous • Hypodermoclysis

20. Case 2 • 78 y.o. female with laryngeal ca • Unable to swallow & dehydrated - Hungry • 2 weeks into admission – pt agrees to a feeding tube • Tube placed into stoma connecting tracheostomy with esophagus

21. Case 2 • Remains hungry - Feeds increase • Chews food for enjoyment • Continues to dehydrate • Tube dislodged • IV fluids started • G- tube inserted

22. Electrolyte Pattern

23. Refeeding Syndrome • Occurs when malnourished patients are fed • Problem in 25% of advanced cancer patient • Palliative patients especially vulnerable (labs) • Characterized by: • acute development of electrolyte depletion • fluid retention • disruption of glucose homeostasis (Marinella, Nutr Rev 2003) (Marinella, J Supp Onc, 2009)

24. Refeeding Syndrome • Malnutrition: • loss of lean tissue mass • depletes phosphate stores • Carbohydrate load: • requires phosphorylatedglycoloysis • further depletes phosphate stores • stimulates release of insulin • leads to a shift in po4, k, mg (Marinella, J Supp Onc, 2009) (Marinella, Nutr Rev 2003)

25. Refeeding Syndrome • Decrease po4 leads to decrease ATP: • heart failure • neuromuscular impairment • diaphragmatic weakness • hemolytic anemia (Marinella, Nutr Rev 2003) (Marinella, J Supp Onc, 2009)

26. Treatment • Prevent Dehydration • Replace phosphate, K, Mg • Resume feeding slowly • Thiamine and B vitamins (Marinella, J Supp Onc, 2009)

28. Case 3 • 52 y.o. Woman with stage 4 cervical cancer • Had chemo and radiation • Bowel obstruction – entero-enterostomy and loop colostomy • Persistent hypokalemia and hypocalcemia • Anorexia, diarrhea, muscle weakness, twitching, parasthesia.

29. Case 3 • Na – 138 • K – 2.9 • Urea – 5.3 • Creat – 57 • Corr Ca – 1.57 • Phos – 1.27 • Any Ideas?

30. Case 3 • Magnesium 0.2 mmol/L (0.65-1.05)

31. Case 3 • Given IV MgSO4 - Dramatic Improvement! • Ca and K normalize over next week • Discharged home and went on ski trip • Died 3 months later of renal failure • Was her treatment appropriate? • Should we routinely check for this in a palliative patient?

32. Hypomagnesemia (Exton, Pall Med 2000)

33. Hypomagnesemia • 7-11% of hospital patients • Common if other electrolytes • Causes refractory K+ & Ca++ • Treat cautiously in: • renal failure • dehydration • myasthenia • bradycardia (Exton, Pall Med 2000)

34. Diabetes in Palliative Care • Common in palliative care • Monitoring • Unsure of best frequency or method • Goal is 10-20 mmol/L and asymptomatic • WRHA - implementing screening if on steroids • Insulin preferred agent for treatment • Primary goal - prevention of hypoglycemia • Stop if patient unconscious

37. Summary • Electrolyte/metabolic abnormalities managed on individual basis • If treatment undertaken - management is similar to management elsewhere • Palliative care patients are particularly vulnerable to electrolyte abnormalities • If questions feel free to consult