16 - Cancer Comorbidity Management Flashcards
How may patients with advanced cancer experience breathlessness and how can we recognise this?
- 70-85%
- Ask the patient, no way to measure it with NEWS score etc
- Increases likelihood of in-hospital death
What are some reversible causes of breathlessness in EOLC AND how can they be reversed?
How can intractable breathlessness in palliative care be managed non-pharmacologically?
- Position patient upright
- Open window or fan on their face
- Physiotherapy
- CBT
- Breathing control techniques
- Pulmonary rehabilitation if well enough
- Trial of oxygen if hypoxic
How can intractable breathlessness be managed pharmacologically in palliative care?
- Very low dose opioids
- Benzodiazepines if anxiety related
What is the pathophysiology of vomiting and what are the different receptors involved in each step?
What are some causes of N+V in cancer patients?
Reduced gastric motility
- May be opioid related
- Related to serotonin (5HT4) and dopamine (D2) receptors
Chemically mediated
- Secondary to hypercalcaemia, opioids, or chemotherapy
Visceral/serosal
- Due to constipation
- Oral candidiasis
Raised ICP
- Usually in context of cerebral metastases
Vestibular
- Related to activation of acetylcholine and histamine (H1) receptors
- Most frequently in palliative care is opioid related
- Can be motion related, or due to base of skull tumours
Cortical
- May be due to anxiety, pain, fear and/or anticipatory nausea
- Related to GABA and histamine (H1) receptors in the cerebral cortex
Which receptors do each of the following anti-emetics work on?
Describe the nature of nausea and what antiemetic is best for chemically induced nausea?
Ondansetron, haloperidol and levomepromazine
Describe the nature of nausea and what antiemetic is best for gastric stasis induced nausea? e.g tumour or ascites obstructing gastric outflow
Do not use metoclopramide if bowel obstruction or after gastric surgery
- Fullness/regurgitation of undigested food
- Reduced appetite
- Vomiting (often large volume) relieves nausea
- Epigastric discomfort
- Hiccups
- Reflux
Describe the nature of nausea and what antiemetic is best for bowel obstruction induced nausea?
High: regurgitation, forceful vomiting of undigested food
Low: colicky pain, large faeculant vomits, visible peristalsis
Describe the nature of nausea and what antiemetic is best for raised ICP induced nausea?
Use cyclizine and dexamethasone together
Can also use radiotherapy
- Nausea worse in the morning
- Projectile vomiting
- Worse on head movement
- Headache
Describe the nature of nausea and what antiemetic is best for psychologically induced nausea?
Anxiety, fear, anticipation
Describe the nature of nausea and what antiemetic is best for post op/radiotherapy induced nausea?
Describe the nature of nausea and what antiemetic is best for constipation induced nausea?
What are some risk factors for vomiting with chemotherapy?
75% will experience it
- Specific chemo agents
- Anxiety
- Female gender
- Age <50 years
- Past Hx of N&V (pregnancy, prior chemotherapy use, motion sickness)
- Concurrent use of opioids
What are the phases of CINV and what antiemetics are used for CINV?
Anticipatory, Acute, Delayed
Low risk
- Metoclopramide
High risk
- 5HT3: Ondansetron. Used more for acute.
- NK1: Aprepitant. Used more for delayed.
- +/- Dexamethasone
What is Aprepitant and what are the side effects of this?
What antiemetics are used for EOLC?
LEVOMEPROMAZINE: very broad spectrum
What route should anti-emetics be given?
- PO preferable
- If the patient is vomiting, has issues with malabsorption, or there is severe gastric stasis can use SC or IV access
What antiemetic is best for vestibular causes of nausea?
Cyclizine
What are some non-pharmacological management options for nausea?
What are some causes of constipation in cancer patients?
(important)
- Exercise
- Increase fluids
- Increase fibre in diet
- Laxido
Give some examples of the following classes of laxatives and their MOA?