Care of the dying

Question 1

Dose reduction in opioid rotation

Answer 1

25-50% of calculated dose

Accounts for incomplete cross-tolerance

Question 2

Calculating breakthrough dose of opioid for breakthrough pain

Answer 2

1/6 of 24-hourly dose given orally, PRN

Question 3

Immediate-release opioid pharmacokinetics

Answer 3

Peak concentration within 1-4h

Question 4

modified-release opioid pharmacokinetics

Answer 4

Peak at 2-6h

Sustained for 12-24h

Question 5

Principles of WHO pain ladder

Answer 5

By the mouth

By the clock

By the ladder

For the individual

Attention to detail

Question 6

Adjuvant drugs for neuropathic pain

Answer 6

NMDA receptor blocker (ketamine)

Antidepressant (amitryptilline)

Anticonvulsant

Question 7

Adjuvant drugs for muscle spasm/cramp

Answer 7

Muscle releaxant (e.g. BDZ)

Question 8

Adjuvant drugs for colic

Answer 8

Antispasmodic (e.g. hyoscine)

Question 9

Adjuvant drugs for bony pain, spinal cord oedema/compression

Answer 9

Bisphosphonates

Steroids

Question 10

GI risk factors for NSAIDs

Answer 10

Age >65

Prev peptic ulcer disease

Concurrent meds: warfarin, aspirin, steroids, SSRIs

Question 11

Dosing for diclofenac

Answer 11

75-150mg daily

Question 12

Dosing for ibuprofen

Answer 12

200-400mg tds po

Question 13

Dosing for naproxen

Answer 13

250-500MG BD PO

Question 14

Opioids for mild-mod pain

Answer 14

Codeine

Tramadol

Question 15

Codeine dosing

Answer 15

30-60mg every 4h

Max 240mg per day

Question 16

Tramadol dosing

Answer 16

50-100mg every 4-6h

Question 17

Drugs accelerating morphine clearance

Answer 17

carbamazepine

Phenobarbitol

Phenytoin

Rifampicin

Question 18

Drugs slowing morphine clearance

Answer 18

Renal impairment

Phenothiazines

TCAs

Cimetidine

Question 19

Conversion between morphine and diamorphine

Answer 19

Diamorphine is 3x as potent

Question 20

Morphine dosage

Answer 20

30-60mg/24h

Question 21

Opioid choice for severe renal impairment

Answer 21

fentanyl (liver metabolism) or alfentanil

Question 22

Fentanyl patch frequency

Answer 22

Switch every 3 days

Question 23

Time to steady state of transdermal fentanyl

Answer 23

72h, do not titrate more frequently

Question 24

Converting from IR ot M/R morphine

Answer 24

When patient is stable, calculate total morphine dose

Dive by 2 –> 12-hourly M/R dose

1/6 dose for breakthrough pain

Question 25

Morphine to codeine

Answer 25

Multiply by 10

Question 26

Morphine PO to tramadol PO

Answer 26

Multiply by 10

Question 27

Codeine/dihydrocodeine/tramadol PO to morphine PO

Answer 27

Divide by 10

Question 28

Morphine PO to morphine SC (e.g. for syringe driver)

Answer 28

Divide by 2

Question 29

CSCI drugs needing NaCl diluent

Answer 29

Diclofenac Octreotide Ketamine

Question 30

CSCI drug diluent total

Answer 30

21ml

Question 31

Morphine PO \> Oxycodone PO

Answer 31

Divide by 1.5

Question 32

Oxycodone SC to Oxycodone PO

Answer 32

Multiply by 1.5

Question 33

Oxycodone PO to morphine PO

Answer 33

Multiply by 1.5

Question 34

Morphine PO to fentanyl TD

Answer 34

Morphine (in mg) in 24 hours divided by 3 = fentanyl patch size in mcg/hr

Question 35

Morphine PRN dose

Answer 35

2.5-5mg hourly

Question 36

Haloperidol PRN anti-emetic dose

Answer 36

0.5-1mg 8-hourly

Question 37

Haloperidol PRN agitation dose

Answer 37

1.5-5mg 8-hourly

Question 38

Metoclopromide anti-emetic PRN dose

Answer 38

10mg 6-hourly

Question 39

Midazolam PRN dose

Answer 39

2.5-5mg hourly

Question 40

Hyoscine PRN dose

Answer 40

20mg hourly (max 120 per 24 h)

Question 41

Signs of endo of life

Answer 41

**PRN ECG** **P**upils: non-reactive **Reaction:** to stimuli reduced **Neck:** Hyperextended **E**yelids: Unable to close fully **Consciousness:** Reduced, sleep \>50% of day **Grunting:** +WOB

Question 42

Management of dry mouth

Answer 42

Ice treatment/ice lollies R/V mouth care every 2h Regular sips

Question 43

Management of delirium/agitation

Answer 43

Consider reversible causes (e.g. retention, constipation) Haloperidol first-line Olanzapine 2d line Midazolam for agitation/restlessness