Deck 1 Flashcards
The five types of cancer that commonly spread to bone
breast bronchus (lung) thyroid kidney (renal cell carcinoma) prostate.
Identify the correctly paired name and description of different cancer pain syndromes
WHO analgesic ladder
The patient develops severe renal failure (eGFR < 15 ml/min) and is becoming more unwell. Which drug is most appropriate to be used in renal failure?
Alfentanil undergoes hepatic metabolism. It has a short half life and is a suitable candidate for use in a sub-cutaneous syringe driver in renal failure. It is less likely to accumulate. Its short half life means that any excess effects subside more quickly when the syringe driver is stopped.
Diclofenac and naproxen are non-steroidal anti inflammatory drugs (NSAIDS), they work by inhibiting cyclo-oxygenase (COX) 1 and 2, preventing prostaglandin formation. They should be avoided in renal failure.
Morphine and diamorphine are opiates they undergo hepatic metabolism. These metabolites are then renally excreted. They should be avoided in severe renal failure. Morphine can be used in smaller doses and less often as the drug can accumulate.
A palliative care specialist should be involved in the decision to prescribe Alfentanil as this is not a commonly used drug.
The patient is reviewed by the acute oncology team. He is getting some pain relief from opiates, however, his pain is still not adequately controlled. Which of the following would be appropriate interventions to relieve his bone pain?
Palliative radiotherapy is an effective treatment of a specific bone metastasis causing pain. A single 8 Gray (dose) in one fraction (treatment) has been shown to reduce pain caused by bone metastases.
Zoledronic acid is a bisphosphonate that has been shown to be effective in relieving bone pain and reducing skeletal related events. Bisphosphonates work by inhibiting osteoclast-driven bone reabsorption.
A JJ stent is a ureteric stent used to relieve hydronephrosis
Vertebroplasty involves the image-guided injection of bone cement into a collapsed vertebral body.
Kyphoplasty involves inflating a balloon in the collapsed vertebral space, then inserting surgical cement.
A surgical option would only be considered if medical management and/or radiotherapy had failed.
The patient has a single fraction of radiotherapy to his spine, his pain has been controlled by MST 30mg BD (long acting Morphine sulfate tablets). On the discharge letter, what would be an appropriate dose of breakthrough analgesia?
The correct break-through dose of analgesia should be a sixth of the total amount used in 24 hours. This patient is having 60mg morphine in 24 hours. A sixth = 10mg;
10mg oramorph once a day is too infrequent
60mg of oramorph is too high a dose
30mg of oxynorm liquid = 60mg oramorph, this is too high a dose
2.5 mg of diamorphine SC = 7.5 mg oramorph – but the patient can take oral medication so doesn’t need SC route.
Which of the following is NOT a common side effect of opiates when used at appropriate doses?
Respiratory depression is a rare side effect of opiates when they are used in appropriate doses, it is important to titrate the dose to the patient. Constipation and nausea are common side effects of opiates, as a result patients should be prescribed a prn anti-emetic and laxative. If a patient is experiencing nausea a regular anti-emetic such as metoclopramide (which is pro-kinetic) can be used. The sedating effects of opiates often subside after 2-3 days.
For palliation of shortness of breath with a significant anxiety component, which two of the following options would be the best initial management?
Lorazepam 0.5mg sublingual PRN QDS
Levomepromazine 6.25 SC PRN BD
When palliating shortness of breath in a patient with normal renal function, which opioid would be first line?
oral morphine sulfate immediate release solution (10mg/5ml)
What would be the best initial starting dose for oral morphine sulfate immediate release solution – (Oramorph)?
10mg PO 4hrly PRN
What additional measures for palliation of shortness of breath may be of benefit if the patient has normal oxygen saturations?
handheld fan
teaching him/his wife acupressure points
The patient gets some relief from morphine sulfate immediate release solution (oramorph) 1mg PRN and is titrated up slowly to 2mg 4-5 times a day with good effect. However, he is struggling to draw the dose up and asks if he can have a tablet instead. Which is the correct equivalent dose?
morphine sulphate modified release 5mg BD
The patient is stable symptomatically on Morphine sulfate modified release tablets 5mg BD and lorazepam 0.5mg sublingual – QDS. However, globally he continues to deteriorate and is thought to be in the last hours to days of life. He has been unable to take his oral medication – and has missed last night and this mornings dose. What is the single best option:
morphine sulfate with midazolam syringe driver
Which would be the equivalent doses via syringe driver for morphine sulfate modified release tablets 5mg BD?
First work out daily dose of morphine sulfate – He is on 5mg BD = 5×2 = 10 mg over 24 hours. Now you need to remember your conversion rate between morpine sulfate PO and SC which is a ratio of 2(po):1(sc). Therefore you need to divide your 24 oral dose by 2 to obtain the appropriate 24 SC dose (in this case it will be 5mg).
The patient has been titrated up to a dose of 15mg morphine sulfate SC over 24 hours in a syringe driver. What is the appropriate PRN morphine sulfate dose?
PRN morphine sulfate should always be 1/6th of the total daily morphine dose. If he is on 15mg SC via a syringe driver over 24 hours, PRN would be 15÷6 = 2.5mg.
