Drugs in palliative care

Question 1

What causes nausea and vomiting in palliative care

Answer 1

Chemo
Constipation
Hypercalcaemia
Oral candidiasis
GI obstruction
Drugs
Severe pain 
Infection 
Renal failure

Question 2

How should anti-emetics be chosen?

Answer 2

Based on the likely mechanism of nausea

Consider the site of action especially when using combination of drugs

Question 3

Describe how Cyclizine works and when it is good for nausea?

Answer 3

Antihistamine and anticholinergic, central action

Good for intracranial disorders

Question 4

Describe how metoclopramide works and when it is good for nausea

Answer 4

Blocks central chemoreceptor trigger zone, peripheral prokinetic effects so good in gastroparesis, monitor for extrapyramidal side effects

Question 5

Describe how domperidone works

Answer 5

Peripheral antidopaminergic so no dystonic effects

Question 6

Describe how haloperidol works and when it is good for nausea

Answer 6

Dopamine antagonist, effective in drug or metabolically induced nausea, use lower doses IV/SC as twice as potent

Question 7

Describe how ondansetron works and when it is good for nausea

Answer 7

Serotonin antagonist

Good for chemo/radiotherapy related nausea, may cause constipation

Question 8

Describe how levomepromazine works and when it is good for nausea

Answer 8

Broad spectrum

Can sedate and be very effective if fear/anxiety are contributing to symptoms

Question 9

List the 5 principles by which pain is managed

Answer 9

By the mouth 
By the clock 
By the ladder
For the individual 
Attention to detail

Question 10

Describe the WHO pain ladder

Answer 10

Step 1 - non opioid eg. paracetamol
Step 2 - opioid for mild to moderate pain eg. codeine
Step 3 - opioid for moderate to severe pain eg morphine, diamorphine, oxycodone

Question 11

What other drugs must be prescribed with opioids

Answer 11

Laxative and antiemetic

Question 12

Describe how you prescribe opioids

Answer 12

Start low and go slow - 5mg oral morphine every 4hrs plus PRN 5mg morphine

Convert to modified release - calculate dose every 12hrs by calculating 24hr oral dose and divide by 2

Use a PRN dose for breakthrough pain - 1/6th total daily dose as an immediate release preparation (oramorph or sevredol)

Question 13

List the side effects of opioids

Answer 13

Drowsiness
Nausea and vomiting
Constipation
Dry mouth

Question 14

Describe the signs of opioid toxicity

Answer 14

Sedation 
Respiratory depression
Visual hallucination 
Myoclonic jerks 
Delirium

Question 15

When should naloxone be used?

Answer 15

Life threatening respiratory depression

Question 16

What happens if naloxone is given when it is not a life threatening situation

Answer 16

Pain crisis and potentially fatal acute withdrawal

Question 17

Describe opioid use in those with renal failure

Answer 17

At risk of toxicity due to accumulation of renally excreted opioids and metabolites

Fentanyl, alfentanil and buprenorphine have predominately hepatic metabolism so may be used in renal failure

Question 18

What drug can be used for rapid analgesia for pain during mobilising to toilet or being changed etc

Answer 18

Buccal fentanyl

Question 19

What causes constipation

Answer 19

Opioids 
Hypercalcaemia
Dehydration 
Drugs
Intra-abdominal disease

Question 20

How is constipation treated

Answer 20

Treat reversible causes
Good fluid intake
Ensure privacy and access to toilet
Medication options include:
- Stimulant (senna or bisacodyl) and softener (sodium docusate)
- Osmotic laxative (macrogol)
- Rectal treatments (Bisacodyl/glycerol suppositories)

Question 21

What causes breathlessness in palliative care

Answer 21

Infection, effusion, anaemia, arrhythmia, the disease, thromboembolism. superior vena cava syndrome

Question 22

How is breathlessness treated in palliative care?

Answer 22

Low dose/ breakthrough dose opioid

Benzodiazepine if associated anxiety (eg. lorazepam/midazolam)

Question 23

List some causes of oral problems in palliative care

Answer 23

Poor oral hygiene
Radiation
Drugs - anticholinergics, chemotherapy and diuretics
Infection - candidiasis and anticholinergics

Question 24

How is oral candidiasis treated?

Answer 24

Topical miconazole or oral fluconazole (check interactions with warfarin)
Oral nystatin may not work and may increase nausea

Question 25

How is herpes simplex treated?

Answer 25

Oral gan/aciclovir

Question 26

List the end of life anticipatory medications

Answer 26

Morphine for pain 
Haloperidol for agitation and N&V
Midazolam for anxiety and agitation
Levomepromazine for N&V
Glycopyrronium for troublesome resp secretions

Question 27

What must be done in terms of prescribing when someone is end of life/final days of life

Answer 27

Remove any unnecessary medications
Prescribe anticipatory medications
Start syringe driver if needed - remember to include regular doses when calculating requirements

Question 28

What are syringe drivers

Answer 28

Allow a continuous SC infusion of drugs, avoid repeated cannulation and injection when the oral route is not feasible