End of life, botanicals Flashcards
1
Q
Opioid clearance
A
- 90-95% excreted renally
- The liver conjugates codeine, morphine, oxycodone, and hydromorphone into glucuronides. Some of their metabolites remain active as analgesics
2
Q
Neuropathic pain management
A
Burning tingling pain
• TCA’s (amitriptyline, imipramine), gabapentin
Shooting stabbing pain
• Gabapentin, carbamazepine, valproate
Complex pain
• Combinations may be required (oral antiarrhythmics,
3
Q
Bone pain management
A
• Opioids = mainstay of treatment
Second-line drugs:
• NSAIDs
• corticosteroids
• calcitonin
4
Q
Corticosteroids
A
- acute nerve compression
- increased intracranial pressure
- bone pain
- visceral pain
- anorexia
- nausea
- depressed mood
5
Q
Anorexia/chachexia
A
• Occur in many illnesses
Management: • non-pharmacological • corticosteroids (eg, dexamethasone) • cannabinoids (eg, dronabinol) • conditions that cause poor intake eg, oral candidiasis, gastritis should be treated
6
Q
Confusion
A
- Distressing for patients and family
- Causes: drugs, hypoxia, intrinsic CNS disorders etc
- Simple causes of confusion & agitation should be sought & managed:
- urinary retention (urinary catheterization) • sleep deprivation
- poorly controlled pain
- anxiety (benzodiazepines)
- severe terminal agitation (barbiturates)
7
Q
Confusion
A
- Causes: drugs (opioids, calcium channel blockers, anticholinergics), decreased mobility, dehydration, autonomic dysfunction etc.
- Cause often not carefully assessed
- If left unmanaged can lead to considerable patient distress eg, abdominal pain, bloating, nausea, vomiting, fecal impaction
8
Q
Constipation
A
- Causes: drugs (opioids, calcium channel blockers, anticholinergics), decreased mobility, dehydration, autonomic dysfunction etc.
- Cause often not carefully assessed
- If left unmanaged can lead to considerable patient distress eg, abdominal pain, bloating, nausea, vomiting, fecal impaction
- Management:
- stimulant laxatives (eg, casanthranol, senna)
- osmotic laxatives (eg, lactulose, sorbitol)
- detergent laxatives (stool softeners eg, docusate) • prokinetic agents
- lubricant stimulants
- large-volume enemas
9
Q
Depression
A
Management:
• psychologic support
• antidepressants for persistent, clinically sig. depression
• anxiety & insomnia (sedating TCA)
• withdrawn, vegetative signs (methylphenidate)
10
Q
Diarrhea
A
- Causes: infections, GI bleeding, malabsorption, medications, obstruction, overflow incontinence, stress etc.
- Persistent diarrhea can lead to dehydration, malabsorption, fatigue, hemorrhoids, perianal skin breakdown
- Management:
- establish normal bowel habits
- avoid gas-forming foods • increase bulk
Tx
• Transient / mild - Attapulgite, bismuth salts
• Persistent / bothersome (slow peristalsis) - Loperamide, diphenoxylate/ atropine, tincture of opium
• Persistent, severe secretory - Octreotide, parenteral fluid support
11
Q
Dyspnea
A
- Causes: anxiety, airway obstruction, bronchospasm, hypoxemia, pulmonary edema, thick secretions etc
- Management:
- oxygen
- opioids (morphine = DOC)
- anxiolytics
12
Q
Fatigue
A
• Most frequent distressing symptom
Management:
• discontinue medications that are no longer appropriate and may make fatigue worse (eg, antihypertensives, diuretics)
• optimize fluid & electrolyte intake
• not easy to treat pharmacologically. Some options are:
• corticosteroids (eg, dexamethasone)
• psychostimulants (eg, methylphenidate)
13
Q
Fluid/edema
A
- Some patients develop relative hypotension, tachycardia & reduced urine output
- At end of life no amount of IV fluids and salt will return intravascular volume to normal
14
Q
Insomnia
A
Management: • avoid caffeine • avoid staying in bed when awake • excess alcohol use • avoid overstimulation before sleep • pharmacological interventions include: • antihistamines (eg, diphenhydramine) • benzodiazepines (eg, lorazepam) • neuroleptics (eg, chlorpromazine)
15
Q
N/V
A
- Common
- 2 important organs involved: brain & GI tract
Management:
• dopamine antagonists (eg, metoclopramide)
• histamine antagonists (eg, meclizine, diphenhydramine)
• anticholinergics (eg, scopolamine)
• serotonin antagonists (eg, ondansetron, granisetron)
• antacids
• cytoprotective agents
16
Q
Pressure ulcers
A
Management:
• hygiene
• protection (thin hydrocolloid dressings)
• supports
• avoid iodine-containing products
• charcoal-impregnated dressings
• superficial infections (topical metronidazole or silver sulfadiazine)
17
Q
Echinacea (E purpurea)
A
- Flavonoids, polyacetylenes and caffeonyl conjugates are the active elements from leaves and roots of Echinacea.
- Effects: Known to activate cytokines -> ↑IL ,TNF and has some anti-inflammatory properties.
- Freshly pressed juice ingestion –within 24 hr of onset; ↑immune function; ↓duration and intensity of common cold symptoms.
- AE: Unpleasant taste, GI symptoms, headache & dizziness.
18
Q
Ephedra (Ma huang)
A
- Contain ephedrine (prescription drug) and pseudoephedrine (OTC as decongestant).
- Effects: Active constituents are indirectly acting sympathomimetics; release NE from nerve endings. sympathomimetics; release NE from nerve endings.
- Used in the Rx of bronchitis, asthma and CNS stimulant. It is promoted for weight loss and ↑ athletic feats (in China used for cold & flu also).
- AE: insomnia, dizziness, anorexia, palpitation, tachycardia, flushing, & urinary retention.
- ↑doses: ↑BP, cardiac arrhythmias, and toxic psychosis.
- Contraindicated in cardiac arrhythmias (stress on CVS), hyperthyroidism, CHF, HTN, glaucoma, pregnancy, DM, bulimia, & anxiety states.
Ephedrine used in hypotension in spinal anesthesia
19
Q
Garlic (allium sativum)
A
- Active component is organic thiosulfinate which forms into allicin (accountable for characteristic smell).
- Effects: Allicin - ↓hepatic HMG-CoA (hydroxymethylglutaryl coenzyme A). Somewhat ↓ platelet aggregation, ↑ NO (nitric oxide), fibrinolytic, antimicrobial and ↓ carcinogenic activation.
- ↓cholesterol, BP with reduction in plaque formation.
- AE: allergic reaction, hypotension and nausea may occur. Anticoagulants and antiplatelet drugs may produce drug interactions.
20
Q
Ginkgo
A
- Flavone glycosides & terpenoids are active constituents.
- Effects: shows antioxidant, free radical-scavenging effects and ↑ NO formation.
- Exhibits reduced blood viscosity and changes in neurotransmitters
- Use: in the Rx of intermittent claudication, cerebral insufficiency, dementia / cognitive impairment, and pretreatment in CABG -> ↓ oxidative stress.
- AE: epileptogenic -> avoid in patients with h/o epilepsy.
- It is associated w/insomnia, headache, anxiety; GI disturbances.
- May produce drug interaction with anticoagulant & antiplatelet drugs (due to its antiplatelet action)
21
Q
Ginseng
A
- Ginsenosides (triterpenoidsaponinglycosides) –active components. Serbian & Brazilian plants do not have this chemical component.
- Effects: improves mental & physical performance. Possible value in type 2 DM and some immuno- modulating effects.
- AE: mastalgia, vaginal bleeding–estrogenic effects.
- Reported cases of nervousness, insomnia, anxiety and HTN.
- Drug interactions with anticoagulants, hypoglycemic, antihypertensive, and psychiatric medications.
22
Q
Milk thistle (Silybum marianum)
A
- Silymarin (flavonolignans)
- Effects: ↓lipid peroxidation, scavenges free radicals, ↑superoxide dismutase, ↓LT formation, ↑hepatic RNA polymerase activity.
- Use: Cytoprotective effect against hepatic injury by alcohol, acetaminophen and Amanita mushroom poisoning.
- No significant drug interaction or side effects except rarely loose stools.
23
Q
St. John’s Wort
A
- Hypericin & hyperforin are active ingredients.
- Effects: Hyperforin - ↓serotonergic reuptake (similarto SSRI & TCA); chronic use cause down regulation of adrenoreceptors and up-regulation of 5HT receptors.
- Use: in the Rx of mild to moderate depression. Photoactivated “Hypericin” may have some antiviral and anticancer effects.
- AE: mild GI disturbances & photosenstivity.
- It interacts with patients receiving MAOI, SSRI and with h/o of bipolar or psychotic disorder.
- It induces cytochrome P450 -> ↓effectiveness of OCs, cyclosporine, digoxin, protease inhibitors, and warfarin.
24
Q
Saw palmetto
A
- Contains photosterols, aliphaticalcohols, polyprenes, and flavonoids.
- Effects: ↓5α-reductase and antagonistic effects at androgen receptors.
- Use: in the treatment of BPH (benign prostatic hyperplasia); have shown some improvement in urinary flow & urologic function.
- AE: GI distress & pain; ↓libido, HTN, and headache.
25
Purified nutritional substances
* Coenzyme Q10 (ubiquinone) – serves as a cofactor for mitochondrial ETC. Its reduced form, ubiquinol, functions as antioxidant .
* Effects: associated with small degree of ↓in BP (systolic & diastolic), used in Rx of CAD and chronic stable angina; slows progression of early PD and migraine attacks. Myopathy a/w HMG COA ↓
* AE: GI symptoms; and rarely rash, thrombocytopenia, irritability, headache and dizziness.
26
Glucosamine
* It is a nitrogen containing sugar, major component of glycosaminoglycans, which is an important ingredient of connective tissues such as cartilage.
* Effects: it is primarily used for Rx of OA (osteoarthritis); ↓ pain associated with OA.
* AE: rare; GI symptoms of diarrhea and nausea. Allergy
27
Melatonin
* Melatonin has been studied for the treatment of cancer, immune disorders, CVS diseases, depression, seasonal affective disorder (SAD), circadian rhythm sleep disorders and sexual dysfunction.
* Effects: melatonin improves sleep onset, duration and quality –can be given to the patients with sleep disorders. Particularly, helps jet lag and as an alternate drug for insomnia.
* AE: sedation, following-day drowsiness.
* ↓mid-cycle surge of luteinizing hormone (LH); Chronic use ↓sperm quality; contraindicated in pregnancy, lactation.
28
Black cohosh (Actaea racemosa)
* It is native to eastern North America.
* Extracts possess analgesic, sedative and anti-inflammatory properties. Treat symptoms associated with menopause and premenstrual tension.
* These physiological effects may be due to black cohosh compounds that bind and activate serotonin receptors.
* Side effects: include dizziness, headaches, and seizures
* Nausea, vomiting and diarrhea
* Liver damage has been reported.
29
Kava
* Produce a drink with sedative properties from roots. Kava is consumed throughout the Pacific Ocean cultures of Polynesia (including Hawaii),
* Kava is sedating and is primarily consumed to relax without disrupting mental clarity. Its active ingredients are called kavalactones.
* Root of the plant used in treating short-term social anxiety.
* Safety concerns have been raised over liver toxicity largely due to the use of stems and leaves.
* Heavy use of kava appears to lead to malnutrition, weight loss, liver damage (causing elevated serum γ –glutamyl transferase and high-density lipoproteins levels), renal dysfunction, rashes, hematological abnormalities.
