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Term 5 Flash Cards > End of life, botanicals > Flashcards

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
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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,

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3
Q

Bone pain management

A

• Opioids = mainstay of treatment

Second-line drugs:
• NSAIDs
• corticosteroids
• calcitonin

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4
Q

Corticosteroids

A
  • acute nerve compression
  • increased intracranial pressure
  • bone pain
  • visceral pain
  • anorexia
  • nausea
  • depressed mood
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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
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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)
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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
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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
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9
Q

Depression

A

Management:
• psychologic support
• antidepressants for persistent, clinically sig. depression
• anxiety & insomnia (sedating TCA)
• withdrawn, vegetative signs (methylphenidate)

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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

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11
Q

Dyspnea

A
  • Causes: anxiety, airway obstruction, bronchospasm, hypoxemia, pulmonary edema, thick secretions etc
  • Management:
  • oxygen
  • opioids (morphine = DOC)
  • anxiolytics
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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)

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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
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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)
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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

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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
Q

Purified nutritional substances

A
  • 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
Q

Glucosamine

A
  • 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
Q

Melatonin

A
  • 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
Q

Black cohosh (Actaea racemosa)

A
  • 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
Q

Kava

A
  • 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.

Term 5 Flash Cards (16 decks)

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