End of Life care Flashcards
Pharmacology of analgesics and
pain therapeutics
Define pain
unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage
what is meant by socrates?
Site, Onset, Characteristics, Radiates, Associated symptoms, Time course, Exacerbating or relieving factors, Severity
give 3 non questionnaire pain assessment tools?
give 3 non questionnaire pain assessment tools?
name 2 pain questionnaires that can be used for pain assessments?
mcgill
lanss
describe the different characteristics of acute pain?
diagnosable cause, protective function, defined cause of onset, expectation of time limit, equal more or less severe to chronic pain
describe the pain characteristics of chronic pain?
no protective function, adaptation of ANS, physical and psychological effects, can lead to hyperalgesia, allodynia and spontaneous pains
chronic pain can lead to what 3 things?
hyperalgesia, allodynia and spontaneous pains
what is meant by Hyperalgesia?
increased painful response to painful stimuli
what is meant by allodynia?
pain evoked by non painful stimuli
what is meant by spontaneous pains?
has no precipitating stimulus
what type of pain is the following;
localised, ache throbbing
soft tissue, bone, visceral, neuropathic or incidental?
soft tissue
what type of pain is poorly localised, throbbing, diffuse, referred and cramping
soft tissue, visceral, bone, neuropathic and incident
visceral
what type of pain is localised aching/ tenderness
soft tissue, visceral, bone, neuropathic and incident
bone
what are the characteristics of neuropathic pain?
difficult to describe, stabbing, burning, sensory loss
what are the key features of incident pain?
episodic, on movement, weight bearing, dressing change
what response does soft tissue + visceral pain have to analgesia?
> 80% control with opioid + non opioid
what response does bone pain have to analgesia?
NSAID + RT
what response does neuropathic pain have to analgesia?
poor
what analgesia could help relieve incident pain?
physio, nitrous oxide, spinal analgesia, short acting steroids
step one of the who analgesic ladder?
non opioids with or without adjuvant
what stage of the pain ladder would nsaids and paracetamol fall under?
1
step 2 of the pain ladder ?
opioid for mild to moderate pain with or without adjuvant
what drugs would you expect to see as part of step 2 of analgesic ladder?
codeine, dihydrocodiene, tramadol
step 3 of the analgesic ladder is opioids for moderate to severe pain with or without adjuvants. List some of the drugs that you might expect to see here?
morphine, diamorphine, fentanyl, oxycodone, hydromorphone, methadone
What is the difference between acute and chronic pain and how might this affect the way that we use the WHO analgesic pain ladder?
Acute pain is short-term and usually caused by tissue damage.
Chronic pain lasts longer than 3 months and is often associated with a chronic condition.
Chronic pain may require higher steps on the WHO ladder.
What are the different ways to manage pain?
- Treat the cause.
- Treat the symptom with analgesics and adjuvants
5 ways to treat cause of pain?
surgery
antibiotics
antivirals
anti-inflammatories
radiotherapy
two ways to treat symptoms of pain?
analgesics
adjuvants
4 things to consider TOTAL pain
physical, social, psychological, spiritual
What is the appropriate use of analgesics for acute pain?
Use analgesics on a short-term basis while healing occurs. Use drugs peri-operatively for post-surgical pain. Use appropriate route of administration (IV, oral).
whats PCA?
Patient Controlled Analgesia
moa of paracetamol?
not fully understood but acts predominatly by inhibiting prostaglandin synthesis in the cns and peripheral action by blocking pain impulse generation
side effects of paracetmol?
allergic reaction, rash, swelling, flushing, low blood pressure
drug interactions of paracetamol?
other products with paracetamol, alcohol, valproate, vincristine and warfarin
NSAIDs moa?
inhibit enzyme cyclooxygenase (COX)- required to convert arachidonic acid into thromboxanes, prostaglandins, and prostacyclins
side effects of NSAIDs?
GI
headache
indigestion
stomach ulcer
drug interactions of NSAIDs?
When combined with blood-thinning medicines (such as warfarin) NSAIDs increase the risk of bleeding.
NSAIDs -> kidney failure when combined with ACEi and diuretics
Prostaglandin synthesis – complete the diagram from your notes
(add in missing arrows and products of arachidonic acid
metabolism)
Membrane phospholipids (Phospholipase A2)
Arachidonic acid
COX1 or COX2
Prostaglandins
Thromboxane
Prostacyclins
5-LOX
Leukotriene B4
Cysteinyl leukotrienes
COX exists in 2 isoforms, which one is responsible for the following
maintain gastric mucosal integrity
platelet aggregation
renal blood flow
COX1
which COX isoform induced in activated inflammatory cells, mediates pain and inflammation
COX2
how are NSAIDs simply classified?
by ability to inhibit cox1 or 2
- variation in potency
name the 4 classes of NSAIDs
preferential COX1
non selective COX inhibitors
preferential COX2 inhibitor
selective COX2 inhibitor
name 2 preferential cox 1 inhibitors?
indometacin and keterolac
aspirin, ibuprofen, naproxen and nabumetone are all examples of what type of cox inhibitors?
non selective cox inhibitors
name 2 preferential cox 2 inhibitors?
diclofenac and meloxicam
name 2 selective cox 2 inhibitors?
celecoxib and etoricoxib
what to remember when initiating NSAIDs?
use lowest effective dose
shortest duration
what 4 things to look at for individual when initiating NSAIDs?
any…
contraindications
drug ints
Med Hx
monitoring needed for oral NSAIDs?
diclofenac and high dose ibuprofen should be avoided in what condition?
HF
if required which 2 nsaids are the most appropriate to be used for the lowest effective dose for the shortest duration?
ibuprofen or naproxen
max ibuprofen daily dose?
1200mg
max naproxen daily dose?
1000mg
why should nsaids be avoided in patients with antihypertensive drugs if their egfr is below 30ml/min/1.73m2?
risk of AKI
true or false, only one nsaid should be prescribed at any one time and concomitant use with low dose aspirin should be avoided?
true
High risk patients: prescribe COX-2 inhibitor with what, to lower risk of GI SEs?
PPI
moderate risk px, to avoid GI SE, use NSAID +
PPI
low risk use non selective NSAID to lower GI SE risk T/F? no PPI
true
why might ibuprofen be used in preference to naproxen in terms of duration?
ibuprofen is short acting
why is buprenorphine different to other opioids?
its a PARTIAL mu receptor agonist. (not full)
codiene is a pro drug of morphine and has low oral ba, acts as an anti tussive and can cause constipation.
Demethylation is blocked by cyp2d6 inhibitors, name 2 drugs where this would be the case?
fluoxetine
paroxetine
tramadol has opioid and non opioid actions and is metabolised to m1 in the liver by cyp2d6 which is 2-4 x more potent than tramadol. What does it inhibit the reuptake of?
nordarenaline and serotonin
T/F: tramadol has much lower affinity for opioid receptors than morphine?
true
tramadol analgesic effect is reduced by what?
ondansetron
does carbamazepine reduce or increase the effect of tramadol?
reduce
what effect might tramadol have on warfarin?
may prolong INR
3 drug interactions with tramadol?
ondansetron
carbamazepine
warafrin
buprenorphine is a partial mu agonist, what makes it suitable for transdermal delivery?
highly lipid soluble
what makes buprenorphine fairly safe in renal impairment?
large vd and high ppb
bu patches are available for what 3 different lengths of time?
72h, 4 day, 7 day
what is the equivalent dose of bu patch in mcg to 30-60mg oral morphine over 24 hrs?
35mcg
is dose reduction of bu required in cases of renal insufficiency, yes or no?
no
morphine t1/2?
2-4 hrs,
longer in renal impairment
peak: 1-2 hrs
morphine metabolism and excretion?
in liver by CYP3A4 -> M3G and M6G, then excreted in urine.
M6G = longer t1/2, accumulate
morphine formulations available?
IR
MR
Morphine can cause several side effects, including
nausea, vomiting, constipation, dizziness, sedation, and respiratory depression
managed with dose adjustments or supportive care.
what is the most serious potential side effect of morphine and requires prompt intervention, such as the administration of naloxone.
Respiratory depression
..
Patients should also be monitored for signs of opioid-induced hyperalgesia, which can occur with prolonged use of opioid
what strength of morphine would be appropriate 4 hrly for frail or elderly patients?
5mg
what modifications can be made to dose of morphine in the case of reduced renal function?
reduce dose or increase dosing interval
true or false, if a patient is using MR morphine they should also be provided with IR morphine liquid or tablets?
true
rescue doses can be opioids that can be prescribed for regular medication with the exception of maybe fentanyl or methadone.
The dose should be what fraction of the 24 hr dose of basal analgesia?
1/6
oral rescue doses should be given max every x-y mins?
60-90
parenteral doses of rescue therapy should be given max every x-y mins?
15-30
what can breakthrough pain, spontaneous pain, incident pain and end of dose failure all be classed as?
episodic pain
what is meant by spontaneous/ idiopathic pain?
unpredicatble
true or false, incident pain is not predictable?
false
what is the term given to the type of pain that occurs before the next dose of opioid is due or exacerbations against a background on controlled pain?
breakthrough
Why might you consider second line
opioids?
- Unable to swallow ? - formulation
- Adverse effects ?
- Renal failure? – choose non-renally excreted opioid
- Genetic differences?
fentanyl is a very lipophilic molecule with a high vd, what is its plasma half life?
3h
what is the inactive metabolite that fentanyl is converted to in the liver?
norfentanyl
transdermal fentanyl patches have the following characteristics
plasma half life 17 h
onset of action 8-12 h
metabolised by cyp3a4
are interactions more likely with the transmucosal or transdermal form?
transmucosal
do you expect to see individual variability in transdermal fentanyl patch abs?
yes
what makes transdermal fentanyl a good option for use in the case of renal failure?
no dose adjustment needed and not removed by haemodialysis
what effect might heat have on abs from transdermal fentanyl patches?
increases absorption
-> FPM in liverwith Transmucosal fentanyl , sublingual and buccal formulations, how much absorbed through mucosa and hm swallowed (GI system)?
25% mucosa
75% swallowed
alfentanil is a lipophilic opioid mu receptor antagonist with rapid onset and shorter duration of action. Is dose reduction required in the case of renal failure, yes or no?
no
potency of alfentanil is X that of fentanyl
1/4
T/F alfentanil is 10-20x morepotent than IV morphine?
true
oxycodone has high oral ba and partly metabolised to oxymorphone by cyp2d6 with an onset of 4-6h.
What happens to its t half life in the case of
- liver failure
- renal failure
doubles, increases
methadone is an agonist at which 2 receptors?
mu and delta
methadone is a nmda receptor channel blocker and works to block what hormone pre synaptically?
serotonin
is methadone removed by haemodialysis?
no
methadone may be used in patients that cannot tolerate other opioids and for neuropathic pain, why must it only be started by a specialist?
inter individual variation means half life can be 5-130 hrs
what class of drugs can be used as an adjuvant analgesic for anti inflammatory action?
NSAIDs
what adjuvant analgesic class of drugs can be used for nerve compression pain?
corticosteroids
name an antidepressant that can be used as an adjuvant analgesic for neuropathic pain?
amitriptyline
name 3 antiepileptic drugs that can be used as adjuvant analgesics for neuropathic pain?
gabapentin, carbamazepine, pregabalin
name 2 agents that can be used for an nmda receptor blockade to help treat neuropathic pain?
ketamine and methadone
name an antispasmodic that can be used as an adjuvant analgesic for GI pain?
hyoscine
name one muscle relaxant that can be used as an adjuvant analgesic?
diazepam
Ethics, law and Palliative Care
what is ethics?
study of what we may classify as a good or a
bad action and provides a framework for us to
weigh that action
difference between
morals
ethics
laws
Morals- personal principles, subjective
Ethics- societal codes of conduct, study or morality, objective
Laws- eg Mental capacity act, doctrine of double effect, Data protection act, (failed) Assisted Dying Bill
4 basic principles of healthcare ethics?
consequentialist
1. beneficience (do good)
2. non maleficience (do no harm)
Deontological
3. respect for autonomy
4. distributive justice
Beneficence vs non maleficence
* Desirable and adverse effects
* Benefits and burdens
example
Fred has carcinoma lung with cerebral metastasis
causing headache. Surgery, radiotherapy and
chemotherapy are not treatment options for him.
Steroids may help symptom control of headache by
reducing peri-tumour oedema and therefore
intracranial pressure
… weigh up beneficence and Maleficence
Beneficence vs non maleficence
EG
* Tight diabetic control with TDS biphasic insulin and
strict diet
Weigh up this treatment regimen for
1. Mina, 30 year old PE teacher
2. Altaf, 70 year old with severe COPD who has
very poor appetite and expected prognosis of
weeks
answers on page 2
what does STOPP tool stand for?
Screening Tool of Older People’s potentially
inappropriate Prescriptions
come back to scenarios from ethics law and palliative care lec
What about when patients do not
have autonomy?
* Cannot make decisions for themselves
* Do not have “Capacity”
MCA- Mental Capacity Act
* ACP-Advance care planning
* LPA- Lasting Power of Attorney
* IMCA- independent mental
capacity advocate
* ADRT-advance decision to
refuse treatment
what does MCA provide?
to make decisions for themselves.
Determines
* Who makes those decisions
* How those decisions should be made
5 key principles of MCA?
- Must assume a person has capacity, unless can establish
incapacity - Individuals should be supported where possible to make own
decisions – capacity may vary, at different times, for different
reasons - Right to make eccentric/unwise decisions
- If lack of capacity established, someone must decide in ‘best
interests’ of the patient - Rights and freedoms must be restricted as little as possible
The two stage test for capacity
1st stage
Does the person have an impairment or disturbance of the
mind or brain?
what to do if no/yes?
- If ‘no’, then it must be concluded that the person has capacity.
- If ‘yes’, then proceed to 2nd stage of the test.
impairment/ disturbance, what conditions come under this?
Conditions associated with some mental illness
* Dementia
* Significant learning disabilities
* Long-term effects of brain damage
* Physical or medical conditions that cause confusion,
drowsiness or loss of consciousness
* Delirium
* Concussion following a head injury, and
* Symptoms of alcohol or drug use
2nd stage…
(come back to page 6)
Care of a dying person workshop
what is palliative care?
affirms dying as normal natural part of life
supports patients to live as well as possible till the end of life
provides support for family and carers to live as well as possible
true or false, palliative care is not about giving up?
true
what does dying look like?
reduced appetite
reduced energy
reduced conciousness
loss of reliable swallow
breathing changes
circulation changes
cold and pale
4 priorities for care of the dying person
- recognise and communicate early
- sensitive communication
- theyre involved in treatment and care decisions
- explore and respect family needs
..5. individual plan of care
what is advance care planning (ACP)?
voluntary discussion between individual and carers
identifies wishes and values, concerns and preferences for care
will take place in anticipation for future deterioration
true or false ACP is a way to communicate wishes if capacity is lost?
true
capacity = autonomy
how can an ACP enhance hope?
information leads to less fear and more control
helps maintain relationships
preserves normality
reduce sense of burden
encouraging sense of control
allows people to prepare
improve satisfaction with eol care
loss of swallow at the eol means that patients might need medicines delivered by what other route?
SC
Symptom control for the
dying phase
additional symptoms that may require just in case meds include…
Pain
Breathlessness
Nausea
“Death Rattle”
Anxiety
Delirium/Agitation
Dry mouth
list 4 just incase medicines that may be given via syringe driver at the eol?
hyoscine butylbromide,
midazolam,
morphine
levomepromazine
what is the purpose of levomepromazine?
nausea and vomiting
what is the purpose of midazolam?
agitation and restlessness
what is the purpose of hyoscine butylbromide?
respiratory secretions
what is the purpose of morphine?
pain and respiratory distress
who is allowed to administer just in case medicines for patients if they wish?
district nurse
what might be the side effects of anticipatory medicines?
drowsiness, nausea and dry mouth
only a x or x can give anticipatory medicines?
doctor or nurse
where should just in case/ anticipatory medicines be taken when they are no longer needed by the patient for safe disposal?
local community pharmacy
what are the benefits of anticipatory medicines?
can manage symptoms whenever they occur
drugs can be hard to get hold of at night or on weekends otherwise
would the following be appropriate on a medication chart at the end of life?
iv fluids, tight diabetic regimen, oral medications such as statins and antihypertensives and prophylatic lmwh?
no
anorexia is almost universal as eol approaches and is due to absence of hunger. artifical or forced feeding does not prolong life once dying. In what ways can it risk reducing the quality of life?
aspiration and nausea
hydration is also a problem at eol as there is a reduction in thirst and fluid homeostasis is dimished, if fluids are forced what are the potential risks?
oedema and respiratory secretions
how often should patients hydration be reviewed?
daily
what can be done for dry mouth?
ice chips
gum
soft toothbrush
stop unecessary medicines
monitor for candida
saliva replacements
name 2 salivia replacements?
glandosane spray and biotene gel
continous subcutanous infusions (csci) can be given via syringe drivers. They are battery powered and can be used at home, care home or hospital. what are the benefits?
can use up to 3 drugs in combination
more comfortable
less infection risk than iv
one resource to consult for syringe drivers is the syringe driver book (Dickman), name a website where you can go to view compatability tables?
palliativedrugs.com
what issues might pharmacists be involved with in eol care?
identify dangerous or erroneous prescriptions
information giving
timely access to meds
safe disposal
communicating with distressed people
tips for communicating with people that are distressed?
listen
acknowledge distress
explore whether they have support
respect they may know what they need
try not to:
- change the subject
- offer premature reassurance
- feel like you have to fix it
- take on more than you can manage
Pain control and syringe drivers workshop
the equivalent dose of morphine is what fraction of a dose of codeine approx?
1/10
what are the potential worries that patients might have regarding morphine?
- Addiction/ dependence
- Social stigma
- AEs
- Morphine = imminent death
- Pain will become resistant to analgesia so ‘nothing left when pain is severe’
what are the potential worries that healthcare professionals might have about morphine?
not confident about conversion
addiction
dependence
respiratory depression
excessive sedation
expediating death
diversion of supply for illegal use
lactulose may not be appropriate for elderly patients with constipation and cancer because it is a osmotic laxative, can you suggest more appropriate alternatives?
- stimulant laxatives like senna or bisocodyl
- sodium docusate
- Or combination of stimulant and osmotic laxative
or stool softeners like movicol if water intake is adequate
what might be a potential issue of having morphine and buccal fentanyl tablets?
morphine drys mouth secretions and fentanyl needs moist membranes for abs
What formulations of fentanyl are available for transmucosal administration
sublingual
buccal
nasal spray
- all need moist membranes
how might you advise patients to take fentanyl lozenges- buccal?
place lozenge in mouth against cheek
move around mouth using applicator
each lozenge sucked for 15 mins
water can be used to moisten buccal mucosa in patients with dry mouths
how might you advise patients to take fentanyl buccal films?
moisten mouth
place film on inner lining of the cheek
hold for 5 secs until it dissolves
if more than one film required place on other side
avoid food until film has dissolved
avoid liquids 5 mins after application
list some different factors that affect drug release from patches?
skin condition
how well its stuck
heat
true or false, morphine has low bioavailability and variable hence all patients are different?
true
how would you advise the change over from oral mr morphine to transdermal fentanyl ie when to take the last tablet and when to administer the first patch?
apply patch same time as last 12hrly dose
what would monitor patients for in hospital that have been started on fentanyl patches?
whether pain is controlled
side effects like respiratory depression and sedation
how would you counsel a patient on the admn of a patch fentanyl?
avoid external heat application
fold in half before disposing
check patch duration
apply to dry , non irritated, non irradiated non hariy skin on upper arm or torso
avoid same body part when changing
avoid using same area for several days
what would amitriptyline 10mg be used for instead of an antipyschotic?
neuropathic pain
why might someone with metastatic cancer be given a corticosteroid such as dexamethasone?
reduce inflammation around tumour site
what might diclofenac be changed to, which is more suitable to be placed inside a syringe driver?
eteorolac
what would be the breakthrough dose of morphine if a patient is taking 180mg daily as background analgesia?
30mg
What alternative options are available for administration of opioids and what doses would be appropriate?
- PEG tubes for swallowing difficulties
- If too weak to take oral med, syringe drivers (continuous SC infusion)
- IV infusion
Other routes of analgesia: (spinal admin of opioids, local anaesthetics, ketamine, clonidine, nerve block/ nerve destruction)
what are the benefits of syringe drivers to deliver medicines?
dont have to swallow
good drug availability
less infection risk as no venous access
well tolerated
easier to administer
true or false the dose of sc is half that of oral morphine, for example an oral dose of 180mg would be an equivalent sc dose of 90mg?
true
name a suitable diluent for subcut morphine?
WFI
if a patient has renal deterioration and toxicity is starting to occur from morphine, what metabolite is likely accumulating?
M6G
When to start a syringe driver?
- Persistent nausea and vomiting
- Difficult swallowing
- Poor alimentary absorption
- Intestinal obstruction
- Unconscious or profoundly weak
- Drug only available as parenteral
if changing from a syringe driver to something else, what should the dose first be converted to?
oral morphine
how often can syringe drivers be changed?
24hrs
for a patient that was previously well controlled on morphine but has now become unacceptably drowsy due to poor renal function, what changes could be made?
reduce morphine, change to fentanyl, change to buprenorphine
true or false, pain control does not need to be stable for change to syrine driver?
true
what fraction of an oral morphine dose is sc afentanil?
1/30 to 1/40
afentanil is lipid soluble which makes it suitable for use in renal failure because it does not?
accumulate
does pain have to be stable before being switched from oral to transdermal analgesia? yes or no
yes
where pain is not stable, should oral morphine be switched to a syringe driver or a transdermal patch of another analgesic agent?
syringe driver
name one resource that you can consult for more information about drugs that can be delivered within a syringe driver?
WM palliative care guidelines
why is it not appropriate for oxycodone and cyclizine to be in the same syringe driver?
causes precipitation
you should generally avoid mixing more than how many drugs in a syringe driver unless you have the stability data?
2
some drugs and syringe drivers be prescribed anticipatorarily, true or false?
true
syringe drivers will not give better analgesia compared to oral or transdermal formulations etc unless what 2 things are the case?
problems with absorption/ administration
why should drugs for syringe drivers generally be diluted with WFI instead of 0.9% saline?
tends to be less stable
tends to be less stable
no
Review all medication
Only meds to control/prevent distressing symptoms. what meds may you stop?
eg iron, vitamins, insulin, antihypertnesives
what might someone be able to place in their mouth if they are dehydrated and have a dry mouth?
ice
Analgesia: usually morphine. name some alternatives
oxycodone, hydromorphone, alfentanil
what are 3 first line anti emetics? (based on underlying cause)
haloperidol
metoclopramide
cyclizine
which first line anti emetic is most suited to emesis that is chemical or opioid induced?
haloperidol
which first line anti emetic might be appropriate for general emesis or if you are unsure of the specific cause?
cyclizine
metaclopramide is a dopamine antagonist, why is it not appropriate to be used an as antiemetic in cases of obstruction?
also a prokinetic so speeds gut motility
what is the 2nd line step for anti emesis?
add another first line or change to broad spec levomepromazine
name a third line anti emetic drug and its class that is not commonly used in end of life?
ondansetron for 3 days, 5ht3 antagonist
what can cyclizine and levomepromazine (Nozinan)cause when given in syringe driver?
infusion site irritation
is 0.9% saline appropriate to be used as a diluent for cyclizine, yes or no?
no
3 things to consider when changing morphine analgesia to alternative?
renal failure, liver failure, stable pain
what different causes might there be for patients that are experiencing agitation or delirium?
opioids, increased calcium, infection, constipation
name an antipsychotic drug that can be used for delirium?
haloperidol/ levomepromazine
name 2 drugs that may be used for restlessness? where agitation and anxiety main features
midazolam/ levmepromazine
what is the difference between the indications of high and low dose levomepromazine?
at high doses used for sedation and at low doses used as anti emetic
what drugs might you consider for mycoclonic jerking or fitting?
midozolam or clonazepam (specialist only)
what 3 pharmacological measures exist for terminal respiratory secretions aka death rattle?
hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium
what non pharmacological measures can be used for death rattle?
positioning and reassurance
which out of: hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium cross BBB?
only hyoscine hydrobromide
which out of hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium
crosses BBB, absorbed transdermally, paradoxical agitation, sedation?
hyoscine hydrobromide
which out of hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium
for colic with intestinal obstruction, may be used to control secretions. Does not cross BBB
hyoscine butylbromide
which out of hyoscine hydrobromide, hyoscine butylbromide and glycopyronnium
for excessive respiratory secretions and bowel colic. Does not cross BBB. Unstable above pH6, avoid mixing with dexamethasone.
glycopyronnium
Symptom control workshop
what is the rationale behind giving morphine for breathlessness?
prolongs breath, increases capacity of air intake and reduces perception of breathlessness
Breathlessness is a common symptom in patients with?
advanced HF
COPD
lung cancer
breathlessness is the perceived mismatch between what?
motor command from respiratory centre and ability of respiratory centre to respond.
what might an appropriate dose in opioid naive patients of morphine MR for breathlessness?
10-30mg
what might an appropriate dose in opioid experienced patients of morphine for breathlessness?
increase opioid dose by 25-50% and titrate
T/F No significant respiratory depression titrating opioids and benzodiazepines together
true
name an alternative drug, class and dose to morphine that would be appropriate to treat symptomatic breathlessness?
short acting benzos
lorazepam 0.5-1mg SL (unlicenced)
are benzos licensed for use in breathlessness, yes or no?
no
what non pharmacological support could you provide to ease the symptoms of breathlessness?
physio
calm manner
fan or open window so air hits face
short frequent meals
relaxation training
aromatherapy
treat anxiety and depression if present
encourage social interactions
peer group support
excercise
apart from morphine and benzos are there any other pharmacological measures that can help ease breathlessness?
corticosteroids, levomepromazine, bronchodilators, oxygen, nasal prongs
why might nasal prongs not be suitable to treat breathlessness?
another tube, noisy, drying, intrusive
how to treat nausea?
Antiemetic medication may be required, such as metoclopramide or ondansetron
how can hypercalaemia be a result of some tumours?
tumour might release PTH-RP which releases calcium from bones
name some cancers that -> hypercalcaemia
- Breast cancer and multiple myeloma
- Squamous cell cancers lung, cervix, head and neck
name some symptoms of (tumour induced) hypercalcaemia
vomiting
polyurea
dehydration
thrist
fatigue
confusion
constipation
name a suitable bisphosphonate that can be used to treat hypercalcaemia?
pamidronate IV
the dose of bisphosphonate will depend on what 2 parameters of the patient?
calcium level and renal function (90mg)
what should the patient be aware of if started on bisphosphonates?
ONJ, avoid invasive dental treatment, report pain, swelling, gum infection
true or false, some patients can experience myoclonic jerking from opioids and therefore a switch may be best for them?
true
Aspirin may need to be reviewed in the context of what?
any potential bleeding risk with an underlying malignancy.
why might platinum based chemo lead to mycoclonic jerking?
not preserving magnesium
What is the symptom called ‘death rattle’? and how to treat it?
Respiratory secretions in the dying phase
bubbly, or noisy breathing
repositioning the patient, suctioning secretions, and moistening the patient’s mouth and lips.
3 medications for death rattle?
anticholinergics
Hyoscine hydrobromide
Hyoscine butylbromide or
Glycopyrronium
does dexamethsone work well when put in a syringe driver, yes or no?
no
can anticholinergics such as glycopyrronium be put in same syrinige driver with morphine?
no - dont mix them with other medications in the same syringe driver. prevents drug interactions and ensure accurate dosing.
instead of delivering dexamethasone in a driver, how else might you give it?
stat dose
true or false, at low doses midazolam and morphine together in a syringe driver do not pose any problems?
true
what 2 drugs cannot be mixed with cyclizine in a syringe driver?
hyoscine and oxycodone
Symptom control in palliative care lec
What are the 4 types of total pain?
physical
social
psychological
spiritual
What is physical pain?
- pain due to disaease locations
- patients can experience other symptoms (nausea)
- there is a physical decline and fatigue in patients with physical pain
What is psychological pain?
- grief and depression, anxiety and anger
- may arise with adjustment to a patients condition
What is social pain?
experience of pain as a result of interpersonal rejection or loss, such as rejection from a social group, bullying, or the loss of a loved one
What is spiritual pain?
feeling that the pain arises as a punishment for previous wrongdoings
What are 3 features of pain assessment?
- history
- examinations
- investigations
What are features of reassessment in pain assessment?
- response of pain to each treatment
- any new pains that have appeared
what to remember about step 1: NSAIDs?
- need gastroprotection especially if also receiving steroids or SSRIs
- contraindications like renal function
- alternative routes like orodispersible piroxicam or s/c diclofenac
for what weight px is paracetamol dose reduction needed?
<50kg or malnourished
- high tablet burden (up to 8 tablets a day)
why is step 2 - codeine difficult drug to use?
effects individuals very differently
in analgesic and side effects
in what px are low dose formulations of buprenorphine useful in?
opioid naive
T/F: buprenorphine is relatively safe in renal and liver impairment?
true
what class drug is tamadol and how does it work?
- opioid and non opioid action (adjuvant/additional role as well) - can show a lot of side effects
- serotonin and noradrenaline reuptake inhibitor
why is morphine the gold standard/ reference opioid in step 3?
- familiar
- cheap
- easy route of administration
- no other opioid proven to be more effective (this does not mean if morphine is ineffective that others wont)
morphine SEs?
Constipation
* Nausea
* Drowsiness, confusion
* Myoclonus
* Sweating
* Pruritis
name 2 morphine long term effects?
HPA suppression
immunosuppression
how may acute severe tox/ OD of morphine present?
respiratory depression
reduced consciousness
pinpoint pupils (but not very helpful diagnostic)
Why is morphine toxicity a concern in renal impairment? (cycle)
renal impairment -> morphine toxicity -> serious drowsiness -> dehydration -> further worsen renal impairment
What is background pain and how is this managed?
Continuous levels of discomfort or baseline pain which is prevented with MR morphine such as ZOMORPH
What is breakthrough pain and how is this managed?
Comes on suddenly, lasts for short periods, and is not relieved by the patient’s normal pain management instead given immediate release formulation like ORAMORPH
difference between zomorph and oramorph in terms of what pain theyre prescribed for?
zomorph: background pain
oramorph: breakthrough pain
What is zomorph?
A modified release formulation of morphine
What is oramorph?
Immediate release morphine given for breakthrough pain
What is incident pain?
occurs predictably after specific movements
- swallowing
- coughing
What is spontaneous pain?
Pain in the absence of a stimulus
unpredictable
- bladder spasm
- stabbing neuropathic pain
diamorphine is another step 3 med. why is it good for admin high doses?
as its a concentrated formulation
3x more potent than oral morphine
T/F:
oxycodone is
as effective as morphine
2x more potent than oral morphine (lower dose)
better tolerated than morphine in some patients
opioid switching is justified
true
why avoid oxycodone in severe hepatic impairment
liver metabolised
why is fnetanyl good in terms of SE profile?
has fewer SE especially constipation
doesnt accumulate in renal impairment
with morphine: remember rescue doses and warn px about what?
constipation and nausea - offer treatment
also drowsiness and driving advice
What are important warnings about fentanyl?
VERY strong analgesic with risks of toxicity
if accidentally sticks to someone else like bed partners or toddlers, it can cause severe side effects
how does transmucosal fentanyl compare to oral morphine IR?
faster onset of action, shorter duration of action
- 15 minute onset
- last about an hour
4 example drug names of transmucosal fentanyl?
- Actiq
- Effentora
- Abstral
- Nasal sprays eg Pecfent
why is transmucosal fentanyl titration challenging?
Difficult to convert dose from morphine therefore need to titrate up regardless of how high morphine dose was
Using strong step 3 opioids: which drug to use?
morphine 1st line
other options if not tolerated
fentanyl if renal impairment
why use ORAL opioids eg
Codeine
Tramadol
Morphine,
Oxycodone
first line
why use SC opioid eg
Morphine,
diamorphine,
oxycodone,
Alfentanyl
dying
vomiting
speed of onset of action
why use TRANSDERMAL opioid eg
fentanyl
buprenorphine
vomiting
px preferences
why use TRANSMUCOSAL opioid eg
fentanyl
speed of onset of action
why use SPINAL opioid eg
morphine
diamorphine
bupivocaine
systemic SEs
What are features of methadone in symptom control?
- very effective analgesic
- effects opioid and NMDA receptors
- no dose conversion with morphine
Seek specialist advice before stopping, pausing, ommitting or changing dose
initiation and titration requires specialist supervision
What is an adjuvant?
a medicine with primary indication that is not an analgesic but has some analgesic effect
Used with conventional analgesics
What is neuropathic pain and its characteristics?
Arising from injury to the nervous system
- burning
- tingling
- shooting disturbance
What are examples of adjuvants for symptom control?
corticosteroids
antidepressants - amitriptyline
antiepileptics - gabapentin
bisphosphonates
NMDA receptor blockade (glutamate receptor blocker)
antispasmodic
muscle relaxant
What factors affect the choice of adjuvant for analgesia? [6]
- Evidence from clinical trials
- Availability
- Side effects
- Cost
- Onset speed
- Prescriber familiarity
4 Limitations of the WHO
ladder?
- Designed for advanced cancer pain, but used more broadly
- Does not incorporate anaesthetic techniques
- Middle rung may not be distinct or necessary
- No focus on non pharmacological
3 medicines for breathlessness management
opioids
oxygen
benzos
Ethics, law, palliative care continued
What are the four criteria to determine if a person lacks capacity for a particular decision?
The ability to understand information related to the decision.
The ability to retain the information for long enough to use and weigh it up.
The ability to use and weigh up the information relevant to the decision.
The ability to communicate the decision in some way.
What is the “best interests” approach?
Best guess as to what they would chose if they
were able
XNot what you would chose or think is best
What are the 6 steps involved in making a best interests decision?
- Encourage participation and enable the person to take part.
- Consider whether the decision can be delayed until the person has capacity.
- Identify all relevant circumstances.
- Find out the person’s views, past and present wishes, feelings, beliefs, and values.
- Consult with friends, family, Attorney or Deputy, if applicable.
- Avoid discrimination.
Who makes best interests decisions? (other than px when they have capacity)
HCP when px lacks capaity
- Family are “advocates”, not decision makers.
- Taking into account family members knowledge of patient wishes and preferences
- If no “advocate” for patient, then appoint an IMCA for important decisions (life changing/threatening treatments, changes in place of residence)
LPA for health (if appointed)
What is an Advance Decision to Refuse Treatment (ADRT)?
decision relating to a specific treatment in specific circumstances that involves refusal, not a request, for treatment. It can be written or verbal, must be written, signed, and witnessed if it includes a refusal of life-sustaining treatment, and will come into effect only when the individual has lost capacity to give or refuse consent. It is legally binding and should be shared with family and the Multi-Disciplinary Team (MDT).
What is a Lasting Power of Attorney (LPA)?
legal document that states in writing who can make decisions for a person if they lack capacity.
can cover property, financial affairs, health, and welfare.
only comes into force when the patient lacks capacity, and the appointed person must make decisions in the patient’s best interests, taking into account their views and attitudes..
what is DNACPR and AND?
do not attempt CPR
allow natural death
Ethical analysis of CPR
beneficience
maleficience
justice
autonomy
Beneficence: aims to restart cardiac and respiratory function
Maleficience: may cause brutal rib #, ventilation, anoxic brain injury, and poor survival and discharge rates even after successful CPR
Justice: not in the interests of distributive justice to offer CPR if it is deemed “futile”
Autonomy: consent for CPR is required, and patients should be informed about DNACPR. Patients should be the decision-maker, not their family. They are entitled to a second opinion on the issue of futility but not offered a decision regarding treatment where it is deemed futile.
T/F:
The subcutaneous dose of morphine is half the total daily oral dose.
true
SC morphine should be presribed PRN for breakthrough pain for that px (SCRIPT)
should be 1/6 of the regular 24hr dose
prescribe an antiemetic PRN in case
what would you prescribe with morphine sulphate 80mg over 24hrs in syringe driver for px with nausea and vomiting?
Cyclizine 150 mg with haloperidol 2.5 mg over 24 hours
Breathlessness can be treated with which ONE of the following drugs?
Gabapentin
Haloperidol
Hyoscine butylbromide
Metoclopramide
Midazolam
Midazolam SC
