General

Question 1

What is the prognosis of this patient?

Answer 1

“His/her life expectancy is likely to be below that of the age-matched population, due to the multiple advanced comorbidities +/- his/her socioeconomic status, which is associated with worse prognosis”

Question 2

Pain Spiel - Tapentadol (4)

Answer 2

Centrally acting dual mechanism - Mu (18x weaker than morphine, NA re-uptake)

Start 50mg BD to 250mg BD (max)

Better GI tolerability

Monitor for serotonin syndrome with TCA, SSRI , SNRIs***

Question 3

Targin Spiel

Answer 3

Oxycodone + Naloxone - minimise opioid induced constipation (NNT = 4)

Naloxone has a low systemic bioavailability - so whilst reducing constipation, minimal systemic effects

Max 40/20mg BD - beyond this naloxone will reach systemic circulation

Reduce dose if CrCl <60 or hepatic impairment (even mild)

Question 4

Tramadol spiel

Answer 4

Weak opioid receptor agonist + 5HT/NA actions

Start 50mg TDS

Watch serotonin syndrome with TCA

Question 5

Buprenorphine (norspan) and fentanyl patch (durogesic) - spiel

Dose equivalent of MS Contin

Answer 5

Once pain is stable - not for acute pain

Patch not suitable for very thin patients

Buprenorphine 5mcg/hr = MS Contin 5mg BD (max 20mcg/hr). Weekly.

Fentanyl 12mcg/hr = MS Contin 24mg BD, every 3 days.

Fentanyl is not suitable for opioid naive patients - risk of fatal overdose