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411 Oncology > L10 - Palliative care > Flashcards

L10 - Palliative care Flashcards

1
Q

What are SEVEN common symptoms needing palliative care?

A 
Pain
Constipation
Nausea & vomiting
Shortness of breath
Anxiety
Delirium
Fatigue
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2
Q

What are SIX nonpharmacological options for treating pain?

A 
Repositioning
Distraction
Physiotherapy
Hypnotherapy
Massage
Hot/cold packs
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3
Q

Why is step 2 of the pain ladder usually skipped?

A

Patients usually end up needing strong opioids eventually

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4
Q

What TWO adjuvant drug classes can be used for neuropathic pain?

A

Tricyclic antidepressants –> eg. amitriptyline, nortriptyline

Antiepileptics –> eg. gabapentin, sodium valproate

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5
Q

What TWO adjuvant drug classes can be used for bone pain?

A

NSAIDs –> eg. diclofenac, ibuprofen, naproxen

Bisphosphonates –> eg. zolderonic acid, pamidronate

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6
Q

What THREE adjuvant drugs can be used for pain from skeletal muscle spasms?

A

MUSCLE RELAXANTS
Diazepam (benzodiazepine)
Clonazepam (benzodiazepine)
Baclofen

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7
Q

What ONE adjuvant drug can be used for pain from smooth muscle spasm?

A

ANTICHOLINERGICS/ANTIMUSCARINICS

Hyoscine butylbromide

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8
Q

What ONE adjuvant drug/product can be used from pain from UTI/bladder pain?

A

Ural sachets

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9
Q

What ONE adjuvant drug class can be used for pain from increased intracranial pressure?

A

Steroids –> eg. dexamethasone

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10
Q

Why is dexamethasone the preferred steroid in palliative care?

A

Least mineralocorticoid component compared to other steroids

Least amount of fluid retention –> reduced intracranial pressure

Long half-life –> OD dosing

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11
Q

Why is morphine not used in renal impairment?

A

Active metabolites accumulate in renal impairment

–> takes times; morphine can be given in last days of life

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12
Q

What is the next opioid to consider following morphine?

A

Oxycodone

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13
Q

Can oxycodone be used in renal impairment?

A

Mild-moderate: yes

Severe: no

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14
Q

What formulation does fentanyl come in?

A

Patches

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15
Q

Why is fentanyl patches only for stable pain?

A

3 days to reach steady-state –> cannot titrate dose fast enough

Lowest patch strength also already quite high –> only for patients who have taken opioids before

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16
Q

Is fentanyl safe in renal impairment?

A

Yes

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17
Q

Is methadone safe is renal impairment?

A

Yes - mostly faecally excreted

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18
Q

Why can methadone also be used in neuropathic pain?

A

Hits same NMDA receptors as ketamine as well as being full opioid agonist

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19
Q

Why should methadone only be prescribed by specialists?

A

Tricky pharmacokinetics

- After distribution to tissues, methadone leeches back out into bloodstream at varying rates

20
Q

How to establish starting background dose of opioids?

A

Morphine given for opioid-naive patients

Total usage in 24 hours
Divide into BD dosing –> m-Eslon SR

21
Q

How to establish breakthrough dose of opioids?

A

1/6th total daily background dose, every hour PRN

If 3 consecutive hours with no pain improvement, stop & see GP/hospice
Readjust background dose

22
Q

How to readjust background dose of opioids if pain not being managed well?

A

Background dose & total breakthrough doses in one day

Total is new daily background dose, split into BD dosing

23
Q

Why is SC preferred to IM or IV?

A

IM: painful

IV: infections in line –> sepsis

24
Q

What are FIVE common side effects of opioids?

A 
Constipation
Nausea & vomiting
Drowsiness
Hallucinations
Itch
25
Q

How is opioid-induced constipation managed?

A

Concurrent laxatives –> Laxsol

Add osmotic laxative Laxsol not enough

Bulk-forming laxatives not recommended –> along with stasis of bowels caused by opioids, can cause bowel obstruction & perforation

26
Q

Does constipation get worse with increasing opioid doses?

A

Yes –> patients do not become tolerant to effect

27
Q

How is opioid-induced nausea & vomiting managed?

A

Prophylactic antiemetics

28
Q

Does nausea & vomiting get worse with increasing opioid doses?

A

Potentially, but patients develop tolerance after 5-7 days

29
Q

How is opioid-induced drowsiness managed?

A

Will subside after 2-3 days

30
Q

How is opioid-induced hallucinations managed?

A

Low-dose haloperidol

Change opioid

31
Q

How is opioid-induced itch managed?

A

High-dose antihistamine

Change opioid

32
Q

Why is lactulose not preferred in palliative care?

A

Too sweet/unpalatable

Can cause flatulence & abdominal cramps

33
Q

Why is Molaxole beneficial in palliative care?

A

Needs to be reconstituted with water- –> increased fluid intake will help with constipation

34
Q

How does methylnaltrexone work for opioid-induced constipation?

A

Opioid antagonist that does not cross BBB –> only acts on opioid receptors in GI tract –> fastest onset of action (30 mins)

SC injection –> last line

35
Q

What are SIX nonpharmacological options for managing nausea & vomiting?

A

Avoid trigger food/smells

Small frequent meals

Ginger

Peppermint tea

Relaxation, breathing

Acupuncture

36
Q

Why is haloperidol the first choice for nausea & vomiting?

A

Toxins/medications/metabolic processes most likely to cause nausea & vomiting –> haloperidol works best

37
Q

How is nausea & vomiting addressed in palliative care?

A

Haloperidol

Prokinetics (metoclopramide, domperidone)
- Domperidone cannot be given SC

Cyclizine

Levomepromazine
- Hits all nausea & vomiting receptors so very effective but causes sedation

Octreotide, hyoscine butylbromide –> good for bowel obstruction: dry up secretions where vomiting is predominant

Dexamethasone –> reduces intracranial pressure & helps with bowel obstruction

38
Q

Why is ondansetron not recommended in palliative care?

A

Causes constipation

SC not funded

39
Q

What are FIVE nonpharmacological options for treating shortness of breath?

A

Using fans

Repositioning

Relaxation

Breathing exercises

Reassurance

40
Q

How can shortness of breath be managed in palliative care?

A

Opioids –> reduce respiratory drive & sensation of breathlessness

Benzodiazepines –> eg. lorazepam, midazolam
- Reduce anxiety associated with shortness of breath

41
Q

How is anxiety usually treated in palliative care?

A

Lorazepam

Midazolam

42
Q

How is delirium usually treated in palliative care?

A

Haloperidol

Levomepromazine

43
Q

What are FIVE nonpharmacological options to treated anxiety/delirium in palliative care?

A

Relaxation

Breathing exercises

Familiar objects/environment

Quiet room

Low lighting

44
Q

How can fatigue be managed in palliative care?

A

RARE TO TREAT

Methylphenidate (Ritalin)
- Improved mood & energy

Dexamethasone

Modafinil

45
Q

What are FIVE reasons why syringe drivers are used in palliative care?

A

Poor absorption of oral drugs –> eg. if tumours pressing on GI tract

Persistent nausea & vomiting

Intestinal obstruction

Swallowing difficulties

Unconscious patient

411 Oncology (9 decks)

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