Medications

Question 1

What should you bear in mind with the maximum paracetamol doses?

Answer 1

Check pt weighs enough - <50kg cant have max dose !!

Do they have any liver impairment?

Question 2

How do NSAIDs work?

Answer 2

inhibit COX (main enzyme for PG synth), can be selective (celecoxib) or non-selective (ibuprofen), work peripherally and CNS

Question 3

What are some examples of weak opioids?

Answer 3

codeine, tramadol, dihydrocodeine

Question 4

What are SE of opioids? what are their adverse effects?

Answer 4

Constipation, nausea, sedated, dry mouth = common
Allergy, resp depress, pruritis = rare
Adverse: Psychomimetic, confused, myoclonus

Question 5

What are some strong opioids?

Answer 5

morphine, fentanyl, oxycodone, Alfentanil, Bupnerphoine

Question 6

How is the PRN opioid dose calculated?

Answer 6

General rule: as needed is 1/6th - 1/10th of 24hr for PRN

Question 7

Which opioids are renal friendly?

Answer 7

Tramadol, Fentanyl, Buprenorphine are nenal friendly

Question 8

Give the equivalent dose of codeien/ tramadol to morphine and morphines equivalence to oxycodone

Answer 8

codeine/ tram are 1/10th potency of morphine

Oxycodone twice as potent as morphine

Question 9

Which opioids are usually given in patch form?

Answer 9

Fentanyl and buprenorphine (remember heat increases absorption rate)

Question 10

Give some examples of moderate release opioids, how long do they last?

Answer 10

12 hrs eg MST, oxycontin

Question 11

Give some examples of immediate release opioids, how long do they last?

Answer 11

4 hrs eg oramorph, oxynorm

Question 12

What is more potent injectable or PO opioids?

Answer 12

Injectable 2x as potent as PO

Question 13

What is the difference between an unlicensed and off licence drug?

Answer 13

Unlicensed = medicine isn't licensed
Off-licence = route/ dose/ indication isn't licensed

Question 14

What are the issues with the different routes of administering meds in palliative care?

Answer 14

SC is generally preferred for parenteral route
IM and IV - may be painful and difficult w cachexia
SL/ buccal - mouth may be too dry
Inhalation - coordination may be an issue

Question 15

What anti-emitic is first line for gastric stasis? How does it work?

Answer 15

Prokinetic agents (prokinetic action is separate to D2 action) eg Metoclopramide, Domperidone, act on D2 receptors

Question 16

Name SE for the prokinetic agents

Answer 16

Side-effects for metoclopramide include extrapyramidal symptoms, drowsiness, diarrhoea, gynaecomastia, galactorrhoea and hyperprolactinaemia.
Side-effects for domperidone include QT-prolongation, drowsiness, dry mouth, diarrhoea and malaise

Question 17

What is an example of a Butyrophenone antipsychotic anti-emitic, how does it work and what are its SE?

Answer 17

eg haloperidol - act on D2 receptors in CTZ, used for opioid induced nausea.
SE = extrapyramidal, QT prolong, depression

Question 18

What is an example of a Phenothiazine antipsychotic anti-emitic? How does it work?

Answer 18

eg Levomepromazine, Prochlorperazine. - act on at Dopamine, H1 and Ach-receptors, used when non-specific or multi-factorial causes, avoid in parkinsons

Question 19

What is an example of a 5-HT3 antagonist? What are some SE?

Answer 19

eg ondansetron. Acts on 5-HT3-receptors. Used for chemo/ radio N+V. SE: constipation, flush, headache, involuntary movement, QT prolong NOT GOOD IN PALLIATIVE AS CAUSES CONSTIPATION

Question 20

What antihistamine anti-emitics are used? What are some SE?

Answer 20

Anti-histamines eg cyclizine, Cinnarizine, Promethazine - act on H1 receptors, used in obstruction, raised ICP and vestibular causes.
SE: anti-muscarinic effects, palpitations & arrhythmias, sleep disturbances, extra-pyramidal symptoms

Question 21

Name some antimuscarinic anti-emitics. What else are they used for?

Answer 21

Antimuscarinics eg Hyoscine butylbromide, Hyoscine hydrobromide- used on Ach receptors, used in SM spasm; secretions, death rattle

Question 22

WHat are the medications usually used in pre-emptive prescribing? What are they trying to address?

Answer 22

morphine (SOB and pain), buscopan (secretions), midazolam (agitation), haloperidol (nausea- for new onset)

Question 23

Name some antitussives vs protussives

Answer 23

anti-cough: Opioids eg morphine and codeine
Demulcents eg cough syrup
Pro-cough: Encourage better cough clearance eg sodium chloride nebs or Carbocisteine

Question 24

How is SOB treated in palliative care?

Answer 24

Opioids - decrease resp effort, consider modified release for ongoing SOB
Benzos - evidence limited, for panic aspect ((Anxiolytic - reduced perception of SOB)
Beta agonists - salbutamol, terbutaline
Antimuscarinics eg ipratropium - better for COPD
Steroids - diminish inflamm, decreased effect over time
Oxygen - unlikely to benefit in palliative unless o2 v low
Also think OT and PT

Question 25

What are some examples of pain adjuvants in palliative care?

Answer 25

usually anti-depressants/ anti-epileptic drugsamitriptyline; carbamazepine; gabapentin, pregabalin; clonazepam; duloxetine

Question 26

What is episodic/ breakthrough pain?

Answer 26

Pt may have PRN pain for episodic/ breakthrough pain → may be incident pain triggered by activity or unpredictable

Question 27

What is a syringe driver?

Answer 27

SC machine that stays in situ for 3 days so that lots of meds + sodium chloride given in one go to a pt to bring down the need for lots of SC injections

Question 28

Can meds be prescribed in ml?

Answer 28

NO is always mg/ mcg etc.

Question 29

What two anti-emitics shouldn’t be prescribed together?

Answer 29

Cyclizine may reduce the effects of metoclopramide

As prokinetic and anti-spasmodic are going to counteract each other

Question 30

What is sometimes used in palliative care for tiredness?

Answer 30

methylphenidate