Medicine - Palliative Flashcards
What is the most common side effect of cyclophosphamide?
Haemorrhagic cystitis
What are the toxicities of cisplatin?
Ototoxic, nephrotoxic, hypomagnasaemia
Which chemotherapy agent is associated with SIADH?
Cyclophosphamide
What is the starting dose of morphine in palliative care?
15mg morphine MR PO BD
5mg oromorph IR PO PRN
Can start with IR and then when pain controlled –> MR
What is the most common side effect of MR morphine?
Nausea
What opioid is best to use for palliative patients with a GFR of 30-60?
Oxycodone
What opioids are best to use for palliative patients with a GFR of <30?
Fentanyl
Buprenorphine
How much should a breakthrough dose of morphine be?
1/6th of total morphine
100mg codeine is equivalent of how many mg of morphine?
10mg
What is the equivalent of 30mg IR morphine in a MR formulation?
15mg
prescribe half when doing MR
Recall 3 ways in which bony met pain can be managed
- Analgesia
- Bisphosphonates
- Radiotherapy
Which anti-emetic is usually prescribed in palliative care?
Cyclizine
What is the usual dose of cyclizine in palliative care?
50mg 8-hourly
In what patients is it inappropriate to prescribe cyclizine and why?
Cardiac cases
Can worsen fluid retention
Recall 2 patient groups in which metoclopramide should be avoided
Parkinson's disease Young women (risk of dyskinesia)
What is the anti-emetic of choice in Parkinson’s?
Domperidone
What is the drug of choice for agitation in palliative care vs for terminal restlessness?
Agitation in palliative pts: haloperidol (and correct underlying cause)
Terminal restlessness: midazolam
Recall the 1st and 2nd line drugs used for secretions in palliative care
- Hyoscine hydrobromide
- Glycopyrronium bromide
What is the first line for treating hiccups in palliative care?
Chlorpromazine
In a patient with cord compression due to spinal mets who is too frail for surgery, what is the treatment of choice?
External beam radiotherapy
What is the anti-emetic of choice for patients with chemo/radio-associated nausea?
Ondansetron + dexamethosone
What is the antiemetic of choice in palliative care for for nausea and vomiting that is due to gastric dysmotility and stasis?
Metoclopramide
End of life care
Conservative:
- Tx reversible causes
- Hydration
- Regular mouth & eye care
Medical:
- PRN ≥3/day –> syringe driver
- Avoid IM injection
Sx at final days:
- Cheyne-stokes breathing (deep breathing then stops for 15-20s)
- Reduced GCS
- Fatigue
- Loss of appetite
- Agitation
- Resp secretions
- Funct decline + social withdrawal
Laxative use in end of life care
- 1st - Osmotic agent e.g. lactulose OR softening agent e.g. docusate
- 2nd - If this doesn’t work ADD a stimulant agent e.g. senna
Anti-emetics in palliative care
-
Haloperidol - chemical causes, renal failure, drug-induced
- Lowers seizure threshold, parkinsonism
-
Cyclizine - central vomiting, CNS lesions, labyrinthitis
- Irritant SC, severe HF
- Ondansetron - ONLY post-chemo, abdo surgery, abdo radio
- Very constipating, QT prolongation
- Metoclopramide/Domperidone - delayed GIT transit, bowel obstruction without colic
- Bowel obstruction with colic, parkinsonism, cardiac conduction disorders, young women - SE movement disorders
- Levomepromazine - all causes but 3rd line
- Long half life, sedating, lowers seizure threshold, severe HF, CVD, parkinsonism
Important opioid conversions
Palliative Mx of breathlessness?
- Tx reversible causes - HF, pleural effusion, PE, pneumonia, hypoxia
- Low-dose opioid (morphine immediate release) with short acting Benzo e.g., Lorazepam
Palliative Sx - possible reversible causes & drugs if no reversible causes?
Opioids:
- Strength of different opioids
- Forms of oral morphine
- Guide to giving morphine
- When to give oxycodone
- Breakthrough analgesia
- Conversion between opioid doses
Strength:
- Weak - codeine, dihydrocodeine
- Moderate - tramadol (surgeons love)
- Strong - morphine, oxycodone, buprenorphine, fentanyl
Oral morphine has 2 forms:
- Oral morphine has 2 forms:
- Immediate-release (e.g. oromorph) - max 4-hourly
- Modified-release (e.g. MST Continus/Zomorph/Morphgesic SR) - 12-hourly (BD) OR 24-hourly (OD)
Guide to morphine:
- If can’t tolerate oral e.g. vomiting alot –> oral dose/2 = IV dose
- Immediate-release PRN (max 4-hourly) –> see how much using
- If using a huge amount –> convert to modified-release (12/24-hourly):
- Add up total daily PRN dose = X
- 24-hourly = X (OD); 12-hourly = X/2 (BD)
When to give oxycodone: renal impairment (eGFR 30-60mL/min)
- Immediate-release: oxycodone oral solution, oxynorm
- Modified-release: oxycontin
- NOTE: same logic as above
- NOTE: fentanyl/buprenorphinene is the best if eGFR <30, oxycodone still partially renaly excreted
Breakthrough analgesia:
- Oral morphine/oxycodone
- 1/10-1/6 of total daily dose of modified-release morphine
Example: 60mg Oromorph –> 30mg MST BD + 6-10mg breakthrough dose
Conversion - 10mg oral morphine:
- Oxycodone - 5mg oral (x/2), 2.5mg IV (x/4)
- Tramadol/Codeine - 100mg oral/IV (x*10) - NOTE: codeine has no IV option
What opioids can I use if renal problem?
Fentanyl, Buprenorphine
Oxycodone can be used if eGFR 30-60 (still partially renaly excreted)
Anticipatory meds - 4 to give if palliative?
Anxiety/distress: Midazolam 2.5-5mg SC 1-2hrly PRN
Secretions/colic: Glycopyrronium 0.2-0.4mg SC QDS PRN
Nausea & vomiting: Haloperidol 0.5-1.5mg SC BD PRN (max 5mg/24hrs)
- Could give Cyclizine 50mg SC TDS PRN
Pain: Morphine 2.5-5mg SC 1-2hrly PRN (or Oxycodone 1.25-2.5mg)
Best palliative medicine for secretions/colic?
Glycopyrronium 0.2-0.4mg SC QDS PRN
Confused & agitated in context of ‘dying’ - Dx? Mx?
Dx: terminal restlessness
Mx: diagnosis of dying so reversible causes have already been excluded
- Midazolam PRN - SC injections/continuous subcut infusion via a syringe driver
