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Final Year MBBS > Medicine - Palliative > Flashcards

Medicine - Palliative Flashcards

1
Q

What is the most common side effect of cyclophosphamide?

A

Haemorrhagic cystitis

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2
Q

What are the toxicities of cisplatin?

A

Ototoxic, nephrotoxic, hypomagnasaemia

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3
Q

Which chemotherapy agent is associated with SIADH?

A

Cyclophosphamide

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4
Q

What is the starting dose of morphine in palliative care?

A

15mg morphine MR PO BD
5mg oromorph IR PO PRN
Can start with IR and then when pain controlled –> MR

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5
Q

What is the most common side effect of MR morphine?

A

Nausea

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6
Q

What opioid is best to use for palliative patients with a GFR of 30-60?

A

Oxycodone

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7
Q

What opioids are best to use for palliative patients with a GFR of <30?

A

Fentanyl
Buprenorphine

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8
Q

How much should a breakthrough dose of morphine be?

A

1/6th of total morphine

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9
Q

100mg codeine is equivalent of how many mg of morphine?

A

10mg

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10
Q

What is the equivalent of 30mg IR morphine in a MR formulation?

A

15mg
prescribe half when doing MR

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11
Q

Recall 3 ways in which bony met pain can be managed

A
  1. Analgesia
  2. Bisphosphonates
  3. Radiotherapy
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12
Q

Which anti-emetic is usually prescribed in palliative care?

A

Cyclizine

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13
Q

What is the usual dose of cyclizine in palliative care?

A

50mg 8-hourly

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14
Q

In what patients is it inappropriate to prescribe cyclizine and why?

A

Cardiac cases
Can worsen fluid retention

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15
Q

Recall 2 patient groups in which metoclopramide should be avoided

A 
Parkinson's disease 
Young women (risk of dyskinesia)
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16
Q

What is the anti-emetic of choice in Parkinson’s?

A

Domperidone

17
Q

What is the drug of choice for agitation in palliative care vs for terminal restlessness?

A

Agitation in palliative pts: haloperidol (and correct underlying cause)
Terminal restlessness: midazolam

18
Q

Recall the 1st and 2nd line drugs used for secretions in palliative care

A
  1. Hyoscine hydrobromide
  2. Glycopyrronium bromide
19
Q

What is the first line for treating hiccups in palliative care?

A

Chlorpromazine

20
Q

In a patient with cord compression due to spinal mets who is too frail for surgery, what is the treatment of choice?

A

External beam radiotherapy

21
Q

What is the anti-emetic of choice for patients with chemo/radio-associated nausea?

A

Ondansetron + dexamethosone

22
Q

What is the antiemetic of choice in palliative care for for nausea and vomiting that is due to gastric dysmotility and stasis?

A

Metoclopramide

23
Q

End of life care

A

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
25
Q

Laxative use in end of life care

A
  • 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
26
Q

Anti-emetics in palliative care

A
  • 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
27
Q

Important opioid conversions

A
28
Q

Palliative Mx of breathlessness?

A
  • Tx reversible causes - HF, pleural effusion, PE, pneumonia, hypoxia
  • Low-dose opioid (morphine immediate release) with short acting Benzo e.g., Lorazepam
32
Q

Palliative Sx - possible reversible causes & drugs if no reversible causes?

A
33
Q

Opioids:

  1. Strength of different opioids
  2. Forms of oral morphine
  3. Guide to giving morphine
  4. When to give oxycodone
  5. Breakthrough analgesia
  6. Conversion between opioid doses
A

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:

  1. If can’t tolerate oral e.g. vomiting alot –> oral dose/2 = IV dose
  2. Immediate-release PRN (max 4-hourly) –> see how much using
  3. 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
34
Q

What opioids can I use if renal problem?

A

Fentanyl, Buprenorphine

Oxycodone can be used if eGFR 30-60 (still partially renaly excreted)

35
Q

Anticipatory meds - 4 to give if palliative?

A

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)

36
Q

Best palliative medicine for secretions/colic?

A

Glycopyrronium 0.2-0.4mg SC QDS PRN

38
Q

Confused & agitated in context of ‘dying’ - Dx? Mx?

A

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

Final Year MBBS (39 decks)

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