Medicine - Palliative Flashcards
What drug can be used to relieve bowel colic in palliative care?
Hyoscine butylbromide (anti-muscarinic)
List 4 potential causes of confusion in palliative patients
Hypercalcaemia
Infection
Urinary retention
Medication
What is the drug of choice for agitation in palliative care vs for terminal restlessness?
Agitation: Haloperidol (2nd line chlorpromazine)
Terminal restlessness: Midazolam
What is the first line for treating hiccups in palliative care? What else can be used?
Chlorpromazine
(Haloperidol, Gabapentin, Dexamethasone)
List 6 syndromes causing nausea and vomiting in palliative patients
Reduced gastric motility
Chemically mediated
Visceral/ serosal
Raised ICP
Vestibular
Cortical
Which are the 2 most common syndromes causing nausea and vomiting in palliative care?
Gastric stasis
Chemical disturbance
Give a potential cause of reduced gastric motility in palliative care
May be OPIOID related
Related to serotonin (5HT4) + dopamine (D2) receptors
Give 3 chemically mediated causes of nausea and vomiting
Hypercalcaemia
Opioids
Chemotherapy
Give 2 visceral/ serosal causes of nausea and vomiting
Constipation
Oral candidiasis
What is a cause of nausea and vomiting in a palliative patient in the context of cerebral mets?
Raised ICP
Describe the vestibular syndrome cause of nausea and vomiting
Related to activation of ACh + Histamine (H1) receptors
Most freq in palliative care is opioid related
Can be motion related/ due to base of skull tumours
Describe the cortical syndrome causing nausea and vomiting in palliative care
May be due to anxiety, pain, fear +/or anticipatory nausea
Related to GABA + histamine (H1) receptors in the cerebral cortex
What is the antiemetic of choice in palliative care for for nausea and vomiting that is due to gastric dysmotility and stasis?
Metoclopramide (dopamine D2 antagonist, pro-kinetic)
(Domperidone)
When should metoclopramide NOT be used?
When pro-kineses may negatively affect the GI tract e.g. complete bowel obstruction, GI perforation or immediately following gastric surgery
What is the anti-emetic of choice for patients with chemically mediated nausea?
If possible correct chemical disturbance 1st
Ondansetron
(Haloperidol, Levomepromazine)
What is the antiemetic of choice in palliative care for nausea and vomiting due to visceral/ serosal causes?
Cyclizine/ Levomepromazine
(anti-cholinergics such as Hycosine can be useful)
What is the antiemetic of choice in palliative care for nausea and vomiting due to raised ICP?
Cyclizine
(Dexamethasone)
(Radiotherapy if due to cranial tumours)
What is the antiemetic of choice in palliative care for nausea and vomiting due to vestibular disturbance?
Cyclizine
If refractory: Metoclopramide/ Prochlorperazine or atypical anti-psychotics e.g. Olanzapine
What is the antiemetic of choice in palliative care for anticipatory nausea? (cortical)
Lorazepam (short acting benzo)
If not ideal: Cyclizine
Which route should be used for administration of anti-emetics?
Oral if possible
If not; IV
Give 3 situations in which administration of oral anti-emetics may not be possible
Vomiting
Issues with malabsorption
Severe gastric stasis
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 starting dose of morphine in palliative care?
15mg morphine MR PO BD
5mg oromorph IR PO PRN
Can start with IR + when pain controlled –> MR
Give 3 side effects of MR morphine
Nausea (most common): Usually transient, offer anti-emetic if persists
Drowsiness: usually transient, dose adjust if persists
Constipation: usually persistent
What should be prescribed to all patients initiating strong opioids?
Laxatives
How much should a breakthrough dose of morphine be?
1/6th of total morphine
(inc. breakthrough doses)
What opioid is best to use for palliative patients with a GFR of 30-60? (mild-moderate renal impairment)
Oxycodone
What opioids are best to use for palliative patients with a GFR of <30? (severe renal impairment)
Alfentanil
Buprenorphine
Fentanyl
Recall 3 ways in which bony met pain can be managed
Analgesia
Bisphosphonates
Radiotherapy
How should opioid doses be increased?
Increase by 30-50%
In addition to strong opioids, bisphosphonates and radiotherapy, what can be used for metastatic bone pain?
Denosumab
100mg codeine is equivalent of how many mg of morphine?
10mg
Codeine to Morphine: Divide by 10
Oral tramadol to oral morphine
Divide by 10
How do the side effects of oxycodone differ to morphine?
Oxycodone: less sedation, vomiting + pruritis than morphine but more constipation.
Oral morphine to oral oxycodone
Divide by 1.5-2
What does a transdermal fentanyl 12 microgram patch equate to in oral morphine?
30mg oral morphine daily
What is the equivalent of 30mg IR morphine in a MR formulation?
15mg
prescribe half when doing MR
Oral morphine to SC morphine
Divide by 2
Oral morphine to SC diamorphine
Divide by 3
Oral oxycodone to SC diamorphine
Divide by 1.5
Describe conservative management of secretions in palliative care
Avoiding fluid overload: particularly stopping IV or SC fluids
Educating family that patient is likely not troubled by secretions
Recall the 1st and 2nd line drugs used for secretions in palliative care
- Hyoscine hydrobromide/ Hycosine butylbromide
- Glycopyrronium bromide
Which drug for managing secretions is less sedating? Why is this?
Hycosine butylbromide
Does not cross BBB thus less likely to cause CNS SE
(Neither does Glycopyrronium bromide)
When is a syringe driver considered in palliative care?
When unable to take oral medication due to nausea, dysphagia, intestinal obstruction, weakness or coma
What are the 2 types of syringe driver in the UK?
Graseby MS16A (blue): delivery rate is given in mm per hour
Graseby MS26 (green): delivery rate is given in mm per 24h
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
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 treatment of choice for headaches caused by raised ICP due to brain cancer/ mets? How does this work?
Dexamethasone
Reduces surrounding oedema + thus reduces the pressure burden.
What is the drug of choice in palliative care for reducing discomfort of a painful mouth?
Benzydamine hydrochloride mouthwash
What is mucositis? Give a risk factor for development
inflammation of oral mucosa often accompanied by painful ulcerations
RF: radiation to head + neck
List 3 risk factors for nausea and vomiting due to chemotherapy
Anxiety
Age <50y
Concurrent use of opioids
Which drugs should be used to prevent nausea in patients undergoing chemotherapy?
Low risk: Metoclopramide
High-risk: Ondansetron (5HT3 receptor antagonist) + Dexamethasone
