Medicines Managements + Palliative Care Flashcards
What is palliative care?
Approach that improves the quality of life of patients + their families facing problems associated with life-threatening illness, through the prevention + relief of suffering by means of early identification + impeccable assessment + treatment of pain + other problems, physical, psychological + spiritual
What are the types of patients that receive palliative care?
Some might be there for short stay = give family rest bite
Cancer - most common
Advanced heart failure
End-stage COPD
Alzheimer’s disease
Parkinson’s disease
Motor neurone disease
What is included in palliative care?
Physical = treatment, disease + symptoms
Psychological = anger, fear + helplessness
Social = worry, loss, abandonment, financial + isolation
Spiritual = purpose of life, faith, why me + what’s the point
What is IPOS?
Integrated Palliative Outcome Scale
= focus on symptoms + how feeling
BED scale used to screen for depression
Why do we have pain in palliative care?
Tumours grow + press on nerves + organs = pain
Bone metastases = pain
What are the different types of pain?
Somatic = well defined + localised = bones + muscles
Visceral = pain in organs, blood vessels - diffusive
Neuropathic = nerves damages/tumours compress = pins + needles, tingling. shooting pains, burning + numbness
Pain receptors for somatic + visceral = opioids receptors = opioids work
Neuropathic = don’t respond to opioids
Why use pain diaries?
To know if the medicine is working + how much
Describe WHO Ladder
Step 1 = non-opioid = paracetamol 1g QDS
Step 2 =weak opioid = codeine + paracetamol
Step 3 = strong opioid = morphine (replace codeine) + paracetamol
Then adjuvants - eg. NSAIDs good for bone pain
What can be the problem with codeine?
It doesn’t work the same for everyone
Metabolised by CYP2D6 + metabolism varies in efficiency of 2D6
= some people respond better than others
= potentially start with morphine = more predictable
What are the principles of prescribing analgesia?
By the WHO ladder
Orally
By the clock = regular analgesia = NOT PRN
Why have opioid alternatives?
Patient has difficult = NOT responding
Renal impairment = morphine not used = accumulates
SEs
Change delivery mechanism = morphine given orally
What are the common initial SEs for opioids?
N+V
Drowsiness
Light-headedness
Delirium
What are the common ongoing SEs for opioids?
Constipation
N+V
Dry mouth
What are the possible ongoing SEs for opioids?
Suppression of immune system
What are the less common SEs for opioids?
Hallucinations
Sweating
Urinary retention
Postural hypotension
Pruritus
What are the rare SEs for opioids?
Respiratory depression
What is the gold standard opioid?
Morphine
= universally available = all across the world
= no sealing effect = NO MAX dose
= recommended as 1st line by everyone (WHO, NICE + EAPC)
= know the drug = lots of experience with it
Describe the metabolites of morphine
Accumulate in renal impairment = SEs
Morphine-3-glucuronide = major = not active as analgesia = renally excreted
Morphine-6-glucuronide = minor = active = renally excreted
How do you manage background pain?
Modified release morphine 12hrs BD
How do you manage breakthrough pain?
Immediate release liquid morphine PRN
How do you communicate when starting a strong opioid?
= addiction
= tolerance = overtime need to increase dose
= SEs = initial/on-going
= fears that treatment implies final stages of life
How do we start a strong opioid?
Option 1 = already had weak opioid
Add up codeine in last 24hrs + divide by 10
Slow-release opioid BD
Immediate release opioid PRN = add in = 1/6th total daily dose
Option 2 = NOT had weak opioid
Titrate immediate release opioid 4hrs + PRN = keep track of use
ALWAYS titrate with PRN
Add up what had in 24hrs + divide by 2
Then 1/6th for breakthrough
Why must you always titrate with immediate release first?
MR takes too long to get to steady state
Describe fentanyl
100x more potent than morphine
Shouldn’t be given to opioid naïve patients
= wrong = respiratory depression
3mg overdose in opioid naïve patients
Describe fentanyl patches
For background pain
= transdermal = 72hrs
Takes 12hrs to work
Only used in stable pain = predictable
= patch can’t be titrated
Better than oxycodone for renal impairment
When to caution fentanyl patches?
Do NOT apply to hot skin
= more fentanyl released = overdose = death
Temperature/ heat pad for pain/ hot shower/ bath
Describe oxycodone
For renal impairment - USE after morphine
Liquid = IR
Tablets = MR
Describe tramadol
Works on opioid + serotonin receptors
Serotonin = increases drug interactions = if already have antidepressant = increases chance of serotonin syndrome
Between mild-strong opioid
Pro-drug
O-demethylation (CYP2D6) = unpredictable
What is allodynia?
Neuropathic pain
Pain stimuli threshold decreased = evoke pain response in minor stimuli
eg. brushing hair
What is hyperalgesia?
Neuropathic pain
Painful stimuli with exaggerated pain
eg. bangs legs = 10/10 pain
What is good for neuropathic pain?
TCA
SNRI
Pregabalin
Describe the neuropathic pain ladder
Step 1 = amitriptyline (TCA)
Step 2 = amitriptyline (TCA) + gabapentin (AC)
Step 3 = amitriptyline (TCA) + valproate (AC)
Step 4 = ketamine or methadone (NMDA-receptor channel blocker)
Describe amitriptyline
TCA
10mg = low dose pain
Time to effect = 3-7 days
SEs = anti-muscarinic
Describe gabapentin
Anticonvulsant
Time to effect = 1-3hrs
SEs = drowsy/dizzy
How do you manage constipation?
Stimulant = senna
Softener = docusate sodium
Methyl naltrexone = specialist
Need to be beware of faecal impaction = if NOT mobile
= can present as overflow diarrhoea
Macrogol = laxative for impaction
How do you manage breathlessness?
1-2.5mg of IR oral morphine 4hrs PRN + titrate upwards
= reduced medullary sensitivity to hypercarbia + hypoxia
= decreased metabolic rate + ventilator requirements
= anxiolytic effects
What can cause N+V in palliative care?
Rifampicin = Abx = SE
Gastric stasis = metoclopramide = prokinetic
Raised intracranial pressure = dexamethasone
Anxiety = benzodiazepines
Describe hypercalcaemia
Too much calcium = bone metastases
Signs + symptoms
= drowsiness/confusion/coma = severe
= N+V/constipation
= thirst/polyuria = most common
Diagnosis
= total Ca + 0.02(40-serum albumin)
Management
= rehydrate
= bisphosphonate = SE = decrease Ca
= zoledronic acid = parental
Describe SVCO (superior vena cava obstruction)
In lung cancer
= becomes distended in abdomen
= high dose dexamethasone/stent (surgery)
Describe spinal cord compression
Tumour in spine
Legs become tingly = neuropathic pain presents the same
= need MRI
Needs high dose dexamethasone
