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Palliative care > Pain management > Flashcards

Pain management Flashcards

1
Q

What analgesics to prescribe a palliative patient when starting treatment?

names, doses + adjuvants

A
  • oral modified-release (MR) or oral immediate-release morphine
  • oral immediate-release morphine for breakthrough pain
  • use 20-30mg of MR a day with 5mg morphine for breakthrough pain
  • laxatives should be prescribed
  • patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
  • drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
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2
Q

What’s the dose of breakthrough morphine?

A

the breakthrough dose of morphine is one-sixth the daily dose of morphine

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3
Q

What are the preferred opioid options for a patient with renal failure

A
  • oxycodone → if renal failure is not severe
  • fentanyl/ alfentanil or buprenorphine → in severe renal failure
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4
Q

How can metastatic bone pain be managed?

A
  • strong opioids
  • bisphosphonates
  • radiotherapy
  • denosumab (monoclonal antibody RANKL inhibitor)

* NSAIDs are not particularly effective for metastatic bone pain

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5
Q

How much should we increase to dose by when increasing the opioids?

A

When increasing the dose of opioids the next dose should be increased by 30-50%.

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6
Q

Convert oral codeine to oral morphine

A

oral codeine → oral morphine

Divide by 10

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7
Q

Convert oral tramadol to oral morphine

A

oral tramadol → oral morphine

Divide by 10

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8
Q

What are the advantages of use of oxycodone instead of morphine?

A

Oxycodone generally causes:

  • may be used in renal failure (unless severe)
  • less sedation, vomiting and pruritis than morphine

*but oxycodone causes more constipation

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9
Q

Convert oral morphine to oral oxycodone

A

oral morphine → oral oxycodone

Divide by 1.5 - 2

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10
Q

How much of transdermal fentanyl equals oral morphine?

A

transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily

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11
Q

How much of transdermal buprenorphine equals oral morphine?

A

transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily

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12
Q

Convert oral morphine to SC morphine

A

oral morphine to SC morphine

divide by 2

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13
Q

in which units do we have alfentanil doses?

A

micrograms

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14
Q

Examples of ‘adjuncts’ to analgesics (classes)

A

Adjuvants → drugs that are not technically analgesics but may relieve pain resistant to conventional analgesics

  • anti-depressants e.g. neuropathic pain (as acting on descending tract)
  • anti - spasmodic (smooth muscle relaxants)
  • selective anti-inflammatory drugs e.g. Coxibs
  • corticosteroids
  • anti-convulsants
  • skeletal muscle relaxants
  • bisphosphonates
  • NMDA-receptor blockers
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15
Q

Examples, MoA and advantage of selective anti-inflammatory drugs

A

‘Coxibs’

MoA: inhibit COX2

Examples: Celacoxib, Etoicoxib

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16
Q

What’s used for muscle spasms? (2)

A

benzodiazepines, baclofen

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17
Q

What are (2) 4th line drugs for neuropathic pain?

A

Ketamine and Methadone

  • both work on NMDA receptors (block them)
  • only specialist use
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18
Q
A
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19
Q

Meaning of 123ABC

A

123 - WHO analgesic ladder

ABC - adjuncts, bowel, co-fctors

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20
Q

WHO analgesic ladder

A

1. Non-opioid (e.g. NSAIDs, paracetamol)

2. Weak opioids (e.g. codeine, tramadol, dihydrocodeine) + paracetamol

3. Strong opioids (e.g. morphine, fentanyl, buprenorphine) + paracetamol

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21
Q

What’s meant by A (in 123 ABC)?

A

Adjuvants: e.g. anti-inflammatory, steroids, anti-epileptics, anti-depressants ⇒ to further manage pain

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22
Q

What’s meant by B in 123 ABC?

A

B - bowels

  • prevent constipation
  • gastric protection PPI (if needed)
  • anti-emetics for sickness
23
Q

What’s meant by C in 123 ABC?

A

C - co-factors

  • non- pharmacological management
  • holistic approach

All extras for pain management ‘CHAIRS’

C - chemotherapy

H - hormones

A - regional analgesia

I - immunotherapy

R - radiotherapy

S - surgery

24
Q

Types of opioid receptors?

A
  • mu
  • delta
  • kappa
  • ORL-1 (opioid like receptor_)

work by:

opioid + receptor → G protein activated → effect via 2nd messager

25
Q

Why do we use heavily opioid analgesics in palliative care but not in any other speciality?

A

Opioids are harmful ling term - e.g. cause infertility

In palliative care we do not worry about long term side effects as more important is symptomatic control

26
Q

Side effects of opioid toxicity (!)

A

This is important, carer’s need to be advised about them

  • sedation and confusion
  • nausea and vomiting
  • constipation
  • pin-point pupils
  • respiratory depression
  • myoclonus (jerky muscles)
  • rashes (due to histamine release)
27
Q

What drug (analgesic) can we use in liver failure?

A

Morphine

(but not in renal failure!)

28
Q

What’s the dose of breakthrough pain analgesic?

A

1/6 of total dose in 24 hours

29
Q
A
30
Q

Examples of ‘non-drug’ methods od pain relief

A
  • massage
  • TENS
  • heat/cold
  • walking aids/wheelchairs
  • immobilisation (splints/slings/corsets)
  • hoists
  • mattresses
  • dressings
31
Q

What’s max dose of paracetamol in 24 hours?

A

4 g

32
Q

Max codeine dose in 24 hours

A

max 240 mg in 24 hours

33
Q

Max dihydrocodeine dose in 24 hours

A

240 mg / 24h

34
Q

Max dose of Tramadol

A

400 mg / 24 hours

35
Q

Convert PO morphine into SC diamorphine

A

Divide by 3

36
Q

Convert PO morphine to SC morphine

A

Divide by 2

37
Q

What type of pain anti-depressants/anti-convulsants may be useful for?

A

Neuropathic pain

38
Q

Can we use Fentanyl patches in an opioid-naive person?

A

No

(the potency is too much)

39
Q

How to prescribe morphine? by weight or volume?

A

By weight e.g. 10 mg (NOT 10 ml)

40
Q

A typical starting dose of morphine regimen

A

1. Immediate release liquid or tablet morphine sulphate 5-10 mg every 4 hours

PLUS

2. Same dose up to hourly PRN for breakthrough pain

PLUS

3. Stimulant and softening laxative e.g. movicol +/- senna

41
Q

What dose of opioid do we start in a very frail or opioid-naive patient?

A

2.5 mg or less

(usually 5 - 10 mg)

42
Q

If we start opioid (starting dose) and the pain is uncontrolled (but responding to opioid) what do we do?

A

Increase regular 4 hourly doses by 30-50%

PLUS

Same dose for breakthrough pain hourly PRN

43
Q

If pain is controlled by starting dose/trial of opioid, what to do?

A

Give total daily dose oral morphine in two divided doses as 12 hr slow release morphine (MST)

(so twice daily every 12 hours)

PLUS

1/12 or 1/6 total daily dose oral morphine as breakthrough pain hourly PRN

44
Q

Management options for N/V associated with opioid analgesia

A

Reassure of temporary nature

Pharmacological options:

  • metoclopramide 10 mg TDS for few days
  • Haloperidol 1.5 mg at 7 pm for few days
  • Cyclizine 50 mg TDS for few days
45
Q

When to change opioids? (pt’s symptoms)

A
  • persistent N/V despite regular anti-emetics
  • mental clouding/confusion
  • hallucinations unresponsive to halloperidol
  • persistent unresponsive postural hypotension
  • pruritis resistant to anti-histamines
  • myoclonus
  • deteriorating renal function
46
Q

How do we prescribe morphine/oxycodone/ fentanyl and why? (brand or generic name)

A

Brand name

  • there are different modified release mechanisms
47
Q

How long does it take for immediate-release morphine to have an effect?

A

20-30 minutes

48
Q

Name for Oxycodone:

A. slow release 12-hour tablet

B. Immediate release capsule/ liquid

A

Oxycodone

A. Slow release 12 hour tablet → Oxycontin

B. Immediate release capsule/ liquid → Oxynorm

49
Q

How much more potent than PO morphine is PO oxycodone?

A

PO oxycodone twice as potent as PO morphine

50
Q

How much potent is injectible oxycodone than PO oxycodone?

A

Injectible oxycodone (oxynorm) is twice as potent as PO oxycodone (oxycontin)

51
Q

How long is one fentanyl patch used for?

A

72 hours

  • the effects continue to act up to 24 hours after removal of patch
  • peak plasma concentration is not reached until 12-24 hours after first patch is applied
52
Q

Alfentanil

  • route
  • use in renal failure
  • how it can be given (2)
  • pothency
A

Alfentanil

  • SC route
  • it’s short-acting
  • can be used in renal failure
  • can be given PRN (hourly) or via CSCI
  • 10 times more potent than injectable diamorphine
53
Q

Buprenorphine

  • route
  • when to evaluate its effects
  • use in renal and hepatic impairment
A

Buprenorphine

  • patch
  • should not evaluate effects for at least 72 hours after application (allow plasma concentration to increase)
  • well - tolerated in renal and hepatic failure

Palliative care (11 decks)

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