Palliative

Question 1

Important considerations agitation/confusion in palliative care

Answer 1

Underlying causes of confusion should be looked for and treated, e.g. hypercalcaemia, infection, urinary retention, medication

Question 2

First line drug treatment confusion/agitation in palliative care

Answer 2

Haloperidol

Question 3

Second line drug treatments confusion/agitation in palliative care

Answer 3

Chlorpromazine
Levomepromazine

Question 4

Treatment agitation/restlessness in terminal phase

Answer 4

Midazolam

Question 5

Treatment intractable hiccups pallaitive care

Answer 5

Chlorpromazine (licensed)
Haloperidol
Gabapentin
Dexamethasone (particularly if hepatic lesions)

Question 6

N&V syndromes in palliative care

Answer 6

Reduced gastric motility
Chemically mediated
Visceral/serosal
Raised ICP
Vestibular
Cortical

Question 7

Anti-emetic choice in N&V cause by reduced gastric motility

Answer 7

Pro-kinetic agents - first line domperidone and metoclopramide

Question 8

Contraindication metaclopramide

Answer 8

Should not be used when pro-kinesis may negatively affect GI tract, e.g. complete bowel obstruction, GI perf, immediately following gastric surgery

Question 9

Anti-emetic choice chemically mediated N&V

Answer 9

Ideally correct chemical disturbance first

Ondansetron, haloperidol, levomepromazine

Question 10

Anti-emetic choice visceral/serosal causes N&V

Answer 10

Cyclizine
Levomepromazine
Hyoscine

Question 11

Anti-emetic choice raised ICP causing N&V

Answer 11

Cyclizine first line

Dexamethasone
Radiotherapy if due to cranial tumours

Question 12

Anti-emetic choice vestibular cause of N&V

Answer 12

Cyclizine first line

Refractory - metoclopramide, prochlorperazine, atypical antipsychotics

Question 13

Anti-emetic choice cortical cause N&V

Answer 13

If anticipatory nausea, short acting benzodiazepine e.g. lorazepam
If benzos not ideal, cyclizine

Question 14

Starting dose morphine

Answer 14

20-30mg MR morphine with 5mg breakthrough

Question 15

SEs morphine and their management

Answer 15

Constipation - co-prescribe laxatives
Nausea - usually transient, if not anti-emetic
Drowsiness - usually transient, if not adjustment of dose

Question 16

Opioids in kidney disease

Answer 16

Oxycodone preferred to morphine in mild-to-moderate renal impairment
Alfentanil, buprenorphine, and fentanyl if renal impairment more severe

Question 17

Treatment metastatic bone pain

Answer 17

Strong opioids
Bisphosphonates
Radiotherapy
Denosumab

Question 18

Converting oral codeine → oral morphine

Answer 18

Divide by 10

Question 19

Converting oral tramadol → oral morphine

Answer 19

Divide by 10

Question 20

Oxycodone vs morphine SE profile

Answer 20

Oxycodone causes less sedation, vomiting, and pruritis, but more constipation

Question 21

Oral morphine → oral oxycodone

Answer 21

Divide by 1.2 - 2

Question 22

Transdermal fentanyl 12microgram = how much morphine

Answer 22

30mg morphine daily

Question 23

Transdermal buprenorphine 10microgram = how much morphine

Answer 23

24mg oral morphine daily

Question 24

Oral morphine → SC morphine

Answer 24

Divide by 2

Question 25

Oral morphine → SC diamorph

Answer 25

Divide by 3

Question 26

Oral oxycodone → SC diamorph

Answer 26

Divide by 1.5