Palliative

Question 1

What is the initial analgesia used in palliative care?

Answer 1

If no comorbidities use 20-30mg of modified release morphine (eg. 15mg BD) with 5mg IR for breakthrough (1/6th daily dose)

Question 2

How much should you increase opiates by?

Answer 2

Increase by 30-50% when uptitrating

Question 3

How is metastatic bone pain managed?

Answer 3

• Strong opiods
• Bisphosphonates
• Radiotherapy
• Denosumab

Question 4

What are the conversions from:
a) oral codeine to oral morphine
b) oral tramadol to oral morphine

Answer 4

a) divide by 10
b) divide by 10

Question 5

What are the conversions from:
a) oral morphine to oral oxycodone?
b) oral morphine to SC morphine?
c) oral morphine to SC diamorphine?
d) oral morphine to fentanyl patch?
e) oral morphine to burprenorphine patch?

Answer 5

a) divide by 1.5-2
b) divide by 2
c) divide by 3
d) 30mg oral morphine > 12microgram patch
e) 24g oral morphine > 10microgram patch

Question 6

What is the preferred analgesia in patients with CKD?

Answer 6

Alfentanil
Buprenorphine
Fentanyl

Question 7

What medication should you use for abdominal colic ?

Answer 7

Anticholinergics (hyoscine butylbromide)

Question 8

What medication should be used for intractable hiccups?

Answer 8

1st line - chlorpromazine
2nd line - haloperidol, gabapentin
3rd line - dexamethasone (esp if hepatic lesions)

Question 9

What medication should be used for agitation?

Answer 9

First rule out REVERSIBLE causes!

1st line - haloperidol
2nd line - clorpromazine, levomepromazine

In terminal phase of illness, treat with SC midazolam

Question 10

When is cyclizine used in palliative care?

Answer 10

Nausea and vomiting in:
- Intracranial/intravestibular
- Gastrointestinal obstruction
- Movement disorders

Question 11

When is domperidone used in palliative care?

Answer 11

Nausea and vomiting in context of gastric stasis

Question 12

When is metoclopramide used in palliative care?

Answer 12

• Acute migraine
• Chemotherapy or radiotherapy induced N&V
• Gastric stasis (functional bowel obstruction)

Dopamine antagonist

Question 13

When is ondansetron used in palliative care?

Answer 13

• Chemotherapy induced N&V

Question 14

When is dexamethasone used in palliative care?

Answer 14

• Nausea related to ICP (add to cyclizine)
• Anorexia
• Spinal cord compression
• Liver capsule pain

Question 15

When is levomepromazine used in palliative care?

Answer 15

• Chemically mediated N&V
• Visceral/serosal causes

Question 16

When are benzodiazepines used in palliative care?

Answer 16

• Nausea related to anxiety

Question 17

What medication is used for bladder spasm?

Answer 17

Oxybutynin

Question 18

What medication is used for rectal pain/tenesmus?

Answer 18

GTN ointment
Lidocaine ointment
Nifedipine

Question 19

When is haloperidol used in palliative care?

Answer 19

• Agitation
• Metabolic causes (eg. hypercalcemia, renal failure)
• Chemical causes of N&V