Palliative care

Question 1

How is background pain managed?

Answer 1

with Modified release (MR) preparation that lasts around 12 hours

Question 2

How is breakthrough pain managed

Answer 2

With immediate release (IR) preparation that lasts around 4 hours.

• PRN Tablets e.g. Sevredik
• Liquid e.g. oramorph

Question 3

How is breakthrough pain calculated?

Answer 3

1/6th of total background dose

Question 4

What is the maximum dose of codeine?

Answer 4

60 mg 4X daily

Question 5

What is the dose of modified-release morphine?

Answer 5

20-30 mg a day

e. g. 15 mg MR tablets 2X a day
e. g. 10 mg MR tablets 2X a day

Question 6

What is the dose of breakthrough morphine

Answer 6

1/6th of total background dose

e.g. 5mg PRN 4x daily

Question 7

How much is the dose of opioids be increased by if needed?

Answer 7

30-50%

Question 8

What can be used to treat metastatic bone pain?

Answer 8

strong opioids, bisphosphonates, and radiotherapy

Question 9

Changing from Codeine to morphine

Answer 9

divide by 10

Question 10

Changing from tramadol to morphine

Answer 10

divide by 10

Question 11

Morphine to oxycodone

Answer 11

divide by 1.5-2

Question 12

Oral morphine to subcutaneous morphine

Answer 12

divide by 2

Question 13

Which anti-emetic is preferred in reduced gastric motility

Answer 13

Metoclopramide or dompiredone

Note: dont use metoclopramide in bowel obstruction, perforation or GI surgery

Question 14

What anti-emetic is prefered in chemically induced nausea

Answer 14

Ondansteraone, haloperidol and levomepromazine

Question 15

Anti-emetic for visceral/serosal causes of nausea

Answer 15

cyclizine, and levomepromazine

Question 16

anti-emetic for raised ICP

Answer 16

cyclizine or dexamethasone

Question 17

vestibular nausea and vomiting

Answer 17

cyclizine

Question 18

cortical nausea and vomiting e.g. anxiety, pain, and fear

Answer 18

benzodiazepines, lorazepam

Question 19

What is a syringe driver

Answer 19

subcutaneous infusion of medication - infused over 24 hours

can use up to three medications. syringe has to be changed daily.

Question 20

patient has been unable to take his morning medications which include morphine sulphate modified release (Zomorph) 30mg twice daily, oramorph 10mg as required, and metoclopramide 10mg three times a day. In the past 24 hours, he has used 4 doses of PRN oramorph.

He is reviewed on the consultant ward round and the decision is made that he should be for end of life care. He is currently comfortable, with no evidence of hallucinations, pruritis or myoclonus. The nurse asks you to convert his medications to a syringe driver.

Answer 20

The first step to calculate doses for use in a CSCI is to calculate the total 24-hour usage of the drug. We are told this patient is taking both zomorph (modified release morphine), and oramorph (immediate release) - we need to include both of these medications in our calculation.

The patient is taking 30mg zomorph twice daily = 60mg/24 hours.
He has also taken 4 doses of 10mg oramorph = 40mg/24 hours.

This gives us a total of 60mg + 40mg = 100mg/24 hours of oral morphine. In order to convert this to subcutaneous morphine, we must divide by two. Therefore the amount of morphine needed in the CSCI is 100mg/2 = 50mg/24 hours.

The patient is comfortable, with no evidence of opioid toxicity, and so there is no indication to change to oxycodone at the moment.

Question 21

A 76-year-old female with multiple myeloma is experiencing acute back pain. Her oral regular analgesic medications include 7.5mg morphine QDS and 1g paracetamol QDS.

What breakthrough dose of morphine should be given?

Answer 21

5 mg

Question 22

A 74-year-old woman with a breast cancer attends a clinic with palliative care due to a recent diagnosis of brain metastases. She reports feeling nauseous and vomited several times in the past week. She asks for some medication to ease these symptoms.

Answer 22

cyclizine

Question 23

A 74-year-old man is being managed palliatively in his last days of life for lung cancer. He has been taking 30 mg of oral modified release morphine sulfate twice a day. He has also required six doses of 5 mg oral immediate-release morphine sulfate for breakthrough pain.

The decision is made to start him on a syringe driver due to poor swallow.

What dose of morphine should be given in the syringe diver over 24-hours?

Answer 23

45 mg

This patient’s total daily dose of morphine is 90 mg, a twice-daily dose of 30 mg slow-release morphine sulfate, with 30 mg of immediate-release morphine sulfate for breakthrough pain. In order to convert this oral dose into a subcutaneous dose for a syringe driver, it is divided by two.

30 x 2 + 5 x 6 = 90
90/2 = 45

45 mg is the correct answer.

Question 24

A 72-year-old male with metastatic lung cancer is referred to the palliative care team for end of life care. Currently, he takes 10mg oral morphine daily which effectively controls his pain. Anticipatory medications are prescribed in a syringe driver.

How much daily subcutaneous morphine needs to be given?

Answer 24

5mg

Question 25

A 79-year-old man has been admitted to hospital following a fall. He has intractable bone pain from advanced metastatic prostate cancer. After discussion with both him and the family, it is agreed that he will be managed conservatively and palliated on the ward.

He required 5 mg of subcutaneous morphine twelve times in 24 hours. He was reviewed by the palliative care team, who advised to start a syringe driver of continuous subcutaneous morphine, which covers the full dose he required for the previous 24 hours. The team also recommended to provide appropriate breakthrough pain relief on the ‘as required’ section of the drug chart.

Which is the correct dose of breakthrough morphine sulphate to prescribe for this patient?

Answer 25

10 mg subcutaneously

Question 26

Brenda is an 86-year-old woman with acute myeloid leukaemia (AML). She has been receiving best supportive care for the last 6 months and it is felt that she is now nearing the end of her life. Her current pain relief consists of 30 mg zomorph twice a day and 10 mg oramorph as needed for breakthrough pain. She typically uses 2 breakthrough doses of oramorph per day. In the last week she has become unable to swallow tablets and the decision is made to change her onto a syringe driver.

Which of the following is the correct conversion dose of subcutaneous (SC) morphine required for a 24 hour period for this patient?

Answer 26

40 mg

Question 27

You are reviewing an elderly man with prostate cancer. Unfortunately his pain is not currently controlled by co-codamol 30/500 2 tablets qds and diclofenac 50mg tds. You decide to switch him to oral morphine. What is the conversion factor between oral codeine and oral morphine?

Answer 27

divide by 10

Question 28

A 76-year-old woman is being managed in a hospice for metastatic lung cancer. Her main symptoms have been pain and agitation.

She has been started on a syringe driver containing morphine sulphate and midazolam. She is receiving the morphine at a rate of 60 mg in 24 hours.

Despite this dose, she remains in pain and you decide to increase her dose of morphine.

Which of the following options is the most appropriate dose to give over the next 24 hours?

Answer 28

75 mg

In palliative care, you would increase the dose of morphine by 30-50% each time until pain is controlled.

In this case, this patient has received 60 mg in 24 hours. A 30% increase of 60 mg is 78 mg. A 50% increase of 60 mg would be 90 mg. Therefore, an appropriate increase in morphine dosing would be anywhere between 78 and 90 mg.

In reality, this patient should also have as-required (PRN) subcutaneous morphine prescribed for breakthrough pain. You’d then increase the 24-hour dose by the total requirement of PRN doses in the previous 24 hours.

Question 29

A 65-year-old man on palliative treatment for metastatic oesophageal cancer is finding it increasingly difficult to take his morphine and as such is in increasing discomfort. His current prescription is for 60 mg BD oral.

Which of the following is the most appropriate option to manage his pain?

Answer 29

switch to subcut morphine infusion at 60 mg/24 hours

Question 30

A 65-year-old man with metastatic prostate cancer is admitted electively to the oncology ward for radiotherapy to bone metastases at T7, T9 and L1.

His usual medications include: paracetamol 1g four times a day, tamsulosin 400 micrograms once daily, atorvastatin 80mg once nocte, morphine sulphate modified release (Zomorph) 30mg twice daily, and ramipril 5mg once daily.

During your afternoon review, he tells you that he is still suffering with pain in his back, despite taking his regular medications this morning. He thinks he usually takes another analgesic as needed, but is unsure of the name or the dose.

What will you prescribe?

Answer 30

oramorph 10 mg PO