Palliative Care Flashcards
Palliative care prescribing: agitation and confusion - what underlying causes should initially be ruled out?
Hypercalcemia
Infection
Urinary retention
Medication
Palliative care prescribing: agitation and confusion - first line drug?
Haloperidol
Palliative care prescribing: agitation and confusion - second line drugs/other options?
Chlorpromazine
Levomepromazine
Palliative care prescribing: agitation and confusion - which drug might be most suitable in the terminal phase to relieve restlessness?
Midazolam
Palliative care prescribing: management of hiccups?
Chlorpromazine - is licensed for the treatment of intractable hiccups
Haloperidol, gabapentin - are also used
#
Dexamethasone - is also used, particularly if there are hepatic lesions
What are the six broad nausea and vomiting syndromes in palliative care?
Reduced gastric motility
Chemically mediated
Visceral/serosal constipation
Raised intra-cranial pressure
Vestibular
Cortical
Six potential nausea and vomiting syndromes have been identified in palliative care - which are the most common and prominent?
Gastric stasis/reduced gastric motility (may be related to opiods)
Chemical disturbance (hypercalcemia, opioids or chemotherapy)
Which receptors are related to reduced gastric motility ?
Serotonin (5HT4)
Dopamine (D2)
What might chemically mediated N&V be secondary to?
Hypercalcemia
Opioids
Chemotherapy
What might visceral/serosal N&V be secondary to?
Constipation
Oral candidiasis
What is raised intra-cranial pressure N&V usually in the context of?
Cerebral metastases
What is vestibular N&V in palliative care usually related to?
Most frequently in palliative care is opioid related
Can be motion related, or due to base of skull tumours
Which receptors are related to vestibular nausea and vomiting?
Related to activation of:
Acetylcholine receptors
Histamine (H1) receptors
Which receptors are related to cortical nausea and vomiting?
GABA
Histamine (H1)
In the cerebral cortex
What might cortical N&V in palliation be related to?
Anxiety
Pain
Fear
Anticipatory nausea
Mechanistic approach to managing reduced gastric motility N&V in pallitive care?
Pro-kinetic agents are useful in these scenarios as the nausea and vomiting is usually resulting from gastric dysmotility and stasis
First-line medications include:
- metoclopramide
- domperidone
However, NICE CKS indicate that metoclopramide should not be used when pro-kinesis may negatively affect the gastrointestinal tract, particularly in complete bowel obstruction, gastrointestinal perforation, or immediately following gastric surgery
When should metoclopramide NOT be used to treat N&V?
Whenever pro-kinesis may negatively affect the GI tract:
- Complete bowel obstruction
- Gastrointestinal perforation
- Immediately following gastric surgery
Mechanistic approach to managing chemically mediated N&V in palliative care?
Correct disturbance (if possible)
Ondansetron
Haloperidol
Levomepromazine
Mechanistic approach to managing visceral/serosal N&V in palliative care?
First-line:
Cyclizine
Levomepromazine
Anti-cholinergics such as hyoscine can be useful
Mechanistic approach to managing raised intra-cranial pressure N&V in palliative care?
Cyclizine - NICE CKS guidelines recommend
Dexamethasone can also be used
Radiotherapy can be considered if there is likely raised intra-cranial pressure due to cranial tumours
Mechanistic approach to managing vestibular N&V in palliative care?
CYCLIZINE
NICE CKS and BMJ best practice recommends use of cyclizine as a first-line treatment in disorders due to the vestibular system
METOCOPRAMIDE OR PROCHLORPERAZINE
Refractory vestibular causes of nausea and vomiting can be treated alternatively with metoclopramide or prochlorperazine
OLANZAPINE OR RESPERIDONE
Atypical antipsychotics such as olanzapine or risperidone can be used in refractory cases according to UptoDate
Mechanistic approach to managing cortical N&V in palliative care?
If anticipatory nausea is the clear cause, a short acting benzodiazepine such as lorazepam can be useful
If benzodiazepines are not ideal, BMJ best practice recommends use of cyclizine
Ondansetron and metoclopramide can also be trialled
Palliative care N&V - route of administration?
NICE CKS recommend that oral anti-emetics are preferable and therefore should be used if possible
Situations where use of oral medications may not be possible include if the patient is vomiting, has issues with malabsorption, or there is severe gastric stasis
If the oral route is not possible the parenteral route of administration is preferred
The intravenous route can be use if intravenous access is already established
NICE CKS recommend that oral anti-emetics are preferable and therefore should be used if possible
Situations where use of oral medications may not be possible include when?
If the patient is vomiting
If the patient has issues with malabsorption
Where there is severe gastric stasis
When starting opioid treatment in palliative care prescribing , what preparations should be offered?
Modified release (MR) or immediate release morphine - pt preference, with oral immediate release morphine for breakthrough pain
Oral modified-release morphine should be used in preference to transdermal patches
If no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
Starting opioid treatment - what should be co prescribed?
laxatives should be prescribed for all patients initiating strong opioids
What side effects should be particularly considered when starting opioids in palliative care?
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
What proportion of the daily dose of morphine should be given as a breakthrough dose?
1/6
Pain control in adults with cancer - mild -moderate renal impairment
Oxycodone is preferred to morphine
Pain control in adults with cancer - severe renal impairment
Alfentanil
Buprenorphine
Fentanyl
are preferred to morphine
What might metastatic bone pain respond to?
Opioids (strong)
Bisphosphonates
Radiotherapy
Inadditon, denosumab may be used to treat metastatic bone pain.
When increasing the dose of opioids the next dose should be increased by how much?
30-50%
Common opioid side effects - transient bs persistent
Usually transient:
Nausea
Drowsiness
Usually persistent:
Constipation
Oral codeine to oral morphine conversion factor?
Divide by 10
Oral tramadol to oral morphine conversion factor?
Divide by 10
Oral morphine to oral oxycodone conversion factor?
Divide by 1.5-2
Oxycodone vs morphine side effects
Oxycodone generally causes:
Less: sedation, vomiting and pruritis
More: constipation.
A transdermal fentanyl 12 microgram patch equates to approximately how much oral morphine daily?
30 mg
A transdermal buprenorphine 10 microgram patch equates to approximately how much oral morphine daily?
24mg
Oral to subcut morphine conversion factor?
Divide by 2
Oral to subcut diamorphine conversion factor?
Divide by 3
Oral oxycodone to subcut diamorphine conversion factor?
Divide by 1.5
Conservative management of secretions in end of life care?
Avoiding fluid overload - particularly stopping IV or subcutaneous fluids
Educating the family that the patient is likely not troubled by secretions
Medical management of secretions in end of life care?
FIRST LINE:
hyoscine hydrobromide
hyoscine butylbromide
glycopyrronium bromide may also be used
When should a syringe driver be considered in the palliative care setting?
When a patient is unable to take oral medication due to:
Nausea
Dysphagia
Intestinal obstruction
Weakness
Coma
What units are syringe driver rates given in?
mm/hour or mm/24 hours
Graseby MS16A (blue): the delivery rate is given in mm per hour
Graseby MS26 (green): the delivery rate is given in mm per 24 hours
The majority of drugs used in a syringe driver are compatible with water for injection - for which drugs is sodium chloride 0/9% reccomeneded?
granisetron
ketamine
ketorolac
octreotide
ondansetron
Commonly used syringe driver drugs?
nausea and vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide
respiratory secretions/bowel colic: hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide.
agitation/restlessness: midazolam, haloperidol, levomepromazine
pain: diamorphine is the preferred opioid
What is the preferred opioid used in syringe drivers?
Diamorphine
Syringe drivers and mixing and compatibility issues - cyclizine
Cyclizine is incompatible with a number of drugs including
Clonidine
Dexamethasone
Hyoscine butylbromide (occasional), Ketamine
Ketorolac
Metoclopramide
Midazolam
Octreotide
Sodium chloride 0.9%
Cyclizine may precipitate with diamorphine when given at higher doses
Medical management of breathlessness in palliation?
Therapeutic oxygen
Morphine
Midazolam
What medications are used for restlessness and confusion in palliation?
Haloperidol
Levomepromazine
Midazolam
What medications are used for respiratory tract secretions in palliation?
Hyoscine hydrobromide
Hyoscine butylbromide
Glycopyrronium
Steps in the WHO pain ladder?
Step 1: Non-opioid medications e.g. Paracetamol and NSAIDs
Step 2: Weak opioids e.g. codeine and tramadol
Step 3: Strong opioids e.g. morphine, oxycodone, fentanyl and buprenorphine
Adjuvants can be combined with drugs in the above analgesic ladder.
They can also be used separately to manage neuropathic pain.
These medications include what?
Amitriptyline: Tricyclic Antidepressant
Duloxetine - SNRI antidepressant
Gabapentin – Calcium Channel blocker used to manage epilepsy and neuropathic pain
Pregabalin – Calcium Channel blocker used to manage epilepsy and neuropathic pain
Capsaicin cream (topical)
Steroids - dexamethasone
Bisphosphonates
Patients will begin to experience significant side effects from chemotherapy once they are at what performance status?
2 or below
What is the WHO PERFORMANCE status?
WHO Performance status classification categorises patients into different groups dependent on their physical fitness and is used to categorise their suitability for chemotherapy.
Chemotherapy as a treatment is not without its side effects, which can limit quality of life and have negative impacts on other comorbidities.
Patients will begin to experience significant side effects from chemotherapy once they are at or below a performance status of 2.
0-4, 0 being able to carry out all normal activity without restriction, 4 being completely disabled; cannot carry out any self-care; totally confined to bed or chair
WHO performance status - 0
Pt is able to carry out normal activity without restriction
WHO performance status - 1
Pt is restricted in strenuous activity but ambulatory and able to carry out light work
WHO performance status - 2
Pt is ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours
WHO performance status - 3
Pt is symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden
WHO performance status - 4
Pt is completely disabled; cannot carry out any self-care; totally confined to bed or chair
What is the WHO performance status in a patient who is completely disabled; cannot carry out any self-care; totally confined to bed or chair?
4
What is the WHO performance status in a patient who is symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden?
3
What is the WHO performance status in a patient who is ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours?
2
What is the WHO performance status in a patient who is restricted in strenuous activity but ambulatory and able to carry out light work?
1
What is the WHO performance status in a patient who is able to carry out all normal activity without restriction?
0
What is the most important site of action of ondansetron?
5-HT3 antagonists are antiemetics used mainly in the management of chemotherapy-related nausea. They mainly act in the chemoreceptor trigger zone area of the medulla oblongata.
What is nociceptive pain, and how might patients describe it?
NOCICEPTIVE = normal nervous system,
identifiable lesion causing tissue
damage
Somatic: originates from
skin/muscles/bone
sharp, throbbing, well localised
Visceral: originates from hollow viscus
or solid organ
diffuse ache, difficult to localise
What is neuropathic pain, and how might patients describe it?
NEUROPATHIC = malfunctioning
nervous system; nerve structure is
damaged
stabbing, shooting, burning, stinging,
allodynia, numbness, hypersensitivity
WHO ANALGESIC LADDER: STEP 1 examples
Paractemol, NSAIDs (COX 2)
WHO ANALGESIC LADDER: STEP 2 examples
Dihydrocodeine
Codeine phosphate
Tramadol
Co-codamol
WHO ANALGESIC LADDER: STEP 3 examples
Oxycodone
Morphine
Fentanyl
Diamorphine
Features of soft tissue pain + opioid response?
Localised ache,
Soft tissue throbbing
Gnawing
Good response to opiods
Features of visceral pain + opioid response?
Poorly localised, deep
ache,
Colicky and episodic,
May be referred
Good/partial response to opioids
BONE PAIN: features + opioid response?
Well localised aching, Partial
Local tenderness
Partial opioid resopnse
NEUROPATHIC PAIN: features + opioid response
Difficult to describe
Assoc motor/sensory loss
Dermatomal, radicular
Often poor response to opioids
Most common reasons cancer patients on opioids suffer respiratory depression?
Developing AKI
Prescribing errors
Common initial adverse effects of opioids
N&V
Drowsiness
Light-headedness/unsteadiness
Cognitive impairment
Common ongoing opoid side effects?
Constipation, dry mouth
What might improve liver pain specifically?
OPIODS
NSAIDS
What does of codeine might you consider stepping yp analegsia?
30mg, QDS
Prepeations of morphine?
IR
Oramorph liquid, 10mg/5mg
SR
Zomorph BD (10,30,60,100,200mg)
MST tablets BD (5,10,15mg)
Parentral (SC)
Morphine sulphate for injection1
What proportion of the TDD should be the IR dose for breakthrough pain?
1/6
D
How long does it take a fentanyl patch to achieve a steady state?
12-24 hours
PRESCRIPTIONS OF CONTROLLED DRUGS
Name and ID of patient
Write prescription as normal
Write SUPPLY and give EXACT instructions
Drug name and formulation (be explicit re tablets/capsules/patches
Number of tablets/drugs in words E.G. 5 (FIVE) PATCHES
DRUG NAME, FORM STRENGTH E.G.
Morphine SR (Zomorph) capsules 10mg
TOTAL NUMBER OF TABLETS/PATHCES
Supply TTOs for 2 weeks
PRN: Cannot state ‘as required’, state ‘take up to 1 hourly’
Anti emetics in PD
avoid metoclopramide and haloperidol
consider domperidide
