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Year 4 Oncology > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

Palliative care prescribing: agitation and confusion - what underlying causes should initially be ruled out?

A

Hypercalcemia
Infection
Urinary retention
Medication

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2
Q

Palliative care prescribing: agitation and confusion - first line drug?

A

Haloperidol

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3
Q

Palliative care prescribing: agitation and confusion - second line drugs/other options?

A

Chlorpromazine

Levomepromazine

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4
Q

Palliative care prescribing: agitation and confusion - which drug might be most suitable in the terminal phase to relieve restlessness?

A

Midazolam

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5
Q

Palliative care prescribing: management of hiccups?

A

Chlorpromazine - is licensed for the treatment of intractable hiccups

Haloperidol, gabapentin - are also used
#

Dexamethasone - is also used, particularly if there are hepatic lesions

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6
Q

What are the six broad nausea and vomiting syndromes in palliative care?

A

Reduced gastric motility

Chemically mediated

Visceral/serosal constipation

Raised intra-cranial pressure

Vestibular

Cortical

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7
Q

Six potential nausea and vomiting syndromes have been identified in palliative care - which are the most common and prominent?

A

Gastric stasis/reduced gastric motility (may be related to opiods)

Chemical disturbance (hypercalcemia, opioids or chemotherapy)

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8
Q

Which receptors are related to reduced gastric motility ?

A

Serotonin (5HT4)

Dopamine (D2)

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9
Q

What might chemically mediated N&V be secondary to?

A

Hypercalcemia

Opioids

Chemotherapy

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10
Q

What might visceral/serosal N&V be secondary to?

A

Constipation

Oral candidiasis

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11
Q

What is raised intra-cranial pressure N&V usually in the context of?

A

Cerebral metastases

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12
Q

What is vestibular N&V in palliative care usually related to?

A

Most frequently in palliative care is opioid related

Can be motion related, or due to base of skull tumours

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13
Q

Which receptors are related to vestibular nausea and vomiting?

A

Related to activation of:

Acetylcholine receptors

Histamine (H1) receptors

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14
Q

Which receptors are related to cortical nausea and vomiting?

A

GABA

Histamine (H1)

In the cerebral cortex

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15
Q

What might cortical N&V in palliation be related to?

A

Anxiety

Pain

Fear

Anticipatory nausea

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16
Q

Mechanistic approach to managing reduced gastric motility N&V in pallitive care?

A

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

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17
Q

When should metoclopramide NOT be used to treat N&V?

A

Whenever pro-kinesis may negatively affect the GI tract:

  • Complete bowel obstruction
  • Gastrointestinal perforation
  • Immediately following gastric surgery
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18
Q

Mechanistic approach to managing chemically mediated N&V in palliative care?

A

Correct disturbance (if possible)

Ondansetron
Haloperidol
Levomepromazine

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19
Q

Mechanistic approach to managing visceral/serosal N&V in palliative care?

A

First-line:
Cyclizine
Levomepromazine

Anti-cholinergics such as hyoscine can be useful

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20
Q

Mechanistic approach to managing raised intra-cranial pressure N&V in palliative care?

A

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

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21
Q

Mechanistic approach to managing vestibular N&V in palliative care?

A

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

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22
Q

Mechanistic approach to managing cortical N&V in palliative care?

A

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

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23
Q

Palliative care N&V - route of administration?

A

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

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24
Q

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?

A

If the patient is vomiting

If the patient has issues with malabsorption

Where there is severe gastric stasis

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25
Q

When starting opioid treatment in palliative care prescribing , what preparations should be offered?

A

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

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26
Q

Starting opioid treatment - what should be co prescribed?

A

laxatives should be prescribed for all patients initiating strong opioids

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27
Q

What side effects should be particularly considered when starting opioids in palliative care?

A

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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28
Q

What proportion of the daily dose of morphine should be given as a breakthrough dose?

A

1/6

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29
Q

Pain control in adults with cancer - mild -moderate renal impairment

A

Oxycodone is preferred to morphine

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30
Q

Pain control in adults with cancer - severe renal impairment

A

Alfentanil
Buprenorphine
Fentanyl

are preferred to morphine

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31
Q

What might metastatic bone pain respond to?

A

Opioids (strong)

Bisphosphonates

Radiotherapy

Inadditon, denosumab may be used to treat metastatic bone pain.

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32
Q

When increasing the dose of opioids the next dose should be increased by how much?

A

30-50%

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33
Q

Common opioid side effects - transient bs persistent

A

Usually transient:
Nausea
Drowsiness

Usually persistent:
Constipation

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34
Q

Oral codeine to oral morphine conversion factor?

A

Divide by 10

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35
Q

Oral tramadol to oral morphine conversion factor?

A

Divide by 10

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36
Q

Oral morphine to oral oxycodone conversion factor?

A

Divide by 1.5-2

37
Q

Oxycodone vs morphine side effects

A

Oxycodone generally causes:

Less: sedation, vomiting and pruritis

More: constipation.

38
Q

A transdermal fentanyl 12 microgram patch equates to approximately how much oral morphine daily?

A

30 mg

39
Q

A transdermal buprenorphine 10 microgram patch equates to approximately how much oral morphine daily?

A

24mg

40
Q

Oral to subcut morphine conversion factor?

A

Divide by 2

41
Q

Oral to subcut diamorphine conversion factor?

A

Divide by 3

42
Q

Oral oxycodone to subcut diamorphine conversion factor?

A

Divide by 1.5

43
Q

Conservative management of secretions in end of life care?

A

Avoiding fluid overload - particularly stopping IV or subcutaneous fluids

Educating the family that the patient is likely not troubled by secretions

44
Q

Medical management of secretions in end of life care?

A

FIRST LINE:
hyoscine hydrobromide
hyoscine butylbromide

glycopyrronium bromide may also be used

45
Q

When should a syringe driver be considered in the palliative care setting?

A

When a patient is unable to take oral medication due to:

Nausea
Dysphagia
Intestinal obstruction
Weakness
Coma

46
Q

What units are syringe driver rates given in?

A

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

47
Q

The majority of drugs used in a syringe driver are compatible with water for injection - for which drugs is sodium chloride 0/9% reccomeneded?

A

granisetron
ketamine
ketorolac
octreotide
ondansetron

48
Q

Commonly used syringe driver drugs?

A

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

49
Q

What is the preferred opioid used in syringe drivers?

A

Diamorphine

50
Q

Syringe drivers and mixing and compatibility issues - cyclizine

A

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

51
Q

Medical management of breathlessness in palliation?

A

Therapeutic oxygen
Morphine
Midazolam

52
Q

What medications are used for restlessness and confusion in palliation?

A

Haloperidol
Levomepromazine
Midazolam

53
Q

What medications are used for respiratory tract secretions in palliation?

A

Hyoscine hydrobromide
Hyoscine butylbromide
Glycopyrronium

54
Q

Steps in the WHO pain ladder?

A

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

55
Q

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?

A

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

56
Q

Patients will begin to experience significant side effects from chemotherapy once they are at what performance status?

A

2 or below

57
Q

What is the WHO PERFORMANCE status?

A

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

58
Q

WHO performance status - 0

A

Pt is able to carry out normal activity without restriction

59
Q

WHO performance status - 1

A

Pt is restricted in strenuous activity but ambulatory and able to carry out light work

60
Q

WHO performance status - 2

A

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

61
Q

WHO performance status - 3

A

Pt is symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden

62
Q

WHO performance status - 4

A

Pt is completely disabled; cannot carry out any self-care; totally confined to bed or chair

63
Q

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?

A

4

64
Q

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?

A

3

65
Q

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?

A

2

66
Q

What is the WHO performance status in a patient who is restricted in strenuous activity but ambulatory and able to carry out light work?

A

1

67
Q

What is the WHO performance status in a patient who is able to carry out all normal activity without restriction?

A

0

68
Q

What is the most important site of action of ondansetron?

A

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.

69
Q

What is nociceptive pain, and how might patients describe it?

A

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

70
Q

What is neuropathic pain, and how might patients describe it?

A

NEUROPATHIC = malfunctioning
nervous system; nerve structure is
damaged
stabbing, shooting, burning, stinging,
allodynia, numbness, hypersensitivity

71
Q

WHO ANALGESIC LADDER: STEP 1 examples

A

Paractemol, NSAIDs (COX 2)

72
Q

WHO ANALGESIC LADDER: STEP 2 examples

A

Dihydrocodeine
Codeine phosphate
Tramadol
Co-codamol

73
Q

WHO ANALGESIC LADDER: STEP 3 examples

A

Oxycodone
Morphine
Fentanyl
Diamorphine

74
Q

Features of soft tissue pain + opioid response?

A

Localised ache,
Soft tissue throbbing
Gnawing

Good response to opiods

75
Q

Features of visceral pain + opioid response?

A

Poorly localised, deep
ache,
Colicky and episodic,
May be referred

Good/partial response to opioids

76
Q

BONE PAIN: features + opioid response?

A

Well localised aching, Partial
Local tenderness

Partial opioid resopnse

77
Q

NEUROPATHIC PAIN: features + opioid response

A

Difficult to describe
Assoc motor/sensory loss
Dermatomal, radicular

Often poor response to opioids

78
Q

Most common reasons cancer patients on opioids suffer respiratory depression?

A

Developing AKI
Prescribing errors

79
Q

Common initial adverse effects of opioids

A

N&V
Drowsiness
Light-headedness/unsteadiness
Cognitive impairment

80
Q

Common ongoing opoid side effects?

A

Constipation, dry mouth

81
Q

What might improve liver pain specifically?

A

OPIODS
NSAIDS

82
Q

What does of codeine might you consider stepping yp analegsia?

A

30mg, QDS

83
Q

Prepeations of morphine?

A

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

84
Q

What proportion of the TDD should be the IR dose for breakthrough pain?

A

1/6

85
Q

D

A
86
Q

How long does it take a fentanyl patch to achieve a steady state?

A

12-24 hours

87
Q

PRESCRIPTIONS OF CONTROLLED DRUGS

A

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’

88
Q

Anti emetics in PD

A

avoid metoclopramide and haloperidol

consider domperidide

Year 4 Oncology (15 decks)

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