palliative care

Question 1

how do you work out a breakthrough pain dose for morphine?

Answer 1

1/6 of TOTAL morphine dose in one day

Question 2

what medication can you give for pain if you have mild-moderate kidney disease?

Answer 2

oxycodone

Question 3

what medication can you give for pain if you have severe kidney disease?

Answer 3

alfentanil
buprenorphine
fentanyl

Question 4

what treatment options can you consider for pain in cancer with bone metastases?

Answer 4

1. strong opioids
2. radiotherapy
3. bisphosphonates eg alendronate
4. denosumab

3) used to treat bone lytic diseases- including osteoporosis, Paget’s disease, and tumor-induced hypercalcemia

Question 5

what medications can be used if someone presents with confusion or agitation and ruled out acute causes of this?

Answer 5

1st line: haloperidol
2nd line: chlorpromazine, levomepromazine

if terminal stages- subcut midazolam

Question 6

how do you convert oral morphine to subcutaneous morphine?

Answer 6

divide by 2

oral/2 = subcut dose
eg 10mg PO /2 = 5mg SC

Question 7

how do you convert oral morphine to oral oxycodone?

Answer 7

divide by 1.5

3mg morphine/1.5 = 2mg oxycodone

Question 8

how do you convert oral morphine to subcut diamorphine?

Answer 8

divide by 3

oral/3= subcut diamorphine
12mg morphine/3 = 4mg subcut diamorphine

Question 9

how do you convert from oral oxycodone to subcut diamorphine?

Answer 9

divide by 1.5

PO oxycodone/1.5 = SC diamorphine

3mg PO oxycodone/1.5 = 2mg SC diamorphine

Question 10

what does 12 microgram transdermal fentanyl patch equate to for morphine?

Answer 10

30mg PO morphine daily

Question 11

what does 10 microgram transdermal buprenoprhine patch equate to oral morphine?

Answer 11

24mg PO morphine daily

Question 12

how do you increase the dose of opioids?

Answer 12

increase the next dose by 30-50%

Question 13

how do you convert from oral codeine to oral morphine?

Answer 13

divide by 10

PO codeine/10 = PO morphine
30 mg codeine/10 = 3mg morphine

Question 14

how do you convert from oral tramadol to oral morphine?

Answer 14

divide by 10

PO tramadol/10 = PO morphine
30mg tramadol/10 = 3mg morphine

Question 15

how do you convert from oral morphine to oral oxycodone?

Answer 15

divide by 1.5- 2

PO morphine/1.5 = PO oxycodone

3mg morphine/1.5 = 2mg oxycodone

Question 16

what are the side effects of opioids?

Answer 16

transient: nausea + drowsiness

persistent: constipation

Question 17

why is oxycodone sometimes better tolerated than morphine?

Answer 17

oxycodone can cause less sedation, vomiting and pruritis than moprhine

but can cause more constipation

Question 18

what dose to SIGN guideliens suggest to start someone with advanced progressive disease?

Answer 18

20-30mg MR morphine with 5mg IR morphine for breakthrough pain

Question 19

how do you treat intractable hiccups in palliative care?

Answer 19

1st: chlorpromazine
haloperidol
gabapentin
dexamethasone if hepatic lesions

Question 20

when is cyclizine good as 1st line anti-emetic?

Answer 20

intracranial causes/raised ICP
intra-vestibular causes/movement disorders
GI obstruction

Question 21

when is domperidone good to use as an anti-emetic?

Answer 21

gastro-intestinal pain

dopamine antagonist (blocks dopamine receptors) so increases gastric/intestinal muscle contraction- food moves quicker through tract

(dopamine inhibits gut motility)

Question 22

when is metoclopramide good to use as an anti-emetic?

Answer 22

acute migraine
chemo or radiotherapy-induced N+V

prokinetic agent

Question 23

when is ondansetron good to use as an anti-emetic?

Answer 23

prevention and treatment of N+V related to chemotherapy

selective 5-HT3 antagonist
hydroxytryptamine

Question 24

when is dexamethasone good to use as an anti-emetic?

Answer 24

treatment of nausea, anorexia, spinal cord compression, liver capsule pain

raised ICP in addition to cyclizine

Question 25

what are the 6 broad nausea and vomiting syndromes?

Answer 25

1. reduced gastric motility
2. chemically mediated
3. visceral/serosal
4. raised ICP
5. vestibular
6. cortical

Question 26

explain reduced gastric motility

Answer 26

may be opioid related
related to serotonin 5HT4 and dopamine D2 receptors

pro-kinetic agents useful as nausea results from gastric dysmotility + stasis
eg metoclopramide + domperidone

Question 27

explain chemically mediated cause of nausea

Answer 27

secondary to hypercalcaemia, opioids or chemo

correct chemical disturbance
ondansetron, haloperidol, levomepromazine

Question 28

explain visceral/serosal causes of nausea

Answer 28

due to constipation
oral candidiasis

1st line- cyclizine + levomepromazine
anticholinergics eg hyoscine can be useful

Question 29

explain raised ICP causes of nausea

Answer 29

usually in context of cerebral metastases
cyclizine +/- dexomethasone
radiotherapy

Question 30

explain vestibular causes of nausea

Answer 30

related to activation of acetylcholine + histamine H1 receptors
usually due to opioids
can be motion related or due to skull base tumours

1st line cyclizine
2nd line metoclopramide/prochloperazine
3rd line olanzapine/risperidone

Question 31

explain cortical causes of nausea

Answer 31

due to anxiety, pain, fear, anticipatory nausea
related to GABA + histamine H1 receptors in cerebral cortex

short acting benzo eg lorazepam
or cyclizine, ondansetron, metoclopramide