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Yr 4 - CCC > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

What symptoms are commonly seen in patients nearing the end of life?

A
  • Agitation
  • Pain
  • Excess secretions
  • N&V
  • Breathlessness
  • Constipation
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2
Q

What are anticipatory medications?

A

End of life medicines

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3
Q

What are the 4 main classes of anticipatory medication?

A

1) Analgesia - for pain

2) Anti-emetic - for N&V

3) Anxiolytic - for agitation

4) Anti-secretory - for respiratory secretions

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4
Q

How are anticipatory medications usually prescribed?

A

Anticipatory medications are prescribed as SC injections (injected under the skin) as patients nearing the end of life are often unable to take oral medications.

They should be prescribed PRN, or ‘as needed’, rather than regularly.

Unless the patient has previously received the medications, a low dose should be started and titrated up according to response.

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5
Q

When prescribing anticipatory medications, what details should be included?

A
  • Drug name
  • Drug dose
  • Route e.g. (SC)
  • Indication for each medication: to make it clear which medication should be used for which symptom
  • Frequency of delivery (e.g. 1 hourly)
  • Maximum dose in twenty-four hours: to ensure safe levels of medication are given, this will also prompt regular reviews if a patient is requiring frequent doses
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6
Q

Choice of medication and starting doses vary depending on several patient factors such as:

A

1) PMH –> e.g. specific considerations for patients with Parkinson’s disease, lower starting doses are used in frail patients.

2) Organ dysfunction –> renal and liver dysfunction affect the choice of medications and require lower starting doses

3) DH –> if patients are already on a background opiate their PRN dose should be calculated based on this, rather than using the dose for an opioid naïve patient

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7
Q

Recognising pain in end of life patients is important, especially if patients are less responsive and therefore unable to articulate symptoms.

What changes might be observed that could indicate pain?

A
  • Facial expressions such as grimacing
  • Verbalisations such as moaning or shouting out
  • Body movements such as guarding a particular area/part of the body
  • Autonomic reactions such as increased heart rate or temperature
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8
Q

What is a common first line analgesic in end of life patients?

A

Morphine sulphate

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9
Q

What dose of Morphine sulphate is typically given for opiate naïve patients in end of life care?

A

1 – 2.5mg SC.

Do not repeat within 1-hour
Maximum 4 doses in 24 hours

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10
Q

If there is reduced renal function (eGFR <50), what can be used as an alternative to morphine sulphate in end of life care?

A

Oxycodone 1-2 mg SC

Do not repeat within 1-hour, maximum 4 doses in 24 hours

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11
Q

For patients already on a background dose of opioid medication, what is the PRN anticipatory dose?

A

Generally 1/6th of the total subcutaneous background dose in 24 hours.

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12
Q

Example:

Mr Y has been taking 30mg BD slow-release morphine but is now approaching the last days of life and is not able to swallow his usual medications. This is equivalent to 30mg SC morphine in 24 hours.

What should the PRN anticipatory dose be?

A

5mg SC morphine (30/6)

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13
Q

What combination of opioids is typically seen in palliative care?

A

1) Background opioids (e.g., 12-hourly modified-release oral morphine)

2) Rescue doses for breakthrough pain (e.g., immediate-release oral morphine solution) –> these doses arre 1/6 of background dose

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14
Q

Patient X is on 30mg of modified-release morphine every 12 hours; what would be the correct breakthrough dose?

A

30x2 = 60 –> patient is receiving 60mg background morphine every 24 gours

60/6 = 10mg –> correct breakthrough dose

REMEMBER each rescue dose is 1/6 of the 24-HOUR background dose.

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15
Q

What should you monitor for when prescribing morphine?

A
  • Constipation
  • Unwanted sedation
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16
Q

Opioid conversion

The following table shows dose equivalents of 10mg oral morphine:

A

Codeine/tramadol/dihydrocodeine oral –> 100mg

Diamorphine IM/IV/SC –> 3mg

Morphine IM/IV/SC –> 5mg

Oxycodone oral –> 5mg

Oxycodone SC –> 2.5mg

Alfentanil SC –> 0.3mg

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17
Q

Conversion factor from oral codeine to oral morphine?

A

Divide by 10

I.e. 100mg of oral codeine = 10mg of oral morphine

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18
Q

Conversion factor from oral tramadol to oral morphine?

A

Divide by 10

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19
Q

Conversion factor from oral morphine to SC morphine?

A

Divide by 2

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20
Q

Conversion factor from oral morphine to oral oxycodone?

A

Divide by 1.3-2 (depends on trust guidelines)

If in doubt, always opt for the lower dose and titrate up.

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21
Q

Conversion factor from oral morphine to SC diamorphine?

A

Divide by 3-3.3 (trust guidelines)

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22
Q

Conversion rate from oral oxycodone to SC diamorphine?

A

Divide by 1.5

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23
Q

What is the equivalent dose of oral tramadol to 10mg oral morphine?

A

100mg

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24
Q

What is the equivalent dose of SC diamorphine to 10mg oral morphine?

A

3mg

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25
Q

What is the equivalent dose of SC morphine to 10mg oral morphine?

A

5mg

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26
Q

It is also possible to use opioid patches for background analgesia. What 2 opioid patches are used?

A

1) Buprenorphine patches

2) Fentanyl patches

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27
Q

When increasing the dose of opioids, what should the next dose be increased by?

A

30-50%

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28
Q

How do the side effects of oxycodone differ from morphine?

A

Oxycodone generally causes less sedation, vomiting and pruritis than morphine but MORE constipation.

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29
Q

What should be prescribed for all patients initiating strong opioids?

A

laxatives

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30
Q

What are some potential causes of N&V in endof life patients?

A
  • Constipation
  • Medication side effects
  • Biochemical disturbance e.g. hypercalcaemia
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31
Q

What medications can be given for N&V in palliative care?

A

Levomepromazine
Cyclizine
Haloperidol
Metoclopramide

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32
Q

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

A

1) Reduced gastric motility –> may be opioid related, related to serotonin (5HT4) and dopamine (D2) receptors

2) Chemically mediated –> 2ary to hypercalcaemia, opioids, or chemotherapy

3) Visceral/serosal –> e.g. Ddue to constipation, oral candidiasis

4) Cerebral

5) Vestibular

6) Cortical

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33
Q

What are the symptoms of gastric stasis/irritation nausea and vomiting syndrome?

A

o Sickness comes on very suddenly and is relieved by vomiting
o Early satiety
o Hiccups
o Heart burn

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34
Q

Causes of gastric stasis/irritation nausea and vomiting syndrome?

A

o Stomach cancer
o Liver mets squashing liver, ascites
o Pyloric stenosis
o Gastritis from NSAIDs etc – stop drug, consider PPI
o Diabetes → slow motility
o May be opioid related
o May be related to serotonin and dopamine receptors

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35
Q

1st line pharmacological management (anti-emetic) of reduced gastric motility N&V in palliative care?

A

1) Metaclopramide
- 10-20mg PO/SC (30 mins before meals)
- 30-60mg SC over 24 hours

2) Or Dopmeridone

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36
Q

When is Metaclopramide NOT indicated in reduced gastric motility N&V in palliative care?

A

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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37
Q

What class of drug is metoclopramide?

A

Anti-emetic –> dopamine (D2) receptor antagonist

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38
Q

Mechanism of action of metoclopramide?

A

Dopamine D2 antagonist.

Antiemetic effects –> dopamine D2 antagonist in the chemoreceptor trigger zone (CTZ) in the brain. This relieves the symptoms of nausea and vomiting.

Gut motility –> Increases gastric emptying

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39
Q

Via what 3 mechanisms does metoclopramide promote gut motility?

A

1) inhibition of presynaptic and postsynaptic D2 receptors

2) stimulation of presynaptic excitatory 5-HT4 receptors

3) antagonism of presynaptic inhibition of muscarinic receptors

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40
Q

Why are pro-kinetic agents (e.g. metoclopramide) useful in reduced gastric motility N&V?

A

As the nausea and vomiting is usually resulting from gastric dysmotility and stasis

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41
Q

What are some causes of toxic/chemically mediated N&V?

A

o Alcohol
o Chemotherapy/radiotherapy
o Opiates
o Digoxin
o Hypercalcaemia (bone mets)
o Electrolyte abnormality
o Renal/liver failure
o Infections

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42
Q

Symptoms of toxic/chemically mediated N&V?

A

o Feel sick a lot of the time
o May be sick a little bit but won’t feel much better –> ‘possets’
o Retching

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43
Q

Which anti-emetic is used in toxic/chemically mediated N&V in palliative care?

A

1) Haloperidol - 1.5-5mg PO/SC nocte

2) Or cyclizine

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44
Q

What are some cerebral causes of N&V in palliative care?

A

o Brain metastases
o Raised intracranial pressure (usually in context of cerebral metastases)
o Sights/smells
o Anxiety –> before chemo
o Radiotherapy to brain

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45
Q

Symptoms of cerebral causes of N&V in palliative care?

A

o Early morning headache
o Vomiting
o May be little nausea
o Associated neurological symptoms/signs

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46
Q

Which anti-emetic is used in management of cerebral causes of N&V in palliative care?

A

1) Cyclizine if rased ICP
2) Dexamethasone
3) Unless Anxiety –> Lorazepam

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47
Q

Which anti-emetic is used in management of anxiety/anticipatory nausea
in palliative care?

A

Benzos e.g. lorazepam (short dose)

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48
Q

Describe the steps of the analgesic ladder

A

Don’t use 2 from same step – move up ladder

Step 1:
- Nonopioid analgesics e.g. NSAIDs, paracetamol 1g QDS

Step 2:
- Weak opioids e.g. co-codamol 30/500 2 QDS

Step 3:
- Strong opioids e.g. methadone (oral, transdermal), morphine, codeine

Step 4:
- Nerve block e.g. epidurals

Can use adjuvants at any stage e.g. NSAIDs

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49
Q

What are some potential causes of agitation in palliative care?

A
  • Pain
  • Medications (side effects and withdrawals)
  • Constipation
  • Urinary retention
  • Infection
  • Hypercalcaemia

Look for and treat underlying causes.

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50
Q

Potential signs of agitation?

A

Fidgeting/moving arms and legs
Confused
Vocalisations

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51
Q

1st line choice of anxiolytic (for agitation)?

A

Haloperidol

Other options –> chlorpromazine, levomepromazine

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52
Q

In the terminal phase, what is agitation of restlessness best treated with?

A

Midazolam

2.5 – 5mg SC. Do not repeat within 1 hour, maximum 4 doses in 24 hours.

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53
Q

Why can end of life patients experience increased secretions?

A

With reduced levels of consciousness, patients may become unable to swallow or clear their normal respiratory secretions/saliva, resulting in pooling in the upper respiratory tract.

This can cause noisy breathing/a rattling noise as air passes over the pooled secretions.

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54
Q

Non-pharm management of secretions in palliative care?

A

Offering reassurance to those looking after the patient that it is not a distressing symptom, as well as repositioning the patient may be helpful.

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55
Q

anticipatory medications used for respiratory tract secretions?

A

Hyoscine butylbromide

20mg SC. Do not repeat within 1-hour, maximum dose 120mg in 24 hours

Others:
- Hyoscine hydrobromide
- Hyoscine butylbromide
- Glycopyrronium

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56
Q

Mechanism of Hyoscine butylbromide?

A

Has anticholinergic effect –> reduces saliva production (dry mouth)

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57
Q

Potential signs of end of life?

A
  • Profound weakness
  • Confined to bed for most of the day
  • Drowsy for extended periods
  • Disorientated
  • Severely limited attention span
  • Losing interest in food and drink
  • Too weak to swallow medication
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58
Q

When should clinical hydration/nutrition be stopped?

A

Continue with clinically assisted hydration if there are signs of clinical benefit. Reduce or stop clinically assisted hydration if there are signs of possible harm to the dying person, such as fluid overload, or if they no longer want it.

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59
Q

What are some possible benefits of withdrawing artificial hydration/nutrition?

A

▪ Less vomiting and incontinence
▪ Reduction in barriers between patient and family
▪ Prevention of painful venepuncture

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60
Q

In palliative care, what medications should be stopped and which should be continued?

A

Only continue medication needed for symptom management:

Stop:
o Vitamins/iron
o Hormones
o Anticoagulants
o Antibiotics
o Anticonvulsants used for pain
o Antidepressants
o Cardiovascular drugs
o Think about corticosteroid

Keep:
o Analgesics
o Antiemetics
o Antisecretories
o Anxiolytics
o Type 1 diabetics – keep insulin
o May keep anticonvulsants also
o Give SC if needed

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61
Q

What are syringe drivers?

A

Syringe drivers are small battery-powered pumps used to deliver medications as a continuous subcutaneous infusion (CSCI) over a 24-hour period.

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62
Q

What are 2 indications for the use of a syringe driver in patients nearing the end of life?

A

1) Requiring two or more doses of any one of the anticipatory medications in a 24 hour period

2) Being unable to take oral medications that need replacing (e.g. modified release opiates, anti-epileptic medications)

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63
Q

Why can syringe drivers help to achieve better symptom control?

A

Continuous infusion provides a constant level of medication to the patient

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64
Q

What associated features should you ask about when a patient with cancer presents with pain?

A
  • Cough (productive or not), fever, malaise
  • Weakness in legs, sensory changes
  • Back pain, bladder/bowel symptoms
  • Facial swelling, distended veins in neck/chest, swelling of hands/arms
  • Skin changes, reflux symptoms (radiotherapy)
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65
Q

Differentials for chest pain in palliative oncology patient?

A

Cancer:
- Invasion; bone, pleura, chest wall
- Neuropathic pain
- Bone mets
- SVCO
- MSCC

Cancer related:
- Radiotherapy; skin, oesophagitis
- Chemotherapy; peripheral neuropathy

Co-exsisting:
- Pneumonia
- MI
- PE
- Anxiety
- GORD
- MSK

Most of these can be ruled in/out by taking a thorough pain history.

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66
Q

What are the 5 principles of the WHO analgesic ladder?

A

1) Oral administration of analgesics should be used whenever possible

2) Analgesics should be given at regular intervals with the duration and dose of medication supporting the patient’s level of pain

3) Analgesics should be prescribed according to the pain intensity characterised by the patient (this should be free from judgement from the clinician)

4) Dosing of pain medication should be adapted to the individual, starting at the lowest dose and duration possible but titrating accordingly to response

5) Consistent administration of analgesics is vital for effective pain management

67
Q

Describe the steps of the WHO analgesic ladder

A

1) Non-opioids (e.g. paracetamol or NSAIDs) +/- adjuvants

2) Weak opioids (e.g. co-codamol, codeine, dihydrocodeine, tramadol) +/- adjuvants

3) Strong opioids (e.g. morphine, oxycodone, methadone, buprenorphine, fentanyl) and non-opioids +/- adjuvants

N.B. adjuvants can be used along any step of the ladder e.g. antidepressants, anticonvulsants, corticosteroids, anxiolytics

68
Q

What 2 groups can pain be broadly split into?

A

1) Nociceptive
2) Neuropathic

69
Q

What is nociceptive pain?

A

Nociceptive pain is a type of pain caused by damage to body tissue.

70
Q

What are the 2 types of nociceptive pain?

A

1) Somatic (muscle, skin, bones)
2) Visceral (internal organs)

71
Q

What is neuropathic pain?

A

Caused by direct damage to nerve tissue (central or peripheral)

72
Q

What are adjuvant analgesics?

A

1) Neuropathic agents –> amitriptyline, pregabalin, gabapentin

2) NSAIDs

3) Corticosteroids

4) Non-pharmalogical –> TENS, radiotherapy, acupuncture, heat

73
Q

General principles of prescribing opioids?

A

Patients will be on a regular BACKGROUND opioids

AND

A PRN immediate release opioid.

74
Q

Give some administration options for the regular background opioid

A

1) Oral - modified release 12 hours apart/BD e.g. MST, zomorph, oxycontin, longtec

2) 24 hourly CSCI syringe driver

3) Transdermal patch change every 3-7 days e.g. buprenorphine, fentanyl

75
Q

How is the PRN immediate release opioid given?

A

Oral or SC

76
Q

What dose is the PRN immediate release opioid?

A

1/6 of regular 24 hourly dose

77
Q

Give 2 examples of a PRN immediate release opioid?

A

Oramorph, oxynorm (these are liquid opioids given orally)

78
Q

Onset and duration of PRN immediate release opioid?

A

Onset: 30 mins

Duration: 4 hours

79
Q

What is usual starting dose of a strong opioid?

A

5-10mg modified release morphine

5mg (or 2mg if patient is frail) immediate release opioid

80
Q

What are some side effects of opioids?

A
  • Constipation
  • Drowsiness & impaired concentration (may alter someone’s ability to drive)
  • N&V
  • Dry mouth
  • Flushing
  • Hallucinations
  • Headaches
  • Itch

All opioids carry a risk of dependence and addiction.

Longer term side effects:
- Falls
- Erectile dysfunction
- Amenorrhoea
- Infertility
- Depression
- Fatigue
- Opioid induced hyperalgesia

81
Q

How can N&V be managed in patients taking opioids?

A

anti-emetics (e.g. cyclizine)

82
Q

How can constipation be managed in patients taking opioids?

A

all patients who start strong opioids should be prescribed a laxative to prevent constipation

83
Q

Symptoms of opioid overdose?

A

1) Constricted pupils (miosis)
2) Respiratory depression
3) Reduced consciousness

84
Q

How are opioids excreted?

A

Renally –> caution prescribing in renal impairment due to increased risk of opioid accumulation and subsequent toxicity

85
Q

For patients with renal impairment, what opioid is preferred? Why?

A

Oxycodone - it is primarily metabolised by the liver, with only a small proportion excreted by the kidney.

86
Q

In patients with mild renal or hepatic impairment, how should an opioid dose be changed?

A

Doses should be reduced by 50%

Specialist advice should be sought before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment.

87
Q

Contraindications of opioids?

A
  • Severe renal & hepatic impairment (specialist advice needed)
  • Pregnancy
  • Breastfeeding (presence in breast milk)

Other notes:
- Reduced doses in elderly
- Cessation of treatment should be tapered slowly

88
Q

What should be discussed with the patient when considering the need for analgesia?

A

1) The severity of the pain, its impact on lifestyle and activities of daily living, including sleep disturbance

2) The cause of the pain and whether there has been a deterioration

3) Why a particular treatment is being offered

4) The benefits and adverse effects of pharmacological treatment when considering the patient’s underlying health condition

5) The importance of adherence to medication and dosage titration

89
Q

What is typical drug dosing for (oral) paracetamol?

A

0.5-1g every 4-6 hours, maximum 4g daily

90
Q

Side effects of NSAIDs?

A
  • Dyspepsia
  • Peptic ulcer disease
  • Skin reactions
91
Q

What should be prescribed alongside NSAIDs?

A

PPI

92
Q

Contraindications to NSAIDs?

A

Active bleeding or history of active bleeding
IHD
Severe hepatic impairment
Severe renal impairment
Uncontrolled HTN
Asthma

93
Q

What 3 classes of drugs can interact with NSAIDs and increase risk of bleeding?

A

1) Anticoagulants (e.g. warfarin)

2) Antiplatelets (e.g. aspirin)

2) Selective serotonin reuptake inhibitors (e.g. sertraline)

94
Q

How do NSAIDs affect the kidneys?
1) sodium levels
2) potassium levels

A

Can decrease renal function and lead to:
1) hyponatraemia
2) hyperkalaemia

95
Q

What 2 classes of drugs can interact with NSAIDs and increase risk of electrolyte imbalances?

A

1) ACEi e.g. ramipril (increased risk of hyperkalaemia)

2) Diuretics e.g. spironolactone (increased risk of hyponatraemia or hyperkalaemia)

96
Q

How do NSAIDs affect seizure activity?

A

Can worsen seizure activity

97
Q

What class of drugs can interact with NSAIDs and increase risk of seizures?

A

Fluoroquinolone antibiotics (e.g. ciprofloxacin)

98
Q

Typical dose for (oral) ibuprofen for mild to moderate pain?

A

Initially 300-400mg 3-4 times a day; increased up to 600mg 4 times a day if necessary; maintenance 200-400mg three times a day

99
Q

Typical drug dose for oral codeine?

A

30-60mg every 4 hours as required

100
Q

What 3 doses does co-codamol come in?

A

8/500mg, 15/500mg and 30/500mg.

101
Q

What is an alternative if codeine/co-codamol is ineffective or cannot be tolerated?

A

Tramadol

102
Q

Before prescribing any strong opiate, consider ABC.

What is this?

A

A - start Antiemetic

B - consider Breakthrough pain

C - prescribe laxative for Constipation

103
Q

For patients with renal impairment, what opiate can be used?

A

Consider oxycodone

104
Q

Typical drug dosing for (oral) morphine in acute pain?

A

initially 10mg every 4 hours; use a lower initial dose in the elderly (5mg every 4 hours)

105
Q

Typical drug dosing for (oral) morphine in chronic pain?

A

5-10mg every 4 hours

106
Q

What is neuropathic pain?

A

Neuropathic pain is caused by damage to the somatosensory nervous system, which can result in allodynia, hyperalgesia, and paraesthesia.

107
Q

Common causes of neuropathic pain?

A

Diabetic neuropathy
Chronic alcohol use
Infection
Trigeminal neuralgia
Trauma
Spinal cord injuries
Multiple sclerosis
Malignancy

108
Q

What are some non-pharmacological treatments for neuropathic pain?

A

Physical and psychological treatments
Surgery

109
Q

1st line pharmacological options for neuropathic pain?

A

Amitriptyline
Duloxetine
Gabapentin
Pregabalin

110
Q

What class of drug is amitriptyline?

A

tricyclic antidepressant

111
Q

Side effects of amitriptyline?

A

The most common side effects are anticholinergic:

Dry mouth
Blurred vision
Dry eyes
Constipation
Urinary retention
Postural hypotension

CAUTION - overdose is associated with a high mortality rate.

112
Q

What class of drug is duloxetine?

A

selective serotonin noradrenaline uptake inhibitor (SNRI).

113
Q

Side effects of duloxetine?

A

Increased BP (caution in CVS disease)
Anxiety
Dry mouth
Flushing
Gastrointestinal discomfort
Palpitations
Sexual dysfunction

114
Q

What class of drug is gabapentin and pregabalin ?

A

Anticonvulsants

115
Q

Side effects of pregabalin and gabapentin?

A

Drowsiness
Dizziness
Ataxia

116
Q

What is 1st line in trigeminal neuralgia?

A

Carbamazapine

117
Q

What can be considered for people with localised neuropathic pain who wish to avoid oral treatments?

A

capsaicin cream

118
Q

Give some cerebral causes of N&V

A

Raised ICP
Brain mets
Intracranial haemorrhage
Pain
Anxiety
Primary CNS tumour
Psychological

119
Q

Give some toxic causes of N&V

A

Medication
Biochemical
Uraemia
Hypercalcaemia
Hyponatraemia
Hyperbilirubinaemia
Infection
Hyperglycaemia

120
Q

Give some gastric causes of N&V

A

Bowel obstruction
Gastroparesis
Pancreatitis
Hepatomegaly
Gastroenteritis
Ascites
Constipation
Dyspepsia

121
Q

Give some vestibular causes of N&V

A

Inner ear pathology
Labyrinthitis
Motion sickness
Vertigo

122
Q

Describe typical N&V in cerebral causes

A
  • Nausea > vomiting
  • Timing
  • Position dependent
  • Headache
  • Neuro symptoms
123
Q

What are the 4 major groups of N&V

A

1) Toxic
2) Cerebral
3) gastric
4) vestibular

124
Q

What class of drug is cyclizine?

A

Antihistamine with anticholinergic activity

125
Q

Which 3 types of N&V are most like to respond to cyclizine?

A

1) cerebral
2) gastric
3) vestibular

due to presence of histamine receptors in CNS and vestibular system and presence of ACh receptors in GI and vestibular area.

126
Q

Side effects of cyclizine?

A

Dry mouth
Hypotension
Drowsiness

127
Q

What also can be used in cerebral N&V to reduce peri-tumoural oedema?

A

Steroids e.g. dexamethasone (but this is not an anti-emetic)

128
Q

What are 2 anti-emetics that are prokinetics with dopaminergic activity?

A

1) metoclopramide (acts centrally)
2) domperidone (acts peripherally only)

129
Q

Major contraindication of metoclopramide?

A

Parkinson’s

130
Q

Can domperidone be used in Parkinson’s?

A

Yes

131
Q

What type of N&V can metoclopramide & domperidone be used in?

A

Gastric

132
Q

What anti-emetic is typically chosen for toxic causes of N&V?

A

Haloperidol

133
Q

What are the 2 chosen anti-emetics for end of life?

A

1) haloperidol
2) levomepromazine

134
Q

Contraindications of haloperidol
and levomepromazine?

A

Parkinson’s disease

135
Q

Which anti-emetic is typically used for chemo-related N&V?

A

Ondansetron

136
Q

Most common side effect of ondansetron?

A

Constipation

137
Q

What is a common cause of N&V in dvanced intra-abdominal malignancy ie ovarian, bowel, peritoneal?

A

Malignant bowel obstruction

138
Q

Medical management of bowel obstruction?

A

1) Give IV fluids.

2) Give an anti-secretory e.g. hyoscine butylbromide (buscopan) or ranitidine - to reduce how much bowel is secreting into lumen

3) Give steroids

4) Give anti-emetic (depends on presence or absence of colick, if not present can give metoclopramide, if present give haloperidol)

5) Give pain relief

139
Q

What are the 4 main types of laxatives?

A

1) bulk forming e.g. fybogel

2) softeners e.g. docusate

3) stimulants e.g. senna, bisacodyl

4) osmotic e.g. lactulose

Combination (softeners and stimulants) e.g. macrogols (movicol/laxido)

140
Q

What is the 1st line laxative in palliative care?

A

Senna

141
Q

Typical management of SVCO?

A

SVC stent

142
Q

What can be used in reducing the discomfort associated with a painful mouth that may occur at the end of life?

A

Benzydamine hydrochloride mouthwash or spray

143
Q

1st line anti-emetic for intracranial causes of nausea and vomiting?

A

Cyclizine

144
Q

3 options for metastatic bone pain?

A

1) analgesia
2) bisphosphonates
3) radiotherapy

145
Q

Pharmacological managment of confusion/agitation in palliative care but for patients NOT in the terminal phase?

A

Oral haloperidol (if the patient was in the terminal phase and agitated then subcutaneous midazolam would be indicated)

146
Q

What is analgesic of choice in patients with:
a) mild-moderate renal impairment
b) severe renal impairment (eGFR <10)

A

a) oxycodone
b) buprenorphine or fentanyl

147
Q

Why is buprenorphine or fentanyl preferred in patients with severe renal impairment?

A

not renally excreted and therefore are less likely to cause toxicity than morphine

148
Q

What can be used to manage bowel colic in palliative care?

A

Hyoscine butylbromide

149
Q

Conversion from oral morphine to SC diamorphine?

A

Total daily morphine dose divided by 3

150
Q

Pharmacological management of hiccups in palliative care?

A

chlorpromazine or haloperidol

151
Q

What is the benzodiazepine of choice in terminal agitation/restlessness?

A

Midazolam

152
Q

Why is diazepam not given as an end of life drug?

A

It is an irritant when given subcut

153
Q

What is 1st line in cancer related breathlessness when no reversible element?

A

Low dose immediate release PO morphine (i.e. oramorph)

154
Q

Describe performance status 1-5

A

0 = normal

1 = symptomatic & ambulatory, cares for self

2 = ambulatory >50% of the time

3 = ambulatory <50% of the time, nursingcare required

4 = bedridden

5 = dead

155
Q

What drug is indicated for agitation and confusion in patients who are NOT in the terminal phase?

A

Haloperidol

156
Q

What drug is indicated for agitation and confusion in patients who are in the terminal phase?

A

SC midazolam

157
Q

What is the codeine to morphine conversion?

A

divide by 10

158
Q

What class of medication is metoclopramide?

A

D2 receptor antagonist

159
Q

What drug can be used in the management of intractable hiccups in palliative care?

A

Chlorpromazine or haloperidol.

160
Q

What are 3 management options for metastatic bone pain?

A

1) strong opioids

2) bisphosphonate infusion

3) radiotherapy

161
Q

Conversion of oral morphine to diamorphine?

A

Divide by 3

162
Q

What may be useful in reducing the discomfort associated with a painful mouth that may occur at the end of life?

A

Benzydamine hydrochloride mouthwash or spray

163
Q
A

Yr 4 - CCC (54 decks)

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