Palliative care

Question 1

What is the first line drug for agitation/confusion in palliative care? what is useful for the terminal phase of illness?

Answer 1

first choice: haloperidol
other options: chlorpromazine, levomepromazine

In the terminal phase of the illness then agitation or restlessness is best treated with midazolam

Question 2

What can be useful for the management of hiccups in palliative care?

Answer 2

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

Question 3

Nausea and vomiting in palliative care - reduced gastric motility
-What may this be related to?
-What agents can be useful?

Answer 3

Reduced gastric motility
May be opioid related
Related to serotonin (5HT4) and dopamine (D2) receptors

Pro-kinetic agents are useful in these scenarios as the nausea and vomiting is usually resulting from gastric dysmotility and stasis
According to NICE CKS and BMJ best practice, first-line medications include metoclopramide and 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

Question 4

Nausea and vomiting in palliative care - chemically mediated
-what may this be associated with?
-What is the management?

Answer 4

Chemically mediated
Secondary to hypercalcaemia, opioids, or chemotherapy

If possible, the chemical disturbance should be corrected first
In the context of other chemically mediated syndromes, for example due to opioid medications, there are a number of suggested medications
Key treatment options include ondansetron, haloperidol and levomepromazine

Question 5

Nausea and vomiting in palliative care - visceral/serosal
-what may this be due to?
-What agents may be helpful?

Answer 5

Visceral/serosal
Due to constipation
Oral candidiasis

Cyclizine and levomepromazine are first-line
Anti-cholinergics such as hyoscine can be useful

Question 6

Nausea and vomiting - raised ICP
-what is this usually in context of cerebral metastases

What agents may be helpful?

Answer 6

Raised intra-cranial pressure
Usually in context of cerebral metastases

The NICE CKS guidelines recommend using cyclizine for nausea and vomiting due to intracranial disease
Dexamethasone can also be used
Radiotherapy can be considered if there is likely raised intra-cranial pressure due to cranial tumours

Question 7

Nausea and vomiting - vestibular related
-What is this related to?
-What agent can be helpful?

Answer 7

Vestibular related
Related to activation of acetylcholine and histamine (H1) receptors
Most frequently in palliative care is opioid related
Can be motion related, or due to base of skull tumours

NICE CKS and BMJ best practice recommends use of cyclizine as a first-line treatment in disorders due to the vestibular system
Refractory vestibular causes of nausea and vomiting can be treated alternatively with metoclopramide or prochlorperazine
Atypical antipsychotics such as olanzapine or risperidone can be used in refractory cases according to UptoDate

Question 8

Nausea and vomiting - cortical related
-What may this be due to
-What is this related to?
-what agents can be helpful

Answer 8

Cortical
May be due to anxiety, pain, fear and/or anticipatory nausea
Related to GABA and histamine (H1) receptors in the cerebral cortex

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

Question 9

How to do you convert oral morphine to oral oxycodone?

Answer 9

Oral morphine Oral oxycodone Divide by 1.5-2***

Question 10

How do you convert oral morphine to subcut morphine?

Answer 10

Oral morphine Subcutaneous morphine Divide by 2

Question 11

How do you convert oral morphine to subcut diamorphine?

Answer 11

Oral morphine Subcutaneous diamorphine Divide by 3

Question 12

How do you convert oral morphine to subcut diamorphine?

Answer 12

Oral oxycodone Subcutaneous diamorphine Divide by 1.5

Question 13

How much oral morphine does a transdermal fentanyl 12mcg patch equate to?

Answer 13

a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily