Palliative Care Flashcards
What is an unlicensed medication?
one not approved for marketing in the UK for use in humans for any indication
what is an off-license use of medication?
a licensed medication used for an unlicensed indication - can be route or dose as well as indication
How long does pain have to be present for it to be defined as chronic?
3 months or more
what is pain?
An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage
what is allodynia?
when pain is experienced with sensory inputs that do not normally cause pain
what are the two types of primary afferent nociceptors (nerve fibres) that transmit pain?
C-fibres
A-Delta fibres
what kind of pain do C fibres transmit?
transmit signals slowly and produce dull, diffuse pain sensations
unmyelinated and small diameter neurons
what kind of pain do A-delta fibres transmit?
fast and sharp, localised pain sensation
myelinated larger neurones
what are 2 ways to measure pain?
Numerical rating scale
Visual analogue scale
what is step one on the pain ladder?
non-opioid simple pain killers - paracetamol, NSAIDs
what is step 2 on the pain ladder?
weak opioids - codeine, tramadol
what is step 3 on the pain ladder?
strong opioids - morphine, oxycodone, fentanyl, buprenorphine
what are 4 medications used to treat neuropathic pain?
Amitriptyline
gabapentin
pregabalin
duloxetine
Also capsaicin cream (from chillis) for localised areas
what questionnaire can be used to assess the likelihood of neuropathic pain?
DN4 questionnaire - score >4
what are 6 key side effects of NSAIDs?
Gastritis + dyspepsia
stomach ulcers
exacerbation of asthma
hypertension
renal impairement
coronary artery disease, HF, stroke
what are 6 key side effects of opioids?
constipation
pruitus
nausea and vomiting
altered mental state - sedation, confusion, cognitive impairement, hallucination
respiratory depression
urinary retention
what is the antidote to opioids?
naloxone
what specialist medication can be used to prevent opioid constipation while maintaining analgesia?
methylnaltrexone bromide SC injection dose dependant on body weight
what laxatives should be prescribed alongside opioids?
Stimulant - senna
15mg in the evening - not constipated
15mg BD - constipated
increase dose if ineffective to max of 30mg TDS
how long does modified release morphine last?
12 hours
what does should PRN rescue opioids be?
1/10th to 1/6th of the daily 24h dose
what is the equivalent 10mg PO morphine dose of codeine?
100mg PO codeine
what is the equivalent 10mg PO morphine dose of tramadol?
100mg PO Tramadol
what is the equivalent 10mg PO morphine dose of oxycodone?
6.6mg PO oxycodone
what is the equivalent 10mg PO morphine dose of IV/SC/IM morphine?
5mg IV/SC/IM morphine
what is the equivalent 10mg PO morphine dose of IV/IM/SC diamorphine?
3mg IV/IM/SC diamorphine
what dose of morphine over 24 hours is equivalent to a 5mcg/h patch of buprenorphine?
12mg/24 hours of oral morphine
what dose of morphine over 24 house is equivalent to 12mcg/h patch of fentayl?
30mg/24 hours of oral morphine
what are 5 alternative ways to deal with chronic pain?
supervised group exercise
acceptance and commitment therapy (ACT)
CBT
Acupuncture
Antidepressants
what 3 electrolyte imbalances can cause nausea?
Hyponatraemia
Hypocalcaemia
Hypercalcaemia
what are the 5 areas that can trigger the vomiting centre of the medulla?
GI Tract - gastric stasis, intestinal obstruction, gastric irritation
Chemoreceptors - biochemical upset, drugs, electrolyte imbalance
Vestibular input - motion sickness, morning sickness
Higher centres - from cortex - anxiety, smells/sights
Increased intracranial pressure
what are 4 non-pharmacological ways to manage nausea?
control odours
minimise sight/smell of food
small snacks not large meals
acupressure wrist bands
what is the nausea and vomiting like in gastric stasis?
large volumes
infrequent
vomiting relives symptoms
oesophageal reflux
epigastric fullness
early satiation
what is the nausea and vomiting like in gastric outflow obstruction?
Similar to gastric stasis
more forceful and rapid dehydration
what is the nausea and vomiting like in oesophageal blockage?
brings just swallowed food back up
soon after eating and drinking
sensation of food sticking
what is the nausea and vomiting like in raised ICP?
effortless vomiting often in morning
associated with headache, papilloedema
nausea - may be diurnal
what is the nausea and vomiting like in chemically induced nausea?
constant nausea
variable vomiting
What drug class is haloperidol?
Butyrophenone antipsychotics - used as antiemetic
what condition is a contraindication to the use of haloperidol?
parkinsons
what types of nausea is haloperidol good for?
chemical causes - opioids, chemotherapy
what are 4 side effects of haloperidol?
extrapyramidal side effects
sedation
QT prolongation
Depression
what is the dosing of haloperidol for nausea in palliative care?
0.5mg - 1.5mg OD or every 2 hours as required
Max dose 10mg/24h
what are 2 prokinetic antiemetics?
Metoclopramide - for things attached to the mesentery
Domperidone
what receptors do prokinetic antiemetics act on?
D2 receptors
metoclopramide also acts on 5-HT3/4 receptors
When should pro-kinetic antiemetics be used?
gastric stasis
ileus
delayed chemo induced n+v
what are the 1st line antiemetics for gastric stasis?
Metoclopramide
Domperidone
what are 5 side effects of metoclopramide?
extrapyramidal effects
drowsiness
diarrhoea
gynaecomastia
hyperprolactinaemia
what are 5 side effects of domperidone?
QT prolongation
drowsiness
dry mouth
diarrhoea
malaise
in what condition should metoclopramide not be used in?
parkinsons
what dose is given of domperidone for nausea and vomiting?
10mg up to TDS (for max one week) - take before meals
up to 80mg/24h in palliative care (off licence)
what other condition can metoclopramide be used to treat in palliative care?
hiccups - 10mg every 6-8h
what dose is given of metoclopramide for nausea and vomiting?
10mg PO TDS for 5 days
<60kg => 500mcg/kg/day
CSCI 30-80mg/24h - specialist only
what are 2 examples of phenothazine antipsychotics used as antiemetics?
levomepromazine
prochlorperazine
what are 5 side effects with phenothiazine antipsychotics (used as antiemetics)?
extra-pyramidal symptoms
drowsiness
anti-muscarinic effects
postural hypotension
long QT
in what condition should phenothiazine antipsychotics (prochlorperazine) be avoided (used as antiemetics)?
parkinsons
what are 3 examples of antihistamines that can be used for nausea?
cyclizine
cinnarizine
promethazine
how do antihistamines work as antiemetics?
act on H1 receptors centrally and peripherally to suppress nausea
what antiemetic are used for vertigo/dizziness?
Cyclizine
Prochlorperazine - for when you’re feeling peculiar
what are 2 examples of 5-HT3 antagonists?
granisetron
ondansetron
what is the MOA of ondansetron and granisetron?
act on 5HT3 receptors
what type of nausea are 5HT3 receptors useful for?
chemotherapy and radiotherapy induced nausea and vomiting and postoperative
what are 5 side effects of 5-HT3 antagonists (ondasetron)?
constipation
headache
flushing
involuntary movements
QT prolongation
what is the dose of ondansetron?
4-8mg BD/TDS PO/IV/SC
16-24mg/24h CSCI
what are 3 antimuscarinics that are used as antiemetics?
hyoscine butylbromide
Hyoscine hydrobromide
Glycopryrronium bromide
what is the MOA of antimuscarinics in nausea and vomiting?
act on Ach receptors and cause smooth muscle relaxation and drying up of secretions
when are antimuscarinics used in nausea and vomiting? (3)
in smooth muscle spasm - bladder/gi tract
excessive secretions and death rattle
inoperable bowel obstruction
what is the dosing for hyoscine butylbromide for bowel symptoms?
10-20mg 4 hourly PO
20mg up to hourly PRN SC
60-300mg/24hCSCI
what are 6 side effects of hyoscine butylbromide and hyoscine hydrobromide?
constipation
urinary retention
tachycardia
hypotension
blurred vision
drowsiness/confusion
what is the dose for hyoscine hydrobromide for nausea and vomiting?
400 micrograms PRN SC 4 hourly
1.2-2mg/24 hour CSCI
what is the dose of glycopyronium bromide for bowel colic and resp secretions?
200 micrograms every 4 hours PRN
0.6-1.2 mg/24 hours CSCI
what are a type of antiemetics that are licenced for prevention of chemo related n+v?
Neurokinin- receptor
antagonists
what are 2 examples of Neurokinin- receptor
antagonists used as antiemetics?
aprepitant - oral
fosaprepitant - IV
what is usually the 1st line antiemetic for chemo nausea?
Ondansetron from your oncologist
what antiemetics are used for neuro causes of nausea?
Haloperidol for you head
Cyclizine
Dexamethasone
what are 6 signs of dying?
Sleeping more/Less conscious
Weaker and less able to move around
Breathing changes - shallower or less regular
Upper airway secretions
Loss of appetite
Withdrawal or restlessness
what always needs to be prescribed with a syringe driver?
water for injection or Sodium chloride 0.9%
what should always be prescribed with opioids?
laxatives - senna (simulant laxitive) first and then osmotic (lactulose, macrogol)
what are 3 medications that can be helpful for hiccups?
prokinetics - metoclopramide
antiflatulents - peppermint oil
PPIs
what medication can be given in palliative care for breathlessness?
morphine
benzodiazapines for anxiety related
what medication can be used for bowel colic in palliative care?
hyoscine butylbromide
what are 5 reasons cancer can cause constipation directly?
Bowel obstruction
Compression of infiltration of spinal cord, cauda equina or pelvic plexus
Hypercalcaemia
Painful defecation
Autonomic neuropathy - small cell carcinoma and carcinoid tumours
what is the 1st line pharmological management of palliative constipation?
Stimulant laxative - sena
what is 2nd line management of constipation in palliative care?
ADD osmotic laxative - lactulose or macrogol
OR
Surface wetting laxative - docusate (if ado colic is a problem)
what is the 3rd line management of constipation in palliative care?
Soft stool - bisacodyl OR sodium citrate suppository
Hard - glycerol suppository
VERY hard - arachis oil enema over night
what are 2 laxatives types that should be avoided in palliative care?
Bulk forming
Phosphate enemas - can cause electrolyte disturbance
who should not get rectal constipation interventions?
people on chemo who may be neutropenic
people with thrombocytopenia
rectal or anal disease
what medication can be used for agitation in palliative care?
haloperidol
what antidepressant is good for patients with nausea, insomnia or reduced appetite?
mirtazapine
what is the first line medication for seizure in palliative care?
levetiracetam
what antiepileptic is generally used in CSCIs due to compatibility?
midazolam
what are 2 medications that can be used for respiratory secretions in palliative care?
hyoscine butylbromide
glycopyrronium bromide
what are 2 medications that can be given in pruritus?
levomenthol cream
antihistamines
what 4 medications are commonly in a syringe driver and what doses?
Morphine 10mg/ml - 2.5-5mg if opioid naive otherwise use conversion
Haloperidol 5mg/1ml => 2.5-5mg
Midazolam 10mg/2ml => 10-30mg
Hyoscine butylbromide 20mg/1ml => 60-120mg
what is multiple organ dysfunction syndrome?
a hypometabolic, immunodepressed state with clinical and biochemical evidence of the failure of 2 or more organ systems
what are 6 common causes of multiple organ dysfunction syndrome?
sepsis
traumatic injury - burns, blood loss
pancreatitis
MI
Liver failure
toxic injury/poisoning
what medications can be used to suppress cough?
Opioids
soothing agents - syrups
what are 3 antiemetics that are good for chemically induced nausea?
Haloperidol
Metoclopramide
Levomepromazine
what 2 antiemetics are good for nausea due to raised ICP?
Cyclizine - if just intracranial disease
Dexamethasone - if raised
what antiemetic is used 1st line for vestibular disease and motion sickness?
cyclizine
what are 4 antiemetics which are good for vestibular disease?
Hyoscine hydrobromide
Cinnarizine
levomepromazine
prochlorperazine
what is one medication that can be used to reduce mouth discomfort at the end of life (mucositis)?
benzydamine hydrochloride
