Palliative care

Question 1

Good addition to opioid pain relief in abdominal colic

Answer 1

Anticholinergics e.g. hyoscine butylbromide (Buscopan) 20mg qds po or sc
Or loperamide

Question 2

Good addition to opioid pain relief in liver capsule pain

Answer 2

NSAID or dexamethasone (4-6mg od, with PPI)

Question 3

Good addition to opioid pain relief in bladder spasm

Answer 3

Oxybutynin 2.5-5mg bd-qds po

Question 4

Causes of seizures

Answer 4

Hypoxia
Metabolic disturbance (hypoglycaemia, uraemia, hepatic encephalopathy)
Electrolyte imbalance (low Na, high K/Ca)
Drugs (anticonvulants, antidepressants, antipsychotics, opioids, isoniazid, theophylline)
Drug withdrawal
Trauma
CNS neoplasia
CNS infection
Haemorrhagic or occlusive stroke

Question 5

How often are immediate-release preparations of oral morphine given?
How about modified-release?

Answer 5

Immediate: 4-hourly
Modified: 12-hourly

Question 6

When does upward titration of the dose of morphine stop?

Answer 6

When the pain is relieved or when unacceptable adverse effects occur- then consider alternative measures

Question 7

Which factors should be taken into account when deciding initial dose of morphine?

Answer 7

Previous medication used
Severity of pain
Renal impairment
Increasing age/frailty

Question 8

Drugs that may help relieve anorexia

Answer 8

Prednisolone or dexamethasone

Question 9

Standard prescription for constipation

Answer 9

Lactulose + Senna

Question 10

Measures for dry mouth

Answer 10

Conservative: sugar-free chewing gum, sucking ice/pineapple chunks, artificial saliva
Antifungals for candida
Try to reduce meds causing it e.g. opioids, antimuscarinics (e.g. hyoscine), antidepressants

Question 11

Treatment of hiccups due to gastric distension

Answer 11

Antacid + antiflatulent

If this fails, metoclopramide

Question 12

Medicines for muscle spasm

Answer 12

Diazepam or baclofen

Question 13

Best antiemetics for nausea and vomiting due to opioid therapy

Answer 13

Haloperidol
Metoclopramide
Usually only needed for first 4-5 days

Question 14

What kind of drugs antagonise the prokinetic effects of some antiemetics?

Answer 14

Antimuscarinics

Question 15

When is cyclizine useful for nausea and vomiting?

Answer 15

Mechanical bowel obstruction
Raised ICP
Motion sickness

Question 16

Treatment of pruritis associated with obstructive jaundice

Answer 16

Emollients

Colestyramine

Question 17

Treatment of headache due to raised ICP.

Important prescribing instruction

Answer 17

Dexamethasone- give before 6pm to avoid insomnia. Ideally in the morning.

Question 18

Drugs that are too irritant to be given in a syringe driver

Answer 18

Diazepam
Chlorpromazine
Prochlorperazine
(cyclizine- to an extent)

Question 19

Drugs and doses for a ‘classic’ syringe driver

Answer 19

Analgesia: Morphine e.g. 10mg (but contact the palliative care team if in renal failure)
Restlessness/agitation: Midazolam 10-30mg (Levomepromazine is normally better, but may cause irritation)
Nausea/vomiting: Cyclizine 150mg or Haloperidol 3mg
Secretions: Hyoscine Butylbromide 60mg

Question 20

Treatment adjuvants for rectal pain/tenesmus?

Answer 20

Topical GTN ointment
Nifedipine PO/sublingual
Topical lidocaine gel

Question 21

Management of bone pain

Answer 21

Partially opioid responsive
NSAIDs
Steroids
IV pamidronate
Radiotherapy

Question 22

What can happen if you use tramadol and SSRIs together?

Answer 22

Lowers seizure threshold

Can precipitate serotonin syndrome