Palliative care

Question 1

When should routes other than oral be considered for morphine for pain relief?

Answer 1

If the patient has dysphagia, gastric stasis, intractable N+V, impaired consciousness

Question 2

What are some side effects of opioids?

Answer 2

Constipation, N+V (usually improves after 5 days), drowsiness (often temporary), dry mouth, respiratory depression (rare if prescribed correctly).

Question 3

What should be co-prescribed when prescribing an opioid?

Answer 3

A laxative

Consider adding an anti-emetic.

Question 4

What are some signs suggestive of opioid toxicity?

Answer 4

Persistent N+V, persistent drowsiness, confusion, visual hallucinations, myoclonic jerks, respiratory depression, coma.

Question 5

How do you convert oral codeine dose to equivalent oral morphine dose?

Answer 5

Divide total daily codeine dose (max. is 240mg) by 10

=24mg. NICE recommends starting dose of 20mg, slightly lower if renal failure

Question 6

What PRN dose of oral morphine should be prescribed for breakthrough pain?

Answer 6

Total daily dose or MR morphine (starting dose - 40mg) divided by 6 (=6.666mg so prescribe 5-10mg).

Question 7

How many times can a prn dose of morphine be given in a day?

Answer 7

Maximum 6 doses in 24 hours.

Can be given hourly if needed but should not exceed 6 doses in 24 hours

Question 8

When should oxycodone be considered for pain relief?

Answer 8

If the patient has renal failure or can’t tolerate the side effects of morphine.

Question 9

What are the 4 main mechanisms that stimulate the vomiting centre in the brain thereby producing nausea and vomiting?

Answer 9

Gastric stasis/irritation
Toxic causes (e.g. chemotherapy, palliative drugs)
Cerebral causes (e.g. raised ICP, anxiety, indeterminate)
Vestibular causes

Question 10

Which antiemetic is best suited for the management of nausea and vomiting due to gastric reasons?

Answer 10

Metaclopramide

Question 11

What are the important side effects to be aware of for metaclopramide?

Answer 11

EPSE/Parkinsonian side effects.

QT prolongation

Question 12

What drug should be considered if a patient is unable to tolerate the side effects of metaclopramide?

Answer 12

Domperidone - as this only works peripherally. However, domperidone can only be given orally.

Question 13

When should pro-kinetics (e.g. metaclopramide, domperidone) be avoided in the management of N+V?

Answer 13

When there’s bowel obstruction - use haloperidol instead

Question 14

What are the first and second line antiemetics suited for the management of nausea and vomiting due to toxic causes?

Answer 14

1st line - Haloperidol

2nd line - ondansetron (often given with chemo)

Question 15

Which antiemetic is best suited for the management of nausea and vomiting due to raised ICP?

Answer 15

Dexamethasone 8-16mg po plus Cyclizine 50mg tds

Question 16

Which antiemetic is best suited for the management of nausea and vomiting due to anxiety?

Answer 16

Benzodiazepines may help

Question 17

Which antiemetic is best suited for the management of nausea and vomiting due to vestibular causes?

Answer 17

Consider cyclizine, hyoscine or cinnarazine

Question 18

What type of laxative are lactulose, docusate, poloxamer and Mg salts?

Answer 18

Stool softeners

Question 19

What type of laxative are Senna, bisacodyl and picosulphate?

Answer 19

Stimulants

Question 20

What type of laxative is movicol?

Answer 20

Combination stool softener and stimulant. Predominantly softening action.

Question 21

What are key S/E of the combination laxative co-danthramer to be aware of?

Answer 21

Stains urine red, may cause perianal rash

Question 22

What are some signs that a patient is dying/close to death?

Answer 22

Irreversible life-threatening illness, step-wise change in functioning, day-to-day change, bed bound/profound weakness, reduced consciousness, unable to take meds/food, no easily reversible cause such opioid toxicity/renal failure/hypercalcaemia/infection

Question 23

What 4 anticipatory drugs should be prescribed for end of life patients?

Answer 23

Analgesia (e.g. diamorphine sc for SD)
Antiemetic (e.g. haloperidol)
Anxiolytic (e.g. midazolam)
Anti-secretory (e.g. hyoscine butylbromide)
All can be put in a syringe driver - diluent should be water for injection