Palliative care

Question 1

Morphine

• how can it be given?
• how is it excreted?
• when should you consider other opioids?
• what should you consider in liver patients?

Answer 1

oral, SC, CME T34 syringe

Renally excreted

Consider other opioids in stage 4-5 CKD, dialysis patients

Consider low doses and slow titration in liver impairment\

Question 2

Diamorphine

• how can it be given?
• when should it be used?

Answer 2

SC or CME T34 syringe pump

Used for high dose SC breakthrough injection (> 180mg SC morphine/24 hours)

Question 3

Oxycodone

• when should it be used?
• what preparations are available?
• why might it not be used for SC?
• when should it be avoided?

Answer 3

moderate to severe pain if morpine/diamorphine not tolerated.

Immediate and modified release oral preparations.
SC
CME T34 syringe pump

Lower concentration preparation limits dose for SC injection to 20mg (2ml)

Avoid in moderate/severe liver impairment - clearance is much reduced.

Mild-moderate renal impairment - reduced clearance so titrate slowly and monitor carefully. Avoid in stage 4-5 CKD

Question 4

Fentanyl

• what preparations is it available in?
• how long does a patch last?
• should you reduce dose in renal impairment?
• can it be given in liver impairment?
• can it be initiated at end-of-life when oral route is no longer available?

Answer 4

transdermal patch
- patch lasts 72 hours

No initial dose reduction in renal impairment, but may accumulate overtime.

Liver impairment - dose reduction may be needed in severe liver disease

Do not initiate at end-of-life care when oral route is no longer available. Takes too long to reach steady state.

Sublingual/intranasal
- episodic/incident pain

Question 5

Alfentanil

• how may it be given?
• is it short or long acting?
• do you need to adjust doses in renal impairment?
• can it be used in liver impairment?

Answer 5

SC or in CME T34 syringe pump.
OR may be given sublingually / SC in episodic/incident pain

Dose does not need to be reduced in renal disease including stage 4-5 CKD

clearance may be reduced in liver impairment; reduce dose and titrate

Question 6

Methadone

• who can prescribe it?
• why is dosing difficult?
• is renal function important?
• what happens in severe liver disease?

Answer 6

only used by specialists for complex pain.

Dosing is difficult due to long half life.

No renal excretion so no dose reduction required in CKD

half life prolonged in severe liver disease

Question 7

Symptoms of opioid toxicity

Answer 7

persistent sedation
vivid dreams/hallucinations / shadows at edge of visual field
delirium
muscle twitching/ myoclonus/ jerking
abnormal skin sensitivity to touch

Question 8

What should you do in opioid toxicity if pain is well controlled?

Answer 8

reduce dose by 1/3

ENSURE patient is well hydrated

Question 9

When would you need to use Naloxone?

Answer 9

life-threatening respiratory depression

Question 10

How do you calculate modified release dose?

Answer 10

once pain is controlled - calculate total daily dose including PRN and divide into 12h doses of modified-release preparation

MST continus 12h

Question 11

What should you do before changing an opioid due to SE?

Answer 11

consider reducing the dose, titrating more slowly, adding an adjuvant analgesic