Palliative Care Flashcards by Angeli Alaza

True or False:

In palliative care, Analgesics are more effective in preventing pain than in the relief of established pain.

TRUE.

That is why it is important that they are given regularly.

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What analgesics are considered for MILD PAIN in palliative care?

Paracetamol

NSAID

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What analgesics are used for MODERATE PAIN in palliative care?

Codeine

Tramadol

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What analgesic is first line for SEVERE PAIN? What are the alternatives?

1st line: Morphine

Alternatives: (specialist)

Transdermal Buprenorphine
Transdermal Fentanyl
Hydromorphone
Methadone
Oxycodone

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What is used for pain due to BONE METASTASES?

Radiotherapy

Biphosphonates

Radioactive isotope of Strontium chloride (Metastron)

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What is first line in management of NEUROPATHIC PAIN?

TCA (tricyclic antidepressants)

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What should be added or substituted to TCA if neuropathic pain persists?

Antiepileptics:

Gabapentin
Pregabalin

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What drug is used to manage neuropathic pain that responds poorly to opioid analgesics?

Ketamine (specialist)

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What is used to reduce pain due to nerve compression?

Corticosteroids:

DEXAMETHASONE

It reduces oedema around the tumour, thus reducing compression.

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What is used to manage nerve compression pain if it localised to a specific area?

Nerve blocks or regional anaesthesia techniques (using epidural and intrathecal catheters)

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What is the duration of action of oral morphine preparations? (Immediate and modified release)

Immediate release = 4 hourly

Modified release = 12 hourly

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What is pain that occurs between regular doses of morphine?

Breakthrough pain (managed by a rescue dose)

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In pain management using oral morphine, in what cases do we give rescue doses?

Breakthrough Pain

- 30 minutes before an activity that causes pain ( like wound dressing)

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What is the standard dose of a strong opioid for breakthrough pain?

1/TENTH — 1/SIXTH of the regular 24 hr dose

Repeated every 2-4 hrs prn. Can be up to hourly if severe pain or in last days of life

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When will you review pain management of rescue dose?

If rescue dose is needed TWICE OR MORE daily.

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What formulations of Fentanyl are also licensed for breakthrough pain?

Nasal

Bucal

Sublingual

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In what increments should we adjust morphine dose?

Should not exceed 1/THIRD — 1/HALF of total daily dose every 24 hours.

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What is the usual dose of morphine immediate release and modified release that are adequate to most patients?

IMMEDIATE = 30mg q4h

MODIFIED = 100mg q12h

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True or False:

Pain should be controlled first by immediate release morphine before transferring to modified release preparations.

True

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After switching from immediate-release, when is the first dose of modified-release morphine given?

Given WITH or WITHIN 4 hours of the last dose of immediate-release preparation.

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What opioid is given if patients cannot tolerate morphine?

Oxycodone HCl

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10 mg oral Morphine = ??? Oxycodone

6.6 mg Oxycodone

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10 mg oral Morphine = ??? IM, IV, SC Morphine

5 mg = IM, IV, SC morphine

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10 mg Morphine (oral) = ??? Tramadol / Codeine / Dihydrocodeine

100 mg Tramadol

100 mg Codeine

100 mg Dihydrocodeine

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10mg Morphine (oral) = ??? Diamorphine (Parenteral)

3 mg = Diamorphine (IM, IV, SC)

What opioid is preferred to manage pain if patient becomes unable to swallow?

Generally, MORPHINE = continuous SC infusion Sometimes, DIAMORPHINE = more soluble, thus can be given in smaller volume (If patient can resume oral medicines, infusion is discontinued when first dose of morphine is given)

If rectal administration of Morphine suppository is not recommended, what can be given as alternative?

Oxycodone suppositories (special)

What opioid analgesics are available as transdermal preparations?

Buprenorphine Fentanyl

Transdermal opioid preparations are not suitable in which cases?

- acute pain | - if analgesics requirements are changing rapidly

Why does a transdermal preparation prevents rapid titration of doses?

It takes a long time to reach steady state.

If using transdermal buprenorphine and fentanyl, what can you use for breakthrough pain?

Immediate-release MORPHINE

In switching from oral morphine to transdermal patch (fentanyl/buprenorphine) due to possible OPIOID-INDUCED HYPERALGESIA, reduce the equivalent dose by how much?

1/4 - 1/2

Symptom Control: ANOREXIA

Prednisolone OR Dexamethasone

Symptom Control: BOWEL COLIC and excessive RESPIRATORY SECRETIONS

SC injections: (antimuscarinics) Hyoscine (HYDRO and BUTYL) Glycopyrronium bromide *given Every 4 hrs PRN up to Hourly. * if symptom persists = give regularly by CONTINUOUS INFUSION DEVICE * care required to avoid discomfort of DRY MOUTH

Symptom Control: CAPILLARY BLEEDING

1) Tranexamic acid (PO) * discontinue 1 week after bleeding stopped 2) Gauze soaked in Tranexamic acid or Adrenaline/Epinephrine solution

Treatment and Prevention of bleeding associated with PROLONGED CLOTTING in LIVER DISEASE?

Vitamin K

Absorption of Vitamin K may be impaired in what condition?

Severe Chronic Cholestasis *use Parenteral or Water-Soluble oral Vitamin K instead

Symptom Control: CONSTIPATION

Faecal softener + Stimulant Lactulose + Senna Methylnaltrexone bromide = opioid induced constipation

Licensed as adjunct treatment of opioid induced constipation in palliative care

Methylnaltrexone bromide

Symptom Control: CONVULSIONS prophylaxis

1) Phenytoin OR carbamazepine (both PO) 2) if oral not possible: Diazepam (rectal) Phenobarbital (inj) Midazolam (SC infusion)

Symptom Control: DRY MOUTH

chewing SF gum, sucking ice or pineapple chunks, artificial saliva

Symptom Control: | DRY MOUTH associated with candidiasis

1) Nystatin OR miconazole | 2) Fluconazole (PO)

Symptom Control: | DYSPHAGIA if there is an obstruction due to tumour

Dexamethasone (temporarily)

Symptom Control: DYSPNOEA -breathlessness at rest

Morphine (PO)

Symptom Control: DYSPNOEA -associated with anxiety

Diazepam

Symptom Control: DYSPNOEA - bronchospasm or partial obstruction

Dexamethasone

Symptom Control: FUNGATING TUMOURS

1) dressing and antibacterial drugs: METRONIDAZOLE Topical Systemic = reduces malodour

Symptom Control: GASTRO-INTESTINAL PAIN

Pain of Bowel Colic = LOPERAMIDE

Prokinetic used for gastric distention pain?

Domperidone

Symptom Control: HICCUP

1) ANTACID + ANTIFLATULENT 2) add Metoclopramide (PO, SC, IM) 3) Baclofen Nifedipine Chlorpromazine

Symptom Control: | INSOMNIA advanced cancer

1) TREAT CAUSE FIRST: discomfort, cramps, night sweats, joint stiffness, fear 2) Hypnotics: TEMAZEPAM

Symptom Control: INTRACTABLE COUGH

1) Moist inhalations OR MORPHINE (po)

What should be AVOIDED in management of INTRACTABLE COUGH?

METHADONE LINCTUS - long duration of action and tends to accumulates

Symptom Control: MUSCLE SPASM

Diazepam OR Baclofen

Symptom Control: NAUSEA & VOMITING Cause: gastritis, gastric stasis, functional bowel obstruction

METOCLOPRAMIDE

What class of drugs antagonises the effect of prokinetic drugs (first line antiemetic therapy)?

Antimuscarinics

Symptom Control: NAUSEA & VOMITING Cause: metabolic (e.g. hypercalcaemia, renal failure)

HALOPERIDOL

Symptom Control: NAUSEA & VOMITING Cause: mechanical bowel obstruction, raised IOP, motion sickness

CYCLIZINE

What phenothiazine antipsychotic is used as antiemetic in palliative care? What is the time and route of administration? What is the adjunct?

LEVOMEPROMAZINE Bedtime = PO or SC infusion Adjunct = Dexamethasone

Antiemetic therapy should be reviewed how frequently?

Every 24 hours

Symptom Control: PRURITUS

EMOLLIENTS *even if associated with obstructive jaundice Further measure? = COLESTYRAMINE

Symptom Control: Raised Intracranial Pressure - headache

High dose DEXAMETHASONE (before 6pm to reduce risk of insomnia)

Symptom Control: Restlessness and Confusion

Antipsychotic: (PO or SC) HALOPERIDOL Or LEVOMEPROMAZINE Q2h prn BD = maintenance

Antipsychotic that is licensed to treat pain in palliative care- reserved for distressed patients with severe pain unresponsive to other measures

LEVOMEPROMAZINE

Syringe drivers are used as what type of route of administration?

Continuous SC infusion

What are the indications for PARENTERAL ROUTE in palliative care?

- patient is unable to take medicines by mouth (nausea & vomiting, dysphagia, severe weakness, coma) - presence of malignant bowel obstruction and further surgery is inappropriate (avoiding IV infusion and nasogastric tube insertion) - when patient does not wish to take meds by mouth

Occasionally causes paradoxical agitation. Hyoscine HYDRObromide OR Hyoscine BUTYLbromide ?

HYDRO

Which is more sedating? Hyoscine HYDRObromide OR Hyoscine BUTYLbromide ?

HYDRO

Which is more sedating? Levopromazine OR Haloperidol ?

Levopromazine Haloperidol (little bit sedating :)

It is a sedative and antiepileptic taht may be used in addition to an antipsychotic drug in a very restless patient. Can also be used for myoclonus.

Midazolam

Which benzodiazepine is the antiepileptic of choice for continuous SC infusion in the management of convulsions?

Midazolam

True or False: If a patient has previously been receiving an antiepileptic drug OR With primary/secondary cerebral tumour OR At risk of convulsion, Antiepileptics should NOT be stopped.

TRUE!!!!

In parenteral management of Nausea and Vomiting, which drugs can be given as SC infusion?

Haloperidol Levopromazine (sedation can limit dose) Octreotide

What is the problem in using CYCLIZINE in parenteral route?

Can precipitate if mixed with DIAMORPHINE or other drugs.

What is the problem in using METOCLOPRAMIDE in parenteral route?

Skin reactions

How does OCTREOTIDE works to reduce nausea and vomiting due to bowel obstruction?

Stimulates water and electrolyte absorption -> inhibits water secretion in small bowel -> reduce intestinal secretions = reduce vomiting

What is the parenteral drug of choice in managing PAIN in palliative care?

DIAMORPHINE HCl - highly soluble = large dose can be given in small volume

True or False: The general principle that injections should be given into separate sites (and should not be mixed) does NOT apply in syringe drivers in palliative care.

TRUE Provided there is evidence of compatibility

What drugs are CONTRAINDICATED in syringe drivers? Why?

Chlorpromazine Prochlorperazine Diazepam *skin reactions at injection site

Which drugs can cause local irritations when used in syringe drivers, but to a lesser extent?

Cyclizine Levomepromazine

What is the preferred diluent to dissolve injections? What is the disadvantage?

Water for injections - in theory, can cause pain because of hypotonicity. BUT, SC infusion rates are sooo slow (0.1-0.3 ml/hr) that pain is not usually a problem :)

What is the problem in using 0.9% NaCl in dissolving injections?

Precipitation. -increases when more than one drug is used

What is the rate of SC infusion of syringe drivers?

0.1 - 0.3 ml/hr

What is the maximum strength of Diamorphine in SC infusion?

250 mg/ml

What is the maximum strength of Diamorphine using water for injection and 0.9% NaCl as diluent?

40 mg/ml *greater than this, use water for injection ONLY (to avoid precipitation)

What drugs are compatible to be mixed with Diamorphine?

Imagine an H & M advert on LCD screen at diamorphine street *(H3 M2) ``` Haloperidol Hyoscine HYRObromide Hyoscine BUTYLbromide Midazolam Metoclopramide Levomepromazine Cyclizine Dexamethasone ```

CYCLIZINE precipitates so bad. | In what 3 cases does this particularly happen?

- at concentrations >10 mg/ml - presence of 0.9% NaCl - when concentration of diamorphine relative to cyclizine increases

When Cyclizine is mixed with Diamorphine, how long does it take for the mixture to precipitate?

after 24 hours

Mixture of Haloperidol + Diamorphine - how long does it take to precipitate?

After 24 hours if haloperidol concentration is > 2mg /ml

What is the problem with Diamorphine infusions containing METOCLOPRAMIDE?

- discolouration of infusion. DISCARD! | - can also cause skin reactions

What should you check when monitoring SC infusion solution?

- precipitation - discolouration - correct rate

Problems with syringe drivers: If the SC infusion runs TOO QUICKLY? What to do.. what to do.. omg

- check rate setting and the calculation

Problems with syringe drivers: If the SC infusion runs TOO SLOWLY?

- Check the start button and battery (duh) - Check syringe driver and cannula - Make sure injection site is not inflamed.

Problems with syringe drivers: If there is an INJECTION SITE REACTION?

- make sure that the site of injection does not need to be changed CHANGE it when: -there is pain and inflammation Do NOT change it when: - there is ONLY firmness or swelling