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BNF 2020 > Palliative Care > Flashcards

Palliative Care Flashcards

1
Q

True or False:

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

A

TRUE.

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

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2
Q

What analgesics are considered for MILD PAIN in palliative care?

A

Paracetamol

NSAID

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3
Q

What analgesics are used for MODERATE PAIN in palliative care?

A

Codeine

Tramadol

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4
Q

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

A

1st line: Morphine

Alternatives: (specialist)

Transdermal Buprenorphine
Transdermal Fentanyl
Hydromorphone
Methadone
Oxycodone
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5
Q

What is used for pain due to BONE METASTASES?

A

Radiotherapy

Biphosphonates

Radioactive isotope of Strontium chloride (Metastron)

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6
Q

What is first line in management of NEUROPATHIC PAIN?

A

TCA (tricyclic antidepressants)

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7
Q

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

A

Antiepileptics:

Gabapentin
Pregabalin

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8
Q

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

A

Ketamine (specialist)

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9
Q

What is used to reduce pain due to nerve compression?

A

Corticosteroids:

DEXAMETHASONE

It reduces oedema around the tumour, thus reducing compression.

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10
Q

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

A

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

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11
Q

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

A

Immediate release = 4 hourly

Modified release = 12 hourly

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12
Q

What is pain that occurs between regular doses of morphine?

A

Breakthrough pain (managed by a rescue dose)

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13
Q

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

A
  • Breakthrough Pain

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

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14
Q

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

A

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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15
Q

When will you review pain management of rescue dose?

A

If rescue dose is needed TWICE OR MORE daily.

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16
Q

What formulations of Fentanyl are also licensed for breakthrough pain?

A

Nasal

Bucal

Sublingual

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17
Q

In what increments should we adjust morphine dose?

A

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

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18
Q

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

A

IMMEDIATE = 30mg q4h

MODIFIED = 100mg q12h

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19
Q

True or False:

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

A

True

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20
Q

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

A

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

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21
Q

What opioid is given if patients cannot tolerate morphine?

A

Oxycodone HCl

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22
Q

10 mg oral Morphine = ??? Oxycodone

A

6.6 mg Oxycodone

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23
Q

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

A

5 mg = IM, IV, SC morphine

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24
Q

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

A

100 mg Tramadol

100 mg Codeine

100 mg Dihydrocodeine

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25
Q

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

A

3 mg = Diamorphine (IM, IV, SC)

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26
Q

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

A

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)

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27
Q

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

A

Oxycodone suppositories (special)

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28
Q

What opioid analgesics are available as transdermal preparations?

A

Buprenorphine

Fentanyl

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29
Q

Transdermal opioid preparations are not suitable in which cases?

A
  • acute pain

- if analgesics requirements are changing rapidly

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30
Q

Why does a transdermal preparation prevents rapid titration of doses?

A

It takes a long time to reach steady state.

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31
Q

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

A

Immediate-release MORPHINE

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32
Q

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

A

1/4 - 1/2

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33
Q

Symptom Control:

ANOREXIA

A

Prednisolone

OR

Dexamethasone

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34
Q

Symptom Control:

BOWEL COLIC and excessive RESPIRATORY SECRETIONS

A

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
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35
Q

Symptom Control:

CAPILLARY BLEEDING

A

1) Tranexamic acid (PO)
* discontinue 1 week after bleeding stopped

2) Gauze soaked in Tranexamic acid or Adrenaline/Epinephrine solution

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36
Q

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

A

Vitamin K

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37
Q

Absorption of Vitamin K may be impaired in what condition?

A

Severe Chronic Cholestasis

*use Parenteral or Water-Soluble oral Vitamin K instead

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38
Q

Symptom Control:

CONSTIPATION

A

Faecal softener + Stimulant
Lactulose + Senna

Methylnaltrexone bromide = opioid induced constipation

39
Q

Licensed as adjunct treatment of opioid induced constipation in palliative care

A

Methylnaltrexone bromide

40
Q

Symptom Control:

CONVULSIONS prophylaxis

A

1) Phenytoin OR carbamazepine (both PO)
2) if oral not possible:

Diazepam (rectal)
Phenobarbital (inj)
Midazolam (SC infusion)
41
Q

Symptom Control:

DRY MOUTH

A

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

42
Q

Symptom Control:

DRY MOUTH
associated with candidiasis

A

1) Nystatin OR miconazole

2) Fluconazole (PO)

43
Q

Symptom Control:

DYSPHAGIA
if there is an obstruction due to tumour

A

Dexamethasone (temporarily)

44
Q

Symptom Control:

DYSPNOEA

-breathlessness at rest

A

Morphine (PO)

45
Q

Symptom Control:

DYSPNOEA

-associated with anxiety

A

Diazepam

46
Q

Symptom Control:

DYSPNOEA

  • bronchospasm or partial obstruction
A

Dexamethasone

47
Q

Symptom Control:

FUNGATING TUMOURS

A

1) dressing and antibacterial drugs:

METRONIDAZOLE

Topical
Systemic = reduces malodour

48
Q

Symptom Control:

GASTRO-INTESTINAL PAIN

A

Pain of Bowel Colic = LOPERAMIDE

49
Q

Prokinetic used for gastric distention pain?

A

Domperidone

50
Q

Symptom Control:

HICCUP

A

1) ANTACID + ANTIFLATULENT
2) add Metoclopramide (PO, SC, IM)

3) Baclofen
Nifedipine
Chlorpromazine

51
Q

Symptom Control:

INSOMNIA
advanced cancer

A

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

TEMAZEPAM

52
Q

Symptom Control:

INTRACTABLE COUGH

A

1) Moist inhalations

    OR

MORPHINE (po)

53
Q

What should be AVOIDED in management of INTRACTABLE COUGH?

A

METHADONE LINCTUS

  • long duration of action and tends to accumulates
54
Q

Symptom Control:

MUSCLE SPASM

A

Diazepam

OR

Baclofen

55
Q

Symptom Control:

NAUSEA & VOMITING

Cause: gastritis, gastric stasis, functional bowel obstruction

A

METOCLOPRAMIDE

56
Q

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

A

Antimuscarinics

57
Q

Symptom Control:

NAUSEA & VOMITING

Cause: metabolic (e.g. hypercalcaemia, renal failure)

A

HALOPERIDOL

58
Q

Symptom Control:

NAUSEA & VOMITING

Cause: mechanical bowel obstruction, raised IOP, motion sickness

A

CYCLIZINE

59
Q

What phenothiazine antipsychotic is used as antiemetic in palliative care?

What is the time and route of administration?

What is the adjunct?

A

LEVOMEPROMAZINE

Bedtime = PO or SC infusion

Adjunct = Dexamethasone

60
Q

Antiemetic therapy should be reviewed how frequently?

A

Every 24 hours

61
Q

Symptom Control:

PRURITUS

A

EMOLLIENTS

*even if associated with obstructive jaundice

Further measure?
= COLESTYRAMINE

62
Q

Symptom Control:

Raised Intracranial Pressure

  • headache
A

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

63
Q

Symptom Control:

Restlessness and Confusion

A

Antipsychotic: (PO or SC)

HALOPERIDOL

Or

LEVOMEPROMAZINE

Q2h prn
BD = maintenance

64
Q

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

A

LEVOMEPROMAZINE

65
Q

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

A

Continuous SC infusion

66
Q

What are the indications for PARENTERAL ROUTE in palliative care?

A
  • 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
67
Q

Occasionally causes paradoxical agitation.

Hyoscine HYDRObromide OR Hyoscine BUTYLbromide ?

A

HYDRO

68
Q

Which is more sedating?

Hyoscine HYDRObromide OR Hyoscine BUTYLbromide ?

A

HYDRO

69
Q

Which is more sedating?

Levopromazine OR Haloperidol ?

A

Levopromazine

Haloperidol (little bit sedating :)

70
Q

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.

A

Midazolam

71
Q

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

A

Midazolam

72
Q

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.

A

TRUE!!!!

73
Q

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

A

Haloperidol

Levopromazine (sedation can limit dose)

Octreotide

74
Q

What is the problem in using CYCLIZINE in parenteral route?

A

Can precipitate if mixed with DIAMORPHINE or other drugs.

75
Q

What is the problem in using METOCLOPRAMIDE in parenteral route?

A

Skin reactions

76
Q

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

A

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

77
Q

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

A

DIAMORPHINE HCl

  • highly soluble = large dose can be given in small volume
78
Q

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.

A

TRUE

Provided there is evidence of compatibility

79
Q

What drugs are CONTRAINDICATED in syringe drivers? Why?

A

Chlorpromazine

Prochlorperazine

Diazepam

*skin reactions at injection site

80
Q

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

A

Cyclizine

Levomepromazine

81
Q

What is the preferred diluent to dissolve injections?

What is the disadvantage?

A

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 :)
82
Q

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

A

Precipitation.

-increases when more than one drug is used

83
Q

What is the rate of SC infusion of syringe drivers?

A

0.1 - 0.3 ml/hr

84
Q

What is the maximum strength of Diamorphine in SC infusion?

A

250 mg/ml

85
Q

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

A

40 mg/ml

*greater than this, use water for injection ONLY (to avoid precipitation)

86
Q

What drugs are compatible to be mixed with Diamorphine?

A

Imagine an H & M advert on LCD screen at diamorphine street *(H3 M2)

Haloperidol
Hyoscine HYRObromide
Hyoscine BUTYLbromide
Midazolam
Metoclopramide
Levomepromazine
Cyclizine
Dexamethasone
87
Q

CYCLIZINE precipitates so bad.

In what 3 cases does this particularly happen?

A
  • at concentrations >10 mg/ml
  • presence of 0.9% NaCl
  • when concentration of diamorphine relative to cyclizine increases
88
Q

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

A

after 24 hours

89
Q

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

A

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

90
Q

What is the problem with Diamorphine infusions containing METOCLOPRAMIDE?

A
  • discolouration of infusion. DISCARD!

- can also cause skin reactions

91
Q

What should you check when monitoring SC infusion solution?

A
  • precipitation
  • discolouration
  • correct rate
92
Q

Problems with syringe drivers:

If the SC infusion runs TOO QUICKLY? What to do.. what to do.. omg

A
  • check rate setting and the calculation
93
Q

Problems with syringe drivers:

If the SC infusion runs TOO SLOWLY?

A
  • Check the start button and battery (duh)
  • Check syringe driver and cannula
  • Make sure injection site is not inflamed.
94
Q

Problems with syringe drivers:

If there is an INJECTION SITE REACTION?

A
  • 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

BNF 2020 (2 decks)

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