Palliative Care Drugs Flashcards
What are the common symptoms patients suffer with when nearing end of life?
-Pain
-Restlessness / agitation
-N+V
-RT secretions
-Dyspnoea
How could you manage a patient’s pain when near the end of their life?
Pain relief in oral or syringe driver form:
-Morphine
-Oxycodone
-Alfentanil (very potent)
-Hyoscine Butylbromide (Buscopan)
NB:
-Refer to conversion chart if converting between oral and syringe driver form
-Start on very low doses if opioid naive
-PRN doses should be 1/6 of 24hr dose
How would you manage an agitated patient near the end of their life?
-Must consider alternative causes of agitation eg urinary retention, constipation
-Reassure
-MIDAZOLAM 2.5-5mg subcut PRN
-Consider starting CSCI to prevent distress
-Consider HALOPERIDOL 1.5-5mg PRN for hallucinations, delirium, confusion (NB avoid in Parkinson’s)
-Consider LEVOMEPROMAZINE 12.5mg-50mg for unresolved agitation / restlessness
How would you manage a patient with N+V nearing the end of their life?
-Switch to CSCI (no dose change required for most)
-Still try and discover cause for nausea and prescribe the appropriate anti-emetic
-Consider METOCLOPRAMIDE (gastric) or CYCLIZINE (cerebral, vestibular, gastric) (but not together)
-Consider LEVOMREPROMAZINE 6.25mg-12.5mg/24 hrs as broad spectrum option
-Buscopan and octreotide can also be used for large volume vomits (bowel obstruction)
-Ondansetron is more commonly used for chemo-related N+V
NB digoxin is likely to cause N+V (check levels)
How would you manage RT secretions in a patient nearing the end of their life?
-Adjust positioning
-Reassure family
-Give hyoscine 20mg subcut PRN (starting dose in CSCI is 60mg)
-NB can cause confusion, hallucinations or sedation in which case give glycopyrronium
How would you manage dyspnoea in a patient nearing the end of life?
-Cool air
-Reassurance
-Adjust positioning
-Midazolam to reduce anxiety / panic
-Morphine to reduce respiratory distress
-NB O2 often has no impact unless already on LTOT
What are examples of softener laxatives and when are they used?
-Lactulose
-Macrogols eg movicol, laid
-Phosphate and sodium citrate enemas
-Work by increasing the amount of fluid in the large bowel –> distension –> peristalsis
-NB movicol is commonly used for opioid-induced constipation
What are examples of stimulant laxatives and when are they used?
-Senna (often used for opioid-induced constipation)
-Docusate
-Bisacodyl and sodium picosulfate
-Cause peristalsis by stimulating colonic / colonic + rectal nerves
What are examples of bulk-forming laxatives and when are they used?
-Fybogel
-Methylcellulose
-Ispaghula husk
-Act by retaining fluid in the stool to increase faecal mass –> peristalsis (can also have stool-softening properties
NB poorly tolerated in palliative care
What is an example of a pro kinetic laxative?
-Prucalopride (serotonin receptor agonist, stimulates intestinal motility)
When is metoclopramide contra-indicated?
Complete bowel obstruction as it can cause / exacerbate colic pain
-Useful for partial bowel obstruction as it is a pro-kinetic so encourages peristalsis
How do you calculate a PRN dose of analgesia from their background dose?
eg Oromorph and MST
-1/6 of total MST dose per 24h
-eg 60mg MST in 24h –> 10mg oromorph PRN
What are the most important SEs from opioids?
-Constipation (90%) - always prescribe laxative
-N+V (30%) - prescribe PRN anti-emetic
-Drowsiness / resp depression
-Toxicity - myoclonus, pinpoint pupils, low RR
When would a patient require a syringe driver?
Unable to take medications orally due to:
-Persistent N+V
-Difficulty swallowing
-Comatose / semi-comatose
-Intestinal obstruction
-Malabsorption
-Rectal route unsuitable
-Patient too weak
