Palliative Care Medicines Flashcards
What are the features, causes and management of N+V due to gastric stasis?
Features: early satiety, hiccups, heartburn, epigastric fullness
Causes: tumour, hepatomegaly, ascites, dysmotility
Treatment: metoclopramide 30mins before meals
What are the causes of N+V in patients under palliative care?
Gastric stasis/irritation Toxic causes - drugs Raised ICP Anxiety and anticipatory N+V Indeterminate cause
What are the features, causes and treatment if N+V due to toxic causes?b
Features: Persistent or intermittent nausea, small vomits, possess and retching
Causes: opioids, digoxin, anti epileptics, hypercalcaemia, uraemia, infections
Treatment: haloperidol 1.5-5mg
What are the features and management of nausea due to raised ICP?
Features - early morning headache, vomiting with little nausea, neurological signs
Treatment - dexamethasone 8-16mg PO OD plus cyclizine 50mg TDS PO/sc
What are the features and treatment of anxiety related N+V?
Features - precipitated by certain situations, anxiety and depression
Treatment - BDZ, CBT, complementary therapies
Which Antiemetics are dopamine antagonists?
Haloperidol Metoclopramide Levomepromazine Pro chlorpromazine Olanzapine
What are dopamine antagonist Antiemetics good for?
Toxin related nausea from medications
What are the side effects of dopamine antagonist Antiemetics?
Extrapyramidal side effects (avoid in little old ladies)
Neuroleptic malignant syndrome
Sedation
Which Antiemetics are anticholinergics /antihistamines?
Cyclizine
Hyoscine
What are anticholinergics/antihistamines Antiemetics good for?
Movement related nausea (act on vestibular apparatus)
Cerebral metastases
What are the side effects of anticholinergics/antihistaminergics?
Dry mouth
Drowsiness
Urinalysis retention
Constipation
Antagonise the actions of pro kinetics
What are the prokinetic Antiemetics?
Metoclopramide
Domperidone
Erythromycin
When are prokinetic Antiemetics indicated?
Delayed gastric emptying
Partial bowel obstruction
Motility disorders
What are the side effects of prokinetic Antiemetics?
Colic
Extrapyramidal symptoms
Prolonged QTc
Do not giving complete bowel obstruction - colic!
What are 5HT3 antagonists?
Block action of serotonin in gut and brainstem
Include ondansetron
What are the side effects of ondansetron?
Constipation
Headache
Expensive
What type of antiemetic is aprepitant?
Neurokinin antagonist
What are some non pharmacological treatments for breathlessness?
Relaxation and breathing techniques
Electric fan
Encourage exertion to increase tolerance
Reduce feelings if isolation - daycare - support group
When can bronchodilators be used to relieve dyspnoea in palliative care?
Good for airflow obstruction - lung malignancy, COPD etc
B2 agonist with or without antimuscarinic
When is morphine used to treat breathlessness?
Best in breathlessness at rest
Helps reduce ventilators response to hypercapnoea
Start on 2.5-5mg morphine PO PRN
When are anxiolytics use to treat breathlessness?
Used if breathlessness is related to anxiety
Diazepam 2-5mg PRN
What are are some general measures that can be taken to reduce constipation?
Stop/reduce dose of constipating drugs Mobilise the patient if possible Use commode rather than the bedpan Diet - add fibre Increase fluids Encourage fruit juices
What are the contact/stimulant laxatives?
Codanthramer (dantron and poloxamer
Codanthrusate (dantron and docusate)
Senna
When are stimulant laxatives best used?
Opioid induced constipation
Avoid in colic
What are the stool softeners?
Sodium docusate 100-200mg BD tablets
What are the osmotic laxatives?
Lactulose - 15mls BD
Movicol - 1 sachet twice daily
What are the bulk forming drugs?
Fybogel - 1 sachet twice daily
These are rarely appropriate in palliative care
NOT for opioid induced!
What are the side effects of strong opioids?
Constipation:
co-prescribe Codanthramer
Nausea and vomiting: In one third of patients Usually settles in a few days Co prescribe haloperidol Consider regular antiemetic
Drowsiness:
Usually improves within 48 hours
Confusion and visual hallucinations
Respiratory depression
Psychological dependence
What are signs of opioid toxicity?
Nausea and vomiting Persistent drowsiness Confusion and visual hallucinations Myoclonic jerks Respiratory depression Pinpoint pupils
How long do normal release morphine last?
4 hours
Oromorph
Sevredol
How long does modified/slow release morphine last for?
Up to 12 hours
MST 20mg every four hours if stepping up from max cocodamol
Zomorph
How many times more powerful is parenteral Diamorphine than oral morphine?
Three times
Divide total 24 hour dose by 3 to convert
How many times more powerful is parenteral morphine than oral morphine?
Two times
Divide 24 hour dose by 2 to convert
How long do fentanyl transdermal patches last?
72 hours
For severe chronic pain already stabilised on opioids
What are other strong opioids?
Oxycodone - if morphine not suitable
Alfentanil
Methadone
How should prn doses be calculated?
All patients on MST should have normal release morphine prescribed PRN for breakthrough pain
This should be 1/6th of the total 24 hour morphine dose
This can be taken up to hourly if needed
How should doses of oral morphine be titrated upwards?
Titrate dose upwards by adding on 30-50% of the total daily dose - remember this gives you the new total daily dose!
Or
Can add on the total prn dosage taken
What is a reasonable maximum dose in 24 hours for a PRN normal release oral morphine?
6-10 times the PRN dose
What are some signs that someone is reaching the end of their life?
Profound weakness Confined to bed for most of the day Drowsiness for extended periods Disorientated Reduced attention Loss of interest in food and drink Too weak to swallow
Should patients on terminal care have artificial hydration?
Usually not necessary
Reduced food and fluid intake is part of the process
Artificial hydration does not increase comfort, may cause oedema, and cannulation may be uncomfortable
What medications should be stopped in terminal care?
May be stopped: Vitamins Hormones Anticoagulants Corticosteroids Antibiotics Antidepressants Anticonvulsants
Only keep drugs used for symptom management!
What is death rattle?
Movement of secretions in airways when patient can’t expectorate
Doesn’t bother the patient!
Repositioning may help
When is a syringe driver indicated?
Inability to swallow - reduced consciousness, last days of life Persistent nausea and vomiting Intestinal obstruction Malabsorption of drugs Dysphagia
