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Oncology > Palliative Care Medicines > Flashcards

Palliative Care Medicines Flashcards

0
Q

What are the features, causes and management of N+V due to gastric stasis?

A

Features: early satiety, hiccups, heartburn, epigastric fullness

Causes: tumour, hepatomegaly, ascites, dysmotility

Treatment: metoclopramide 30mins before meals

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1
Q

What are the causes of N+V in patients under palliative care?

A 
Gastric stasis/irritation
Toxic causes - drugs
Raised ICP
Anxiety and anticipatory N+V
Indeterminate cause
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2
Q

What are the features, causes and treatment if N+V due to toxic causes?b

A

Features: Persistent or intermittent nausea, small vomits, possess and retching

Causes: opioids, digoxin, anti epileptics, hypercalcaemia, uraemia, infections

Treatment: haloperidol 1.5-5mg

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3
Q

What are the features and management of nausea due to raised ICP?

A

Features - early morning headache, vomiting with little nausea, neurological signs

Treatment - dexamethasone 8-16mg PO OD plus cyclizine 50mg TDS PO/sc

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4
Q

What are the features and treatment of anxiety related N+V?

A

Features - precipitated by certain situations, anxiety and depression

Treatment - BDZ, CBT, complementary therapies

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5
Q

Which Antiemetics are dopamine antagonists?

A 
Haloperidol
Metoclopramide
Levomepromazine
Pro chlorpromazine
Olanzapine
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6
Q

What are dopamine antagonist Antiemetics good for?

A

Toxin related nausea from medications

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7
Q

What are the side effects of dopamine antagonist Antiemetics?

A

Extrapyramidal side effects (avoid in little old ladies)

Neuroleptic malignant syndrome

Sedation

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8
Q

Which Antiemetics are anticholinergics /antihistamines?

A

Cyclizine

Hyoscine

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9
Q

What are anticholinergics/antihistamines Antiemetics good for?

A

Movement related nausea (act on vestibular apparatus)

Cerebral metastases

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10
Q

What are the side effects of anticholinergics/antihistaminergics?

A

Dry mouth
Drowsiness
Urinalysis retention
Constipation

Antagonise the actions of pro kinetics

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11
Q

What are the prokinetic Antiemetics?

A

Metoclopramide
Domperidone
Erythromycin

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12
Q

When are prokinetic Antiemetics indicated?

A

Delayed gastric emptying
Partial bowel obstruction
Motility disorders

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13
Q

What are the side effects of prokinetic Antiemetics?

A

Colic
Extrapyramidal symptoms
Prolonged QTc

Do not giving complete bowel obstruction - colic!

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14
Q

What are 5HT3 antagonists?

A

Block action of serotonin in gut and brainstem

Include ondansetron

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15
Q

What are the side effects of ondansetron?

A

Constipation
Headache
Expensive

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16
Q

What type of antiemetic is aprepitant?

A

Neurokinin antagonist

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17
Q

What are some non pharmacological treatments for breathlessness?

A

Relaxation and breathing techniques
Electric fan
Encourage exertion to increase tolerance
Reduce feelings if isolation - daycare - support group

18
Q

When can bronchodilators be used to relieve dyspnoea in palliative care?

A

Good for airflow obstruction - lung malignancy, COPD etc

B2 agonist with or without antimuscarinic

19
Q

When is morphine used to treat breathlessness?

A

Best in breathlessness at rest

Helps reduce ventilators response to hypercapnoea

Start on 2.5-5mg morphine PO PRN

20
Q

When are anxiolytics use to treat breathlessness?

A

Used if breathlessness is related to anxiety

Diazepam 2-5mg PRN

21
Q

What are are some general measures that can be taken to reduce constipation?

A 
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
22
Q

What are the contact/stimulant laxatives?

A

Codanthramer (dantron and poloxamer
Codanthrusate (dantron and docusate)
Senna

23
Q

When are stimulant laxatives best used?

A

Opioid induced constipation

Avoid in colic

24
Q

What are the stool softeners?

A

Sodium docusate 100-200mg BD tablets

25
Q

What are the osmotic laxatives?

A

Lactulose - 15mls BD

Movicol - 1 sachet twice daily

26
Q

What are the bulk forming drugs?

A

Fybogel - 1 sachet twice daily

These are rarely appropriate in palliative care

NOT for opioid induced!

27
Q

What are the side effects of strong opioids?

A

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

28
Q

What are signs of opioid toxicity?

A 
Nausea and vomiting
Persistent drowsiness
Confusion and visual hallucinations
Myoclonic jerks
Respiratory depression
Pinpoint pupils
29
Q

How long do normal release morphine last?

A

4 hours

Oromorph
Sevredol

30
Q

How long does modified/slow release morphine last for?

A

Up to 12 hours

MST 20mg every four hours if stepping up from max cocodamol

Zomorph

31
Q

How many times more powerful is parenteral Diamorphine than oral morphine?

A

Three times

Divide total 24 hour dose by 3 to convert

32
Q

How many times more powerful is parenteral morphine than oral morphine?

A

Two times

Divide 24 hour dose by 2 to convert

33
Q

How long do fentanyl transdermal patches last?

A

72 hours

For severe chronic pain already stabilised on opioids

34
Q

What are other strong opioids?

A

Oxycodone - if morphine not suitable
Alfentanil
Methadone

35
Q

How should prn doses be calculated?

A

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

36
Q

How should doses of oral morphine be titrated upwards?

A

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

37
Q

What is a reasonable maximum dose in 24 hours for a PRN normal release oral morphine?

A

6-10 times the PRN dose

38
Q

What are some signs that someone is reaching the end of their life?

A 
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
39
Q

Should patients on terminal care have artificial hydration?

A

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

40
Q

What medications should be stopped in terminal care?

A 
May be stopped:
Vitamins
Hormones
Anticoagulants
Corticosteroids
Antibiotics
Antidepressants
Anticonvulsants

Only keep drugs used for symptom management!

41
Q

What is death rattle?

A

Movement of secretions in airways when patient can’t expectorate

Doesn’t bother the patient!

Repositioning may help

42
Q

When is a syringe driver indicated?

A 
Inability to swallow - reduced consciousness, last days of life
Persistent nausea and vomiting
Intestinal obstruction
Malabsorption of drugs
Dysphagia

Oncology (8 decks)

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