Palliative care prescribing

Question 1

Six syndromes causing N+V in pall care?

Answer 1

Reduced gastric mobility
Chemically mediated - Secondary to hypercalcaemia, opioids, or chemotherapy
Viseral/serosal - due to consitpation
Raised ICP - usually cerebral metastases
Vestibular - Most frequently in palliative care is opioid related - Can be motion related, or due to base of skull tumours

Cortical - May be due to anxiety, pain, fear and/or anticipatory nausea

Question 2

Tx of N+V due to reduced gastric mobility?

Answer 2

• Pro-kinetic agent – 1st line = metoclopramide or domperidone – do not use metoclopramide if pro-kinesis may negatively affect the gastrointestinal tract, particularly in complete bowel obstruction, gastrointestinal perforation, or immediately following gastric surgery

Question 3

Tx of Chemically mediated N+V?

Answer 3

• Correct chemical disturbance

* Key treatment options include ondansetron, haloperidol and levomepromazine

Question 4

Tx of visceral/serosal N+V

Answer 4

 Tx: 1st line = Cyclizine and levomepromazine – anticholinergics can be usedul (eg. Hyoscine)

Question 5

Tx of raised ICP N+V?

Answer 5

1st line: Cyclizine – also dexamethasone

• Radiotherapy can be considered if there is likely raised intra-cranial pressure due to cranial tumours

Question 6

Tx of vestibular N+V?

Answer 6

Tx: 1st line – Cyclizine
• Refractory vestibular causes – Tx with metoclopramide or prochlorperazine
• Atypical antipsychotics such as olanzapine or risperidone can be used in refractory cases

Question 7

Tx of Cortical N+V?

Answer 7

 Tx: If anticipatory nausea is the clear cause, a short acting benzodiazepine such as lorazepam can be useful – if benzos not ideal – cyclizine. Can also try Ondansetron and metoclopramide.

Question 8

Pain Tx in pall care?

Answer 8

o patients with advanced and progressive disease:
 regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain (

Patients with cancer (SIGN guidance)
 breakthrough dose of morphine is one-sixth the daily dose of morphine
 Opioids used in caution in patients with CKD - Oxycodone preferred if mild-moderate renal impairment
alfentanil, buprenorphine and fentanyl are preferred in severe renal impairment

Strong opioids, bisphosphonates or radiotherapy or denosumab for metastatic bone pain

Question 9

Pall care Tx for hiccups?

Answer 9

Chlorpromazine for intractable hiccups; also haloperidol or gabapentin, also dexamethasone (esp. if hepatic lesions)

Question 10

Pall care Tx of confusion?

Answer 10

o Treat underlying cause – eg. hypercalcaemia, infection, urinary retention and medication
o If specific treatments fail – haloperidol (1st) or chlorpromazine, levomepromazine
o In the terminal phase of the illness then agitation or restlessness is best treated with midazolam

Question 11

Pall care tx of secretions?

Answer 11

o Conservative Mx: Avoid fluid overload; Educate family that patient is likely not troubled by secretions
o Medical: hyoscine hydrobromide or hyoscine butylbromide = 1st line
 Also glycopyrronium bromide

Question 12

When to consider syringe drivers?

Answer 12

o Considered if patient is unable to take oral medication due to nausea, dysphagia, intestinal obstruction, weakness or coma

Question 13

Drugs that you need 0.9% NaCl for syringe driver?

Answer 13

	granisetron
	ketamine
	ketorolac
	octreotide - SOMATOSTATIN ANALOGUE
	ondansetron

Question 14

Pall care commonly used drugs for N+V, Resp. secretions, bowel colic, agitation/restlessness, pain?

Answer 14

 nausea and vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide
 respiratory secretions: hyoscine hydrobromide
 bowel colic: hyoscine butylbromide
 agitation/restlessness: midazolam, haloperidol, levomepromazine
 pain: diamorphine is the preferred opioid

Question 15

Mixing issues with syringe drivers?

Answer 15

 Diamorphine compatible with the majority of drugs including
• cyclizine*, dexamethasone, haloperidol, hyoscine butylbromide, hyoscine hydrobromide, levomepromazine, metoclopramide, midazolam
• however cyclizine may precipitate at higher doses

 cyclizine is incompatible with a number of drugs including
• clonidine, dexamethasone, hyoscine butylbromide (occasional), ketamine, ketorolac, metoclopramide, midazolam, octreotide, sodium chloride 0.9%