Palliative Care - Prescribing at EoL

Question 1

Agitation management

Answer 1

Address the underlying causes e.g.
-hypercalcemia
-infection
-urinary retention
-medication

1st line - haloperidol
Others - chlorpromazine, levomepromazine

If terminal - midazolam

Question 2

Hiccups management

Answer 2

Intractable hiccups - chlorpromazine

Alts - haloperidol, gabapentin, dexmeth if hepatic lesions

Question 3

Causes of nausea and vomiting - reduced gastric motility
-causes
-receptors
-antiemetics you can use

Answer 3

Causes
-opioid
-ileus

5HT4 - seretonin
D2 - dopamine

Metoclopramide
But don’t use when we don’t want to bowel to move
-BO, GI perforation, immediately after GI surgery

Domperidone - doesn’t cross BBB

Question 4

Chemically mediated
-causes
-receptors
-antiemetics you can use

Answer 4

Causes
-metabolic - renal, liver failure, hypercalcemia of malignancy, electrolyte imbalances
-drugs - opioids, ABx, digoxin, NSAIDs, SSRIs, chemotherapy

Treat the reversible

D2 - dopamine antagonist
-Haloperidol
-Levomepromazine

5HT3 antagonist
-Ondansetron

Question 5

Motion sickness/vestibular
-causes
-receptors
-antiemetics

Answer 5

Motion related
Brain mets, CVA
Opioid - increase vestibular sensitivity

Ach

H1
1st line - cyclizine for vestibular

Refractory vestibular causes alts
-metoclopramide, prochloperazine

Question 6

Increased ICP
-causes
-receptors
-antiemetics you can use

Answer 6

Cerebral mets

Symptoms worse when lying down
Headache, N/V

H1, Ach
1st line - Cyclizine
Steroids - Dexmethasone

Radiotherapy

Question 7

Route of administration of N/V

Answer 7

PO preferable unless
-vomiting
-malabsorption issues
-severe gastric stasis

IV used if IV access available

Question 8

Pain prescribing in palliative care
-starting treatment

Answer 8

Regular MR morphine or IR morphine

PO IR morphine for breakthrough pain
-1/6th to 1/10th of total daily dose
-1/10 used for elderly

PO MR used in preference to transdermal patches

Start laxatives if on strong opioids
Offer antiemetics for nausea

Drowsiness is transient - if it does not settle, adjust dose

Question 9

Pain prescribing in palliative care
-mild/moderate kidney impairment
-severe kidney impairment

Answer 9

Mild/moderate - oxycodone

Severe - alfentanil, buprenorphine, fentanyl

Question 10

Management of metastatic bone pain

Answer 10

Strong opioids
Bisphosphonates
Denosumab
Radiotherapy

Question 11

Increasing opioid dose
-percentage

Answer 11

30-50%

Question 12

Conversion between opioids
-PO codeine => PO morphine
-PO tramadol => PO morphine
-PO morphine => PO oxycodone
-PO morphine => SC morphine

Answer 12

PO codeine =(divide by 10)=> PO morphine

PO tramadol =(divide by 10)=> PO morphine

PO morphine =(divide by 1.5-2) => PO oxycodone

PO morphine =(divide by 2)=> SC morphine

Question 13

Secretions
-management (conservative, medical)

Answer 13

Conservative
-avoid fluid overloading - stop IV/SC fluids

Medical
-hyoscine hydrobromide/butylbromide
-glycopyrronium bromide

Question 14

Syringe drivers
-when to use
-what drugs are given via syringe driver

Answer 14

Considered in the palliative care setting when PO meds are not an option due to nausea, dysphagia, intestinal obstruction, weakness coma

N/V - cyclizine, levomepromazine, haloperidol, metoclopramide
Resp secretions/bowel colic - hyoscine hydropromide/butylbromide, glycopyrronium bromide
Agitation/restlessness - midazolam, haloperidol, levomepromazine
Pain - diamorphine