Palliative medicine Flashcards
routes of administration of meds in palliative care and considerations given to each route
Oral – primary route and should be used if available and appropriate.
Subcutaneous – preferred parenteral route which can be used for intermittent
bolus injections, small volume continuous infusions and hydration.
Intravenous – hazardous and venous access can be difficult in this group of
patients.
Intramuscular – can be painful. Difficult in cachectic patients.
Rectal – patient acceptability can be an issue.
Sublingual/Buccal – sometimes useful but not if patient has a dry mouth.
Transdermal – a route being used increasingly but has some limitations; dose
titration can be difficult in some patients.
Inhalation – patient co-ordination can be an issue in the final stages of the
disease.
Spinal – specialist use only, e.g. epidural, intrathecal.
different causes/exacerbating factors of nausea and vomiting in palliative care patients?
drug side-effects,
constipation, severe pain, anxiety, infection, cough, hypercalcaemia, raised intracranial
pressure, and bowel obstruction.
Non-pharmacological management strategies for N/V
Control odours from colostomy, wounds and fungating tumours
Minimise sight/smell of food
Give small snacks not large meals
Try acupressure wrist bands
what are the different drug options available for N/V in palliative medicine?
- Butyrophenone antipsychotics
- prokinetic agents
- Phenothiazine antipsychotics
- Anti-histamines
- 5-HT3 antagonists
- Antimuscarinics
- Neurokinin- receptor
antagonists - Corticosteroids
- Benzodiazepines
- Somatostatin
analogues
examples of, common SEs of and uses of Butyrophenone antipsychotics
e.g. Haloperidol
Act on dopamine (D2) receptors in the chemo-receptor trigger zone
Used in chemical causes of nausea & vomiting (N&V) e.g. opioids
Side-effects include extrapyramidal symptoms, sedation, QT-prolongation,
depression
Avoid in Parkinson’s disease
examples of, common SEs of and uses of prokinetic agents
e.g. Metoclopramide, Domperidone
Act on dopamine (D2) receptors. In addition metoclopramide acts on 5-HT4
and also 5-HT3 receptors at high doses
Used where N&V is caused by gastric stasis and ileus or for delayed
chemotherapy induced N&V
Side-effects for metoclopramide include extra-pyramidal symptoms
(greater potential in younger patients or at higher doses), drowsiness,
diarrhoea, gynaecomastia, galactorrhoea and hyperprolactinaemia
Side-effects for domperidone include QT-prolongation, drowsiness, dry
mouth, diarrhoea and malaise. Metoclopramide and
domperidone should be used at the lowest dose possible, for the shortest
period of time.
examples of, common SEs of and uses of Phenothiazine
antipsychotics
e.g. Levomepromazine, Prochlorperazine.
Act at Dopamine, H1 and Ach-receptors with varying degrees of efficacy
Wide-ranging mode of action, used when non-specific or multi-factorial
causes of N&V
Side-effects include extra-pyramidal symptoms, drowsiness, anti-
muscarinic effects, postural hypotension and QT-prolongation
Avoid in Parkinson’s disease
examples of, common SEs of and uses of Anti-histamines
e.g. Cyclizine, Cinnarizine, Promethazine
Act on H1-receptors, centrally and peripherally
Used in cases of obstruction, peritoneal irritation, vestibular causes
(motion sickness), raised intra-cranial pressure
Side-effects include anti-muscarinic effects, palpitations & arrhythmias,
sleep disturbances, extra-pyramidal symptoms
examples of, common SEs of and uses of 5-HT3 antagonists
e.g. Granisetron, Ondansetron
Act on 5-HT3-receptors
Used in chemotherapy and radiotherapy induced N&V, post-operative
N&V
Side-effects include constipation, headache, flushing, involuntary
movements and QT-prolongation
examples of, common SEs of and uses of Antimuscarinics
e.g. Hyoscine butylbromide, Hyoscine hydrobromide, Glycopyrronium bromide
Act on Ach-receptors
Used in cases of smooth muscle spasm (bladder, GI tract), excessive
secretions including sialorrhoea, drooling, death rattle and inoperable
bowel obstruction)
hyoscine butylbromide does not cross the blood-brain barrier. Side-
effects include constipation, urinary retention, tachycardia and hypotension
(cardiac side-effects uncommon with oral use). Its use is contra-indicated in patients with tachycardia and it should be used with caution in patients with cardiac disease.
hyoscine hydrobromide- Side-effects include dry mouth,
constipation, drowsiness, blurred vision, urinary retention, agitation and
confusion
glycopyrronium bromide-Side-effects include drowsiness,
dry mouth and constipation
examples of, common SEs of and uses of Neurokinin- receptor
antagonists
e.g. Aprepitant (oral), Fosaprepitant (IV)
Licensed for the prevention of chemotherapy induced N&V associated
with highly and moderately emetogenic chemotherapy in combination with
a 5HT3 antagonist and a corticosteroid. No studies into use in established
N&V
Acts on NK1 receptors
examples of, common SEs of and uses of Corticosteroids
Possess intrinsic anti-emetic activity
Used as an adjunct for nausea. May enhance the effects of other anti-
emetics
Mechanism of action multi-factorial
Side-effects are numerous and include gastro-intestinal upset (including
peptic ulceration), candidiasis, musculoskeletal effects (including proximal
myopathy, osteoporosis) endocrine effects (including adrenal suppression,
Cushing’s syndrome), neuro-psychiatric effects (including euphoria,
depression), impaired healing, immunosuppression and skin atrophy
Caution with diabetes
Monitor blood glucose before starting and regularly during treatment. For
non-diabetics monitor BG on a daily basis
Aim to keep course as short as possible and doses as low as possible to
reduce potential side-effects
examples of, common SEs of and uses of Benzodiazepines
No intrinsic anti-emetic activity
May help to reduce anticipatory N&V via their anxiolytic and amnesic
properties
No indication for use in chronic nausea
Side-effects include sedation, dizziness, ataxia, asthenia and impaired
psychomotor skills
examples of, common SEs of and uses of Somatostatin
analogues
e.g. Octreotide
Short-acting somatostatin analogue
No intrinsic anti-emetic activity
Reduces secretions and promotes re-absorption in GIT
Requires specialist supervision
Side-effects include GI disturbances (anorexia, nausea, vomiting,
abdominal pain, bloating, flatulence, diarrhoea and steatorrhoea), hyper-
and hypoglycaemia
