Palliative Medicine and EOLC Flashcards by Steph Moore

60yo male with metastatic lung ca and CKD 4 c/o generalised pain in his chest. Which opioid is safe to prescribe?
Why?

Oxycodone is the safest opioid to prescribe in patients with renal failure.

Mostly cleared by the liver.
Other options include fentanyl, buprenorphine, alfentanil, methadone BUT d/w palliative care team, first.

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Why is morphine sulphate not recommended in patients with renal failure?

Its active metabolites are renally excreted.

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Why is Naproxen not used in a patient with renal failure?

Nephrotoxic.

Unlikely to provide adequate pain relief in palliative patients.

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When starting opioids in palliative care, who should you offer MR / oral immediate release morphine with immediate-release morphine for breakthrough pain?

Patients with advanced and progressive disease.

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What dose of morphine should you use in a palliative patient with no co-morbidities?

20-30mg of MR / day
PLUS 5mg Morphine for breakthrough pain.

eg. 15mg MR Morphine BD with 5mg of oral morphine as required

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What should you advise a palliative patient when starting them on opioids?

Oral MR Morphine preferable to patches
Prescribe laxatives
Nausea is often transient. Offer an antiemetic if nausea persists.
Drowsiness is usually transient. If this does not settle, consider adjusting the dose of opioids.

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How would you calculate the breakthrough dose of morphine?

Breakthrough dose of morphine is one sixth the daily dose of morphine.

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Which opioids are preferred when a patient has chronic kidney disease?

Alfentanil
Buprenorphine
Fentanyl

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What therapies might metastatic bone pain respond to?

Strong opioids
Bisphosphonates
Radiotherapy
Denosumab
All patients should be considered for referral to a Clinical Oncologist for consideration of further treatments eg. radiotherapy.

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When increasing the dose of opioids in palliative patients, how much should the next dose be increased by?

30 - 50%

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Which opioid side effects are:

i. usually transient
ii. usually persistent

Transient: Nausea, Drowsiness
Persistent: Constipation

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To convert from oral codeine to oral morphine, what is the conversion factor?

Divide by 10

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To convert from oral tramadol to oral morphine, what is the conversion factor?

Divide by 10

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To convert oral morphine to oral oxycodone, what is the conversion factor?

Divide by 1.5-2.

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A transdermal 12microgram fentanyl patch is equivalent to how much oral morphine daily?

Approx 30mg oral morphine

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A transdermal 10microgram Buprenorphine patch is equivalent to how much oral morphine daily?

24mg Oral Morphine Daily.

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To convert Oral Morphine to Subcut Morphine, what is the conversion factor?

Divide by 2

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To convert Oral Morphine to Subcut Diamorphine, what is the conversion factor?

Divide by 3

To convert Oral Oxycodone to Subcut Diamorphine, what is the conversion factor?

Divide by 1.5

Which medications might you offer if a palliative patient has intractable hiccups?

Chlorpromazine, Haloperidol, Gabapentine.

Dexamethasone is also used, particularly if there are hepatic lesions

Palliative pt with Lung ca develops diffuse oral pain as a consequence of his treatment.
Which medication might be useful in reducing oral discomfort that may occur at the end of life?

Benzydamine hydrochloride mouthwash / spray.

What intercurrent oral infections might a palliative patient on chemo experience?

Candida
Haematinic deficiency
Dry mouth (from reduced oral intake)
Mucositis - as a result of chemo and/or radiotherapy.

In palliative care, what might be an underlying cause of a patient’s agitation?

Hypercalcaemia
Infection
Urinary retention
Medication

What is the first line medical management for agitation in palliative patients (not in the terminal phase of illness)?

Haloperidol

Other options include Chlorpromazine, Levomepromazine

What is the first line medical management for agitation in palliative patients who are in the terminal phase of their illness?

subcut Midazolam

Why might Diamorphine be used in a syringe driver instead of morphine?

Diamorphine is much more soluble than morphine therefore easier to administer in high doses. Diamorphine is also compatible with most other drugs which may need to be administered by a subcutaneous infusion. BUT Morphine is preferred in most cases as people do not require doses large enough to cause solubility issues.

What is the side effect profile of Oxycodone?

Generally causes less sedation, pruritus and vomiting than morphine, but more constipation.

What medication would you prescribe in a syringe driver for a palliative patient who has respiratory secretions?

Hyoscine HYDRObromide

What medication would you prescribe in a syringe driver for a palliative patient who has bowel colic?

Hyoscine BUTYLbromide

When should you consider the use of a syringe driver in the palliative care setting?

When patient is unable to take oral medication due to nausea, dysphagia, intestinal obstruction, weakness or coma.

What are the 2 types of syringe driver?

Graseby MS16A (Blue): the delivery rate is given in mm per hour Graseby MS26 (Green): the delivery rate is given in mm per 24 hours

The majority of drugs in syringe drivers are compatible with which solute?

Most drugs are compatible with Water for Injection.

Which drugs which go in syringe drivers are recommended to have an alternative solute? What is this solute?

Solute: Sodium Chloride 0.9% - Granisetron - Ketamine - Ketorolac - Octreotide - Ondansetron

A palliative patient is has nausea and vomiting. Which drug(s) might you prescribe?

- Cyclizine - Levomepromazine - Haloperidol - Metoclopramide

Cyclizine is incompatible with a number of drugs. List these drugs.

- Clonidine - Dexamethasone - Hyoscine butylbromide - Ketamine - Ketorolac - Metoclopramide - Midazolam - Octreotide - Sodium Chloride 0.9%

Which (palliative) patients are suitable for transdermal patches?

Those with stable levels of pain who will not require regular titration of their pain relief. Patches should not be given to opioid naive patients. Where oral treatment is not suitable eg. odynophagia and dysphagia

Which medication might be used in a patient with brain mets? What is its mode of action?

Dexamethasone: used to reduce oedema around brain metastases, to palliate symptoms of raised intracranial pressure

A patient with Sickle Cell Anaemia is experiencing an episode of extreme pain. He has CKD stage 4, T2DM, previous DVT. Which analgesia would be appropriate for him?

Oxycodone - because he's in renal failure. | Oxycodone and alfentanil are mainly metabolised in the liver thus can be safely used in patients with kidney failure.

What are the concerns when managing a patient with Sickle Cell Disease? What about longer term patients?

Sickle cell crisis: severe anaemia; codeine / co-codamol will likely not control the pain. Longer term patients may develop Sickle Cell Nephropathy where haemolysis and vascular occlusion leads to a loss of tubular function. Patients can further develop CKD and later end-stage renal disease.

An 87yoM is end of life and struggling to breathe. He has harsh breath sounds on inspiration, caused by respiratory secretions. What is the most suitable medication for his symptoms?

Hyoscine Hydrobromide. Glycopyrronium Bromide is a suitable second-line agent.

Describe the conservative management for secretions in End of Life Care.

- Avoid fluid overload. Consider stopping IV or subcutaneous fluids - Educate the family that the patient is likely not troubled by secretions.

What are the first- and second- line treatments for secretions in end of life care?

First line: Hyoscine butylbromide Second line: Glycopyrronium bromide

71yo Female with metastatic breast cancer has bone pain (pelvis and ribs) which is not controlled on paracetamol, diclofenac and MST (morphine) 30mg bd. What treatment should you offer?

Increase MST Refer for radiotherapy. Metastatic bone pain may respond to analgesia, bisphosphonates or radiotherapy. * Dexamethasone should be considered if there is metastatic cord compression, but this is not a feature given the location of the lesions.