Palliative medicine & End of Life Care

Question 1

codeine/tramadol to morphine

Answer 1

divide by 10

Question 2

morphine to oxycodone

- less what w oxycodone? but more?

Answer 2

divide by 1.5-2

Oxycodone: less sedation, vomiting and pruritis than morphine but more constipation.

Question 3

oral morphine to

• SC morphine?
• SC diamorphine?

Answer 3

sc morphine: divide by 2

sc diamorphine: divide by 3

Question 4

oral oxycodone to SC diamorphine

Answer 4

divide by 1.5

Question 5

transdermal fentanyl 12 mcg patch = approximately how much oral morphine?

transdermal buprenorphine 10 microgram patch = how much oral morphine?

Answer 5

• transdermal fentanyl 12 mcg patch = approximately 30 mg oral morphine daily
  
  • transdermal buprenorphine 10 microgram patch = approx 24 mg oral morphine daily.

Question 6

what starting morphine - what dose shoudl you use for regular and prn

Answer 6

• advanced and progressive disease: start
○ regular oral MR or IR morphine (dep on patient preference) with oral IR for breakthrough pain
○ if no comorbidities use 20-30mg of MR a day with 5mg PRN. EG 15mg modified-release morphine tablets BD with 5mg of oral morphine solution PRN
○ Break through dose = 1/6th daily dose of morphine
• Laxatives for all when starting strong opioids

Question 7

SE of opioids - whats transient and whats permanent

Answer 7

• Nausea: often transient, if persists: add antiemetic
• Drowsiness: often transient, if persists: consider changing dose
Constipation: persistent

Question 8

when increasing opioid dose how much do you do it by

Answer 8

30-50%

Question 9

CKD
mild mod: use
severe: choice of 3

Answer 9

• Mild-mod renal impairment: oxycodone

* more severe: alfentanil, buprenorphine or fentanyl

Question 10

met bone pain - 4 options

Answer 10

• may respond to strong opioids, bisphosphonates, radiotherapy or denosumab
• Strong opioids: lowest number needed to treat for relieving the pain and can provide quick relief.
But should consider all for referral to clinical oncologist for consideration of further treatments such as radiotherapy

Question 11

hiccups mx

Answer 11

1. Chlorpromazine

2. Or haloperidol, gabapentin, dexamethasone (latter esp if liver lesions)

Question 12

painful mouth mx

Answer 12

• Benzydamine hydrochloride mouthwash/spray

Question 13

when starting morphine do you continue paracetamol

Answer 13

yes has shown benefits even to pts on large doses of morphine

Question 14

met Bone pain not controlled on analgesia - next step

Answer 14

bisphosphonates

Question 15

resp secretions and bowel colic options

Answer 15

hysocine hydrobromide, hyoscine butylbromide or glycopyrronium bromide

Question 16

following drugs sodium chloride 0.9% is recommended for injection

Answer 16

• granisetron
	• ketamine
	• ketorolac
	• octreotide
Ondansetron

Question 17

n&v optinos

Answer 17

cyclizine, levomepromazine, haloperidol, metoclopramide

Question 18

cyclizine is incompatible with?

Answer 18

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

Question 19

terminal illness restlessness/agitation: mx 1

generally pall care: options - 1st line? - 2 others

Answer 19

terminal: midazolam

first choice: haloperidol
other options: chlorpromazine, levomepromazine