Palliative meds

Question 1

Hyoscine Hydrobromide/ butylbromide drug class and clinical indications

Answer 1

Class: Antimuscarinic

ClinInd: To reduce respiratory secretions

Question 2

Hyoscine hydro and butylbromide moa?

Elimination?

Answer 2

Competitively blocks acetylcholine from muscarinic receptor

Stimulation of muscarinic receptor causes rest and digest

This reduces secretions from glands in the respiratory tract and gut

Elim: Metabolised by liver, excreted in urine

Question 3

Hyoscine hydro and butylbromide SEs?

Answer 3

Drowsiness/ confusion in the elderly. Sedation EO- hydro
Blurred vision (occur secondary to blockage of cholinergic stimulation to the ciliary muscle of the crystalline lens)
Dry mouth
Tachycardia
Constipation
Urinary retention

Question 4

Hyoscine hydro and butylbromide interactions

Answer 4

Adverse effects are more pronounced when combined with other antimuscarinic drugs e.g. TCAS

Question 5

Hyoscine hydro and butylbromide dose and administration ?

Answer 5

Hyoscine hydro: SC 400mcg. 1.2-2.4 mcg in 24 hours

Hyoscine butylbromide: SC: 20mg. 60-120mg in 24 hours

Question 6

Midazolam drug class and clinical indications (palliative)

Answer 6

Benzodiazepine

For relief of short term severe, disabling or distressing anxiety

Question 7

Miadazolam moa?

Elimination

Answer 7

Targets GABA-A chloride channel which normally opens in response to GABA binding.
It is the main inhibitory NT in the brain
Benzodiazepine allows enhanced binding of GABA to GABA-A
This has a widespread depressant effect

Metabolised by liver

Question 8

Contraindications/ warnings of midazolam?

Answer 8

Elderly should receive lower doses
Avoid in liver failure as it’ll precipitate hepatic encephalopathy
Avoid in pts with resp impairment or NMD

Question 9

Midazolam interactions?

Answer 9

Effect of benzos are additive to those of other sedating drug inc alcohol and opioids

Benzos depend on cytoP450 metabolism. so P450 inhibitors e.g. amiodarone, diltiazem, macrolides and fluconazole may increase depressive midaz’ effect

Question 10

Midazolam starting dose?

24 hour dose?

Answer 10

SC PRN: 2-5mg

24 hour: 10-80mg

Question 11

Diamorphine drug class and clinical indications

Answer 11

Strong opioid

Analgesic purposes EOL

Question 12

Diamorphine moa?

Elimination?

Answer 12

Agonist that acts on mu, kappa and delta receptors

Excreted via the kidneys as glucuronides

Question 13

Diamorphine SEs?

Answer 13

Respiratory depression 
Nausea and Vomiting 
Decreased motility in GIT
Suppression of cough reflex 
Hypothermia

Question 14

Diamorphine contraindications?

Cautions?

Answer 14

Should be given in reduced doses or with caution to pts with asthma or decreased respiratory reserve
Contraindicated in patients with delayed gastric emptying and phaeochromocytoma patients

Caution in patients with severe cor pulmonale, severe diarrhoea and toxc psychosis

Question 15

Diamorphine interactions?

Answer 15

Benzodiazepines + opioids= NO GO= potentially fatal respiratory depression

Question 16

Diamorphine starting dose?

24 hour dose?

Answer 16

1.25 – 2.5 mg if opioid
naive otherwise
calculate appropriate
dose (subcut prn)

24 hours: 5-10 mg/24 hours if opioid naïve. Otherwise
calculate appropriate
dose

Question 17

Levomepromazine drug class?

Clinical indications?

Answer 17

Phenothiazine

Used for unresolved N+V (3rd line) and for severe delirium/ agitation in the last days of life

Question 18

Levomep MOA?

Levomep elimination?

Answer 18

Adrenergic, dopamine, histamine, cholinergic and serotonin receptor antagonist

Excreted in faeces and urine- half life 20 hours

Question 19

Levomep SEs?

Answer 19

Skin irritation at infusion site 
Drowsiness 
Dry mouth 
Dystonia 
QT prolongation

Question 20

Levomep contraindications?

Levomep, cautions?

Answer 20

Contraindicated in CNS depression, comatose states and phaeochromocytoma

Caution
Lowers BP and can cause hypotenion in ambulant patients: pts receiving large doses should remain supine
Has additive sedative effect
Liver impairment- doe reduction and careful titration

Question 21

Levomep interactions?

Answer 21

Levomep is a potent inhibitor of cytochrome P450: will result in increased plasma concentration

Increased risk of arrythmias when combined with drugs that prolong QT interval e.g. procainamide, amiodarone. Has this effect with erythromycin IV and TCAs e.g. amytriptylline and antihistamines

Question 22

Levomep route of administration and dose?

Answer 22

S/C starting dose: 6.25mg

24 hours dose: 6.25-25mg