Palliative Prescribing

Question 1

How do you prescribe morphine for cancer pain?

Answer 1

Prescribe a modified release for background pain which is given twice daily e.g. MST or zomorph. Then immediate release for breakthrough pain taken PRN which is 1/6 the background dose e.g. Sevredol or oramorph.

Question 2

1st line opioid? What about renal impairment?

Answer 2

1st line opioid = morphine

in mild to moderate renal impairment (egfr 45-59) give oxycodone
in severe renal failure (egfr 15-29) give alfentanil, fentanyl or buprenorphine

Question 3

Normal eGFR and mild, mod and severe renal failure?

Answer 3

normal = > 90
mild to moderate = 45-59
severe = 15-29

Question 4

Oral codeine to oral morphine?

Answer 4

morphine is 10x more potent
so divide dose by 10

Question 5

Oral morphine to oxycodone?

Answer 5

oxycodone is twice as potent as morphine
so divide dose by 2

Question 6

Oral morphine to subcut morphine?

Answer 6

SCUT morphine is twice as potent
so divide the dose by 2

Question 7

Anticipatory just in case medicines?

Answer 7

Pain/ SOB – morphine
Distress – midazolam
Nausea – levomepromazine
Secretions – buscapan (hyoscine butylbromide)

Question 8

Prescribing for bowel obstruction caused by peristaltic failure?

Answer 8

• Stop medications reducing peristalsis e.g. cyclizine, hyoscine, 5HT3 antagonists (odansetron), amitriptyline
• Use prokinetic antiemetic e.g. metoclopramide, stop if colic develops
• Laxatives often needed
• Pain management

Question 9

Prescribing for bowel obstruction caused by a mechanical blockage?

Answer 9

• Target treatment for predominant symptoms
• Laxatives for constipation
• Dexamethasone sometimes helps reverse partial obstruction
• Hyoscine butylbromide can help with colic and nausea

Question 10

Physiology of nausea and vomiting?

Answer 10

Stimulation of the vomiting centre in the medulla is what causes the feeling of nausea and the action of vomiting
Areas that can act on the vomiting centre include:
CTZ – chemo, drugs and metabolic
Vestibular – labyrinthitis and motion sickness
Higher cortical centre – emotions e.g. anxiety
GI

Question 11

If nausea if due to motility issues?

Answer 11

prescribe metoclopramide

Question 12

If nausea is due to anxiety?

Answer 12

prescribe benzodiazepine

Question 13

If nausea is due to chemotherapy?

Answer 13

ondansetron plus dexamethasone

Question 14

If intracranial cause of nausea and vomiting?

Answer 14

prescribe cyclizine

Question 15

Nausea and vomiting caused by oral/ pharyngeal/ oesophageal irritation?

Answer 15

prescribe cyclizine

Question 16

What is broad spectrum and used for intractable nausea and vomiting?

Answer 16

levomepromazine

Question 17

Fentanyl is eGFR is ?

Answer 17

< 30

Question 18

In palliative care if pain is not controlled?

Answer 18

increase the morphine dose by 30-50%

Question 19

Standard dose if starting morphine?

Answer 19

if no co-morbidities, use 20-30mg of MR a day with 5mg for breakthrough

Question 20

Are fentanyl patches appropriate for acute pain?

Answer 20

no - they have a slow onset and are not easily titratable so should not be given for acute pain (can give as other route though)