Passmedicine Flashcards
What drug can be used to alleviate headaches caused by raised ICP due to brain cancer/mets?
Dexamethasone
It reduces oedema around brain mets
What painkiller should those with advanced/progressive disease be offered?
Regular oral modified release morphine with oral immediate release morphine for breakthrough pain
What dose of MR morphine and breakthrough morphine should you start with in someone with co-morbidities?
20-30mg MR
5mg for breakthrough
What should be co-prescribed with opioids?
Laxatives
What are common symptoms with opioid use and how can they be avoided?
Nausea
Often it is transient but if it persists can offer anti-emetics
Drowsiness, usually transient but dose can be altered if req.
How do you calculate how much breakthrough morphine to use?
1/6th the daily dose of morphine
In which group of patients should opioids be used very carefully?
In those with chronic kidney disease
What are the preferred opioids to use in CKD?
Alfentanil, buprenorphine, fentanyl
What is metastatic bone pain most likely to respond to?
Strong opioids
Bisphosphonates
Radiotherapy
Denosumab
By how much should you increase an opioid dose at a time?
30-50%
Which side effect of opioid use is usually persistent?
Constipation
How do you convert a codeine dose to an oral morphine dose?
Divide by 10
How do you convert a tramadol dose to oral morphine?
Divide by 10
How does oxycodone differ from morphine?
Usually causes less sedation, vomiting + pruritus but more constipation
How do you convert a morphine dose to an oxycodone dose?
Divide by 1.5-2
How much does a transdermal fentanyl 12microgram patch equate to in oral morphine?
30mg daily
How much does a transdermal fentanyl 10microgram patch equate to in oral morphine?
24mg daily
How do you convert an oral dose of morphine to a s/c dose?
Half it
How do you convert an oral dose of morphine to a s/c diamorphine dose?
Divide by 3
How do you convert an oral dose of oxycodone to s/c diamorphine?
Divide by 1.5
What drugs are used for the treatment of intractable hiccups?
Chlorpromazine
Haloperidol
Gabapentin
Dexamethasone (if hepatic lesions)
When should a syringe driver be considered in palliative care?
If patient unable to tolerate oral meds, e.g. dysphagia, nausea, intestinal obstruction, weakness, coma etc.
What are the two types of syringe drivers in the UK?
Graseby MS16A (blue) - delivers in mm per hour
Graseby MS26 (green) - delivers in mm per 24h
Which drugs should you mix with sodium chloride when preparing for injection with syringe driver?
Granisetron Ketamine Ketorolac Octreotide Ondansetron
What drugs can be put through a syringe driver for nausea and vomiting?
Cyclizine
Levomepromazine
Haloperidol
Metoclopramide
What drugs can be put through a syringe driver to help break up respiratory secretions?
Hyoscine hydrobromide
What drugs can be put through a syringe driver to help with bowel colic?
Hycosine butylbromie
What drugs can be put through a syringe driver to help with agitation and restlessness?
Midazolam
Haloperidol
Levomepromazine
What drugs can be put through a syringe driver for pain?
Diamorphine is the preferred opioid
What should you do if a palliative patient is confused/agitated?
Investigate for underlying causes, e.g. hypercalcaemia, infection, urinary retention, medications
What medications can you give to help with confusion/agitation?
First line: haloperidol
Second line: chlorpromazine, levomepromazine
What best treats agitation/restlessness in the terminal phase of the illness?
Midazolam
Can you give a patient excess morphine if they are close to dying to end their suffering?
No - we must always start with a presumption in favour of prolonging life and not hasten death
What is the first line pain killer in palliative patients who are unable to take oral medications?
Transdermal opioid patches (e.g. transdermal fentanyl patch 12micrograms/hour)
What is allodynia?
Pain experienced with non painful stimulus
What is hyperalgesia?
Severe pain experienced from mildly painful stimulus
How is morphine metabolised in the body?
Morphine is metabolised in the liver by glucuronidation to morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). M3G is probably inactive. M6G has analgesic properties but is also responsible for the toxicity.
In which organ does the majority of the excretion of the active metabolites of morphine take place?
Kidneys
What are the possible clinical features of opioid toxicity?
Altered consciousness, confusion, vivid dreams, pseudohallucinations, hallucinations, myoclonus, and sometimes hyperalgesia and whole body allodynia
