Pharmacology: Palliative Care

Question 1

What class of drug is metoclopramide?

Answer 1

Dopamine receptor antagonist / prokinetic agent / anti-emetic

Question 2

Indications of metoclopramide?

Answer 2

1) Symptomatic treatment of N&V e.g:
a) acute migraine
b) delayed (but not acute) chemo N&V
c) radiation N&V
d) prevention of postop N&V

2) N&V in palliative care

3) Acute migraine

4) Stimulates gastric emptying e.g. diabetic gastroparesis

Question 3

Mechanism of metoclopramide?

Answer 3

1) Inhibits dopamine D2 and serotonin 5-HT3 receptors in chemoreceptor trigger zone (CTZ).

2) Also antagonism of muscarinic receptor inhibition –> increased ACh

This leads to prokinetic effects and increased gastric emptying

Question 4

How can metoclopramide reduce N&V in end of life?

Answer 4

When N&V is due to gastric stasis, metoclopramide increases gastric emptying.

Question 5

Contraindications of metoclopramide?

Answer 5

1) bowel obstruction / perforation

2) Parkinson’s - risk of increasing EPSEs (due to dopamine antagonism)

3) epilepsy (due to lowered seizure threshold)

Question 6

Side effects of metoclopramide?

Answer 6

Diarrhoea
Asthenia (lack of energy/strength)
Parkinsonism (e.g. acute dystonia)
Hypotension

Question 7

Starting syringe driver dose of metoclopramide?

Answer 7

30mg

Question 8

What type of N&V is metoclorpamide best used to manage in palliative care?

Answer 8

Gastric stasis induced

Question 9

If extrapyramidal effects are a problem with metoclopramide in palliative care, what can be used as an alternative?

Answer 9

domperidone

Question 10

What should you not give metoclopramide alongside?

Answer 10

Do not give prokinetics concurrently with drugs with antimuscarinic activity (for example cyclizine and hyoscine).

Question 11

Indications of haloperidol?

Answer 11

1) Palliative care: N&V, restlessness and confusion

2) Schizophrenia

3) Acute delirium

4) Postop N&V (prophylaxis and treatment)

5) Moderate to severe manic episodes associated with bipolar I disorder

6) Acute psychomotor agitation associated with psychotic disorder or manic episodes of bipolar I disorder

7) Persistent aggression and psychotic symptoms in moderate to severe Alzheimer’s dementia and vascular dementia

Question 12

Contraindictions of haloperidol?

Answer 12

1) dementia with Lewy bodies

2) CNS depression

3) congenital long QT syndrome

4) Parkinson’s disease

5) recent acute myocardial infarction

6) history of torsade de pointes

Question 13

What are some anti-emetics used in end of life care?

Answer 13

1) Metoclopramide
2) Haloperidol
3) Cyclizine
4) Levomepromazine

Question 14

What are some anxiolytics used in end of life care?

Answer 14

1) Midazolam
2) Haloperidol

Question 15

What are some analgesics used in end of life care?

Answer 15

Morphine sulphate

Oxycodone (in renal impairment)

Question 16

What anti-secretory medication is used in end of life care?

Answer 16

Hyoscine butylbromide (buscopan)

Question 17

Side effects of haloperidol?

Answer 17

1) Anticholinergics: dry mouth, constipation, urinary retention, blurred vision

2) EPSE’s: acute dystonia, tardive dyskinesia, neuroleptic malignant syndrome, akathisia

3) Hyperprolactinaemia: amenorrhoea, galactorrhoea, ED

4) Antiadrenergic e.g. prolonged QT interval, hypotension, ED, arrhythmias

5) Risk of neuromalignant syndrome: rigidity, rhabdomyolysis

6) Sedation

Question 18

What are the 4 main types of laxatives?

Answer 18

1) bulk forming e.g. fybogel

2) softeners e.g. lactulose

3) stimulants e.g. senna, bisacodyl

4) combination (softeners and stimulants) e.g. macrogols (movicol/laxido)

Question 19

What is the 1st line laxative in palliative care?

Answer 19

Senna