Prescribing in palliative care

Question 1

In addition to the usual analgesics (and adjunct antidepressants/antiepileptics), what other substances can be useful for pain due tobone metastases? (3)

Answer 1

1. Radiotherapy
2. Bisphosphonates
3. Radioactive isotopes of strontium chloride (Metastron)

Question 2

What two ‘gaba’ drugs are licensed for neuropathic pain?

Answer 2

Gabapentin and pregabalin

Question 3

What is sometimes used under specialist supervision for neuropathic pain the responds poorly to opioid analgesics?

Answer 3

Ketamine

Question 4

Pain due to nerve compression may be reduced by a corticosteroid such as what? How?

Answer 4

Dexamethasone.

Which reduces oedema around the tumour, thus reducing compression.

Question 5

If pain occurs between regular doses of morphine (‘breakthrough pain’), an additional dose (‘rescue dose’) of immediate-release morphine should be given. An additional dose should also be given 30 minutes before an activity that causes pain, such as wound dressing. That standard dose of a strong opioid for breakthrough pain is what?

Answer 5

Usually one-tenth to one-sixth of the regular 24-hour dose, repeated every 2-4 hours as required.

Pain management should be revieved if rescue analgesic is required frequently (twice daily or more),

Formulations of fentanyl that administered nasally, buccally or sublingually are also licensed for breakthrough pain.

Question 6

When adjusting the dose of morphine, the number of rescue doses required and the response to them should be taken into account; increments of morphine should not exceed what?

Answer 6

Should not exceed one-thrid to one-half of the total daily dose every 24 hours. Thereafter, the dose should be adjusted with careful assesment of the pain, and the use of adjuvant analgesics should also be considered.

Question 7

Once their pain is controlled, patients started on 4-hourly IR morphine can be transferred to the same total 24-hour dose of morphine given as MR for 12-hourly or 24-hourly. The first dose of the MR prep is given when?

Answer 7

Either with, or within 4 hours of, the last dose of the immediate-release preparation.

Question 8

What can be used in patients who require an opioid but cannot tolerate morphine?

Answer 8

Oxycodone hydrochloride.

Question 9

The equivalent parenteral dose of morphine (SC, IM or IV) is about what of the oral dose?

Answer 9

About half.

Question 10

Why are transdermal preparations of fentanyl and buprenorphine not suitable for acute pain or in patients whose analgesic requirements are changing rapidly?

Answer 10

They take a long time to reach steady state.

Question 11

When switching due to possible opioid-induced hyperalgesia, the calculated equivalent doses of the new opioid should be reduced by what?

Answer 11

one-quarter to one-half.

Question 12

Anorexia in the palliative setting can be helped by what?

Answer 12

Prednisolone or dexamethasone.

Question 13

Bowel colic and excessive respiratory secretions may be reduced by a subcutaneous infection of what?

Answer 13

Hyoscine hydrobromide, hyoscine butylbromide or glycopyrronium bromide.

These antimuscarinics are generally given every 4 hours when required, but hourl use is occasionally necessary.

Question 14

How is capillary bleeding managed?

Answer 14

With tranexamic acid by mouth, treatment is usually discontinued one week after the bleeding has stopped.

Gauze soaked in tranexamic acid 100mg/ml or adrenaline solution 1mg/ml can be applied to the affected area.

Vitamin K may be useful for the treatment and prevention of bleeding associated with prolonged clotting in liver disease.

Question 15

What are the faecal softeners with peristaltic action?

Answer 15

Co-danthramer

Question 16

What is licensed for the treatment of opioid-induced constipation?

Answer 16

Methylnaltrexone bromide

Question 17

Dry mouth can be caused by what medicines used in palliative care?

Answer 17

1. Opioids
2. antimuscarinic drugs like hyoscine.
3. Antidepressants
4. Some antiemetics.

Question 18

Hiccup due to gastric distension may be helped by a preparation incorporating an antacid with an antiflatulent. If this fails, what can be given by mouth of by subcutaneous of intramuscular injection?

Answer 18

Metoclopramide or baclofen or nifedipine or chlorpromazine.

Question 19

What CCB can be tried for hiccup?

Answer 19

Nifedipine

Question 20

Intracatable cough may be relieved by what?

Answer 20

Moist inhalations or by regular administration of oral morphine.

Question 21

What preparation should be avoided in intractable cough?

Answer 21

Methadone because it has a long duration of action and tends to accumulate.

Question 22

Why is erythromycin a prokinetic?

Answer 22

Due to agonism at motilin receptors.

Question 23

In advanced cancer, nausea and vomiting are common. What type of antiemetic may be the preferred choice for first-line therapy?

Answer 23

Prokinetic:

Metoclopramide.

Question 24

Nausea and vomiting may occur with opioid therapy particularly in the initial stages but can be prevented by giving an antiemetic such as what?

Answer 24

Haloperidol or metoclopramide.

Only the first 4 or 5 days.

Question 25

Drugs with antimuscarinic effects do what to prokinetic drugs such as metoclopramide?

Answer 25

They antagonise prokinetic drugs and, if possible, should not be used concurrently.

Question 26

Haloperidol is used by mouth for mostly what causes of vomiting?

Answer 26

Metabolic: hypercalcaemia, renal failure

Question 27

Cyclizine is given by mouth for nausea and vomiting caused by what? (3)

Answer 27

Mechanical bowel obstruction, raised intracranial pressure and motion sickness.

Question 28

Pruritus, even when associated with obstructive jaundice, often responds to simple measures such as application of emollients. In the case of obstructive jaundice, what can be used?

Answer 28

Colestyramine

Question 29

Headache due to raised intracranial pressure often responds to a high dose of what? When should it be given to reduce the risk of insomnia?

Answer 29

Dexamethasone/ a high dose of a corticosteroid.

Should be given before 6pm to reduce the risk of insomnia.

Question 30

Restlessnes and confusion in palliative care may require treatment with what?

Answer 30

An antipsychotic such as haloperidol or levomeprozamine.

Levomeprozamine is licensed to treat pain in palliative care - this use is reserved for distressed patients with severe pain unresponsive to other measures.

Question 31

What drug, which stimulates water and electrolyte absorption and inhibits water secretion in the small bowel, can be used by subcutaneous infusion to reduce intestinal secretions and to reduce vomiting due to bowel obstruction?

Answer 31

Octreotide.

Can also be used for:
Reduced intestinal secretions in palliative care.

Acromegaly.

Prevention of complications following pancreatic surgery

Symptoms associated with carcinoid tumours with features of carcinoid syndrome, glucagonomas.

Question 32

Not all medication can be used in subcutaneous infusions. In particular what? (3)

Answer 32

Chlorpromazine, prochlorperazine and diazepam as they cause skin reactions at the injection site and to a lesser extent so can cyclizine and levopromazine.

Question 33

Diamorphine is the preferred opioid in pallative care because:

It is less likely to be abused
It is the cheapest option
It has greater solubility which allows effective doses to be given in a small volume.
There are fewer side effects compared to other opioids.
There is no maximum dose.

Answer 33

Diamorphine has greater solubility which allows effective doses to be given in a small volume.