Prescribing in palliative care

Question 1

Opioid drug of choice for pain management in palliative care? Which CD class?

Answer 1

Morphine CD2

Question 2

What morphine is CD5?

Answer 2

Oral morphine solution with strength below 13mg/5ml

Question 3

Dosing of Immediate release morphine for palliative care

Dosing of Modified release morphine for palliative care

Answer 3

IR - 4 hourly - Dose increments not more than 1/3 or 1/2 of total daily dose every 24 hours

MR - 12 hourly, 24 hourly - when pain controlled, switch from IR < 4 hours of last dose

Question 4

Alternative to oral morphine for palliative care

Answer 4

Oxycodone (choice morphine alternative)

Other strong oral opioids: Hydromorphone, Methadone
Transdermal patches: Fentanyl or Buprenorphine
(Parental): Diamorphine

Question 5

What is the rescue dose for breakthrough pain? For IR or MR?

Answer 5

Rescue dose with immediate release preparations e.g oral morphine solution, oxycodone oral solution.

1/6th to 1/10th of total daily dose

Repeat every 2 to 4 hours when required
Review the dose if taking twice daily or more.

Question 6

1. When to use parental route of morphine?
2. Convert oral morphine to parental? e.g 100mg morphine
3. Convert oral morphine to diamorphine? e.g. 90mg of morphine
   Why is diamorphine preferred in emaciated patients.
4. Which strength of SC diamorphine to use physiological saline and Water for Injection?

Answer 6

1. Dysphagia, severe N/V, coma, weakness
2. Parental (IV, IM, SC) morphine = HALF of oral dose of morphine (50mg)
3. Diamorphine = THIRD of oral dose of morphine (30mg)
   Preferred over parenteral morphine; more soluble = large dose in a small volume
4. Up to 250mg/ml with physiological saline or WFI. Above 40mg/ml use WFI to avoid precipitation

Question 7

When is transdermal route used for morphine?
Two options

If switching due to hyperalgesia

Answer 7

Fentanyl patches 3 days 72 hours
Buprenorphine patches 7 day/4day
Used in chronic pain that is stabilised on dose of I/R opioid reduce new opioid dose by 25-50%.

Question 8

3 opioid side effects

Answer 8

Constipation, N+V, Dry Mouth

Question 9

How to manage constipation from opioids?

Answer 9

A suitable laxative should be routinely prescribed : faecal softener + stimulant

• Senna (stimulant) + Lactulose (softener)
• Co-danthramer/danthrusate
• Methylnaltrexone (opioid receptor antagonist)

Question 10

How to manage nausea and vomiting with opioids?

Answer 10

Metoclopramide (prokinetic) OR Haloperidol (antipsychotic) for 4 to 5 days

Question 11

How to manage dry mouth from opioids?

Answer 11

Maintain good oral hygene

• Suck on ice cubes, chew sugar-free gum, artificial saliva
• Candidiasis: antifungal e.g. nystatin, oral miconazole gel, fluconazole

Question 12

What’s used to treat neuropathic pain?

Answer 12

Tricyclic antidepressant/antiepileptic

Question 13

How to treat bone metastases pain?

Answer 13

Radiotherapy, bisphosphonate, strontium ranelate

Question 14

How to treat pain due to nerve compression

Answer 14

Dexamethasone

Question 15

Symptom control in palliative care: anorexia

Answer 15

Prednisolone or Dexamethasone (increases appetite/weight gain)

Question 16

Symptom control in palliative care: Bowel colic, excess respiratory secretions

Answer 16

Subcutaneous injections of: Hyoscine or Glycopyrronium (antimuscarinics)
Bowel colic: Loperamide (anit-motility drug)

Question 17

Symptom control in palliative care: capillary bleeding

Answer 17

Tranexamic acid (antifibrinolytic) / Adrenaline, Vitamin K in prolonged clotting in liver disease

Question 18

Symptom control in palliative care: convulsions due to uraemia/cerebral tumour

Answer 18

Phenytoin or Carbemazepine, SC midazolam

Question 19

Symptom control in palliative care: Dysphagia due to obstruction by tumour

Answer 19

Dexamethasone

Question 20

How to manage Dry Mouth in opioids?

Answer 20

• Maintain good oral hygiene

- Suck on ice cubes, chew sugar-free gum, artificial saliva