Prescribing in Palliative Care and Elderly Patients Flashcards
What is the first line oral analgesic used in palliative care
morphine
What oral morphine forms are there
Immediate release
- 4 hourly (not more then 1/2 of the total daily dose per increment)
Modified Release
- 12 hourly
- 24 hourly
when pain is controlled, switch from quick to slow release within 4 hours of last dose
What is breakthrough pain
pain the occurs between regular doses of strong opioids
How to treat breakthrough pain
use a rescue dose
1/10 to 1/6 of total daily dose immediate release
repeat every 2 to 4 hours when required
When should you use parental forms of analgesics
- dysphagia
- severe nausea / vomiting
- coma
- weakness
Parental morphine dose compared to oral
Parental is half of oral dose
Parental diamorphine dose compared to oral
parental is third of oral dose of morphine
Why is parental diamorphine preferred over parental morphine
- more soluble
- large dose in small quantity
- ideal in emaciated patient (huge loss of muscle and fat)
What are the two solutions for injection
- Saline
- Water for injection
SC diamorphine concentration and injections solutions
- Diamorphine concentration goes up to 250mg/ml
- If the strength prescribed is 40mg/ml or above, the injection solution used must be water for injection to avoid precipitation
When should you use transdermal patches over parental analgesia
if a patients pain can be managed by in immediate release opioid
Why should you use transdermal patches over parental analgesia for patients with pain stabilised by immediate release opioid
This stability suggests that their pain management needs are predictable and can be maintained with a consistent delivery system like a patch.
What should happen to a patch’s dose if switching due to hyperplasia
reduce dose by 25 to 30%
What are opioid side effects
- constipation
- nausea / vomiting
- dry mouth
Managing opioid side effects: Constipation
laxative should be prescribed
- senna + lactulose
- co-danthramer
Managing opioid side effects: Nausea / vomiting
- Metoclopramide
- Haloperidol (4 to 5 days)
Managing opioid side effects: Dry mouth
- maintain good oral hygiene
- suck on ice cubes
- artificial saliva
- can be due to candidiasis (antifungal= nystatin, fluconazole)
Other types of pain and how to treat
- Neuropathic
(tricyclic antidepressants / anti-epileptic) - Bone Metastases
(bisphosphonates, strontium ranelate) - Pain due to nerve compression
(dexamethasone)
Symptoms in palliative Care
- Anorexia
- Bowel colic and excess respiratory secretions
- capillary bleeding
- convulsions
- dysphagia due to obstruction by tumour
- Dyspnoea
- Fungating tumours
Symptoms in Palliative Care Part 2
- Gastric distenion
- Hiccup due to gastric distension
- insomnia
- intractable coughs
- muscle spasms
- nausea and vomiting
- pruritis
- headache due to raised intracranial pressure
- Restlessness and confusion
How to treat Symptoms on palliative care: Anorexia
- Prednisolone
- Dexamethasone
increases appetite/weight gain
How to treat Symptoms on palliative care: Bowel colic and excess respiratory secretions
- subcutaneous injections of Hyoscine
Bowel colic (painful cramps)
- Loperamide
How to treat Symptoms on palliative care: Capillary Bleeding
- Tranexamic acid
- Adrenaline
- Vitamin K
How to treat Symptoms on palliative care: Convulsions
- Phenytoin
- Carbamazepine
- SC Midazolam
How to treat Symptoms on palliative care: Dysphagia due to obstruction by tumour
Dexamethasone
How to treat Symptoms on palliative care: Dyspnoea (shortness of breath)
- Oral morphine
Dyspnoea with anxiety
- Diazepam
Bronchospasm or partial obstruction
- Corticosteroids
How to treat Symptoms on palliative care: Fungating Tumours
Metronidazole
How to treat Symptoms on palliative care: Gastric Distension
- Antacids
- Anti-flatulent
- Prokinetic Drug (gastro motility)
How to treat Symptoms on palliative care: Hiccup due to Gastric Distension
- Antacids with Anti-flatulence
if fails…
- add metoclopramide
How to treat Symptoms on palliative care: Insomnia
Benzodiazepines
How to treat Symptoms on palliative care: Intractable coughs
- oral morphine (reduces respiratory drive)
- avoid methadone linctus as it can accumulate
How to treat Symptoms on palliative care: Muscle Spasms
- Diazepam
- Baclofen
How to treat Symptoms on palliative care: Nausea and Vomiting
Prokinetic antiemetic
- Haloperidol
- Levomepromazine
- Cyclizine
- Metoclopramide
- Dexamethasone
How to treat Symptoms on palliative care: Pruritis (severe itching)
Emollients
How to treat Symptoms on palliative care: Headache due to raised intracranial pressure
Dexamethasone (before 6 to reduce risk of insomnia)
How to treat Symptoms on palliative care: Restlessness and Confusion
- Haloperidol
- Levomepromazine
At what age is a person considered elderly
65+
What are elderly doses meant to be compared to adult doses
50% of adult dose
What is an examples of a drug that should be avoided in elderly patients
Glibenclamide
What are the impacts of polypharmacy in elderly patients
- increased amount of drugs taken
- increased chance of interaction
- increase chance of non-adherence
What is the impact of reduced renal clearance in elderly patients
- excretes drugs slowly
- more susceptible to nephrotoxic drugs
- acute illnesses can lead to rapid decline in renal function
What is the impact of reduced hepatic metabolism in elderly patients
- reduced metabolism of lipid soluble drugs and vitamins due to reduced liver volume
- this will affect narrow therapeutic drugs
What is the impact of increased nervous system sensitivity in elderly patients
- more prone to side effects
Common elderly side effects
- confusion
- constipation with antimuscarinics and antipsychotics
What is the impact of long term diuretics in elderly patients
- postural hypotension
- falls
- gravitational oedema
(raise or move legs/ use stockings)
What drugs have increased risk of bleeding in elderly patients
NSAIDs
Warfarin
What two complications can come from taking NSAIDs as an elderly patient
- cardiac disease
- renal impairment
If an elderly patient has osteoarthritis, soft lesions and back pain what is the 1st Line
- weight reduction if obese
- warmth
- walking stick
If an elderly patient has osteoarthritis, soft lesions, back pain and pain in rheumatoid arthritis what is the treatment
1st Line:
- paracetamol
or
- low dose NSAID
2nd Line:
- max dose paracetamol
and
- low dose NSAID
or
- give opioid with paracetamol
What is the usual maintenance dose of digoxin in elderly
125mcg daily
(if renal impairment then 62.5 mcg daily)
