Prescribing in palliative + elderly

Question 1

Pain management: oral

Answer 1

MR every 12 + 24h
- Max dose increments 1/3 or 1/2 of total daily dose

Question 2

Pain management: parenteral

Answer 2

Morphine: 1/2 oral

Diamorphine: 1/3 oral morphine

More soluble = larger dose in smaller volume

Question 3

Pain management: transdermal

Answer 3

For hyperalgesia: red dose by 1/4 - 1/2

Fentanyl patch (72h)

Buprenorphine patch (72h, 4 day/7 day)

Question 4

Pain management: Break through

Answer 4

Rescue dose: 1/10 - 1/6 every 2-4 hrs as required

Use IR - oral morphine solution, oxycodone solution

Given 30 minutes before activity that causes pain

Review dose if taking twice daily/more

Question 5

Pain management: adjuvants

Answer 5

Neuropathic pain: amitriptyline + gabapentin + pregabalin)
- Ketamine - specialist supervision if poor response to opioids

Pain due to nerve compression: dexamethasone (anti-inflammatory)

Pain due to bone metastases: radiotherapy, bisphosphonates, strontium

Question 6

Constipation

Answer 6

Laxatives: senna (stimulant) → add lactulose (osmotic)

Opioid induced constipation: Methylnaltrexone if other laxatives are inadequate

Question 7

Nausea + vomiting

Answer 7

Gastric stasis, bowel obstruction: metoclopramide, domperidone

Morphine induced: haloperidol

Raised intracranial pressure: cyclizine

Question 8

Dry mouth

Answer 8

Maintain good oral hygiene

Suck ice cubes, sugar free gum, artificial saliva

Associated with candidiasis: antifungal (nystatin, miconazole, fluconazole)

Question 9

Dysphagia

Answer 9

Dexamethasone

Question 10

Bowel colic

Answer 10

Hyoscine butylbromide

Question 11

Prescribing in elderly: lower dose (50% adult dose)

Answer 11

Avoid: LA sulphonylureas, benzodiazepines

Question 12

Prescribing in elderly: inc side effect

Answer 12

Confusion + drowsiness: opioids, benzo, antipsychotic drugs, antiparkinsonian drugs

Fainting + falls: anti-hypertensives, diuretics

Constipation: antimuscarinics

Bleeding: NSAIDs, warfarin

Drug induced blood dyscrasias: digoxin

Question 13

Prescribing in elderly: NSAIDs

Answer 13

Caution in cardiac disease or renal impairment

Osteo, soft tissue lesion, RA + back pain:
- First line: paracetamol OR low dose NSAID
- If necessary: inc NSAID OR opioid and paracetamol

Require long term NSAID gastroprotection

Don’t give 2 NSAIDs together

Question 14

Prescribing in elderly: diuretics

Answer 14

Used for gravitational oedema - avoid long term