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Yr 5 - Palliative Care > Revision - Anticipatory Meds > Flashcards

Revision - Anticipatory Meds Flashcards

1
Q

What dose of Morphine sulphate is typically given for opiate naïve patients in end of life care?

A

1 - 2.5mg SC

Do not repeat within 1 hour
Max 4 doses in 24h

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2
Q

If there is reduced renal function (eGFR <50), what can be used as an alternative to morphine sulphate in end of life care?

A

Oxycodone 1-2mg SC

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3
Q

Opioid conversion

The following table shows dose equivalents of 10mg oral morphine:

A

Codeine/tramadol oral –> 100mg

Morphine IM/IV/SC –> 5mg

Oxycodone oral –> 5mg

Diamorphine IM/IV/SC –> 3mg

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4
Q

Conversion factor from oral morphine to SC morphine?

A

Divide by 2

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5
Q

Conversion factor from oral morphine to oral oxycodone?

A

Divide by 1.3-2 (depends on trust guidelines)

If in doubt, always opt for the lower dose and titrate up.

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6
Q

It is also possible to use opioid patches for background analgesia. What 2 opioid patches are used?

A

1) fentanyl

2) buprenorphine

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7
Q

When increasing the dose of opioids, what should the next dose be increased by?

A

30-50%

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8
Q

How do the side effects of oxycodone differ from morphine?

A

Oxycodone causes less sedation, vomiting & pruritus but more constipation

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9
Q

What medications can be given for N&V in palliative care?

(4)

A

1) cyclizine

2) haloperidol

3) levomepromazine

4) metoclopramide

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10
Q

1st line pharmacological management (anti-emetic) of reduced gastric motility N&V in palliative care?

A

1) Metoclopramide

2) Domperidone (consider use in patients with PD)

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11
Q

When is Metaclopramide NOT indicated in reduced gastric motility N&V in palliative care?

A

Should not be used when pro-kinesis may negatively affect the GI tract, particularly in complete bowel obstruction, GI perforation, or immediately following gastric surgery.

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12
Q

What class of drug is metoclopramide?

A

D2 receptor antagonist

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13
Q

Mechanism of action of metoclopramide?

A

1) Antiemetic effects –> dopamine D2 antagonist in the chemoreceptor trigger zone (CTZ) in the brain. This relieves the symptoms of N&V

2) Increased gastric emptying

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14
Q

Which anti-emetic is used in toxic/chemically mediated N&V in palliative care?

(2)

A

1) Haloperidol

2) Cyclizine

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15
Q

Which anti-emetic is used in management of cerebral causes of N&V in palliative care?

(2)

A

1) Cyclizine (if raised ICP)

2) Dexamethasone

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16
Q

Which anti-emetic is used in management of anxiety/anticipatory nausea in palliative care?

A

Benzos e.g. lorazepam

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17
Q

1st line choice of anxiolytic (for agitation) in palliative care?

A

Haloperidol

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18
Q

In the terminal phase, what is agitation of restlessness best treated with?

(i.e. anticipatory meds)

A

Midazolam

2.5 – 5mg SC.

Do not repeat within 1 hour, maximum 4 doses in 24 hours.

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19
Q

anticipatory medications used for respiratory tract secretions?

A

1) hyoscine butylbromide: 20mg SC

2) hyoscine hydrobromide

3) glycopyrronium

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20
Q

Mechanism of hyoscine butylbromide?

A

Anticholinergic effect

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21
Q

What are 2 indications for the use of a syringe driver in patients nearing the end of life?

A

1) requiring 2 or more doses of any one of the anticipatory medications in a 24 hour period

2) being unable to take oral meds that need replacing

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22
Q

What 2 groups can pain be broadly split into?

A

1) Nociceptive

2) Neuropathic

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23
Q

What is nociceptive pain?

A

Pain caused by damage to body tissue

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24
Q

What are the 2 types of nociceptive pain?

A

1) somatic (skin, muscle, bones)

2) visceral (internal organs)

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25
Q

What is neuropathic pain?

A

Direct damage to nerve tissue (peripheral or central)

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26
Q

What are adjuvant analgesics?

A

1) Neuropathic agents –> amitriptyline, pregabalin, gabapentin

2) Corticosteroids

3) NSAIDs

4) Non-pharmalogical –> TENS, radiotherapy, acupuncture, heat

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27
Q

Give 3 administration options for the regular background opioid

A

1) Oral modified release 12 hours (BD) e.g. MST, zomorph

2) 24h syringe driver

3) Transdermal patch e.g. fentanyl, buprenorphine

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28
Q

What is usual starting dose of a strong opioid?

A

5-10mg modified release morphine

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29
Q

Are opioids a cause of pruritus?

A

Yes

30
Q

How are opioids excreted?

A

Renally

Caution prescribing in renal impairment due to increased risk of opioid accumulation and subsequent toxicity

31
Q

For patients with renal impairment, what opioid is preferred? Why?

A

Oxycodone - primarily metabolised by liver

32
Q

In patients with mild renal or hepatic impairment, how should an opioid dose be changed?

A

Doses should be reduced by 50%

Specialist advice should be sought before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment.

33
Q

Are opioids safe in breastfeeding?

A

No

34
Q

Max paracetamol dose in 24h?

A

4g

35
Q

What 3 classes of drugs can interact with NSAIDs and increase risk of bleeding?

A

1) Anticoagulants (e.g. warfarin)

2) Antiplatelets (e.g. aspirin)

2) SSRIs (e.g. sertraline)

36
Q

How do NSAIDs affect the kidneys?
1) sodium levels
2) potassium levels

A

Can decrease renal function and lead to:

1) hyponatraemia
2) hyperkalaemia

37
Q

What 2 classes of drugs can interact with NSAIDs and increase risk of electrolyte imbalances?

A

1) ACEi –> increased risk of hyperkalaemia

2) Diuretics e.g. spironolactone (increased risk of hyponatraemia or hyperkalaemia)

38
Q

How do NSAIDs affect seizure activity?

A

Can worsen seizure threshold

39
Q

What class of drugs can interact with NSAIDs and increase risk of seizures?

A

Fluoroquinolone antibiotics (e.g. ciprofloxacin)

40
Q

Whart are 2 key side effects of fluoroquinolones (e.g. ciprofloxacin)?

A

1) lower seizure threshold

2) risk of tendon rupture

41
Q

Typical drug dose for oral codeine?

A

30-60mg every 4 hours as required

42
Q

What 3 doses does co-codamol come in?

A

8/500mg
15/500mg
30/500mg

43
Q

Before prescribing any strong opiate, consider ABC.

What is this?

A

A - start antiemetic

B - consider breakthrough pain

C- constipation, prescribe laxative

44
Q

Typical drug dosing for (oral) morphine in acute pain?

A

Initially 10mg every 4 hours

45
Q

What class of medication is duloxetine?

A

SNRI

46
Q

What can be considered for people with localised neuropathic pain who wish to avoid oral treatments?

A

Capsaicin cream

47
Q

Side effects of cyclizine?

A

Dry mouth
Hypotension
Drowsiness

(antihistamine with some anticholinergic properties)

48
Q

Major contraindication of metoclopramide?

A

Parkinson’s (use domperidone instead)

49
Q

What anti-emetic is typically chosen for toxic causes of N&V?

e.g. hypercalcaemia

A

Haloperidol

50
Q

What are the 2 chosen anti-emetics for end of life?

A

1) haloperidol

2) levopromethazine

51
Q

Contraindications of haloperidol and levomepromazine?

A

Parkinson’s

52
Q

Most common side effect of ondansetron?

A

Constipation

53
Q

What are the 4 main types of laxatives?

A

1) bulk forming e.g. ispaghula husk

2) stimulant e.g. senna

3) osmotic e.g. lactulose

4) softener e.g. docusate

54
Q

What is the 1st line laxative in palliative care?

A

Senna

55
Q

What can be used in reducing the discomfort associated with a painful mouth that may occur at the end of life?

A

Benzydamine hydrochloride spray/mouthwash

56
Q

1st line anti-emetic for intracranial causes of nausea and vomiting?

A

Cyclizine

57
Q

3 options for metastatic bone pain?

A

1) analgesia
2) bisphosphonates
3) radiotherapy

58
Q

Pharmacological managment of confusion/agitation in palliative care but for patients NOT in the terminal phase?

A

Oral haloperidol (if the patient was in the terminal phase and agitated then SC midazolam would be indicated)

59
Q

What can be used to manage bowel colic in palliative care?

A

Hyoscine butylbromide

60
Q

Pharmacological management of hiccups in palliative care?

A

Chlorpromazine or haloperidol

61
Q

What is the benzodiazepine of choice in terminal agitation/restlessness?

A

Midazolam

62
Q

Why is diazepam not given as an end of life drug?

A

Irritant when given SC

63
Q

What is 1st line in cancer related breathlessness when no reversible element?

A

Low dose immediate release PO morphine (i.e. oramorph)

64
Q

Describe performance status 1-5

A

0 = normal

1 = symptomatic & ambulatory, cares for self

2 = ambulatory >50% of time

3 = ambulatory <50% of time

4 = bedridden

5 = dead

65
Q

How does metoclopramide achieve the effect of increased gastric emptying?

A

Antagonist of muscarinic receptor inhibition –> i.e. increased ACh

66
Q

Starting syringe driver dose of metoclopramide?

A

30mg

67
Q

Side effects of haloperidol?

A

1) EPSEs

2) Anticholinergic effects

3) Hyperprolactinaemia

4) Antiadreneric e.g. prolonged QT interval

5) Risk of NMS

6) Sedation

68
Q

Contraindications of haloperidol?

A

1) LBD

2) Parkinson’s disease

3) CNS depression

4) Congenital long QT syndrome

5) Recent acute MI

6) History of torsades de pointes

69
Q

What can be used to treat bowel colic 2ary to mechanical obstruction?

A

Hyoscine butylbromide

70
Q
A

Yr 5 - Palliative Care (1 decks)

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