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PR3136 > Supportive care > Flashcards

Supportive care Flashcards

1
Q

List the common sx in advanced cancer

A
  • Constipation x Diarrhea
  • Intestinal Obstruction
  • Dyspnea
  • NNV
  • Depression
  • Xerostomia
  • Delirium
  • Pruritis
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2
Q

Causes of Constipation in Advanced Cancer

A
  1. Biochemical: Hyper-Ca/Hypo-K
  2. Fluid depletion: Poor fluid intake, or increased loss
  3. Medication: Opioids, Ca, Fe
  4. Weakness: Inability to raise intra-abdominal Pa
  5. Disease related: Immoility, tumour-mediated obstruction, Decreased food intake, low residue diet
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3
Q

Complications of Constipation in Advanced Cancer and how are the complications caused?

A
  1. Obstruction: Cause Faecal incontinence
  2. Urinary Retention: Confusion/restlessness if severe
  3. Colic/ constant abdominal discomfort: Overflow diarrhea
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4
Q

What are the two considerations that must be done before prescribing medications to cancer patients who present with constipation?

A
  1. Rule out obstruction
  2. Consider the underlying cause of the constipation (e.g. Hyper-Ca, drugs)

Purpose: To find out whether there is really a need for laxatives

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5
Q

Three classes of laxatives that can be used in patients with constipation. Name some examples for each class and describe their MoA.

A
  1. Bulk forming: Fybogel, Metamucil
    - Intraluminal fluid retention: Soften faeces and stimulates peristalsis
  2. Osmotic Laxatives: Lactulose, Forlax, Phosephate Enemas, PEG
    - Draw fluid into bowel by osmosis
  3. Stimulant Laxatives: Senna, Bisacodyl
    - Stimulate peristalsis directly by irritating SM
    - Alter water and electrolyte secretion = fluid accumulation in intestine
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6
Q

Dosing for the following drugs for adults:

  1. Fybogel
  2. Senna
  3. Bisacodyl
  4. Lactulose
A
  1. Fybogel 1 sachet bd
  2. Senna 2-4 tabs daily
  3. Bisacodyl 5-10mg ON, max 20mg a day
  4. Lactulose 10-15mL bd
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7
Q

In cancer patients with constipation, if the rectum is impacted, what are the management plans if:

  1. Stools are soft
  2. Stools are hard
A
  1. If stools are soft:
    - Use rectal stimulant (supp. / P enema)
    - Once disimpacted, use PO laxatives
  2. If stools are hard:
    - Lubricate using glycerin supps/ Soften with olive oil enema, then P enema once softened
    - Once disimpacted, use PO laxatives
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8
Q

In cancer patients with constipation, if the rectum is empty, what are the management plans if:

  1. Rectum is empty but not dilated
  2. Rectum is “ballooned” (dilated)
A
  1. If not dilated:
    - Exclude obstruction
    - Ensure patient on regular laxatives
    - Consider adding osmotic laxatives for 3 days
  2. If rectum is “Ballooned”
    - Constipation is higher up
    - Give P enema for several days till constipation resolves
    - Check for presence of colic:
    > If present, reduce stimulant laxative, add softener/osmotic agent
    > If absent: add/increase stimulant laxative, w or w/o softener
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9
Q

In cancer patients, what are some advices on preventing constipation

A
  1. Prevention before constipation develops
  2. Use regular laxatives in patients on opioids
  3. Encourage fluids like fruit juice/ fruits
  4. Always optimise patients’ existing laxative regimen
  5. Monitor bowel habit
  6. Educate patient and family member
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10
Q

What is the most likely cause of Intestinal Obstruction (I/O) in Cancer patients and what are some ways in which I/O is classified?

A

Cause: Malignancy

Classifications:

  1. Upper vs Lower
  2. Mechanical vs Functional (whether motility issue)
  3. Complete vs Incomplete
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11
Q

Goal of managing I/O and the general management for I/O

A

Goal: Reverse obstruction and provide sx relief

  1. Gut Rest
  2. NBM (Nil by Mouth) – restriction from eating and drinking
  3. IV Hydration
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12
Q

Compare the sx of upper GI and lower GI I/O

Hint: VCAAA

A

Upper GI VS Lower GI:

  1. Vomiting: Bilious, large vol. VS Faeculent, small vol.
  2. Constipation: Late VS Early feature
  3. Anorexia: Early VS Late feature
  4. Abdominal distension: May be absent VS present
  5. Abdominal Pain: Both have, can be colicky/ constant pain
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13
Q

What are the approach to managing I/O according to whether it is:

  • Potentially operable or not
  • Whether I/O is complete or imcomplete
A
  1. Operable: Consider stenting
  2. Not operable: Cannot stent. Trial Steriods 8-16mg to reduce peritumoral edema and improve intestinal transit
  3. Complete I/O:
    - Opioids + cholinergics if colic
    - NNV: Trial haloperidol; consider NGT/octreotide in high vol vomiting
    - Prokinetics C/I due to perforation risk
  4. Incomplete I/O
    - Fentanyl + buscopan if pain not relieved
    - NNV: Metoclopramide
    - Continue high fleet/lactulose to clear bowels
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14
Q

What are some dietary advices for I/O patients?

A

Take low residue/low fiber diet:

  • Avoid food made with seeds/nuts or raw/dried food
  • Avoid whole grain breads and cereals
  • Avoid raw fruits/vege. Remove skin before cooking
  • Limit fat intake
  • Avoid tough fibrous meats
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15
Q

Define Diarrhea

A

> 3 unformed stools within 24h

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16
Q

What are possible causes of Diarrhea in cancer patient?

A
  1. Diet: Fruit, spicy, alc
  2. Treatment-related: Radio, Chemo
  3. Medications: Laxatives, antacids, Abx, NSAIDs, Chemo, sugar-free elixirs
  4. Disease-related: Pancreatic insufficiency, Inflammatory bowel disease (e.g. Crohn)
  5. Others: Fecal impaction = diarrhea due to overflow
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17
Q

What are the two considerations that must be done before prescribing medications to cancer patients who present with diarrhea?

A
  1. Rule out fecal impaction, I/O and infective causes

2. Consider underlying causes (e.g. drugs, disease, diet)

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18
Q

List the pharmacological management of Diarrhea and their dosage. What is the common SE and C/I for all of the drugs?

A
  1. Codeine Phosphate 30-60mg q4-6h PRN
  2. Octreotide (somatostatin analogue) 50-200mcg SC bd-tds
  3. Loperamide HCl 4-16mg OD
  4. Diphenoxylate/atropine 1-2 tabs 3-4 times a day, max 8/day

Common SE: Constipation
Common C/I: Infectious Diarrhea

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19
Q

Some cautions when using: the following drugs in managing diarrhea:

  • Codeine Phosphate
  • Diphenoxylate/atropine
A
  1. Codeine Phosphate:
    - Avoid use in respiratory disease (risk of resp depression)
    - Avoid concurrent use of sedatives, narcotics or alcohol
  2. Diphenoxylate/atropine:
    - Caution in Elderly (anticholinergic SE)
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20
Q

Non-pharmacological advices for managing diarrhea in cancer patients

A
  1. Small frequent meals
  2. Low fiber-food (e.g. white bread/rice)
  3. Maintain adequate fluid intake (2L/day)
  4. Avoid high-fiber food, coffee/tea/milk/milk products, alc and sweets, and fried/spiced food
  5. Gradually reintroduce proteins then fats in diet as diarrhea resolves
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21
Q

What is carcinoid syndrome in cancer patients, and what is one management option?

A

Sx secondary to carcinoid tumours such as edema and flushing

Management; Octreotide

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22
Q

Define Dyspnea. Why is it significant in cancer treatment?

A

A subjective experience of breathing discomfort consisting of qualitatively distinct sensations that vary

Significant as it is one of the top reason to visit the emergency department

23
Q

Possible causes of Dyspnea in Cancer patients

CARS

A
  1. Respiratory-related: e.g. pleural effusion, COPD exacerbation
  2. CV-related: e.g. pericardial effusion, CHF
  3. Abdominal related: E.g. ascites
  4. Systemic causes: E.g. anaemia
24
Q

General Principles of managing dyspnea

A
  • Treat reversible cause and underlying disease to get the best relief
  • Non-drug measures are essential, but meds rq if illness progress
25
Q

List of Management options for Dyspnea and when to use them

A
  1. Oxygen: Hypoxic patients
  2. Opioids: SOB at rest/minimal exertion @ terminal phase in cancer.non-cancer patients
  3. Steroids to reduce peri-tumoural edema
  4. Anxiolytics: Anxious patients not responding to opioids alone
  5. Treatment of secretions to help expectorate if patients can
26
Q

List the drugs and their dosing in the management of dyspnea in cancer patients

A
  1. Opioids:
    - Morphine 2.5-5mg q4h PRN
    - Fentanyl for renal impairment 6mcg/h to SC/IV 5-10mcg/h (severe)
  2. Steroids: Dexamethasone 8-16mg/day
  3. Anxiolytics
    - S/L Lorazepam 0.5mg PRN/bd
    - IV/SC Midalozam 5-10mg/24h, w PRN 2.5mg up to 2-4 hourly for breakthroughs
    - Escitalopram 10-20mg OD for panic attack
  4. Treatment of secretions:
    - Nebulised NaCl 0.9%, 5mL PRN
    - Buscopan SC 20mg PRN/q6h or Cl 60-240mg OD
27
Q

What are some advice to cancer patients with Dyspnea

A
  1. Break tasks
  2. Learn breathing and anxiety mngt techniques
  3. Find comfortable positions
  4. Increase airflow like using fans
  5. Opioid users: consider breakthrough opioids before major tasks/movements
  6. Longer prognosis: join support grps and rehab programs
28
Q

Distinguish between Nausea, Retching and Vomiting/emesis

A
  • Nausea: Subjective unpleasant sensation, associated with flushing, tachycardia, and awareness of urge to vomit
  • Retching: Spasmodic contractions of diaphragm, thoracic and abdominal wall muscles, without expulsion of gastric contents
  • Vomiting/emesis: Contraction of abdominal muscles, descent of diaphragm and opening of gastric cardia, resulting in expulsion of stomach contents from mouth
29
Q

Possible causes of NNV in cancer patients

A
  1. Biochemical: Chem/toxic causes - E.g. Opioid, chemo, hyperCa, uremia
  2. Treatment related: Radio/chemo
  3. Opioids
  4. Multifactorial/unknown/refractor or Higher Centres (e.g. pain/fear/anxiety)
  5. Disease-related: Tumour obstruction, I/O, gastric stasis, raised ICP from brain metastases

(ICP: intracranial Pressure)

30
Q

Considerations before prescribing for established NNV

A
  1. Hx SEPARATELY for N and V
    - Triggers
    - Exacerbating and relieving factors
    - Bowel habit
    - Meds that may be causing it
    - Any drugs tried and routes used
  2. Exclude regurgitation (different approach)
  3. Check concurrent sx
31
Q

List the Pharmacological management of NNV. State their MoA and their ORAL doses

A
  1. Domperidone: Prokinetic 10-20mg tds
  2. Metoclopramide: D2 antagonist, prokinetic 10mg tds - 20mg qds
  3. Haloperidol: D antagonist 0.5-1.5mg ON - 5mg BD
  4. Ondansetron: 5HT3 antagonist 4mg BD - 8mg tds
  5. Buclizine: Anti-H on vestibular system 50mg tds
  6. Mirtazapine: NaSSa 7.5-15mg ON, max 45mg OD
  7. Olanzapine: H, HT, M, D antagonist 2.5-10mg ON
32
Q

List the Pharmacological options for NNV that are available via SC or IV route and state their dose

A
  1. Metoclopramide: 30-40mg/24h max 240mg/24h
  2. Haloperidol 0.5-15mg/24h max 10mg/24h
  3. Ondansetron 8-16mg/24h
33
Q

Advices for cancer patient experience NNV

A
  1. Eat 6-8 small meals
  2. Rinse mouth before eating with 1 tsp of baking soda/NaHCO3 to remove bad taste
  3. Avoid hot spicy, sweet, fatty, greasy food
  4. Find relaxed atmosphere to eat
  5. Candies like lemon drops and peppermints can relieve nausea
  6. Drink clear liquids as often as possible to prevent dehydration
34
Q

Match the NNV drug class to the causes of NNV

A
  1. D antagonist/Haloperidol: Clinical toxicity or metabolic/biochem upset
  2. Prokinetic: Motility disorders
  3. Anti-M or Anti-H, steroids, prochlorperazine: Intracranial disorders (e.g. motion disorders, vestibular dysfunc)
  4. Anti-M or Anti-H: Oral/pharangeal/oesophageal irritation
  5. Broad spectrum anti-emetic: Unknown/multifactorial/refractory cause
  6. Optimise pain control for higher centres
  7. Local guidelines: For chemo/radio induced Nnv
35
Q

What are some ways to manage depression in cancer patients?

A
  1. Allow patients to express feelings and involve them in decision/plans
  2. Explain disorder in terms of reaction to their illness and situation
  3. Explore support mechanisms: e.g. psychiatrist
  4. Consider therapy with psychological benefits (e.g. relaxation)
36
Q

What are some considerations before pharmacological management in depression

A
  1. No evi of superior efficacy for particular anti-depressant
  2. Use what was used and was effective before
  3. Consider SE + co-morbid illness
  4. Check for DDI
  5. Consider therapeutic benefit when choosing therapy
37
Q

Cornerstone class of medication used to manage depression in cancer patients

A

SSRI

38
Q

Goals of pharmacologic treatment for depression in cancer patients

A
  • Resolve current sx

- Prevent further episodes of depression

39
Q

important counselling point for cancer patients who are receiving antidepressant

A

AE occurs immediately but resolution of sx take 2-4 weeks or longer. Hence adherence is essential even if patient feels no effect

40
Q

What to rule out when evaluating a patient for presence of depresison?

A
  1. Medical causes

2. Drug-induced depression

41
Q

Preferred therapy for mild depression

A

psychological support (as effective as medication)

42
Q

Benefit of mirtazapine in patients with depression

A

Well tolerated in the elderly and patients with heart failure

43
Q

Define Xerostomia. What are its symptoms?

A

Dryness of mouth caused by alterations in salivation

  • Affect eating sleeping, speaking and physical exercise
  • Patient may rq expectorate more frequently, or manually remove thick saliva
44
Q

Possible causes of Xerostomia in Cancer Patients

A
  1. Radio to neck and head
  2. Surgery of head and neck, involving removal of salivary glands
  3. Some Chemo agents
  4. Oral infections
45
Q

Pharmacologic option for Xerostomia

A

Pilocarpine 5-10mL tds

46
Q

Non-pharmacologicals for Xerostomia in cancer patients

A
  1. Frequent oral rinses and sips of water/juice (e.g. papaya juice to dissolve saliva)
  2. Mouth care before and after meals, and at bedtimes
  3. Foods: choose soft and moist foods, use gravies and sauces, avoid dry and sticky foods like peanut butter/bread
  4. Increase fluid intake during meals and avoid alc and carbonated drinks
  5. Suck/chew on hard sugarless candies and gum
  6. Lubricate oral cavity
  7. Use lip moisturiser to prevent drying and lips chapping
47
Q

The three types of delirium that may be experienced by cancer patients

A
  1. Hyperactive: Increased arousal and agitation
  2. Hypoactive: often missed/ misdiagnosed as depression
  3. Mixed pattern
48
Q

Possible causes of Delirium in cancer patients. What are the nature of these causes

A

Main point: Causes are complex and multifactorial

  1. Drugs (e.g. opioids, anti-M)
  2. Drug withdrawl (e.g. nicotine, sedatives)
  3. Dehydration, constipation, urinary rentention, uncontrolled pain
  4. Liver/renal impairment, electrolyte disturbances
  5. Visual impairment and deafness
  6. Depression, dementia
49
Q

Assessment tools for Delirium. What is the most important factor in assessing patients?

A

Most important: Get accurate hx from someone who knows patient

Tools:

  • Mini-mental state examination (MMSE)
  • Confusion Assessment method (CAM)
50
Q

Pharmacological management of Delirium

A
  1. Haloperidol 500mcg-3mg PO/SC OD
    - Maintenance for cases that are not reversible: 500mcg-3mg PO or 2mg SC OD
  2. BZDs
    - Lorazepam 500mcg-1mg PO/SL
    - Midazolam SC 2-5mg, q1-2h
    - Diazepam PO/PR 5mg q8-12h
51
Q

Important points to take note about Delirium in cancer patients

A
  1. Attention to environment is essential
  2. Elderly: Opioid toxicity common cause of delirium
  3. Corticosteroids: can cause florid delirium
  4. Encourage patients to keep taking oral fluids if can
  5. Presence of close friend/relative helps reassure patient
52
Q

Pharmacological and non-pharmacological management of pruritis in cancer patients

A
  1. Emollients PRN, and as soap substitute
  2. Crotamiton 10%/Capsaicin 0.025% cream for localised itch
  3. Topical steroids
  4. Lidocaine patches: Review benefit after 3 days
53
Q

Important points to take note regarding the agents used for Pruritis in cancer patients

A
  1. Avoid topical anti-H: may cause contact dermatitis
  2. Avoid vasodilators (e.g. caffeine, alc, spices)
  3. Systemic treatment usually unnecessary, reserved for patients with sx despite topical therapy
  4. Ointments relieve dry skin better than creams/lotion, but take longer to be absorbed into skin, and may not be as well tolerated

PR3136 (18 decks)

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