Supportive Care (Part 2)

Question 1

Causes of nausea

Answer 1

1. Disease-related: tumour obstruction, intestinal obstruction, gastric stasis, raised ICP from brain metastases
2. Biochemical: chemical/toxic causes (hypercalcemia, uraemia, drugs)
3. Treatment-related: radiotherapy, chemotherapy
4. Supportive medications: opioids

Question 2

Before prescribing for established nausea/vomiting:

Answer 2

1. History - a separate history for both nausea and vomiting
2. exclude regurgitation
3. check for other concurrent symptoms

Question 3

Nausea and vomiting - management

Answer 3

1. Metoclopramide (first-line, is a prokinetic)
   2, Haloperidol (dopamine agonist, another option)
2. Ondansetron, mirtazapine, olanzapine - not first line

Question 4

Nausea and vomiting - non-pharmacological advice

Answer 4

1. Breaking up into smaller meals/day rather than 3 large meals
2. Rinse mouth before eating with 1 teaspoon of soda/sodium bicarbonate powder to remove bad tastes
3. Avoid hot spicy foods / foods that are very sweet, fatty or greasy
4. Find a peaceful eating place / relaxed atmosphere
5. Certain candies like lemon drops, peppermints can relieve nausea
6. Drink clear liquids as much as possible to relieve diarrhoea

Question 5

Dopamine receptor antagonists

1. Types of drugs
2. Causes

Answer 5

1. Metoclopramide, haloperidol

2. Clinical toxicity, metabolic/biochemical upset

Question 6

Drugs that cause motility disorders

Answer 6

Prokinetics - metoclopramide, domperidone

Question 7

Drugs that cause intracranial disorders , as well as oral or pharyngeal irritation

Answer 7

Anticholinergic or antihistamine (hyoscine, prochlorperazine

Question 8

Management of depression

Answer 8

• set aside time for patient to clarify concerns and express his feelings
• explain their disorder to them in terms of illness and situation, as well as supportive mechanism
• recommend CBT, relaxation and creative therapies with psychological benefits etc.

Question 9

Assessment of depression (palliative care)

Answer 9

PHQ-9 tool

Question 10

Antidepressant common treatment medications

Answer 10

SSRI, mirtazapine

Question 11

Cause of xerostomia

Answer 11

• radiation therapy to the neck and head area
• surgery of the neck and head involving the removal of salivary glands
• certain chemotherapeutic agents
• oral infections

Question 12

management of xerostomia

Answer 12

1. frequent oral rinses and sips of water or juice (papaya).
2. mouth care before or after meals. Avoid dry, sticky foods and choose soft, moist foods instead.
3. Increase intake of fluids during meals (avoid alcohol and carbonated drinks)
4. Suck on hard sugarless candies or chew on surgarless gum to lubricate the oral cavity
5. Apply lip moisturiser (pilocarpine) to prevent drying and chapping of lips.

Question 13

Characteristics of delirium, as well as types of delirium

Answer 13

• acutely confused, agitated and restless
• types:
  1. hyperactive: increased arousal and agitation
  2. hypoactive: quiet, withdrawn and inactive
  3. mixed pattern

Question 14

Assessment of delirium

Answer 14

• MMSE, CAM
• check for infection (urine infection in the elderly)
• assess for opioid toxicity (reduce opioid dose by a third, consider switching if delirium persists)
• check for sensory impairment
• check for constipation, urinary retention or catheter problems.

Question 15

Pharmacological management

Answer 15

First choice: haloperidol, dose once orally or subcutaneously and repeat 2 hours again if necessary.
» maintenance dose may be needed.

Second choice: benzodiazepines
» do not improve cognition but help with anxiety.
» PO or SLT lorazepam
» SC midazolam 1-2 hourly, or PO diazepam 8-12 hourly

Question 16

pruritis management for:

1. Cholestasis
2. Uremia
3. Lymphoma
4. Opioid-induced pruritus
5. Paraneoplastic

Answer 16

1. rifampicin, sertraline, cholestyramine (once daily)
2. gabapentin (administer naltrexone in the event of renal impairment, or dose adjust) (once daily)
3. prednisolone (three times daily)
4. chlorpheniramine (use three times daily if there’s benefit)
5. paroxetine (once daily)

Question 17

pruritus non-pharmacological management

Answer 17

• use emollient frequently and liberally, as moisturiser
• add emollient to bath water, use emollient as soap substitute
• apply topical corticosteroids once daily for 2-3 days if the area is infected but not inflamed, review after 7 days.
• review benefit of lidocaine patches after 3 days

Question 18

pruritus practice points

Answer 18

• avoid topical antihistamines: may cause contact dermatitis
• avoid vasodilators such as caffeine, alcohol, spices and hot water.
• ointments take longer to be absorbed into the skin, may not be as well tolerated.