Supportive treatment Flashcards
Learning Outcomes At the end of the sessions, you will be able to Describe common symptoms in advanced cancer Understand the causes of these symptoms Know how to assess and recommend management of these symptoms 2
1
Common Symptoms in cancer include: C\_\_ D\_\_ D\_\_ D\_\_ I\_\_ P\_\_ N\_\_ X\_\_
Constipation Diarrhea Dyspnea Depression Delirium Intestinal Obstruction Pruritis Nausea and Vomiting Xerostomia
Constipation can have disease related causes such as i_______
t____ i__ leading to obstruction
Decreased f____ i___ and
L__ r____diet
- Immobility
- Tumor invasion
- food intake
- Low residue (low fibre)
Biochemical fluctuations such as __ and __ can lead to constipation. Fluid depletion via __ and __ may be a factor as well.
- Hypo-Kalaemia
- Hyper-Calcaemia
- Poor fluid intake
- Increased fluid loss
Medication such as __ (90%), __ and __ commonly cause constipation. The inability to __ (weakness) may be a reason as well.
anti cancer drug, ______, can also cause constipation
- opioids
- Iron and Calcium
- raise intra-abdominal pressure
- vinka alkaloids
Constipation cause the following complications :
- *______ or constant ______ discomfort
- __ diarrhea
- *______ obstruction
- __ incontinence
- ____ ____/_____ (due to compressions on bladder)
- *_____ or ______ if severe
- *Colic or constant abdominal discomfort
- Overflow diarrhoea
- Intestinal obstruction
- Faecal incontinence
- Urinary retention/ frequency
- *Confusion or restlessness if severe
Before prescribing laxatives for a constipated patient, we must __ and consider __.
- rule out bowel obstruction
2. underlying causes i.e. Hyper-Calcaemia or drugs
Patients on __ (i.e. Fybogel, Metamucil) should be counselled __. The usual dosing is __.
- bulk forming agents
- to drink extra fluids
- 1 sachet BD
Bulk forming agents can be Unpalatable, cause __ and __. Patients may feel bloated and abdominal discomfort. These agents are not commonly used in __ setting and is contraindicated in __.
- colic
- flatulence
- palliative care
- bowel obstruction
(KIV) Stimulant laxatives are commonly used at high doses in oncology. The usual dose for Senna is __ while the usual dose for bisacodyl is __, Max: __.
- 2-4 tabs daily
2. 5-10mg ON, Max: 20mg OD
Stimulant laxatives (i.e. Senna, Bisacodyl) are not suitable for patients with __. They may cause __, colic and __ due to the continued passing of fluid.
- complete bowel obstruction
- dehydration
- electrolyte imbalance
Patients on osmotic laxatives (i.e. Forlax, Phosphate enemas, PEG, Lactulose) must be counselled to __.
KIV: Lactulose is a commonly dispensed item that has a very sweet flavor and is usually dosed at __.
- drink extra fluids
2. 10-15ml BD
Osmotic laxatives have similar adverse effects as Bulk forming agents and may cause __, flatulence, __ and __ in debilitated patients
- Colic
- Dehydration
- electrolyte imbalance
__ is an osmotic laxative that also increases the stool volume and triggers colon motility via neuromuscular activity.
Macrogol (Forlax)
If the patient’s rectum is impacted with hard stools, we should l__ using ______ or soften with ______ enema, followed by ______ enema once softened. Once disimpacted, we should commence/increase ______ or ______.
- lubricate using glycerin suppositories
- olive oil
- phosphate
- oral stimulant or softener
If the patient’s rectum is impacted with soft stools, we should use a _______ i.e. bisacodyl suppositories or phosphate enema. Once disimpacted, we should commence/increase _______.
- a rectal stimulant
2. oral stimulants
If the patient’s rectum is empty but not dilated, we should exclude i_____ o_____. Ensure that the patient is on r_____ l______ and consider if additional l_____ are required. If exclusions are ruled out, __ are sufficient.
- intestinal obstruction
- regular laxatives
- additional laxatives i.e. osmotic laxatives (oral fleet) 15mls x 3 days
- regular laxatives
If the patient’s rectum is empty but dilated/’ballooned’, it often suggests that the constipation is higher up. We can give ______ over several days until it resolves. If colic is present, we should reduce any _______ and add ________ i.e. Forlax/lactulose. If colic is absent, add or increase _________ with softener being optional.
- high fleet (phosphate) enema
- stimulant laxatives
- softener/osmotic agent
- stimulant laxative
To prevent opioid induced constipation, we must ensure __. By optimizing the patient’s __, we can prevent constipation as well.
- compliance in bowel regime (regular laxatives)
2. existing laxative regimen
To prevent constipation, we should encourage __. Educating the patient and their family to __ is a good idea as well.
- fluid intake, particularly fruit juice and fruit
2. monitor bowel habits
Intestinal obstructions are often caused by cancers and classified by:
- __ vs __ (location)
- __ vs __ (i.e. motility issue)
- Complete vs incomplete
- Upper vs Lower GI tract
2. Mechanical vs Functional
Patient reported symptoms for intestinal obstruction is useful for differentiating __. __ is a common feature.
- location of obstruction
2. Abdominal pain (can be colickly/constant)
Upper GI obstruction suggested when patient presents with __ vomit, an early feature of __ and late feature of __. Abdominal distension may be __.
- bilious, large volume
- anorexia
- constipation
- absent
Lower GI obstruction suggested when patient presents with __ vomit, an early feature of __ and late feature of __. Abdominal distension may be __.
- faeculent, small volume
- constipation
- anorexia
- present
In intestinal obstruction, we want to __ and reverse obstruction if possible. We may do this via __, Nil-by-mouth or __.
- provide symptom relief
- Gut rest
- IV hydration
In complete intestinal obstruction, we may provide pain relief using __ and add on __ for colic. Trial of __ can be used for nausea/vomiting, __ can be used there is a high volume of vomiting.
- Opioids (i.e. morphine as it is most cost-effective)
- anti-cholinergic agents i.e. hyoscine butylbromide (buscopan)
- haloperidol
- NGT or octreotide
For in-complete intestinal obstruction, we may provide pain relief using __ (less constipating) and add on buscopan only if __. __ can be used for nausea/vomiting. We should continue to __ using __.
- fetanyl
- pain is not relieved
- Metoclopramide
- clear bowels
- high fleet/lactulose
If the patient’s intestinal obstruction (I/O) is not operable (i.e. not for stenting), we may consider __ as it can reduce peritumoral edema and improve intestinal transit.
trial of steroids (8-16mg)
Patients with __ are contraindicated for stenting. Patients with __ are also poor candidates due to risk of stent migration. Otherwise, stenting may be a strategy to relieve Intestinal obstruction.
- multiple levels of obstruction
2. rectal tumors
Prokinetics may be contraindicated in complete intestinal obstruction due to __.
risk of perforation
We should advise patients with Intestinal obstruction/Gastric outlet obstruction to:
- Avoid
- ____, ____ or ____ fruits
- ________
- raw fruits/vegetables and remove skins before cooking
- __ meats - Limit __ (can increase stool bulk)
- seeds, nuts or raw/dried
- whole grain
- tough fibrous
- fat intake
Diarrhea can be a distressing and exhausting symptom for both the patient and their carers . It is important to remember that it can be __ and impacts __, mood and __.
- embarrassing
- dignity
- relationships
Diarrhea may be caused by diet when __, __ and __ is consumed.
- fruit
- hot spices
- alcohol
__ and __ (particular when involving abdomen or pelvis) can cause diarrhea.
- Chemotherapy
2. radiotherapy
Certain disease states can cause diarrhoea: __ insufficiency, __ (i.e. Crohn’s disease, ulcerative colitis), gastrointestinal infection and __ (overflow diarrhoea).
- Pancreatic
- inflammatory bowel disease
- faecal impaction
Diarrhoea can occur when the patient is on:
__ (overdose), antacids, antibiotics, __ and __ (sugar free) elixirs.
- Laxatives
- NSAIDs
- disaccharide containing
Before giving pharmacological treatment for diarrhea, we must rule out __, __ and __ related causes. We should consider the underlying cause as well.
- faecal impaction
- intestinal obstruction
- infection
(KIV) Codeine phosphate is dosed at __mg Q__hrs PRN for diarrhoea treatment. (lower than analgesic dose)
- 30-60
2. 4-6
For patients on codeine phosphate, they should avoid concurrent use of n__. Use with caution in patients with __ disease (elimination affected).
- narcotics
2. Hepatic/renal
Codeine phosphate may cause __ and __, which is why it should be used with caution in patients with __ (respiratory conditions). Understandably, concurrent use of __ and __ should be avoided as well.
- sedation
- respiratory depression
- COPD, Asthma
- sedatives
- alcohol
Codeine phosphate may cause c__, n__,
sedation, h__, d__ and respiratory depression in patients as side effects.
- constipation
- nausea
- hypotension
- dry mouth
(kiv) Diphenoxylate/atropine (Lomotil) is dosed at __ tabs __ times daily, Max: __ in oncology diarrhea management.
- 1-2
- 3-4
- 8/day
Diphenoxylate/atropine (Lomotil) should not be used for patients __, __ disease or __ diarrhea.
- <12 years old
- liver
- infectious
Diphenoxylate/atropine (Lomotil) may cause anti-cholinergic side effects, particularly in the elderly. They include: __ and __. Other side effects include: s__, d__ and r__.
- dry mouth
- urinary retention
- Sedation
- dizziness
- rash
(KIV) Loperamide HCl (Imodium) is dosed at __mg (2-4 capsules) daily. Max __/day in oncology diarrhea management.
- 4-16
2. 8 capsules
Loperamide HCl (Imodium) should not be used for patients __, or __ diarrhea.
- <12 years old
2. Infectious
Loperamide HCl (Imodium) can cause similar side effects as diphenoxylate: __, __, skin __, headache
- Constipation
- dry mouth
- rash
(KIV) Octreotide (Sandostatin) is dosed at SC __ mcg, __ times daily in oncology diarrhea management. It works by reducing secretions into the GI compartment and should used __.
note: used when there is a secretory effect from the tumor
- 50-200
- 2-3
- only as a last resort
Octreotide (Sandostatin) should not be used if patients have __.
Infectious diarrhea
Being an injectable, Octreotide (Sandostatin) may cause __. Other side effects include: Nausea, __, __ (rare) and __ imbalance.
- Pain at injection site
- abdominal cramps
- cholelithiasis
- glucose
We should advise diarrhea patients to avoid:
- __ (such as whole grain breads, cereals, raw vegetables, beans, nuts, seeds and dried fruits)
- __ (coffee, tea, milk and milk products, alcohol and sweets)
- __ (fried, greasy, or highly spiced food)
- high fiber food
- Gut stimulants
- Irritating foods