Symptom control / Cancer pain Flashcards by Lorna Chapman

What is the medication used in palliative care for pain symptoms control?

Morphine sulfate (1st line),
oxycodone (2nd line),

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What is the medication used in palliative care for pain symptoms control if renal impairment?

fentanyl/alfentanyl or

buprenorphine (renal impairment)

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What medication is used for pain control if Nil by mouth/unsafe swallow?

transdermal fentanyl if NBM/ unsafe swallow

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As well as just giving pain meds for palliative pain what else should be done?

non-medical managment: support etc
+ treat cause of bone pain
e.g. urinary retention, bowel spasm, bony mets –>
if metastatic bone pain = bisphosphonates or radiotherapy

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What is the medication used for agitation?

Midazolam 2.5-5mg/4h

Or levopromazine 12.5mg SC 6-12hrly

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What medications / must be done for N&V?

Haloperidol 1-2.5mg/8h

or cyclizine 50mg/8h,

+ treat reversible causes e.g. laxatives (constipation can –>N&V)

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What medication is used for the symptom control of respiratory secretions?

Hycosine hydrobromide 0.4mg/8h

or glycopyrronium 1.2-2mg/24h SC

(anti-cholinergics)

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antacids, chlorpromazine and haloperidol can helpn with what palliative symptoms?

Hiccups

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O2, morphine, relaxation techniques, open windows & fans can help with what palliative symptom?

SOB

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emollients, chlorphenamine, cetrizine, colestryamina and ondanestron can help with which palliative symptom?

Pruritus

Chlorphenamina = anti histamine

colestryamine = obstructive jaundice

Ondansetron (5HT antagonist dc comm. in the vomiting centre)

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Saline neds, antihistamines, simple/codeine linctus, morphine

all help with what palliative symptom?

cough

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checking: Ca2+ or dehydration,

& try bisacodyl 5mg at night

helps with what palliative symptom?

constipation

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How can palliative pts look after their mouths?

treat any candida infections,
chewing ice chips/pineapple chunks/gum;
mouth washes,
chlorhexidine & saliva substitutes

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What do D2 antagonists, H1 antagonists, phenothiazines and 5HT antagonists all have in common?

they can act as N&V prophylaxis and treatment!

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metoclopramide & domperidone are D2 antagonists what are their MOA & indications…?

block dopamine in the chemoreceptor trigger zone (CTZ)
- TF used in drug induced nausea
& works in the GUT promoting gastric empyting
- TF good for opioids, gastroparesis

Indication: N&V (prophylaxis & treatment) - particularly reduced gut motility

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What are the adverse effects & CI/interactions of metroclopramide and domperidone?

(D2 antagonists used for N&V proph and Rx - particularly in reduced gut motility)

Adverse effects TF:

Diarrhoea (inc gastric emptying)
extra pyramidal
acute dystonic reaction

Contraindications:

CI: gastrointestinal obstruction & perforation (pro-kinetic)
Caution: SE’s ↑common in children & young adults
Interactions: extra-pyramidal SEs↑w/ anti-psychotics, don’t prescribe w/ Parkinson’s meds (as these are D2 agonists)

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Cyclizine, cinnarizine and promethazine are all H1 antagonists. WHat are their MoA and indications?

Block H1 & Ach musc in vomiting centre & vestibular system
- Rx: N&V of a wide range of causes - (drug, post-op, radiotherapy) - prophylaxis & treatment
- particularly motion sickness or vertigo

What are the adverse effects and CI/interactions of Cyclizine, cinnarizine and promethazine?

are all H1 antagonists - N&V (prophylaxis & treatment) – particularly motion sickness, vertigo

Adverse effects: Drowsiness, anti-cholinergic effects, tachycardia

Caution: hepatic encephalopathy (sedating effect), prostatic hypertrophy (risk of urinary retention)

Interactions: other sedating or anti-cholinergic drugs may enhance effects

prochlorperazine and chlorpromazine are both phenothiazines. What are their MoA and indications for Rx?

Block D2 in Chemoreceptor Trigger Zone & gut, H1 antagonists and Ach musc. as above

TF good for:

N&V (prophylaxis & treatment) –& vertigo but SE’s!! (as blocks all the receptors of both D2 antagonists and H1 antagonists)
Psychotic disorders (typical antipsychotic)

prochlorperazine and chlorpromazine are both phenothiazines what are their adverse effects/CI & interactions?

prochlorperazine and chlorpromazine are both phenothiazines that block D2 in the CTZ & gut, H1 and Ach musc.

Adverse effects:

Drowsiness, (H1)
postural hypotension,
extra-pyramidal, (D2)
acute dystonic reaction, (D2)
tardive dyskinesia, (D2)
QT-interval prolongation (D2)

Cautions/interactions:

Caution: severe liver disease (SE’s & hepatotoxicity), prostatic hypertrophy (risk of urinary retention) [H1 antagonists]

Reduce doses in elderly

Interactions: drugs that prolong the QT interval (anti-psychotics, amiodarone, ciprofloxacin, macrolides, quinine, SSRI)

Ondansetron and graniestron are 5-HT3 antagonists. What is their mechanism of action and what are they used as Rx for?

Used for: N&V (prophylaxis & treatment) – general anaesthesia & chemo
- Block 5-HT3 in CTZ
  - drug-induced nausea
- & gut (response to emetogenic stimuli)
  - Gut infection, radiotherapy
- 5HT-3 → vagus nerve → solitary tract nucleus → vomiting centre
- NOT motion (no 5HT communication between vestibular & vomiting centre)

NB: the receptors in the CTZ TF = D2, H1 and 5HT3

 What side effects/cautions/interactions do 5-HT3 antagonists ondansetron, graniestron have?

Rare
- Constipation, diarrhoea (gut response) & headache
Interactions: drugs that prolong the QT interval
- (anti-psychotics, quinine, SSRIs, ciprofloxacin, macrolides)

What are the 2 types of pain?

nociceptive pain - from pain receptors
neuropathic pain - from nerve damage

The 2 types of pain are nocieptive pain (pain receptors) and neuropathi pain (nerve damage)

together total pain = physical + psychological + social + spiritual

There are 2 subtypes of nociceptive pain - what are these & their differences in symptoms?

Somatic -
1. continuous ache,
2. tender to pressure,
3. worse on movement,
4. localised, dull pain
Visceral - (e.g. think period cramps)
1. cramping,
2. deep pain,
3. may be aching/dull,
4. not usually related to movement
5. & poorly localised

The 2 types of pain are nocieptive pain (pain receptors) and neuropathi pain (nerve damage) together total pain = physical + psychological + social + spiritual What are the symptoms of neuropathic pain?

* Burning, stabbing, “electric shock”, shooting * Intermittent * Not movement related * May have allodynia, hyperalgesia, and/or sensory deficit

What things should be included in a pain assessment?

* SOCRATES * impact on QoL * phsychological wellbeing * sleep quality

What are the first 3 steps of the WHO pain ladder?

* Step 1 - * paracetamol +/- NSAIDs (naproxen, diclofenac) * Step 2 - * codeine, tramadol (cognitive SE's e.g. delirium) * Step 3 - * fentanyl, buprenorphine, morphine, diamorphine, oxycodone, methadone, alfentanil

The WHO pain ladder also reccomends beyond the 3 steps to use adjuvants. What are these?

Adjuvants - work in different ways 1. Anti-convulsants e.g. Gabapentin, Pregabalin 2. Antidepressants e.g. Amitriptyline 3. Bisphosphonates 4. Steroids 5. Other treatments e.g. nerve blocks, radiotherapy,

What non-pharmacological approaches are there for pain?

* Trans-cutaneous electrical nerve stimulation (TENS) * Complementary therapy e.g. massage * Counselling * Relaxation techniques * Spiritual support

What is the first line strong opioid for most patients with normal renal function?

**_can be --\> oral or IV_** _Two methods of **oral** administration:_ * _Immediate release_ (e.g. Oramorph liquid, Sevredol tablets): duration of action **4 hours** * _Modified release capsules_ (e.g. Zomorph) or tablets (e.g. MST): duration of action **12 hours**

What other strong, injectable opioids are there?

* Oxycodone (modified or immediate release, injectable) * Alfentanil (injectable) * Diamorphine (injectable)

What transdermal patches are there for pain? When should they not be used?

avoid transdermal if pain is unstable * Buprenorphine: * e.g. Butrans (change every 7 days), * Transtec (change every 96 hours) * Fentanyl: * change every 72 hours **Both Buprenorphine and Fentanyl are significantly more potent than Morphine (100:1)**

What are the legal requirements when prescribing controlled drugs?

1. **Legible** capital letters, indelible ink 2. **Patient** details 3. **Prescriber** details 4. **Drug details**: formulation, strength (if applicable), dose and frequency, total quantity supplied in words and figures 5. **Eliminate space** for additions

What is a syringe driver?

* Use of a syringe driver (CSCI) enables **continuous _subcutaneous_ delivery of drug(s) over 24 hours** * They are **not** limited to end-of-life care and do not signal the ‘terminal phase’ * Other uses include: * intractable nausea/vomiting * dysphagia and * poor oral absorption * Can be a **temporary** measure * Are **not restricted to Morphine**

For morphine dose conversion always convert back to what type whan doing dose conversion What are the conversions between oral opioids\>

Calculations - always covert back to **_oral morphine_** when doing dose conversions Morphine - 1 Codeine - 1/10 Tramadol - 1/10 Oxycodone - 2

What is the conversion from oral --\> subcut morphine?

subcut morphine/oxycodone is 2x as potent Oral --\> subcut morphine divide by 2 Oral --\> subcut oxycodone divide by 2

PRN doses of opioids are available. How are these prescribed vs when should the background opioid dose be reviewed?

* For PRN "as required" opioids --\> \*\*Use **1/6th of the total 24hr** opioid dose * If **\>3 PRN** doses are needed, the background opioid dose should be reviewed \*\*prescribe a regular LAXATIVE and PRN antiemetic (w opioids!!)

What are common **initial** and common _ongoing_ adverse effects of opioid analgesics?

_Common initial:_ * N&V, * drowsiness, * unsteadiness, * delirium (confusion) _Common ongoing:_ * Constipation, * N&V, * dry mouth

What are the occasional and rareadverse effects of opioid analgesics?

_Occasional_: * sweating, * pruritus, * hallucinations, * myoclonus, * urinary retention _Rare_: * respiratory depression, * psychological dependence

What cautions are there in opioid analgesics?

Organ failure * use lower starting doses, * longer dose intervals * & avoid modified release preparations Renal impairment * use opioids without active metabolites where possible e.g. alfenanil

When does opioid toxicity occur?

Often precipitated by another clinical event e.g. AKI, sepsis

What features do these represent? * Drowsiness * Confusion * Myoclonic jerks * Vivid dreams * Hallucinations

**_Opioid toxicity!_** Respiratory depression: rare with careful Opioid titration and a **late** sign