Symptom control / Cancer pain Flashcards
What is the medication used in palliative care for pain symptoms control?
- Morphine sulfate (1st line),
- oxycodone (2nd line),
What is the medication used in palliative care for pain symptoms control if renal impairment?
fentanyl/alfentanyl or
buprenorphine (renal impairment)
What medication is used for pain control if Nil by mouth/unsafe swallow?
transdermal fentanyl if NBM/ unsafe swallow
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
What is the medication used for agitation?
Midazolam 2.5-5mg/4h
Or levopromazine 12.5mg SC 6-12hrly
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)
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)
antacids, chlorpromazine and haloperidol can helpn with what palliative symptoms?
Hiccups
O2, morphine, relaxation techniques, open windows & fans can help with what palliative symptom?
SOB
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)
Saline neds, antihistamines, simple/codeine linctus, morphine
all help with what palliative symptom?
cough
checking: Ca2+ or dehydration,
& try bisacodyl 5mg at night
helps with what palliative symptom?
constipation
How can palliative pts look after their mouths?
- treat any candida infections,
- chewing ice chips/pineapple chunks/gum;
- mouth washes,
- chlorhexidine & saliva substitutes
What do D2 antagonists, H1 antagonists, phenothiazines and 5HT antagonists all have in common?
they can act as N&V prophylaxis and treatment!
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
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)
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
- Block 5-HT3 in CTZ
- 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 -
- continuous ache,
- tender to pressure,
- worse on movement,
- localised, dull pain
- Visceral - (e.g. think period cramps)
- cramping,
- deep pain,
- may be aching/dull,
- not usually related to movement
- & 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
- Anti-convulsants e.g. Gabapentin, Pregabalin
- Antidepressants e.g. Amitriptyline
- Bisphosphonates
- Steroids
- 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?
- Legible capital letters, indelible ink
- Patient details
- Prescriber details
- Drug details: formulation, strength (if applicable), dose and frequency, total quantity supplied in words and figures
- 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
