Symptom management + palliative care Flashcards
What are the different types of pain?
Nociceptive - normal nervous system, identifiable lesion causing tissue damage
eg. somatic - skin, muscle, bone
visceral - solid organ
Neuropathic - prob w nervous system, nerve structure damaged
Can be mixed
What is the WHO analgesic ladder and what drugs fit into each bit?
- Simple analgesics/non opioids - paracetamol, NSAIDs, COX-2
- Weak opioids - tramadol, co codamol, codeine, dihydrocodeine
- Strong opioids - diamorphine, morphine, fentanyl, oxycodone
When should you use an NSAID and when should you use a COX-2?
No CVS or GI risk = NSAID eg. naproxen, ibuprofen, diclofenac
GI risk = Cox-2 eg. celecoxib
CV risk = NSAID
Prescribe PPI for all in cancer
What are adjuvants?
Drugs whose primary indication isn’t for pain
Used for pain that doesn’t respond to opioid analgesia
What are some examples of adjuvants?
Amitryptilline and duloxetine = tricyclic antidepressant
Pregabalin and gabapentin = antiepileptics
Diazepam and clonazepam = benzos
Dex
Bisphosphonate for bone pain
What is the dose equivilate of morphine to codeine?
Codeine : morphine = 10:1
eg. 240mg codeine = 24mg morphine
What are some SEs of opioids when used for persistant pain?
Constipation
Dry mouth
N+V
Drowsiness/sedation
What are some opioid prescribing principles?
- If prescribing slow release reg morphine, always prescribe PRN immediate release
- Always prescribe w laxative and anti emetic
What is are the principles for up titration of opioid dose?
If using lots and lots of PRN intermediate release = indicator that not given enough slow release
Add up total daily dose = how much they are taking in 24 hours
TDD divide by 2 = new morphine slow release dose (BD)
TDD divide by 6 = new morphine immediate release PRN dose
What is the ratio of SC to oral morphine?
Oral to SC = 2:1 ???? pretty sure
What are the principles of a fentanyl patch?
Needs to be changed every third day
Takes 12-24 hours to achieve steady state pain relief
Give additional oramoprh PRN
What are the CF of opioid toxicity and what are some causes?
CF - miosis, hallucination, drowsy, vom, confusion, myoclonic jerks, resp depression
Causes - escalated dose too quickly, renal impairment, pain doesn’t respond to opioid but escalated anyway
What do you need to write for a controlled drug prescription?
Drug name, form eg. capsules or oral solution, strength, brand name too
Number of tablets or bottles
Total in words and figures - 1(one)
What is intractable breathlessness? How can it be treated?
Untreatable fixable breathlessness
Normally use morphine ~2.5-5mg
What are the anticipatory meds?
Morphine 2.5-5mg SC PRN - pain and breathlessness
Midazolam 2.5-5mg SC PRN - agitation
Levomepromazaine 2.5-5mg SC PRN - N+V
Glycopyrronium 200-400 mcg SC PRN - resp secretions
What are the indications for a syringe driver?
Uncontrollable vomiting
Unsafe swallow
Decreased conc
>2 doses of anticipatory med
What are the common causes of N+V in a pt w cancer?
Infections eg. UTI, gastro, thrush
Metabolic eg. renal and hepatic impairment, electrolyte disturb
Drug related
Gastric stasis and GI disturb eg. organomegaly, ascites, tumours, obstruction, constipation
Organ damage
Neuro - raised ICP
Anxiety and fear
What are the main anti emetics used in cancer care? What do they act on?
Haloperidol - potent D2 inhibitor
Metoclopramide - D2 inhib
Cyclizine - Ach and histamine inhib
Levomepromazine - acts on everywhere
Ondansetron - seratonin inhib
What are the treatments for different causes of vomiting?
Biochemical - haloperidol
Gastric stasis + func bowel obstruction - metoclopramide
Bowel obstruction and raised ICP - cyclizine and dex
Psychological factors - benzo
Post op/RT/chemo - ondansetron
Constipation - laxatives
Vestibular - prochlorperazine
What are the different types of laxatives?
Stimulant eg. senna
Softener eg. docusate
Osmotic eg. lactulose (bloat), movicol
