Symptoms Flashcards
D2 antagonists, cat. 1A
more potent and longer acting: haloperidol* (though IV formulations maybe less likely to prolong QTc than orals), olanzapine, chlorpromazine (thorazine, not first-line agent due to risk of sedation).
D2 antagonists, cat. 1B
weaker/shorter acting: examples include prochlorperazine (compazine)
D2 antagonists, cat. 1C
Promotility: metoclopramide* is a promotility agent for gastroparesis. Use for 3 months or more is associated with a risk for tardive dyskinesia, particularly in patients with renal/hepatic impairment, diabetes, or who are older than 70.
Meds besides opioids that constipate
anticholinergics (tricyclic antidepressants, scopolamine, oxybutinin, promethazine, diphenhydramine), lithium, verapamil, bismuth, iron, aluminum, calcium salts.
When patients have multi-organ failure, some paralytics may not be cleared for
2-18 hours. If in doubt, utilize a peripheral nerve stimulator, ok to extubate when you see muscle twitches with 4 consecutive nerve stimulations.
itch is mediated by
unmylenated C fibers
drugs that cause pruritis
opioids, aspirin, drug reactions
More direct cooling agent than calamine or methol
EMLA cream, a mixture of lidocaine and prilocaine
Best medications for itch
combined H1 (classics, first and second gen)/H2 (lower stomach acid, like famotidine)
TCA like doxepin if refractory
Antidepressants for itch, paraneoplastic pruritis
paroxetine, mirtazapine
Antidepressants for itch, CKD pruritis
sertraline, amitriptyline, doxepin (another TCA)
Antidepressants for itch, cholestatic pruritis
sertraline
Ondanstreon and other 5HT3 antagonists treat pruritis caused by
opioids, cholestatis and renal disease
peristent versus intractable hiccups
peristent, longer than 48 hours; intractable, longer than 1 month
hiccup etiologies (10)
gastric or esophageal distention, corticosteroids, idiopathic, post-surgical, chemotherapy, cancer, myocardial infarction, liver disease, uremia, and CNS lesions
Hiccups non-pharm treatments
SSMI (deep deep breathing), HiccAway, breath-holing, hyperventilation, vagal stimulation, carotid massage, rubbing C5 to disrupt phrenic nerve
The only FDA approved drug for hiccups
Chlorpromazine (thorazine) 25mg-50mg PO TID or QID
Anticonvulsants for hiccups (4)
Gabapentin 300-400mg TID
Phenytoin (central hiccups), VAL, CARB
Baclofen for hiccups
the only drug RTC’d, 5mg Q8H, symptomatic relief despite continued hiccuping
Hiccups from stomach distention treatment
metacloprmide 10 q6h
Interventions for refractory hiccups (3)
acupuncture, diaphragmatic pacing electrodes, surgical ablation of the reflex arc
Kaolin and Pectin (Kaopectate) indication and time to effect
diarhhea, 48h, may impair absorbtion of meds
diphenoxylate
Lomotil, opioid that treats diarrhea, more BBB crossing so more side effects than Loperimide (Immodium)
Lopermide (imodium) class and mechanism
opioid, reduces peristalsis, increases water reabsorbtion, only weakly crosses BBB, max dose of 16mg per day, (54mg have been used)
Aspirin and Cholestyramine can reduce the diarrhea in
radiation enteritis. pysllium may also help
Mesalamine treats diarrhea in
IBD
Octreotide treats diarrhea in
HIV, chemo induced, high stoma volume (expensive and IV/SC infusion)
duration of “primary insomnia”
1 month
Benzos for insomnia
short term, improve sleep quality, total sleep time and fewer awakenings; high incidence of amnesia and rebound insomnia
Mechanism of Zolpidem and Zaleplon
Benzodiazepine receptor agonists. These are rapidly absorbed, metabolized by the liver, do not have active metabolites, have low abuse potential and do not cause rebound insomnia
atypical antipsychotics (quetiapine, olanzapine and ziprasidone) in insomnia
Most of the atypical antipsychotics (quetiapine, olanzapine and ziprasidone), except for risperidone, improve total sleep time and/or sleep efficiency in healthy subjects and schizophrenic patients. These may be beneficial in patients with insomnia who do not respond to front-line treatment or insomnia in medically ill patients with delirium.
Melatonin efficacy
not proven! but ramelteon has a short half life, reduces sleep latency and increases total sleep time in older adults with chronic insmonia
Herbal remedies for insomnia
valerian, as effective as mild hypnotics. The major side effects are hepatotoxicity, cardiotoxicity and delirium. Evidence is lacking for other medications like kava kava, L-tryptophan, chamomile, St. John’s wort and Jamaican dogwood.
deathe rattle prognosis
one study indicated the median time from onset of symptoms to death was 16 hours.
meds that worsen death rattle
Medications which increase saliva production (e.g., pilocarpine, clozapine), mucosal irritation (e.g., doxycycline), or dose-dependent drooling as a medication side effect (e.g., clobazam).
scopalomine time to onset
about 12h, 24h to steady state, lasts 72h
glycopyrrolate PO time to onset
30min, lasts 2-4hours
glycoprrolate IV time to onset
1 minute, lasts 7 hours
atropine SL time to onset
30 min, lasts 2 hours
Aerosolized N-acetylcysteine
reduce sputum viscosity to treat death rattle
associated with myoclonus (7)
opioids, anticonvulsants (gabapentin, phenytoin, valproate, lamotrigine, and phenobarbitol), tricyclic antidepressants and selective serotonin reuptake inhibitors, contrast dye, anesthetics, antibiotics (penicillins, cephalosporins, imipenem, and quinolones), cannabinoids and the chemotherapeutic agent ifosfamide
AEDs to treat myoclonus
benzos, LEV, valproate (note, valproate also causes myoclonus!)
Dantrolene
is a msucle relaxant? may treat myoclonus
5-fluoruracil, doxorubicin and methotrexate commonly cause
mucositis (vincristine does not)
Timing of mucositis
1-2 weeks after RT, as soon as 3d after chemo
prevention of RT-indcued mucositis in H/N cancers (4)
povidone iodine rinses; honey swish and spits administered before each radiation dose, daily zinc supplementation, and 5-15 grams of oral glutamine 2-3 times a day may help prevent mucositis.
Shown in RTCs to reduce ucler rate and need for opioids in mucocitis
benzydamine (NSAID)
diagnostic features of panic attack in a dying person
presence of derealization, depersonalization and fear of loss of control are more useful in making the diagnosis of panic disorder in the terminally ill.
Panic attacks, prognosis of several weeks or more
Selective serotonin reuptake inhibitors (SSRI) either as monotherapy or augmented with low dose benzodiazepines for a period of 3 to 4 weeks (taper off benzodiazepines after 3 weeks)
First line for thrush in PC setting
Clotrimazole
Nystatin suspension in immunocompromised patients
much less effective than azoles!
Guaifenesin mechanism
Expectorant! Guaifenesin acts by stimulating gastric mucosa and the gastric nerve to stimulate the cough reflex, and also induces a vagally mediated increase in airway secretion.
Nebulizers for increased secretions
Hypertonic saline, elevated pH of secretions, weakening the saccharide bonds of the mucus. Additive with N-acetylcysteine (Mucomyst, severes glycoproteins); NOT GOOD in COPD (can trigger bronchospasm)
Beta-adrenergic agonists and drugs containing aminophylline improve mucus clearance by
increasing ciliary activity
most prevalent and disabling symptom of cancer
fatigue
Exercise for cancer related fatgieu
Aerobic (low to mod) is ideal, resistance may help, 20-30min 3 days a week
Methylphenyldate for cancer related fatigue
First line? improves fatigue for up to 5 hours as needed. avoid dosing after noon
Modafinil for fatigue
pilots suggest efficacy in depression, MS, ALS, HIV
Antidepressants for fatigue
Bupropion (4 weeks to benefit), Paroxetine (superior to methyphenidate, modafinil, works in weeks to months)
Herbal/other remedies for fatigue
2000mg of genseng qd, acupunture
meds causing dry mouth
antiemetics, antihistamines, antipsychotics, antispasmodics, antidepressants (especially the tricyclics), and bronchodilators, alpha-blockers (e.g. terazosin), alpha-2 agonists (e.g. clonidine), beta-blockers (e.g. metoprolol). Opioids and benzodiazepines cause dry mouth, although the mechanisms are not known.
meds to treat dry mouth
candy with xylitol, vitamin c; cholinergic agonists like pilocarpine, cevimeline (contraindicated in asthma, narrow angle glaucoma; caution in COPD, cardiac dz)
Non-opioid antitussives
don’t work! same as placebo. use expectorants (guaifenesin) and mucomyst/hypertonic saline
opioids for cough
only effective central anti-tussive. suppress the brainstem cough center through mu and kappa opioid receptor agonism; codeine, dextromethorphan, hydrocodone; often compounded with guaf or antihistamines
Tx complicated grief
CBT, group therapy , maybe SSRIs
Prophylactic AEDs for seizure in brain tumor
Don’t work, can dc unless patient has had seziures.
AEDs that can be given rectally
Phenobarbital, pentobarbital, carbamazepine, valproic acid, and lamotrigine (no dose adjustment needed)
Aborting seizures at home
IN midazolam 0.2mg/kg. Rectal diazepam less preferred.
SSRIs and P450 “2D6”
INHIBITORS! Paroxetine and fluoxetine are the strongest CYP2D6 inhibitors, followed, in order of decreasing potency of inhibition, by sertraline, citalopram, and venlafaxine
Best D2 drugs to avoid EPS
Thorazine (chlorpromazine) has a lower risk than other older antipsychotics; quetiapine has lowest D2 receptor affinity; olanzapine is better than risperidone, aripiprazole.
meds to treat EPS if you can’t rotate
mirtazapine, propranolol, clonidine, benadryl, benzos and benztropine
Pain in post-herpetic neuralgia
gabapentin/pregabalin and TCAs, topical lidocaine. Opioids (short course) and magnesium are are second line
drugs that cause urinary retention
antipsychotics, antihistamines, anti-emetics and antidepressants, opioids and anesthetics, alpha-agonists, benzodiazepines, NSAIDs, detrusor relaxants (e.g., oxybutynin), and calcium channel antagonists.
Will naloxone and methylnaltrexone treat urinary retnetion?
Maybe
methylnaltrexone cost, efficacy, contraindications and side effects
$55/dose, 50% within 4 hours, bowel obstrction, nausea, diarrhea and cramping
Cancer patients most at risk for dysguesia (3)
Patients with head and neck cancer and those exposed to tyrosine kinase inhibitors or taxane based regimens
medication for dysguesia
zinc 100-150mg daily, dronabinol 2.5mg BID or alpha lipoic acid
