Symptoms 2 Flashcards
What is the analgesic ladder?
Step 1: Simple analgesia:
- Paracetamol = 1g PO QDS max; <50kg need to half dose; liver function
- NSAIDs = renal function, bleeding risk, asthma etc; PPI co-prescribe
Step 2: Weak/mild opiates:
- Codeine phosphate = 15-60mg PO QDS max
- (or tramadol if not tolerated; oxycodone etc)
Step 3: Strong opiates:
- Morphine; fentanyl TD; methadone etc
- IV paracetamol
Step 4: interventional methods
- Nerve blocks, epidural, PCA pumps etc
Adjuvants:
- Can be used at any stage
- Dependent on cause/type of pain e.g. neuropathic or bony pain
- Psychosociospiritual aspects
What are some adjuvant analgesics and their indications and side effects?
Amitriptyline:
- Neuropathic pain
- 10-70mg PO ON (as sedating)
- SE: anticholinergic, sedation, postural hypotension, QTc prolongation
Carbamazepine:
- Neuropathic pain, esp. trigeminal neuralgia
- 100mg PO OD and titrate up
- SE: headache, drowsiness, dizziness, ataxia
Gabapentin:
- Peripheral neuropathic pain
- 100mg PO ON, titrate up
- Schedule 3 controlled drug
- SE: drowsiness, constipation, dry mouth, HTN
Pregabalin:
- Central + peripheral neuropathic pain
- 25-600mg/day
- Schedule 3
- SE: drowsiness, dry mouth, GI upset
Duoloxetine:
- Neuropathic pain, including diabetic peripheral neuropathy
- 30mg OD, and up
- SE: dizziness, drowsiness, dry mouth, headache, nausea
Others:
- Local anaesthetics
- Baclofen
- Benzodiazepines
- Antidepressants
- Corticosteroids
- Bisphosphonates
What are some key principles of strong opioid prescribing? (titration for background and breakthrough pain, switching from PO to SC)
Take into account previous exposure and titrate dose accordingly
Titration:
- Prescribe on a regular basis every 4hrs OR prescribe on a four hourly PRN basis
- Assess pain after 24hrs
- If pain free = sum total dose in last 24hrs and convert to BD modified release by 24hr dose/2
- If not = check adherence then increase dose and check again in 24hrs
Breakthrough pain:
- Should be prescribed 1/6th to 1/10th of the total 24hr dose to cover episodic pain
PO to SC:
- There are tables available to help you convert between PO and SC opiates (also between differing opiates)
- As a general rule - PO dose/2 = SC dose
What are the side effects of opiates?
N+V
- Prescribe suitable antiemetic; if persistent then switch opiate
Constipation
- Prescribe a laxative
- NOT a bulk forming
- USE osmotic + stimulant laxatives
Cognitive impairment, drowsiness, myoclonus, dyssphoria, resp. depression = dose related side effects
- Reduce dose +/- review adjuvants +/- opiate switch
Urinary retention
Dry mouth
Sweating
Pruritis
Hallucinations
What are some alternatives to morphine and their features?
Oxycodone:
- 2nd line to morphine, 2x as potent so dose/2
- More constipating that morphine
- Dose reduce in renal + hepatic impairment
Fentanyl:
- Transdermal patch = most common use; achieves effective analgesia in 12-15hrs and half-life after removal is 13-27hrs = be mindful when switching - need to continue regular PO for 12hrs after patch application
- Less effective if sweating; but more absorbed when hot
- Less constipating and nauseating than morphine
- Useful in renal impairment
Buprenorphine:
- Patch
- Useful in renal impairment
Alfentanyl = 30x more potent than morphine
Methadone
Ketamine
What are the different causes of nausea?
Gastrointestinal tract:
- D2, 5HT3
- Obstruction, stasis, irritation from drugs
Chemoreceptor trigger zone (CTZ):
- D2, 5HT3
- Biochemical upset from drugs
Higher centres:
- H1
- Anxiety, raised ICP
Vestibular input:
- Ach, H1
- Motion sickness
What are some non-pharmacological methods of managing nausea?
Peppermint tea
Avoiding fatty, spicy, strongly smelling large meals
Eating small amounts of plain food whenever hungry but not forcing self to eat
Eating sat up
Optimising SEs of medications e.g. switch to fentanyl if on morphine; switch off oxy.
Acupressure wrist bands
Control odours from wounds etc
No alcohol
What are the different types of antiemetics and their features?
Prokinetics:
- Metoclopramide (D2 + 5HT3) and Domperidone (D2)
- Good for gastric stasis, ileus
- SE metoclopramide: extrapyramidal signs, drowsiness, hyperprolactinaemia
- SE domperidone: QTc prolongation, drowsiness
Haloperidol:
- D2 receptors in the CTZ
- Chemical causes e.g. opiates
- SE: EPSEs, long QTc, sedation
Antihistamines:
- Cyclizine, promethazine
- H1 receptors centrally and peripherally
- Obstruction, peritoneal irritation, motion sickness, raised ICP
5HT3 antagonists:
- Ondansetron
- Chemo + radiotherapy induced N+V and post op N+V
Prochlorperazine:
- D2, H1 and Ach
- Multifactorial or unknown causes of N+V
Neurokinin-receptor anatongists:
- Aprepitant, fosaprepitant
- NK1 receptors
- Prevention of chemo induced N+V
Dexamethasone:
- Adjunct, may enhance effects of other antiemetics
What are some common causes of breathlessness in palliative medicine?
Asthma COPD Malignancy Heart failure SCVO Chest infections Resp. depression - from muscle weakness, opiate overdose etc.
What are some non-pharmacological methods for treating breathlessness?
Cool draught (open window, fan)
Breathing exercises, relaxation therapy
Positioning and modifying lifestyle (e.g. bed downstairs, walking aids)
Refer to physiotherapy and occupational therapy where
appropriate
What drugs can be used to treat breathlessness ?
Treat reversible causes:
- Heart failure = diuretics, ACE-i’s, digoxin
- Asthma/COPD = bronchodilators, corticosteroids, antimuscarinics
- SVCO = high dose dex, radio/stenting/chemo
Opiates:
- Likely reduces ventilatory response to hypercapnia/hypoxia/exercise - reducing resp. effort and dyspnoea
- Morphine 1.25-2.5mg PO 4hrly for opiate naive; may need to increase PRN dose by 25-50% for those already on opiates
Benzodiazepines:
- For the anxiety component of breathlessness
- Loraz or diaz
Oxygen:
- Generally not indicated unless significantly hypoxic
What are some causes of bleeding in palliative care?
Advanced cancer
- Bleeding occurs in c.20%
Possible:
- Thrombocytopaenia
- Vit K deficiency
- Heparin-induced thrombocytopaenia
- Hepatic and renal impairment
- Haemoptysis (chest infection, tumour progression in lungs, PE)
How do you manage mild/moderate bleeding?
Spotting may not need treatment but should not be ignored
Systemic treatment for surface bleeding at any site:
- Tranexamic acid 1g PO TDS-QDS (max 2g)
Topical treatment:
- Fungating wounds and anterior epistaxis
- Gauze soaked in 1:1000 adrenaline or tranexamic acid 500mg/5ml injection - apply pressure for 10 mins
Radiotherapy:
- For cases of lung bleeding
How do you manage major/terminal bleeding?
Major catastrophic bleeds are rare but can occur when a tumour invades a major artery
- Can often be predicted e.g. with staging, ‘herald bleeds’ and so discussed with patients and carers
Active treatment usually inappropriate as death will occur rapidly
- Stay with patient, comfort them
- Dark coloured towels can help if bleed is external
- Miazolam 5-10mg IV/IM to reduce awareness and fear
What are some causes of secretions?
COPD, pulmonary oedema
NM weakness so no cough, cough/swallow impairment of other cause
Drowsiness, dehydration, semi-supine/recumbent position
