Palliative Care Medicines

Question 0

What are the features, causes and management of N+V due to gastric stasis?

Answer 0

Features: early satiety, hiccups, heartburn, epigastric fullness

Causes: tumour, hepatomegaly, ascites, dysmotility

Treatment: metoclopramide 30mins before meals

Question 1

What are the causes of N+V in patients under palliative care?

Answer 1

Gastric stasis/irritation
Toxic causes - drugs
Raised ICP
Anxiety and anticipatory N+V
Indeterminate cause

Question 2

What are the features, causes and treatment if N+V due to toxic causes?b

Answer 2

Features: Persistent or intermittent nausea, small vomits, possess and retching

Causes: opioids, digoxin, anti epileptics, hypercalcaemia, uraemia, infections

Treatment: haloperidol 1.5-5mg

Question 3

What are the features and management of nausea due to raised ICP?

Answer 3

Features - early morning headache, vomiting with little nausea, neurological signs

Treatment - dexamethasone 8-16mg PO OD plus cyclizine 50mg TDS PO/sc

Question 4

What are the features and treatment of anxiety related N+V?

Answer 4

Features - precipitated by certain situations, anxiety and depression

Treatment - BDZ, CBT, complementary therapies

Question 5

Which Antiemetics are dopamine antagonists?

Answer 5

Haloperidol
Metoclopramide
Levomepromazine
Pro chlorpromazine
Olanzapine

Question 6

What are dopamine antagonist Antiemetics good for?

Answer 6

Toxin related nausea from medications

Question 7

What are the side effects of dopamine antagonist Antiemetics?

Answer 7

Extrapyramidal side effects (avoid in little old ladies)

Neuroleptic malignant syndrome

Sedation

Question 8

Which Antiemetics are anticholinergics /antihistamines?

Answer 8

Cyclizine

Hyoscine

Question 9

What are anticholinergics/antihistamines Antiemetics good for?

Answer 9

Movement related nausea (act on vestibular apparatus)

Cerebral metastases

Question 10

What are the side effects of anticholinergics/antihistaminergics?

Answer 10

Dry mouth
Drowsiness
Urinalysis retention
Constipation

Antagonise the actions of pro kinetics

Question 11

What are the prokinetic Antiemetics?

Answer 11

Metoclopramide
Domperidone
Erythromycin

Question 12

When are prokinetic Antiemetics indicated?

Answer 12

Delayed gastric emptying
Partial bowel obstruction
Motility disorders

Question 13

What are the side effects of prokinetic Antiemetics?

Answer 13

Colic
Extrapyramidal symptoms
Prolonged QTc

Do not giving complete bowel obstruction - colic!

Question 14

What are 5HT3 antagonists?

Answer 14

Block action of serotonin in gut and brainstem

Include ondansetron

Question 15

What are the side effects of ondansetron?

Answer 15

Constipation
Headache
Expensive

Question 16

What type of antiemetic is aprepitant?

Answer 16

Neurokinin antagonist

Question 17

What are some non pharmacological treatments for breathlessness?

Answer 17

Relaxation and breathing techniques
Electric fan
Encourage exertion to increase tolerance
Reduce feelings if isolation - daycare - support group

Question 18

When can bronchodilators be used to relieve dyspnoea in palliative care?

Answer 18

Good for airflow obstruction - lung malignancy, COPD etc

B2 agonist with or without antimuscarinic

Question 19

When is morphine used to treat breathlessness?

Answer 19

Best in breathlessness at rest

Helps reduce ventilators response to hypercapnoea

Start on 2.5-5mg morphine PO PRN

Question 20

When are anxiolytics use to treat breathlessness?

Answer 20

Used if breathlessness is related to anxiety

Diazepam 2-5mg PRN

Question 21

What are are some general measures that can be taken to reduce constipation?

Answer 21

Stop/reduce dose of constipating drugs
Mobilise the patient if possible
Use commode rather than the bedpan
Diet - add fibre
Increase fluids
Encourage fruit juices

Question 22

What are the contact/stimulant laxatives?

Answer 22

Codanthramer (dantron and poloxamer
Codanthrusate (dantron and docusate)
Senna

Question 23

When are stimulant laxatives best used?

Answer 23

Opioid induced constipation

Avoid in colic

Question 24

What are the stool softeners?

Answer 24

Sodium docusate 100-200mg BD tablets

Question 25

What are the osmotic laxatives?

Answer 25

Lactulose - 15mls BD | Movicol - 1 sachet twice daily

Question 26

What are the bulk forming drugs?

Answer 26

Fybogel - 1 sachet twice daily These are rarely appropriate in palliative care NOT for opioid induced!

Question 27

What are the side effects of strong opioids?

Answer 27

Constipation: co-prescribe Codanthramer ``` Nausea and vomiting: In one third of patients Usually settles in a few days Co prescribe haloperidol Consider regular antiemetic ``` Drowsiness: Usually improves within 48 hours Confusion and visual hallucinations Respiratory depression Psychological dependence

Question 28

What are signs of opioid toxicity?

Answer 28

``` Nausea and vomiting Persistent drowsiness Confusion and visual hallucinations Myoclonic jerks Respiratory depression Pinpoint pupils ```

Question 29

How long do normal release morphine last?

Answer 29

4 hours Oromorph Sevredol

Question 30

How long does modified/slow release morphine last for?

Answer 30

Up to 12 hours MST 20mg every four hours if stepping up from max cocodamol Zomorph

Question 31

How many times more powerful is parenteral Diamorphine than oral morphine?

Answer 31

Three times Divide total 24 hour dose by 3 to convert

Question 32

How many times more powerful is parenteral morphine than oral morphine?

Answer 32

Two times Divide 24 hour dose by 2 to convert

Question 33

How long do fentanyl transdermal patches last?

Answer 33

72 hours For severe chronic pain already stabilised on opioids

Question 34

What are other strong opioids?

Answer 34

Oxycodone - if morphine not suitable Alfentanil Methadone

Question 35

How should prn doses be calculated?

Answer 35

All patients on MST should have normal release morphine prescribed PRN for breakthrough pain This should be 1/6th of the total 24 hour morphine dose This can be taken up to hourly if needed

Question 36

How should doses of oral morphine be titrated upwards?

Answer 36

Titrate dose upwards by adding on 30-50% of the total daily dose - remember this gives you the new total daily dose! Or Can add on the total prn dosage taken

Question 37

What is a reasonable maximum dose in 24 hours for a PRN normal release oral morphine?

Answer 37

6-10 times the PRN dose

Question 38

What are some signs that someone is reaching the end of their life?

Answer 38

``` Profound weakness Confined to bed for most of the day Drowsiness for extended periods Disorientated Reduced attention Loss of interest in food and drink Too weak to swallow ```

Question 39

Should patients on terminal care have artificial hydration?

Answer 39

Usually not necessary Reduced food and fluid intake is part of the process Artificial hydration does not increase comfort, may cause oedema, and cannulation may be uncomfortable

Question 40

What medications should be stopped in terminal care?

Answer 40

``` May be stopped: Vitamins Hormones Anticoagulants Corticosteroids Antibiotics Antidepressants Anticonvulsants ``` Only keep drugs used for symptom management!

Question 41

What is death rattle?

Answer 41

Movement of secretions in airways when patient can't expectorate Doesn't bother the patient! Repositioning may help

Question 42

When is a syringe driver indicated?

Answer 42

``` Inability to swallow - reduced consciousness, last days of life Persistent nausea and vomiting Intestinal obstruction Malabsorption of drugs Dysphagia ```