Prescribing In Palliative Care

Question 1

Pain management

Answer 1

Morphine is the drug of choice
Oral morphine solution

Question 2

Drug formulation of pain

Answer 2

Immediate release - 4 hourly; dose increments no more than 1/3 or 1/2 total daily dose every 24 hours
MR; 12 or 24 hourly when pain is controlled switch to IR <4 hours of last dose

Question 3

Alternative to oral morphine

Answer 3

Oxycodone
Other strong oral opioid - hydro morphine, methadone
Transdermal patches - fentanyl or buprenorphine
Parenteral - diamorphine

Question 4

Breakthrough pain

Answer 4

Pain that occurs between regular doses of a strong opioid
Rescue dose with IR preparations e.g oral morphine or oxycodone
1/6th to 1/10th of total daily dose
Repeat every 2-4 hours when required; review dose if taking BD or more

Question 5

Parenteral route

Answer 5

Use in dysphagia, severe nausea and vomiting, coma and weakness
IV, IM, SC morphine - half of oral dose of morphine
Diamorphine; third of oral dose of morphine (preferred over morphine as its more soluble)
Compatibility issues; SC diamorphine up to strength 250 mg/mL with physiological saline/WFI above 40 mg/mL use WFI prevent percipitation

Question 6

Transdermal route

Answer 6

Used in chronic pain that is stabilised on dose of IR opioid
Fentanyl patches; 3 days or 72 hours
Buprenorphine patches 7 days or 4 days
If switching due to hyperalgesia reduce new opioid dose by 25 to 50%

Question 7

Constipation in opioid use

Answer 7

Suitable laxative routinely prescribed, faecal softener and stimulant
Senna (stimulant) and lactulose (softener) OR co-danthramer/danthrusate
Methylnaltrexone (opioid receptor antagonist)

Question 8

Nausea and vomiting in opioid use

Answer 8

Metoclopramide - prokinetic
Haloperidol - antipsychotic for 4-5 days

Question 9

Dry mouth in opioid use

Answer 9

Maintain good oral hygiene
Sugar free gum
Artificial saliva
Suck ice cubes
Candidiasis; antifungals e.g nystatin, oral miconazole gel

Question 10

Other types of pain in palliative care

Answer 10

Neuropathic pain - TCAs and antiepileptic
Bone metastes - radiotherapy, biphosphonates, strontium ranelate
Pain due to nerve compression - dexamethasone

Question 11

Symptom control in palliative care

Answer 11

Anorexia - prednisolone/dexamethasone (increase appetite or weight gain)
Bowel colic, excess secretions - s/c inj of hyoscine/glycopyronium
Capillary bleeding - tranexamic acid / adrenaline, vit K in prolonged clotting in liver disease
Convulsion due to uraemia/cerebral tumour - phenytoin, carbamezapine/ s/c Midazolam
Dysphagia due to obstruction by tumour - dexamethasone
Dyspnoea - oral morphine (decrease resp drive to relieve breathlessness)
Dyspnoea with anxiety - diazepam,
Fungating tumours - metronidazole
Gastric distension - antacid with anti flatulent and prokinetic drug (domperidone before meals)
Insomnia - benzodiazepines
Hiccup due to gastric distension - antacid with anti flatulent if fails add metoclopramide
Muscle spasm - diazepam or baclofen
Pruritis - emollients,
Obstructive cholestatic jaundice- colestyramine
Headache due to raised intracranial pressure - dexamethasone (before 6 pm as it can cause insomnia)
Restlessness and confusion - haloperidol or levomepromazine