CPTP 4.21-23

Question 1

e.g. of step 2 WHO analgesic ladder drugs

Answer 1

codeine, tramadol

Question 2

new adaptation of analgesic ladder

Answer 2

encourages bidirectional application, can start at top in some cases. adds a 4th step - nerve blocks, epidurals,

Question 3

COX 1 function

Answer 3

gastroprotection, dilates afferent renal arterioles, makes thromboxane - platelet aggregation

Question 4

COX 2 function

Answer 4

induced by pain and inflammation

Question 5

What kind of asthmatic are NSAIDs contraindicated in

Answer 5

aspirin sensitive (can make them wheezy)

Question 6

pharmodynamics of codeine

Answer 6

converted to morphine in liver and acts on mew receptors

Question 7

why is codeine ineffective in some and toxic in others?

Answer 7

variable expression of enzymes in population, poor metabolisers (ineffective) and excess metabolisers (toxic). as metabolite = morphine?

Question 8

what should you co-prescribe with codeine

Answer 8

laxatives

Question 9

are tramadol’s effects reversed by naloxone

Answer 9

not totally

Question 10

good opioid after bowel surgery

Answer 10

tramadol - not as constipating

Question 11

tramadol mechanism of action

Answer 11

prevent serotonin and NE reuptake, NMDA antagonist,, ACh (nicotinic) antagonist.

Question 12

opioid receptor - signal transduction?

Answer 12

g protein coupled

Question 13

side effects of tramadol

Answer 13

serotonin syndrome, anticholinergic SEs, opiate side effects

Question 14

types of morphine

Answer 14

MST - morphine sulphate tablets, zomorph (modified release), oramorph (liquid), sevredol (tablet form of immediate acting), diamorphine (IV), oxycodone, fentanyl

Question 15

morphine mechanism of action

Answer 15

acts on µ-opioid receptors

Question 16

analgesic ass with pruritus side effect

Answer 16

opiates

Question 17

what do you prescribe for breakthrough pain when on morphine

Answer 17

PRN morphine - 1/6-1/10 total regular dose in 24h

Question 18

timing of morphine doses?

Answer 18

either immediate release 4hrly or modified release 12 hrly

Question 19

e.g. of immediate release morphine

Answer 19

oramoph, sevredol tablets

Question 20

MR morphine?

Answer 20

zomorph

Question 21

opioid by patch?

Answer 21

fentanyl, buprenorphine

Question 22

early sign of opiate toxicity

Answer 22

myoclonic jerks

Question 23

other signs of opiate toxicity

Answer 23

pin point pupils, hallucinations, confusion, reduced RR

Question 24

reason for opiate toxicity in 90% cases?

Answer 24

AKI

Question 25

adjuvant in muscle spasm/cramp

Answer 25

baclofen

Question 26

adjuvant in bone pain (bone mets, breast cancer, myeloma)

Answer 26

bisphosphonates (pamidronate in myeloma)

Question 27

adjuvant in abdomen spasms

Answer 27

hyoscine butyl bromide

Question 28

administration route at the end of life

Answer 28

SC (injections and infusions)

Question 29

prescribing for pain at EOL if eGFR > 30

Answer 29

morphine

Question 30

prescribing for pain at EOL if eGFR <30

Answer 30

alfentanil (less renally excreted)

Question 31

prescribing for N&V at EOL if eGFR >30

Answer 31

cyclizine

Question 32

prescribing for N&V at EOL if eGFR<30

Answer 32

haloperidol

Question 33

agitation at end of life (prescription)

Answer 33

midazolam

Question 34

tx of secretions at EOL if GFR >30

Answer 34

hyoscine hydrobromide

Question 35

tx of secretions at EOL if GFR <30

Answer 35

hyoscine butylbromide (buscopan)

Question 36

neuropathic pain mx options

Answer 36

TCAs (amitriptyline), SSRIs, Gabapentin (FIRST LINE), Pregabalin, ketamine (if all else fails), lidocaine

Question 37

rule on increasing morphine dose in 24h

Answer 37

shouldn't increase by > 50%

Question 38

mx of opioid side effects

Answer 38

opioid rotation (tramadol, fentanyl patches), reduce dose and add adjuvant

Question 39

conversion of morphine oral to SC

Answer 39

/2

Question 40

breakthrough pain at the end of life

Answer 40

prescribe 1/6 of syringe driver dose SC

Question 41

What is the most appropriate opiate to use in renal failure via a syringe driver

Answer 41

Alfentanil (30 times more potent than oral morphine however)