L10 - Palliative care

Question 1

What are SEVEN common symptoms needing palliative care?

Answer 1

Pain
Constipation
Nausea & vomiting
Shortness of breath
Anxiety
Delirium
Fatigue

Question 2

What are SIX nonpharmacological options for treating pain?

Answer 2

Repositioning
Distraction
Physiotherapy
Hypnotherapy
Massage
Hot/cold packs

Question 3

Why is step 2 of the pain ladder usually skipped?

Answer 3

Patients usually end up needing strong opioids eventually

Question 4

What TWO adjuvant drug classes can be used for neuropathic pain?

Answer 4

Tricyclic antidepressants –> eg. amitriptyline, nortriptyline

Antiepileptics –> eg. gabapentin, sodium valproate

Question 5

What TWO adjuvant drug classes can be used for bone pain?

Answer 5

NSAIDs –> eg. diclofenac, ibuprofen, naproxen

Bisphosphonates –> eg. zolderonic acid, pamidronate

Question 6

What THREE adjuvant drugs can be used for pain from skeletal muscle spasms?

Answer 6

MUSCLE RELAXANTS
Diazepam (benzodiazepine)
Clonazepam (benzodiazepine)
Baclofen

Question 7

What ONE adjuvant drug can be used for pain from smooth muscle spasm?

Answer 7

ANTICHOLINERGICS/ANTIMUSCARINICS

Hyoscine butylbromide

Question 8

What ONE adjuvant drug/product can be used from pain from UTI/bladder pain?

Answer 8

Ural sachets

Question 9

What ONE adjuvant drug class can be used for pain from increased intracranial pressure?

Answer 9

Steroids –> eg. dexamethasone

Question 10

Why is dexamethasone the preferred steroid in palliative care?

Answer 10

Least mineralocorticoid component compared to other steroids

Least amount of fluid retention –> reduced intracranial pressure

Long half-life –> OD dosing

Question 11

Why is morphine not used in renal impairment?

Answer 11

Active metabolites accumulate in renal impairment

–> takes times; morphine can be given in last days of life

Question 12

What is the next opioid to consider following morphine?

Answer 12

Oxycodone

Question 13

Can oxycodone be used in renal impairment?

Answer 13

Mild-moderate: yes

Severe: no

Question 14

What formulation does fentanyl come in?

Answer 14

Patches

Question 15

Why is fentanyl patches only for stable pain?

Answer 15

3 days to reach steady-state –> cannot titrate dose fast enough

Lowest patch strength also already quite high –> only for patients who have taken opioids before

Question 16

Is fentanyl safe in renal impairment?

Answer 16

Yes

Question 17

Is methadone safe is renal impairment?

Answer 17

Yes - mostly faecally excreted

Question 18

Why can methadone also be used in neuropathic pain?

Answer 18

Hits same NMDA receptors as ketamine as well as being full opioid agonist

Question 19

Why should methadone only be prescribed by specialists?

Answer 19

Tricky pharmacokinetics

- After distribution to tissues, methadone leeches back out into bloodstream at varying rates

Question 20

How to establish starting background dose of opioids?

Answer 20

Morphine given for opioid-naive patients

Total usage in 24 hours
Divide into BD dosing –> m-Eslon SR

Question 21

How to establish breakthrough dose of opioids?

Answer 21

1/6th total daily background dose, every hour PRN

If 3 consecutive hours with no pain improvement, stop & see GP/hospice
Readjust background dose

Question 22

How to readjust background dose of opioids if pain not being managed well?

Answer 22

Background dose & total breakthrough doses in one day

Total is new daily background dose, split into BD dosing

Question 23

Why is SC preferred to IM or IV?

Answer 23

IM: painful

IV: infections in line –> sepsis

Question 24

What are FIVE common side effects of opioids?

Answer 24

Constipation
Nausea & vomiting
Drowsiness
Hallucinations
Itch

Question 25

How is opioid-induced constipation managed?

Answer 25

Concurrent laxatives --> Laxsol Add osmotic laxative Laxsol not enough Bulk-forming laxatives not recommended --> along with stasis of bowels caused by opioids, can cause bowel obstruction & perforation

Question 26

Does constipation get worse with increasing opioid doses?

Answer 26

Yes --> patients do not become tolerant to effect

Question 27

How is opioid-induced nausea & vomiting managed?

Answer 27

Prophylactic antiemetics

Question 28

Does nausea & vomiting get worse with increasing opioid doses?

Answer 28

Potentially, but patients develop tolerance after 5-7 days

Question 29

How is opioid-induced drowsiness managed?

Answer 29

Will subside after 2-3 days

Question 30

How is opioid-induced hallucinations managed?

Answer 30

Low-dose haloperidol Change opioid

Question 31

How is opioid-induced itch managed?

Answer 31

High-dose antihistamine Change opioid

Question 32

Why is lactulose not preferred in palliative care?

Answer 32

Too sweet/unpalatable Can cause flatulence & abdominal cramps

Question 33

Why is Molaxole beneficial in palliative care?

Answer 33

Needs to be reconstituted with water- --> increased fluid intake will help with constipation

Question 34

How does methylnaltrexone work for opioid-induced constipation?

Answer 34

Opioid antagonist that does not cross BBB --> only acts on opioid receptors in GI tract --> fastest onset of action (30 mins) SC injection --> last line

Question 35

What are SIX nonpharmacological options for managing nausea & vomiting?

Answer 35

Avoid trigger food/smells Small frequent meals Ginger Peppermint tea Relaxation, breathing Acupuncture

Question 36

Why is haloperidol the first choice for nausea & vomiting?

Answer 36

Toxins/medications/metabolic processes most likely to cause nausea & vomiting --> haloperidol works best

Question 37

How is nausea & vomiting addressed in palliative care?

Answer 37

Haloperidol Prokinetics (metoclopramide, domperidone) - Domperidone cannot be given SC Cyclizine Levomepromazine - Hits all nausea & vomiting receptors so very effective but causes sedation Octreotide, hyoscine butylbromide --> good for bowel obstruction: dry up secretions where vomiting is predominant Dexamethasone --> reduces intracranial pressure & helps with bowel obstruction

Question 38

Why is ondansetron not recommended in palliative care?

Answer 38

Causes constipation SC not funded

Question 39

What are FIVE nonpharmacological options for treating shortness of breath?

Answer 39

Using fans Repositioning Relaxation Breathing exercises Reassurance

Question 40

How can shortness of breath be managed in palliative care?

Answer 40

Opioids --> reduce respiratory drive & sensation of breathlessness Benzodiazepines --> eg. lorazepam, midazolam - Reduce anxiety associated with shortness of breath

Question 41

How is anxiety usually treated in palliative care?

Answer 41

Lorazepam Midazolam

Question 42

How is delirium usually treated in palliative care?

Answer 42

Haloperidol Levomepromazine

Question 43

What are FIVE nonpharmacological options to treated anxiety/delirium in palliative care?

Answer 43

Relaxation Breathing exercises Familiar objects/environment Quiet room Low lighting

Question 44

How can fatigue be managed in palliative care?

Answer 44

RARE TO TREAT Methylphenidate (Ritalin) - Improved mood & energy Dexamethasone Modafinil

Question 45

What are FIVE reasons why syringe drivers are used in palliative care?

Answer 45

Poor absorption of oral drugs --> eg. if tumours pressing on GI tract Persistent nausea & vomiting Intestinal obstruction Swallowing difficulties Unconscious patient