Medicine - Palliative

Question 1

What is the most common side effect of cyclophosphamide?

Answer 1

Haemorrhagic cystitis

Question 2

What are the toxicities of cisplatin?

Answer 2

Ototoxic, nephrotoxic, hypomagnasaemia

Question 3

Which chemotherapy agent is associated with SIADH?

Answer 3

Cyclophosphamide

Question 4

What is the starting dose of morphine in palliative care?

Answer 4

15mg morphine MR PO BD
5mg oromorph IR PO PRN
Can start with IR and then when pain controlled –> MR

Question 5

What is the most common side effect of MR morphine?

Answer 5

Nausea

Question 6

What opioid is best to use for palliative patients with a GFR of 30-60?

Answer 6

Oxycodone

Question 7

What opioids are best to use for palliative patients with a GFR of <30?

Answer 7

Fentanyl
Buprenorphine

Question 8

How much should a breakthrough dose of morphine be?

Answer 8

1/6th of total morphine

Question 9

100mg codeine is equivalent of how many mg of morphine?

Answer 9

10mg

Question 10

What is the equivalent of 30mg IR morphine in a MR formulation?

Answer 10

15mg
prescribe half when doing MR

Question 11

Recall 3 ways in which bony met pain can be managed

Answer 11

1. Analgesia
2. Bisphosphonates
3. Radiotherapy

Question 12

Which anti-emetic is usually prescribed in palliative care?

Answer 12

Cyclizine

Question 13

What is the usual dose of cyclizine in palliative care?

Answer 13

50mg 8-hourly

Question 14

In what patients is it inappropriate to prescribe cyclizine and why?

Answer 14

Cardiac cases
Can worsen fluid retention

Question 15

Recall 2 patient groups in which metoclopramide should be avoided

Answer 15

Parkinson's disease 
Young women (risk of dyskinesia)

Question 16

What is the anti-emetic of choice in Parkinson’s?

Answer 16

Domperidone

Question 17

What is the drug of choice for agitation in palliative care vs for terminal restlessness?

Answer 17

Agitation in palliative pts: haloperidol (and correct underlying cause)
Terminal restlessness: midazolam

Question 18

Recall the 1st and 2nd line drugs used for secretions in palliative care

Answer 18

1. Hyoscine hydrobromide
2. Glycopyrronium bromide

Question 19

What is the first line for treating hiccups in palliative care?

Answer 19

Chlorpromazine

Question 20

In a patient with cord compression due to spinal mets who is too frail for surgery, what is the treatment of choice?

Answer 20

External beam radiotherapy

Question 21

What is the anti-emetic of choice for patients with chemo/radio-associated nausea?

Answer 21

Ondansetron + dexamethosone

Question 22

What is the antiemetic of choice in palliative care for for nausea and vomiting that is due to gastric dysmotility and stasis?

Answer 22

Metoclopramide

Question 23

End of life care

Answer 23

Conservative:

• Tx reversible causes
• Hydration
• Regular mouth & eye care

Medical:

• PRN ≥3/day –> syringe driver
• Avoid IM injection

Sx at final days:

• Cheyne-stokes breathing (deep breathing then stops for 15-20s)
• Reduced GCS
• Fatigue
• Loss of appetite
• Agitation
• Resp secretions
• Funct decline + social withdrawal

Question 25

Laxative use in end of life care

Answer 25

• 1st - Osmotic agent e.g. lactulose OR softening agent e.g. docusate
• 2nd - If this doesn’t work ADD a stimulant agent e.g. senna

Question 26

Anti-emetics in palliative care

Answer 26

* **Haloperidol** - chemical causes, renal failure, drug-induced * Lowers seizure threshold, parkinsonism * **Cyclizine** - central vomiting, CNS lesions, labyrinthitis * Irritant SC, severe HF * Ondansetron - _ONLY_ post-chemo, abdo surgery, abdo radio * Very constipating, QT prolongation * Metoclopramide/Domperidone - delayed GIT transit, bowel obstruction without colic * Bowel obstruction with colic, parkinsonism, cardiac conduction disorders, young women - SE movement disorders * Levomepromazine - all causes but 3rd line * Long half life, sedating, lowers seizure threshold, severe HF, CVD, parkinsonism

Question 27

Important opioid conversions

Answer 27

Question 28

Palliative Mx of breathlessness?

Answer 28

* Tx reversible causes - HF, pleural effusion, PE, pneumonia, hypoxia * **Low-dose opioid** (morphine immediate release) with **short acting Benzo e.g., Lorazepam**

Question 32

Palliative Sx - possible reversible causes & drugs if no reversible causes?

Answer 32

Question 33

**Opioids:** 1. Strength of different opioids 2. Forms of oral morphine 3. Guide to giving morphine 4. When to give oxycodone 5. Breakthrough analgesia 5. Conversion between opioid doses

Answer 33

**Strength:** * Weak - codeine, dihydrocodeine * Moderate - tramadol (surgeons love) * Strong - morphine, oxycodone, buprenorphine, fentanyl **Oral morphine has 2 forms:** * Oral morphine has 2 forms: * Immediate-release (e.g. oromorph) - max 4-hourly * Modified-release (e.g. MST Continus/Zomorph/Morphgesic SR) - 12-hourly (BD) OR 24-hourly (OD) **Guide to morphine:** 1. If can't tolerate oral e.g. vomiting alot --\> **oral dose/2 = IV dose** 2. Immediate-release PRN (max 4-hourly) --\> see how much using 3. If using a huge amount --\> convert to modified-release (12/24-hourly): * **Add up total daily PRN dose = X** * **24-hourly = X (OD); 12-hourly = X/2 (BD)** **​When to give oxycodone:** renal impairment (eGFR 30-60mL/min) * Immediate-release: oxycodone oral solution, oxynorm * Modified-release: oxycontin * NOTE: same logic as above * NOTE: fentanyl/buprenorphinene is the best if eGFR \<30, oxycodone still partially renaly excreted **Breakthrough analgesia:** * Oral morphine/oxycodone * 1/10-1/6 of total daily dose of modified-release morphine **_Example: 60mg Oromorph --\> 30mg MST BD + 6-10mg breakthrough dose_** **Conversion** - 10mg oral morphine: * Oxycodone - 5mg oral **(x/2)**, 2.5mg IV **(x/4)** * Tramadol/Codeine - 100mg oral/IV **(x\*10)** - NOTE: codeine has no IV option

Question 34

What opioids can I use if renal problem?

Answer 34

Fentanyl, Buprenorphine Oxycodone can be used if eGFR 30-60 (still partially renaly excreted)

Question 35

Anticipatory meds - 4 to give if palliative?

Answer 35

Anxiety/distress: Midazolam 2.5-5mg SC 1-2hrly PRN Secretions/colic: Glycopyrronium 0.2-0.4mg SC QDS PRN Nausea & vomiting: Haloperidol 0.5-1.5mg SC BD PRN (max 5mg/24hrs) * Could give Cyclizine 50mg SC TDS PRN Pain: Morphine 2.5-5mg SC 1-2hrly PRN (or Oxycodone 1.25-2.5mg)

Question 36

Best palliative medicine for secretions/colic?

Answer 36

Glycopyrronium 0.2-0.4mg SC QDS PRN

Question 38

Confused & agitated in context of 'dying' - Dx? Mx?

Answer 38

Dx: terminal restlessness Mx: diagnosis of dying so reversible causes have already been excluded * Midazolam PRN - SC injections/continuous subcut infusion via a syringe driver