Medicines Managements + Palliative Care

Question 1

What is palliative care?

Answer 1

Approach that improves the quality of life of patients + their families facing problems associated with life-threatening illness, through the prevention + relief of suffering by means of early identification + impeccable assessment + treatment of pain + other problems, physical, psychological + spiritual

Question 2

What are the types of patients that receive palliative care?

Answer 2

Some might be there for short stay = give family rest bite
Cancer - most common
Advanced heart failure
End-stage COPD
Alzheimer’s disease
Parkinson’s disease
Motor neurone disease

Question 3

What is included in palliative care?

Answer 3

Physical = treatment, disease + symptoms
Psychological = anger, fear + helplessness
Social = worry, loss, abandonment, financial + isolation
Spiritual = purpose of life, faith, why me + what’s the point

Question 4

What is IPOS?

Answer 4

Integrated Palliative Outcome Scale
= focus on symptoms + how feeling
BED scale used to screen for depression

Question 5

Why do we have pain in palliative care?

Answer 5

Tumours grow + press on nerves + organs = pain
Bone metastases = pain

Question 6

What are the different types of pain?

Answer 6

Somatic = well defined + localised = bones + muscles
Visceral = pain in organs, blood vessels - diffusive
Neuropathic = nerves damages/tumours compress = pins + needles, tingling. shooting pains, burning + numbness
Pain receptors for somatic + visceral = opioids receptors = opioids work
Neuropathic = don’t respond to opioids

Question 7

Why use pain diaries?

Answer 7

To know if the medicine is working + how much

Question 8

Describe WHO Ladder

Answer 8

Step 1 = non-opioid = paracetamol 1g QDS
Step 2 =weak opioid = codeine + paracetamol
Step 3 = strong opioid = morphine (replace codeine) + paracetamol
Then adjuvants - eg. NSAIDs good for bone pain

Question 9

What can be the problem with codeine?

Answer 9

It doesn’t work the same for everyone
Metabolised by CYP2D6 + metabolism varies in efficiency of 2D6
= some people respond better than others
= potentially start with morphine = more predictable

Question 10

What are the principles of prescribing analgesia?

Answer 10

By the WHO ladder
Orally
By the clock = regular analgesia = NOT PRN

Question 11

Why have opioid alternatives?

Answer 11

Patient has difficult pain = NOT responding
Renal impairment = morphine not used = accumulates
SEs
Change delivery mechanism = morphine given orally

Question 12

What are the common initial SEs for opioids?

Answer 12

N+V
Drowsiness
Light-headedness
Delirium

Question 13

What are the common ongoing SEs for opioids?

Answer 13

Constipation
N+V
Dry mouth

Question 14

What are the possible ongoing SEs for opioids?

Answer 14

Suppression of immune system

Question 15

What are the less common SEs for opioids?

Answer 15

Hallucinations
Sweating
Urinary retention
Postural hypotension
Pruritus

Question 16

What are the rare SEs for opioids?

Answer 16

Respiratory depression

Question 17

What is the gold standard opioid?

Answer 17

Morphine
= universally available = all across the world
= no sealing effect = NO MAX dose
= recommended as 1st line by everyone (WHO, NICE + EAPC)
= know the drug = lots of experience with it

Question 18

Describe the metabolites of morphine

Answer 18

Accumulate in renal impairment = SEs
Morphine-3-glucuronide = major = not active as analgesia = renally excreted
Morphine-6-glucuronide = minor = active = renally excreted

Question 19

How do you manage background pain?

Answer 19

Modified release morphine 12hrs BD

Question 20

How do you manage breakthrough pain?

Answer 20

Immediate release liquid morphine PRN

Question 21

How do you communicate when starting a strong opioid?

Answer 21

= addiction
= tolerance = overtime need to increase dose
= SEs = initial/on-going
= fears that treatment implies final stages of life

Question 22

How do we start a strong opioid?

Answer 22

Option 1 = already had weak opioid
Add up codeine in last 24hrs + divide by 10
Slow-release opioid BD
Immediate release opioid PRN = add in = 1/6th total daily dose

Option 2 = NOT had weak opioid
Titrate immediate release opioid 4hrs + PRN = keep track of use
ALWAYS titrate with PRN
Add up what had in 24hrs + divide by 2
Then 1/6th for breakthrough

Question 23

Why must you always titrate with immediate release first?

Answer 23

MR takes too long to get to steady state

Question 24

Describe fentanyl

Answer 24

100x more potent than morphine
Shouldn’t be given to opioid naïve patients
= wrong = respiratory depression
3mg overdose in opioid naïve patients

Question 25

Describe fentanyl patches

Answer 25

For background pain = transdermal = 72hrs Takes 12hrs to work Only used in stable pain = predictable = patch can't be titrated Better than oxycodone for renal impairment

Question 26

When to caution fentanyl patches?

Answer 26

Do NOT apply to hot skin = more fentanyl released = overdose = death Temperature/ heat pad for pain/ hot shower/ bath

Question 27

Describe oxycodone

Answer 27

For renal impairment - USE after morphine Liquid = IR Tablets = MR

Question 28

Describe tramadol

Answer 28

Works on opioid + serotonin receptors Serotonin = increases drug interactions = if already have antidepressant = increases chance of serotonin syndrome Between mild-strong opioid Pro-drug O-demethylation (CYP2D6) = unpredictable

Question 29

What is allodynia? Neuropathic pain

Answer 29

Pain stimuli threshold decreased = evoke pain response in minor stimuli eg. brushing hair

Question 30

What is hyperalgesia? Neuropathic pain

Answer 30

Painful stimuli with exaggerated pain eg. bangs legs = 10/10 pain

Question 31

What is good for neuropathic pain?

Answer 31

TCA SNRI Pregabalin

Question 32

Describe the neuropathic pain ladder

Answer 32

Step 1 = amitriptyline (TCA) Step 2 = amitriptyline (TCA) + gabapentin (AC) Step 3 = amitriptyline (TCA) + valproate (AC) Step 4 = ketamine or methadone (NMDA-receptor channel blocker)

Question 33

Describe amitriptyline

Answer 33

TCA 10mg = low dose pain Time to effect = 3-7 days SEs = anti-muscarinic

Question 34

Describe gabapentin

Answer 34

Anticonvulsant Time to effect = 1-3hrs SEs = drowsy/dizzy

Question 35

How do you manage constipation?

Answer 35

Stimulant = senna Softener = docusate sodium Methyl naltrexone = specialist Need to be beware of faecal impaction = if NOT mobile = can present as overflow diarrhoea Macrogol = laxative for impaction

Question 36

How do you manage breathlessness?

Answer 36

1-2.5mg of IR oral morphine 4hrs PRN + titrate upwards = reduced medullary sensitivity to hypercarbia + hypoxia = decreased metabolic rate + ventilator requirements = anxiolytic effects

Question 37

What can cause N+V in palliative care?

Answer 37

Rifampicin = Abx = SE Gastric stasis = metoclopramide = prokinetic Raised intracranial pressure = dexamethasone Anxiety = benzodiazepines

Question 38

Describe hypercalcaemia

Answer 38

Too much calcium = bone metastases Signs + symptoms = drowsiness/confusion/coma = severe = N+V/constipation = thirst/polyuria = most common Diagnosis = total Ca + 0.02(40-serum albumin) Management = rehydrate = bisphosphonate = SE = decrease Ca = zoledronic acid = parental

Question 39

Describe SVCO (superior vena cava obstruction)

Answer 39

In lung cancer = becomes distended in abdomen = high dose dexamethasone/stent (surgery)

Question 40

Describe spinal cord compression

Answer 40

Tumour in spine Legs become tingly = neuropathic pain presents the same = need MRI Needs high dose dexamethasone