Palliative Care

Question 1

What percentage of those with advanced cancer experience pain?

Answer 1

80-90%

Question 2

Give 3 examples of opioids for mild-moderate pain

Answer 2

Codeine, dihydrocodeine, tramadol

Question 3

Give 4 examples of strong opioids

Answer 3

Morphine, diamorphine, fentanyl, oxycodone

Question 4

What are some non-opioid adjuvants that can be used in pain management?

Answer 4

NSAIDs, bisphosphonates, radiotherapy, corticosteroids

Question 5

How much more potent is morphine compared to codeine?

Answer 5

10 times

Codeine is 1/10th the potency of morphine

Question 6

What is the maximum dose of codeine phosphate per day?

Answer 6

240mg a day (60mg QDS)

Question 7

How would you convert a maximum daily dose of codeine to morphine?

Answer 7

240mg of codeine = 24mg of morphine

Give 30mg of morphine in 24 hours (15mg slow release morphine BD)

Question 8

When should you avoid tramadol?

Answer 8

Epilepsy

Question 9

What is the equivalent morphine dose of tramadol?

Answer 9

Divide dose of tramadol by 10 for equivalent morphine dose

Question 10

How do you convert to modified released morphine?

Answer 10

Calculate total daily dose + PRN and divide into two 12 hour doses of a modified release preparation

Question 11

How do you work out the PRN dose?

Answer 11

1/6th of total daily dose as an immediate release preparation eg oramorph

Question 12

What are the main side effects of opioids?

Answer 12

Constipation
Nausea+Vomiting
Drowsiness
Dry mouth

Question 13

What are some signs and symptoms of opioid toxicity?

Answer 13

Pinpoint pupils
Sedation
Respiratory depression
Hallucinations
Confusion

Question 14

Which opioids are safe to give in renal failure?

Answer 14

Fentanyl, alfentanil, buprenorphine

Question 15

What does a 25mcg/h fentanyl patch equate to?

Answer 15

25mcg/h fentanyl patch = 60mg/24h oral morphine

Question 16

How much stronger than morphine is oxycodone?

Answer 16

Twice as strong

Question 17

How much stronger than morphine is diamorphine?

Answer 17

Three times as strong

Question 18

Name an appropriate laxative to be prescribed alongside an opioid

Answer 18

Movicol (Macrogol) - osmotic laxative

Question 19

When should you avoid pregabalin?

Answer 19

Decreased renal function

Question 20

What is an appropriate dose of amitriptyline for the management of neuropathic pain?

Answer 20

Amitriptyline 10-25 mg nocte

Question 21

What is an appropriate dose of gabapentin for the management of neuropathic pain?

Answer 21

Gabapentin 300mg TDS over 3 days

Question 22

What is an appropriate dose of pregabalin for the management of neuropathic pain?

Answer 22

Pregabalin 75mg BD

Question 23

When shouldn’t amitriptyline be used?

Answer 23

Ischaemic heart failure, previous MI, previous arrhythmias

Question 24

Give some causes of N+V in palliative care

Answer 24

Pain
Infection
Renal/hepatic impairment
Drugs like chemo or opioids
Hypercalcaemia
Constipation
Bowel obstruction

Question 25

Which antiemetic should be used in chemical causes like Hypercalcaemia?

Answer 25

Haloperidol

Question 26

Which antiemetic should be used for gastric stasis?

Answer 26

Metoclopramide | Domperidone

Question 27

Which antiemetic should be used in bowel obstruction?

Answer 27

Cyclizine | Dexamethasone

Question 28

Which antiemetic should be used for brain mets or raised ICP?

Answer 28

Cyclizine | Dexamethasone

Question 29

Which antiemetic should be used in psychological factors?

Answer 29

Benzodiazepines

Question 30

Which antiemetic should be used for chemo sickness?

Answer 30

Ondansetron

Question 31

Which antiemetic should be used post op or radiotherapy?

Answer 31

Ondansetron

Question 32

Which antiemetic should be used in constipation?

Answer 32

Metaclopramide | Laxatives

Question 33

How does cyclizine work?

Answer 33

Antihistamine (H1 blocker)

Question 34

What are some side effects of cyclizine?

Answer 34

Drowsiness, dry mouth, constipation, trouble with vision, urinary retention

Question 35

How does metaclopramide work?

Answer 35

Dopamine receptor blocker (D2 receptors in the chemoreceptor trigger zone in the CNS)

Question 36

Name some antiemetics that are dopamine receptor blockers

Answer 36

Metaclopramide, domperidone, haloperidol, prochlorperazine

Question 37

How does ondansetron work?

Answer 37

Serotonin 5 HT3 receptor antagonist

Question 38

What sort of arrhythmia has ondansetron been associated with?

Answer 38

Use of ondansetron has been associated with prolongation of the QT interval, which can lead to a potentially fatal heart rhythm known as torsades de pointes

Question 39

Give some non pharmacological measures to relieve breathlessness

Answer 39

Position patient to aid respiration Air flow over the face - fan or open window Give oxygen only if hypoxic

Question 40

What is the first line medication for breathlessness at the end of life?

Answer 40

Morphine 1-2mg SC PRN

Question 41

What drugs are used in anticipatory prescribing at the end of life?

Answer 41

``` Morphine 2.5-5mg Midazolam 2.5-5mg Haloperidol 2.5-5mg Glycopyrronium 200mcg Levomepromazine 6.25-12.5mg ```

Question 42

What is a WHO performance status of 0?

Answer 42

Fully active

Question 43

What is a WHO performance status of 1?

Answer 43

Restricted in physically strenuous activity but can do housework etc

Question 44

What is a WHO performance status of 2?

Answer 44

Ambulatory and capable of selfceare but not able to carry out work activities Up and about more than 50% of waking hours

Question 45

What is a WHO performance status of 3?

Answer 45

Capable of only limited selfcare Confined to bed/chair for more than 50% of waking hours

Question 46

What is a WHO performance status of 4?

Answer 46

Completely disabled, unable to carry out any selfcare

Question 47

What is a WHO performance status of 5?

Answer 47

Dead

Question 48

How is death verified?

Answer 48

- Absence of a carotid pulse over 1 minute - Absence of heart sounds over 1 minute - Absence of respiratory movements and breath sounds over 1 minute - Fixed, dilated pupils not responsive to bright light - No response to a trapezius squeeze