Palliative Care Flashcards
(169 cards)
1
Q
______ applies not only to incurable malignant
disease and HIV/AIDS but also to several other
diseases, such as end-stage organ failure (heart
failure, kidney failure, respiratory failure and hepatic
failure) and degenerative neuromuscular diseases.
A
Palliative care
2
Q
The GP is the ideal person to manage palliative care
for a variety of reasons—
1.
2
3
A
availability, knowledge of
the patient and family, and the relevant psychosocial
influences
3
Q
_____________ is the best policy when discussing
the answers to these questions with the patient
and family.
A
Caring honesty
4
Q
Patients must not be made to feel isolated or be
victims of the so-called _______in
which families collude with doctors to withhold
information from the patient
A
‘conspiracy of silence’
5
Q
The worst feeling a dying patient can sense is one
of rejection and discomfort on the part of the
______
A
doctor.
6
Q
The Gold Standards Framework (UK)
This framework, which provides an optimal model for
palliative care by the primary care team, focuses on
seven key tasks:
A
1 optimal quality of care 2 advanced planning (including out of hours) 3 teamwork 4 symptom control 5 patient support 6 carer support 7 staff support
7
Q
_______ is the commonest, most feared, but generally
the most treatable symptom in advanced cancer
A
Pain
8
Q
The
principles of relief of cancer pain are:
1 Treat the cancer.
2 Raise the pain threshold:
3 _______, for
example, opioids (if necessary).
A
Add analgesics according to level of pain
9
Q
The
principles of relief of cancer pain are:
4 _______—not all pain
responds to analgesics (refer TABLE 11.2 ).
5 Set realistic goals.
6 Organise supervision of pain control.
A
Use specific drugs for specific pain
10
Q
The right drug, in the right dose, given at the
right time relieves _______ of the pain. Reports of
the undertreatment of cancer pain persist.
A
80–90%
11
Q
The World Health Organization (WHO) analgesic
ladder is an appropriate guide for the management of
cancer pain:
Step 1: Mild pain
Start with basic non-opioid analgesics:
1.
2.
A
aspirin 600–900 mg (o) 4 hourly (preferred)
or
paracetamol 1 g (o) 4 hourly ± NSAID
12
Q
Use low dose or weak opioids (according to age
and condition) or in combination with non-opioid
analgesics (consider NSAIDs. What kind of pain?
A
Step 2: Moderate pain
13
Q
Options for moderate pain
add ________ 5 to 10 mg (o) 4 hourly (2.5 mg
in elderly)
increase in increments of 30–50% up to
15–20 mg
or
\_\_\_\_\_\_\_\_ 2.5 mg (in elderly) up to 10 mg (o) 4 hourly or CR 10 mg (o) 12 hourly or oxycodone 30 mg,\_\_\_\_\_\_\_ 8 hourly
A
morphine
oxycodone
rectally,
14
Q
Step 3: Severe pain
Maintain non-opioid analgesics. Larger doses of
opioids should be used and _______ is the drug of
choice
A
morphine
15
Q
How to give Morphine in severe pain:
morphine 10–15 mg (o) 4 hourly, increasing to
________ if necessary
or
morphine CR/SR tabs or caps _______
A
30 mg
(o) 12 hourly or
once daily
16
Q
Usual starting dose for morphine CR
A
The usual starting dose is 20–30 mg bd
17
Q
To convert to morphine CR/SR, calculate the
daily oral dose of regular morphine and divide by
_______
A
2 to get the 12 hourly dose
18
Q
How to give Morphine:
Starting doses are usually in the range of
_____
A
5–20 mg (average 10 mg)
19
Q
How to give Morphine:
If analgesia is inadequate, the next dose should
be increased by ______until pain control is
achieved
A
50%
20
Q
How to give Morphine:
____ is a problem, so treat
prophylactically with regular laxatives and
carefully monitor bowel function.
A
Constipation
21
Q
How to give Morphine:
Order a ________ for
breakthrough pain or anticipated pain (e.g. going
to toilet
A
‘rescue dose’ (usually 5–10 mg)
22
Q
How to give Morphine:
Order antiemetics ______
A
(e.g. haloperidol prn at first;
usually can discontinue in 1–2 weeks as tolerance
develops).
23
Q
Using morphine as a mixture with other
substances _________has no
particular advantage
A
(e.g. Brompton’s cocktail)
24
Q
How to give Morphine:
______ is not recommended (short half-life,
toxic metabolites) and codeine and IM morphine
should be avoided
A
Pethidine
25
______is a potent synthetic opioid which is
available as a transdermal system. Effective and
good for compliance. It is the least constipating
opioid and can be used in ______
Fentanyl
kidney failure
26
_____ is a potent analgesic available
as oral liquid, tablets and injection and is now
widely used in palliative care.
Hydromorphone
27
Hydromorphone:
It facilitates oral
dosing when a high opioid dose is required and
because of its ______ may reduce
the incidence of side effects in the frail and
elderly but like oxycodone may need to be given
_______
short half-life (2–3 h)
4 hourly if used alone.
28
This practice involves changing from one strong
opioid to another in patients with dose-limiting side
effects. Different opioids have differences in opioid
receptor binding
Opioid rotation
29
How to convert PO to SC
• Divide oral dose morphine by 3 for equivalent
SC dose 9
e.g. 30 mg oral morphine = 10 mg SC
• 10 mg morphine SC = 150 mcg fentanyl SC or
2–3 mg hydromorphone SC
30
Indications for IV Morphine
1. unable to swallow (e.g. severe oral mucositis;
dysphagia; oesophageal obstruction)
2. bowel obstruction
3. severe nausea and vomiting
4. at high oral dose (i.e. above 100–200 mg dose)
there appears to be no additional benefit from
further dose increments
31
When the oral and/or rectal routes are not possible
or are ineffective, a subcutaneous infusion with a
_______ can be used
syringe driver (pump)
32
SQ Morphine advantages:
It may avoid bolus peak effects
________ or trough effects
________ with intermittent parenteral
morphine injections.
(sedation, nausea or vomiting)
| breakthrough pain
33
_______ is sometimes
indicated for pain below the head and neck, where
oral or parenteral opioids have been ineffective
Epidural or intrathecal morphine
34
Sx control: anorexia
1.
2.
3
```
metoclopramide 10 mg tds
or
corticosteroids (e.g. dexamethasone 2–8 mg
tds)
high-energy drink supplements
```
35
If opioids need to be maintained, the laxatives need
| to be ________, not bulk-forming agents
peristaltic stimulants
36
Laxatives:
Aim for firm faeces with bowels open about every __________
third day.
37
How to use laxatives
_______ 20 mL bd
or
_______ one to two sachets, in 125 mL water,
1, 2 or 3 times daily
Rectal suppositories, microenemas or enemas
may be required (e.g. Microlax).
lactulose
Movicol,
38
_______ cocktail is useful for severe
constipation. With a small quantity of water melt one
tablespoon of Senokot granules in a microwave oven
Shaw’s (or PCU)
39
Noisy breathing and secretions:
Conservative:____________
repositioning to one side, reduced
| parenteral fluids and nasogastric suction
40
Noisy breathing and secretions:
• __________20 mg SC, 4
hourly or 60-80 mg daily by SC infusion
or
• ________ 0.2 mg SC as a single dose followed
by 0.6-1.2 mg/24 hrs by continuous SC infusion
hyoscine butylbromide (Buscopan)
glycopyrrolate
41
Noisy breathing and secretions:
For unconscious patient, as above, also consider:
________ 0.4 mg SC, 4 hourly or
0.8-2.4 mg/24 hrs by continuous SC infusion
or
________0.4-0.6 mg SC 4-6 hourly (be cautious of
delirium
* hyoscine hydrobromide
| * atropine
42
Dyspnoea
Identify the cause, such as a _______, and
treat as appropriate
pleural effusion
43
Morphine can be used for _______ e.g. 2.5–5 mg (o) 4 hourly, together with haloperidol or a phenothiazine for nausea.
intractable dyspnoea
44
Dyspnea
Use a short acting benzodiazepine e.g.
______ 0.25–5 mg sublingually if anxiety is a
component.
lorazepam
45
Terminal distress/restlessness:
1st choice:
_______
0.5 mg SC bolus or 0.25–0.5 mg (o) 12 hourly
(drops SL) (3 drops = 0.3 mg) or tabs 7
1–4 mg over 24 hours in SC syringe driver
_________ 2.5–5 mg SC 1–3 hourly prn or
2.5–10 mg sublingual or intranasal
(or 15 mg/day by SC) infusion
clonazepam
midazolam
46
Terminal distress/restlessness:
If very severe: add _____ as SC infusion or
(with care because of fitting) haloperidol
phenobarbitone
47
Options for nausea and vomiting:
If due to Morphine:
```
___________ 1.5–5 mg daily 1
(can be reduced after 10 days)
o r
___________10–20 mg (o) or SC 6 hrly
or
__________ (Stemetil)
5–10 mg (o) qid
or
25 mg rectally bd
```
haloperidol
metoclopramide
prochlorperazine
48
Alternatives for nausea and vomiting due to Morphine:
Alternatives: promethazine, cyclizine
49
Nausea and vomiting:
If due to poor gastric emptying, use a prokinetic
agent: _____
metoclopramide or cisapride or domperidone
50
Consider _____ and _____ for nausea
and vomiting induced by cytotoxic chemotherapy and
radiotherapy
ondansetron or tropisetron
51
Wound dressings
To reduce pain, apply a mixture of 10 mg/mL _______
topical
| morphine with 8 g/mL Intrasite hydrogel
52
Cerebral metastases
Common symptoms are headache and nausea.
Consider __________ (e.g. dexamethasone
4–16 mg daily). Analgesics and antiemetics such as
haloperidol are effective
corticosteroid therapy
53
Hiccoughs 7, 8
Try a starting dose of
_____ 0.25–1 mg (o) bd
or
______ 2.5 mg bd
clonazepam
haloperidol
54
Depression
```
______ 30 mg (o) daily, helpful for nighttime
sedation and appetite.
• consider ___________
5 mg (o) bd since evidence indicates an
improvement in symptoms
```
• mirtazapine
methylphenidate (psychostimulant)
55
Weakness and weight loss
This problem may be assisted by a high-calorie and
high-protein diet. Otherwise consider _________
total parenteral nutrition.
56
Delirium
Determine the cause, including adverse opioid
effect. Investigations include FBE, MCU, CXR, pulse
oximetry. Consider treatment with _____ and ____
olanzapine and
| haloperidol
57
Consider _______ in the presence of
drowsiness, confusion, twitching and abdominal
pain.
hypercalcaemia
58
Hypercalcemia:
It may be a ______ effect of myeloma
and cancers (particularly lung and breast). It carries a
poor prognosis—monitor serum calcium_____
paraneoplastic
>3 mmol/L.
59
The commonest malignancy is________. Other important malignancies include: lymphomas, cerebral tumours, bone
tumours and solid tumours
acute lymphatic
| leukaemia
60
Palliative care in children:
_______is the most commonly used opioid for
pain although fentanyl and hydromorphone are
now widely used
Morphine
61
Special problems for palliative care in children
Adverse reactions to tranquillisers,
corticosteroids, anti-emetics and aspirin are a
special problem
62
It should be an uncommon experience to be confronted
with a request for the use of ________, especially as
the media clichés of ‘ extreme suffering’ and ‘agonising
death’ are uncommonly encountered in the context
of attentive whole-person continuing care
euthanasia
63
Origin of pain:
1. Skin mucosa Bones and joints Pleura and peritoneum
symptoms?
1 Somatic
Localised stinging or burning
Dull ache
± Pain on movement
64
Origin of pain:
Solid or hollow organs
Visceral
Deep, diffuse pain
Poorly localised
± Colic
± Nausea and vomiting
65
Origin of pain:
Skeletal muscle
Smooth muscle
Symptoms
Muscle spasm
Pain worse on movement
Severe colic
Tenesmus
66
Types of nocicieptive pain
symptoms
Somatic, visceral and muscle spasm
67
Types of neuropathic pain
Neuropathic and central pain
68
Origin of pain
Nerve compression or peripheral nerve
damage
Prolapse IV disc
Limb amputation
Peripheral neuropathies
Post-herpetic neuralgia
69
Symptoms of central pain
Various pain syndromes (see text)
| ± Trophic changes
70
Pain can be subcategorised as:
* acute pain
* cancer/palliative pain
* chronic non-cancer pain
71
Acute pain is pain of recent onset and short duration
that usually has an obvious cause and a predictable
duration. It is usually _____ sensitive. It is often due
to ______ (e.g. postoperative pain).
opioid
nociception
72
_____ may be defined as pain present for
a period greater than 3 months or pain present for
4 weeks more than the expected time of recovery.
Chronic pain
73
example of unidimensional scale for pain
VAS
74
Examples of multidimensional scale for pain
McGill Pain Questionnaire
Pain Disability Index
Form 36 Health Survey (SF-36)
• Oswestry low-back pain questionnaire
75
The pain threshold can be lowered by factors
| such as :
fatigue, anger, depression, loneliness,
| home or work environment
76
______ is treated with antidepressants,
antiepileptics and membrane stabilisers. Agents
used to treat muscle pain are ____ and ______
Neurogenic pain
muscle relaxants and
baclofen
77
_______ has minimal anti-inflammatory activity
but moderate analgesic (equipotent with aspirin) and
antipyretic properties
Paracetamol
78
Half life of paracetamol
4 hrs
79
________has both analgesic and anti-inflammatory
activity and is a very effective drug in adults for mild to
moderate acute pain.
Aspirin
80
Commonly used agents for severe pain are the
weaker opioids—
stronger ones—
codeine, oxycodone, buprenorphine, tramadol
morphine,
fentanyl, hydromorphone and methadone
81
what is the 5A assessment for pain
analgesic effect, activity, affect, abnormal
| behaviour, adverse effects.
82
______, which is methylmorphine, is metabolised to
| morphine
Codeine
83
Controlled trials have shown codeine 32 mg
| to be no more effective than ____
aspirin 600 mg
84
Codeine is best avoided because of its variable metabolism secondary to ______
cytochrome CYP 2D6 polymorphism
85
_________ is a synthetic opioid that is very effective
orally. It is useful for moderate pain in bridging the gap
between the simple analgesics and strong opioids
Oxycodone
86
Oxycodone
| The oral form has a duration of action of _____
4 hours.
87
True of false, oxycodone is equianalgesic to morphine.
T
88
How to give oxycodone
```
Usual dosage:
10 mg (o) 4 hourly (max. 60 mg/day),
controlled release, (various strengths) 12 hourly
30 mg rectally (8–12 hourly [Prolodone]
```
89
This controversial drug is structurally related to
methadone. Adverse effects include serious cardiac
disorders, dysphoria, confusion, lightheadedness and
constipation.
Dextropropoxyphene
90
Dextropropoxyphene
Caution when taken in overdose, especially
with ____
Continuous use should be discouraged,
particularly in_____and _____
Avoid prescribing it for _____
alcohol.
elderly patients and those with cardiac
disease.
new patients
91
______ is the most effective and ‘gold standard’
opioid for the relief of moderate to severe pain and
cancer pain
Morphine
92
T or F
injections are more effective than oral
administration in achieving pain relief
F
93
_____ is an effective oral analgesic with a long
but variable half-life; it is given, preferably, once or
at most twice a day
Methadone
94
Methadone:
It should not be used in ___ patients or those with
_____
elderly
kidney dysfunction
95
Methadone:
Its place is in management of
opioid dependency but it needs to be used with care
because of the ______ and _____
risk of respiratory depression and
| accumulation.
96
_____ is a synthetic opioid with a short
| duration of action
Pethidine
97
Pethidine
problematic adverse effect is
accumulation of its toxic metabolite (norpethidine),
which can cause ______ and ____
myoclonic and general seizures
98
T or F
Pethidine
It has no place in the management of chronic pain,
whether cancer or non-cancer
t
99
________ is a very potent synthetic opioid which can
be administered IV, IM, SC, intranasal (children),
transdermal or by the epidural route
Fentanyl
100
The conversion
factor is: 10 mg (SC) morphine = ______
fentanyl.
150–200 mcg (SC)
101
This is structurally similar to morphine but five times
more potent. It is available for oral, parenteral and
intraspinal use in moderate to severe pain
Hydromorphone
102
Usual dose of hydroxymorphone
2–4 mg (o) every 4 hours
1–2 mg IM, SC or IV (slow) every 4–6 hours
4–8 mg daily of SR (sustained release
103
_____ is an atypical analgesic with both opioid
and non-opioid features. Its use is suitable for mild to
moderate mixed nociceptive and neuropathic pain
Tramadol
104
SE of Tramadol
______
dizziness, vertigo, nausea, vomiting, constipation,
headache, somnolence, tremor, confusion and
_________
serotonin effect,
hypersensitivity reactions
105
This is a partial agonist opioid derived from the opium
| alkaloid thebaine. It is useful in pain management
Buprenorphine
106
Buprenorphine
_________(0.2 mg, 0.4 mg, 2 mg, 8 mg)
are used for acute, chronic and cancer pain
Sublingual preparations
107
Components of combined analgesic
They usually consist of
a simple analgesic such as paracetamol or aspirin
combined with an opioid analgesic (usually codeine
108
Important concept of combined analgesic
The analgesics have an additive effect because
| they act at different receptor sites. The
109
This is a volatile anaesthetic agent that is administered
as inhalational analgesia with the Penthrox Inhaler in
emergency situations such as at the roadside
Methoxyflurane
110
Methoxyflurane:
It provides pain relief after
_________ breaths and it continues for several minutes
8–10
111
Prescribing guidelines for opioids
SR ______ is more ‘likeable’ for patient.
TD _________ is often a good starting
agent.
oxycodone
buprenorphine
112
Prescribing guidelines for opioids
_____is useful but has a potential serotonin
adverse effect and ceiling effect.
_______ is potent and its use questionable
Tramadol
• Fentanyl
113
Prescribing guidelines for opioids
• Do not initiate with _______
• Hydromorphone is very complex—best for
palliative care.
hydromorphone or fentanyl.
114
Prescribing guidelines for opioids
_______has complex kinetics so avoid
initiating unless well informed.
At least 80% of total daily opioid should be given
as an _______
Use_______ as a guide to
consolidate SR doses
Methadone
SR formulation.
immediate release (IR)
115
Prescribing guidelines for opioids
Avoid _______—use co-analgesics to
limit dose and side effects.
• Do not use hydromorphone or transdermal
fentanyl as first-line opioids in ______
IR-only regimens
opioid-naive
patients with chronic pain.
116
Prescribing guidelines for opioids
* Ensure that the pain syndrome is ______
* Good record keeping is mandatory.
* Beware of drug escalation
opioid sensitive.
117
T or F
Guiding principles for pain relief in children:
If a child complains of pain, they are serious and
it is organic until proved otherwise
T
118
The three most commonly used analgesics in children
| are _______, ______ ________
paracetamol, NSAIDs and opioids
119
The analgesic hierarchy in children
1. Paracetamol
2. NSAID (ibuprofen, naproxen)
3. Combination oral therapy:
4. Parenteral opioid:
• bolus IM, IV; infusion; PCA
5. Combination parenteral therapy:
•
2. NSAID (ibuprofen, naproxen)
3. • paracetamol/codeine mixes
• alternate: NSAID/paracetamol
5. NSAID/opioid/ketamine
• adjuvant clonidine
120
Paracetamol (acetaminophen) in children
This is generally safe and effective even in asthmatics
in therapeutic doses. It is rapidly absorbed orally
within ______ and well absorbed _______
30 minutes
rectally
121
Paracetamol in children
Hepatotoxicity is rare and does not usually occur
in doses below______ but acute paracetamol
overdose _________ is a potentially
life-threatening event
150 mg/kg/day
| single doses of >100 mg/kg
122
Aspirin in children is not in common use in children and should not be used <16 years since it has been associated
with _____
Reye syndrome
123
_______ have a proven safety and efficacy in children for
mild to moderate pain and can be used in conjunction
with paracetamol and opioids such as codeine and
morphin
NSAIDs
124
advantage of NSAID
opioid-sparing effect
125
CI to NSAID
hypersensitivity,
severe asthma (especially if aspirin sensitive), bleeding
diatheses, nasal polyposis and peptic ulcer disease.
126
Usual doses of NSAID in children
__________ 5–10 mg/kg (o) 6–8 hourly (max.
40 mg/kg/day)
_______ 5–10 mg/kg (o) 12–24 hourly (max.
1 g/day)
______1 mg/kg (o) 8 hourly (max. 150 mg/day)
_________ 1.5–3 mg/kg (o) bd
* ibuprofen:
* naproxen:
* diclofenac:
* celecoxib
127
Doses of opioid analgesics in children:
1. ________Usual dosage: • 0.5–1 mg/kg (o), 4–6 hourly prn (max. 3 mg/kg/ day)
2. ______Immediate release: • 0.2–0.4 mg/kg (o) 4 hourly prn
Codeine
Morphine
128
Fentanyl citrate in children can be administered orally
(transmucosal) as ______transcutaneously as
_______, or intranasally via a mucosal atomiser
device (for painful procedures).
‘lollipops’,
‘patches’
129
These are the most powerful parenteral analgesics for
children in severe pain and can be administered in
intermittent boluses (IM, IV or SC) or by continuous
infusion (IV or SC).
Parenteral opioids
130
T or F
Infants under 12 months are
more sensitive and need careful monitoring (e.g.
pulse oximetry).
T
131
T or F
As a general
rule, most elderly patients are not sensitive to
opioid analgesics and to aspirin and other NSAIDs but
there may be considerable individual differences in
tolerance
F (more sensitive)
132
Patients over _____years should receive lower
initial doses of opioid analgesics with subsequent
doses being titrated according to the patient’s needs
65
133
MOA of NSAIDs
They inhibit synthesis of
prostaglandins by inhibiting cyclo-oxygenase (COX)
present in COX-1 and COX-2. They are very effective
against nociceptive pain
134
Of particular concern, however, is the widespread use
of NSAIDs for common problems such as_____
when the main cause is dysfunctional or mechanical
without evidence of inflammation
back pain
135
Both _________
are more effective for the spondyloarthropathies and
gout.
indomethacin and phenylbutazone
136
NSAIDs with short half-lives include :
aspirin,
diclofenac, tiaprofenic acid, ketoprofen, ibuprofen
and indomethacin.
137
MOA of NSAIDs
Non-selective inhibitors of COX-1
and COX-2, mainly in CNS
Paracetamol
138
Non-selective inhibitors of COX-1
and COX-2, acting in both CNS
and periphery
Aspirin
Ketorolac
Other NSAIDs
139
Specific inhibitors of COX-2
Celecoxib
Etoricoxib
Meloxicam
Paracoxib
140
Preferential inhibitors of COX-2
| over COX-1
Meloxicam
141
```
Persons at higher risk from NSAID-induced
side effects (after Ryan)1
```
Definite
```
Age >65 years
Prior ulcer disease or complication
High-dose, multiple NSAIDs
Concomitant corticosteroid therapy
Duration of ther
```
142
Persons at higher risk from NSAID-induced
side effects:
Possible
```
Conditions necessitating NSAID treatment (e.g. RA)
Female sex
Ischaemic heart disease/hypertension
Kidney impairment
Smoking
Alcohol excess
```
143
T or F
There is evidence that peptic ulcers that develop
in patients taking NSAIDs heal faster if the NSAID is
dropped
t
144
trials have indicated that the efficacy of using H 2 -receptor
antagonists for preventing NSAID gastrointestinal
complications is low to absent.trials
have indicated that the efficacy of using H 2 -receptor
antagonists for preventing NSAID gastrointestinal
complications is low to absent.
T
145
An anti-inflammatory dose of _________ should
be considered as part of long-term treatment to
minimise NSAID use
fish oil
146
These both
act as rate-limiting enzymes in prostaglandins and
thromboxane synthesis
cyclo-oxygenase 1
| COX-1) and cyclo-oxygenase 2 (COX-2
147
The______ are a group of NSAIDs synthesised
to inhibit COX-2 specifically. They are on a par
as an analgesic with the COX-1 inhibitors
coxibs
148
The cardiovascular problems,
including increased blood pressure, thrombosis (fatal
myocardial infarction and stroke), and impairment of
kidney function experienced with________indicate
the potential problems of these agents
rofecoxib
149
NSAIDs with short half-lives __________may be safer in the elderly and all NSAIDs
should be used in reduced dosage
(e.g. ibuprofen and
| diclofenac)
150
Prescribing NSAIDs:
Intermittent courses for 14 days can work well in chronic
conditions, remembering that it takes about
______days for NSAIDs to achieve maximal
effectiveness.
______ is usually first choice
10
Ibuprofen
151
_______ can be defined as pain associated
| with injury, disease or surgical section of the peripheral or central nervous system
Neuropathic pain
152
Neuropathic pain:
It is a common
(affects about _______ of the population) although underidentified
condition.
1%
153
Neuropathic pain:
For initial pain relief, use ________
aspirin or paracetamol
| or a NSAID
154
Adjuvants for neuropathic pain:
tricyclic antidepressants [TCAs] and anti-epileptics)
| or parenterally, such as lignocaine or ketamine
155
TCAs:
_____10–25 mg (o) nocte increasing every
7 days to 75–100 mg max.
Consider another TCA (e.g. _____ and _____
amitriptyline
nortriptyline or doxepin
156
SNRIs
_______(consider for peripheral diabetic
neuropathy) 30 mg (o) daily (to max. 60 mg)
duloxetine
157
AED for Neuropathic pain:
```
________ 50–100 mg (o) bd initially
increasing to 400 mg bd max.
or
______ 100–300 mg (o) daily (nocte)
initially, increasing as tolerated to three times
daily (max. 2400 mg)
```
carbamazepine
gabapentin
158
Test dose for gabapentin
100 mg (o) at night
159
_____________ have been used for the central
desensitisation of chronic neuropathic pain but
evidence of benefit is limited
Ketamine infusions
160
• _______s may be better for constant burning pain.
• ________ may be better for sharp shooting
pain.
_________ is the drug of choice for
trigeminal neuralgia.
______ are much smaller than those for
treating depression.
TCA
Anti-epileptics
* Carbamazepine
* Doses of TCAs
161
Level 1 evidence shows that about ________
of patients have a significant response to
carbamezepine.
70%
162
The newer anti-epileptic ________has proven
efficacy for diabetic neuropathy 20 and postherpetic
neuralgia.
gabapentin
163
DPN:
Pain in the feet and legs is
found in 11.6% of people with _____ and in
31.2% of people with _______
type 1 diabetes
type 2 diabetes
164
The classic complaint is burning in the feet with
possible associated aching, cramping and tingling
sensations.
DPN
165
Non-diabetic causes of painful neuropathy
| can include deficiency states associated with
alcoholism and vitamin B12 deficiency, uraemia and
ischaemic neuropathy associated with peripheral
vascular disease
166
the patient complains of severe
and distressing pain that has the qualities of pain
arising from a physical (somatic) cause, but which
cannot be attributed to objectively demonstrable
organic pathology
somatoform pain, which is sometimes referred to
| as psychogenic pain
167
DDx for somatoform pain disorder
Differential diagnoses include occult organic pain,
depression, substance abuse, malingering and rare
disorders such as sickle cell anaemia and porphyria
168
Tx for somatoform pain disorder
Psychological
treatments are directed towards helping the patient
to cope and ‘live with the pain’. The
169
Tx for somatoform pain disorder
Referral for CBT or similar psychotherapies
| or to a pain clinic are options.
