Passmedicine

Question 1

What drug can be used to alleviate headaches caused by raised ICP due to brain cancer/mets?

Answer 1

Dexamethasone

It reduces oedema around brain mets

Question 2

What painkiller should those with advanced/progressive disease be offered?

Answer 2

Regular oral modified release morphine with oral immediate release morphine for breakthrough pain

Question 3

What dose of MR morphine and breakthrough morphine should you start with in someone with co-morbidities?

Answer 3

20-30mg MR

5mg for breakthrough

Question 4

What should be co-prescribed with opioids?

Answer 4

Laxatives

Question 5

What are common symptoms with opioid use and how can they be avoided?

Answer 5

Nausea
Often it is transient but if it persists can offer anti-emetics

Drowsiness, usually transient but dose can be altered if req.

Question 6

How do you calculate how much breakthrough morphine to use?

Answer 6

1/6th the daily dose of morphine

Question 7

In which group of patients should opioids be used very carefully?

Answer 7

In those with chronic kidney disease

Question 8

What are the preferred opioids to use in CKD?

Answer 8

Alfentanil, buprenorphine, fentanyl

Question 9

What is metastatic bone pain most likely to respond to?

Answer 9

Strong opioids
Bisphosphonates
Radiotherapy
Denosumab

Question 10

By how much should you increase an opioid dose at a time?

Answer 10

30-50%

Question 11

Which side effect of opioid use is usually persistent?

Answer 11

Constipation

Question 12

How do you convert a codeine dose to an oral morphine dose?

Answer 12

Divide by 10

Question 13

How do you convert a tramadol dose to oral morphine?

Answer 13

Divide by 10

Question 14

How does oxycodone differ from morphine?

Answer 14

Usually causes less sedation, vomiting + pruritus but more constipation

Question 15

How do you convert a morphine dose to an oxycodone dose?

Answer 15

Divide by 1.5-2

Question 16

How much does a transdermal fentanyl 12microgram patch equate to in oral morphine?

Answer 16

30mg daily

Question 17

How much does a transdermal fentanyl 10microgram patch equate to in oral morphine?

Answer 17

24mg daily

Question 18

How do you convert an oral dose of morphine to a s/c dose?

Answer 18

Half it

Question 19

How do you convert an oral dose of morphine to a s/c diamorphine dose?

Answer 19

Divide by 3

Question 20

How do you convert an oral dose of oxycodone to s/c diamorphine?

Answer 20

Divide by 1.5

Question 21

What drugs are used for the treatment of intractable hiccups?

Answer 21

Chlorpromazine
Haloperidol
Gabapentin
Dexamethasone (if hepatic lesions)

Question 22

When should a syringe driver be considered in palliative care?

Answer 22

If patient unable to tolerate oral meds, e.g. dysphagia, nausea, intestinal obstruction, weakness, coma etc.

Question 23

What are the two types of syringe drivers in the UK?

Answer 23

Graseby MS16A (blue) - delivers in mm per hour

Graseby MS26 (green) - delivers in mm per 24h

Question 24

Which drugs should you mix with sodium chloride when preparing for injection with syringe driver?

Answer 24

Granisetron
Ketamine
Ketorolac
Octreotide
Ondansetron

Question 25

What drugs can be put through a syringe driver for nausea and vomiting?

Answer 25

Cyclizine Levomepromazine Haloperidol Metoclopramide

Question 26

What drugs can be put through a syringe driver to help break up respiratory secretions?

Answer 26

Hyoscine hydrobromide

Question 27

What drugs can be put through a syringe driver to help with bowel colic?

Answer 27

Hycosine butylbromie

Question 28

What drugs can be put through a syringe driver to help with agitation and restlessness?

Answer 28

Midazolam Haloperidol Levomepromazine

Question 29

What drugs can be put through a syringe driver for pain?

Answer 29

Diamorphine is the preferred opioid

Question 30

What should you do if a palliative patient is confused/agitated?

Answer 30

Investigate for underlying causes, e.g. hypercalcaemia, infection, urinary retention, medications

Question 31

What medications can you give to help with confusion/agitation?

Answer 31

First line: haloperidol | Second line: chlorpromazine, levomepromazine

Question 32

What best treats agitation/restlessness in the terminal phase of the illness?

Answer 32

Midazolam

Question 33

Can you give a patient excess morphine if they are close to dying to end their suffering?

Answer 33

No - we must always start with a presumption in favour of prolonging life and not hasten death

Question 34

What is the first line pain killer in palliative patients who are unable to take oral medications?

Answer 34

Transdermal opioid patches (e.g. transdermal fentanyl patch 12micrograms/hour)

Question 35

What is allodynia?

Answer 35

Pain experienced with non painful stimulus

Question 36

What is hyperalgesia?

Answer 36

Severe pain experienced from mildly painful stimulus

Question 37

How is morphine metabolised in the body?

Answer 37

Morphine is metabolised in the liver by glucuronidation to morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). M3G is probably inactive. M6G has analgesic properties but is also responsible for the toxicity.

Question 38

In which organ does the majority of the excretion of the active metabolites of morphine take place?

Answer 38

Kidneys

Question 39

What are the possible clinical features of opioid toxicity?

Answer 39

Altered consciousness, confusion, vivid dreams, pseudohallucinations, hallucinations, myoclonus, and sometimes hyperalgesia and whole body allodynia