Revision - Anticipatory Meds Flashcards by Esme Cosham

What dose of Morphine sulphate is typically given for opiate naïve patients in end of life care?

1 - 2.5mg SC

Do not repeat within 1 hour
Max 4 doses in 24h

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If there is reduced renal function (eGFR <50), what can be used as an alternative to morphine sulphate in end of life care?

Oxycodone 1-2mg SC

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Opioid conversion

The following table shows dose equivalents of 10mg oral morphine:

Codeine/tramadol oral –> 100mg

Morphine IM/IV/SC –> 5mg

Oxycodone oral –> 5mg

Diamorphine IM/IV/SC –> 3mg

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Conversion factor from oral morphine to SC morphine?

Divide by 2

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Conversion factor from oral morphine to oral oxycodone?

Divide by 1.3-2 (depends on trust guidelines)

If in doubt, always opt for the lower dose and titrate up.

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It is also possible to use opioid patches for background analgesia. What 2 opioid patches are used?

1) fentanyl

2) buprenorphine

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When increasing the dose of opioids, what should the next dose be increased by?

30-50%

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How do the side effects of oxycodone differ from morphine?

Oxycodone causes less sedation, vomiting & pruritus but more constipation

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What medications can be given for N&V in palliative care?

(4)

1) cyclizine

2) haloperidol

3) levomepromazine

4) metoclopramide

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1st line pharmacological management (anti-emetic) of reduced gastric motility N&V in palliative care?

1) Metoclopramide

2) Domperidone (consider use in patients with PD)

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When is Metaclopramide NOT indicated in reduced gastric motility N&V in palliative care?

Should not be used when pro-kinesis may negatively affect the GI tract, particularly in complete bowel obstruction, GI perforation, or immediately following gastric surgery.

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What class of drug is metoclopramide?

D2 receptor antagonist

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Mechanism of action of metoclopramide?

1) Antiemetic effects –> dopamine D2 antagonist in the chemoreceptor trigger zone (CTZ) in the brain. This relieves the symptoms of N&V

2) Increased gastric emptying

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Which anti-emetic is used in toxic/chemically mediated N&V in palliative care?

(2)

1) Haloperidol

2) Cyclizine

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Which anti-emetic is used in management of cerebral causes of N&V in palliative care?

(2)

1) Cyclizine (if raised ICP)

2) Dexamethasone

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Which anti-emetic is used in management of anxiety/anticipatory nausea in palliative care?

Benzos e.g. lorazepam

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1st line choice of anxiolytic (for agitation) in palliative care?

Haloperidol

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In the terminal phase, what is agitation of restlessness best treated with?

(i.e. anticipatory meds)

Midazolam

2.5 – 5mg SC.

Do not repeat within 1 hour, maximum 4 doses in 24 hours.

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anticipatory medications used for respiratory tract secretions?

1) hyoscine butylbromide: 20mg SC

2) hyoscine hydrobromide

3) glycopyrronium

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Mechanism of hyoscine butylbromide?

Anticholinergic effect

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What are 2 indications for the use of a syringe driver in patients nearing the end of life?

1) requiring 2 or more doses of any one of the anticipatory medications in a 24 hour period

2) being unable to take oral meds that need replacing

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What 2 groups can pain be broadly split into?

1) Nociceptive

2) Neuropathic

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What is nociceptive pain?

Pain caused by damage to body tissue

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What are the 2 types of nociceptive pain?

1) somatic (skin, muscle, bones)

2) visceral (internal organs)

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What is neuropathic pain?

Direct damage to nerve tissue (peripheral or central)

What are adjuvant analgesics?

1) Neuropathic agents --> amitriptyline, pregabalin, gabapentin 2) Corticosteroids 3) NSAIDs 4) Non-pharmalogical –> TENS, radiotherapy, acupuncture, heat

Give 3 administration options for the regular background opioid

1) Oral modified release 12 hours (BD) e.g. MST, zomorph 2) 24h syringe driver 3) Transdermal patch e.g. fentanyl, buprenorphine

What is usual starting dose of a strong opioid?

5-10mg modified release morphine

Are opioids a cause of pruritus?

Yes

How are opioids excreted?

Renally Caution prescribing in renal impairment due to increased risk of opioid accumulation and subsequent toxicity

For patients with renal impairment, what opioid is preferred? Why?

Oxycodone - primarily metabolised by liver

In patients with mild renal or hepatic impairment, how should an opioid dose be changed?

Doses should be reduced by 50% Specialist advice should be sought before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment.

Are opioids safe in breastfeeding?

Max paracetamol dose in 24h?

What 3 classes of drugs can interact with NSAIDs and increase risk of bleeding?

1) Anticoagulants (e.g. warfarin) 2) Antiplatelets (e.g. aspirin) 2) SSRIs (e.g. sertraline)

How do NSAIDs affect the kidneys? 1) sodium levels 2) potassium levels

Can decrease renal function and lead to: 1) hyponatraemia 2) hyperkalaemia

What 2 classes of drugs can interact with NSAIDs and increase risk of electrolyte imbalances?

1) ACEi --> increased risk of hyperkalaemia 2) Diuretics e.g. spironolactone (increased risk of hyponatraemia or hyperkalaemia)

How do NSAIDs affect seizure activity?

Can worsen seizure threshold

What class of drugs can interact with NSAIDs and increase risk of seizures?

Fluoroquinolone antibiotics (e.g. ciprofloxacin)

Whart are 2 key side effects of fluoroquinolones (e.g. ciprofloxacin)?

1) lower seizure threshold 2) risk of tendon rupture

Typical drug dose for oral codeine?

30-60mg every 4 hours as required

What 3 doses does co-codamol come in?

8/500mg 15/500mg 30/500mg

Before prescribing any strong opiate, consider ABC. What is this?

A - start antiemetic B - consider breakthrough pain C- constipation, prescribe laxative

Typical drug dosing for (oral) morphine in acute pain?

Initially 10mg every 4 hours

What class of medication is duloxetine?

SNRI

What can be considered for people with localised neuropathic pain who wish to avoid oral treatments?

Capsaicin cream

Side effects of cyclizine?

Dry mouth Hypotension Drowsiness (antihistamine with some anticholinergic properties)

Major contraindication of metoclopramide?

Parkinson's (use domperidone instead)

What anti-emetic is typically chosen for toxic causes of N&V? e.g. hypercalcaemia

Haloperidol

What are the 2 chosen anti-emetics for end of life?

1) haloperidol 2) levopromethazine

Contraindications of haloperidol and levomepromazine?

Parkinson's

Most common side effect of ondansetron?

Constipation

What are the 4 main types of laxatives?

1) bulk forming e.g. ispaghula husk 2) stimulant e.g. senna 3) osmotic e.g. lactulose 4) softener e.g. docusate

What is the 1st line laxative in palliative care?

Senna

What can be used in reducing the discomfort associated with a painful mouth that may occur at the end of life?

Benzydamine hydrochloride spray/mouthwash

1st line anti-emetic for intracranial causes of nausea and vomiting?

Cyclizine

3 options for metastatic bone pain?

1) analgesia 2) bisphosphonates 3) radiotherapy

Pharmacological managment of confusion/agitation in palliative care but for patients NOT in the terminal phase?

Oral haloperidol (if the patient was in the terminal phase and agitated then SC midazolam would be indicated)

What can be used to manage bowel colic in palliative care?

Hyoscine butylbromide

Pharmacological management of hiccups in palliative care?

Chlorpromazine or haloperidol

What is the benzodiazepine of choice in terminal agitation/restlessness?

Midazolam

Why is diazepam not given as an end of life drug?

Irritant when given SC

What is 1st line in cancer related breathlessness when no reversible element?

Low dose immediate release PO morphine (i.e. oramorph)

Describe performance status 1-5

0 = normal 1 = symptomatic & ambulatory, cares for self 2 = ambulatory >50% of time 3 = ambulatory <50% of time 4 = bedridden 5 = dead

How does metoclopramide achieve the effect of increased gastric emptying?

Antagonist of muscarinic receptor inhibition --> i.e. increased ACh

Starting syringe driver dose of metoclopramide?

30mg

Side effects of haloperidol?

1) EPSEs 2) Anticholinergic effects 3) Hyperprolactinaemia 4) Antiadreneric e.g. prolonged QT interval 5) Risk of NMS 6) Sedation

Contraindications of haloperidol?

1) LBD 2) Parkinson's disease 3) CNS depression 4) Congenital long QT syndrome 5) Recent acute MI 6) History of torsades de pointes

What can be used to treat bowel colic 2ary to mechanical obstruction?

Hyoscine butylbromide

Revision - Anticipatory Meds Flashcards

(70 cards)