Scribd Logo
Upload

Welcome to Scribd!

  • 413 views

    Passmedicine MRCP Notes-Palliative Medicine and End of Life Care

    Uploaded by

    Mayar Wael
    This document provides guidance on palliative care prescribing for pain, agitation, hiccups, secretions, and the use of syringe drivers. It summarizes guidelines for treating pain with opioids like morphine and oxycodone. It recommends treatments for agitation like haloperidol and confusion like midazolam. For hiccups it suggests chlorpromazine, haloperidol, and gabapentin. Secretions in the last days are generally not troubling but can be managed conservatively or with hyoscine butylbromide or glycopyrronium bromide. It outlines how to use syringe drivers and common drugs that are compatible or incompatible when mixed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Passmedicine MRCP Notes-Palliative Medicine and End of Life Care

    Uploaded by

    Mayar Wael
    413 views5 pages
    This document provides guidance on palliative care prescribing for pain, agitation, hiccups, secretions, and the use of syringe drivers. It summarizes guidelines for treating pain with opioids like morphine and oxycodone. It recommends treatments for agitation like haloperidol and confusion like midazolam. For hiccups it suggests chlorpromazine, haloperidol, and gabapentin. Secretions in the last days are generally not troubling but can be managed conservatively or with hyoscine butylbromide or glycopyrronium bromide. It outlines how to use syringe drivers and common drugs that are compatible or incompatible when mixed.

    Original Title

    PASSMEDICINE MRCP NOTES-PALLIATIVE MEDICINE AND END OF LIFE CARE

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides guidance on palliative care prescribing for pain, agitation, hiccups, secretions, and the use of syringe drivers. It summarizes guidelines for treating pain with opioids like morphine and oxycodone. It recommends treatments for agitation like haloperidol and confusion like midazolam. For hiccups it suggests chlorpromazine, haloperidol, and gabapentin. Secretions in the last days are generally not troubling but can be managed conservatively or with hyoscine butylbromide or glycopyrronium bromide. It outlines how to use syringe drivers and common drugs that are compatible or incompatible when mixed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    413 views5 pages

    Passmedicine MRCP Notes-Palliative Medicine and End of Life Care

    Uploaded by

    Mayar Wael
    This document provides guidance on palliative care prescribing for pain, agitation, hiccups, secretions, and the use of syringe drivers. It summarizes guidelines for treating pain with opioids like morphine and oxycodone. It recommends treatments for agitation like haloperidol and confusion like midazolam. For hiccups it suggests chlorpromazine, haloperidol, and gabapentin. Secretions in the last days are generally not troubling but can be managed conservatively or with hyoscine butylbromide or glycopyrronium bromide. It outlines how to use syringe drivers and common drugs that are compatible or incompatible when mixed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    PASSMEDICINE NOTES

    PALLIATIVE MEDICINE &


    END OF LIFE CARE
    CONTENTS
    No Topic Page
    1 PALLIATIVE CARE PRESCRIBING: PAIN
    2 PALLIATIVE CARE PRESCRIBING: AGITATION AND CONFUSION
    3 PALLIATIVE CARE PRESCRIBING: HICCUPS
    4 PALLIATIVE CARE PRESCRIBING: SECRETIONS
    5 SYRINGE DRIVERS
    PALLIATIVE CARE PRESCRIBING: PAIN
    NICE guidelines
    In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed
    below. Please see the link for more details.

    Starting treatment
     when starting treatment, offer patients with advanced and progressive disease regular oral
    modified-release (MR) or oral immediate-release morphine (depending on patient preference),
    with oral immediate-release morphine for breakthrough pain
     if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For
    example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine
    solution as required
     oral modified-release morphine should be used in preference to transdermal patches
     laxatives should be prescribed for all patients initiating strong opioids
     patients should be advised that nausea is often transient. If it persists then an antiemetic should
    be offered
     drowsiness is usually transient - if it does not settle then adjustment of the dose should be
    considered

    SIGN guidelines
    SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
     the breakthrough dose of morphine is one-sixth the daily dose of morphine
     all patients who receive opioids should be prescribed a laxative
     opioids should be used with caution in patients with chronic kidney disease
    o oxycodone is preferred to morphine in palliative patients with mild-moderate renal
    impairment
    o if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred
     metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The
    assertion that NSAIDs are particularly effective for metastatic bone pain is not supported by
    studies. Strong opioids have the lowest number needed to treat for relieving the pain and can
    provide quick relief, in contrast to radiotherapy and bisphosphonates*. All patients, however,
    should be considered for referral to a clinical oncologist for consideration of further treatments
    such as radiotherapy

    Other points
    When increasing the dose of opioids the next dose should be increased by 30-50%.

    In addition to strong opioids, bisphosphonates and radiotherapy, denosumab may be used to treat
    metastatic bone pain.
    Opioid side-effects

    Usually transient Usually persistent


    Nausea Constipation
    Drowsiness

    Conversion between opioids

    From To Conversion factor


    Oral codeine Oral morphine Divide by 10
    Oral tramadol Oral morphine Divide by 10**

    Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more
    constipation.

    From To Conversion factor


    Oral morphine Oral oxycodone Divide by 1.5-2***

    The current BNF gives the following conversion factors for transdermal perparations
    a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily
    a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine
    daily.

    From To Conversion factor


    Oral morphine Subcutaneous morphine Divide by 2
    Oral morphine Subcutaneous diamorphine Divide by 3
    Oral oxycodone Subcutaneous diamorphine Divide by 1.5

    *BMJ 2015;350:h315 Cancer induced bone pain

    **this has previously been stated as 5 but the current version of the BNF states a conversion of 10

    ***historically a conversion factor of 2 has been used (i.e. oral oxycodone is twice as strong as oral
    morphine). The current BNF however uses a conversion rate of 1.5
    PALLIATIVE CARE PRESCRIBING: AGITATION AND CONFUSION
    Underlying causes of confusion need to be looked for and treated as appropriate, for example
    hypercalcaemia, infection, urinary retention and medication. If specific treatments fail then the
    following may be tried:
     first choice: haloperidol
     other options: chlorpromazine, levomepromazine

    In the terminal phase of the illness then agitation or restlessness is best treated with midazolam

    PALLIATIVE CARE PRESCRIBING: HICCUPS


    Management of hiccups
     chlorpromazine is licensed for the treatment of intractable hiccups
     haloperidol, gabapentin are also used
     dexamethasone is also used, particularly if there are hepatic lesions

    PALLIATIVE CARE PRESCRIBING: SECRETIONS


    These are common in the last days of life, but are generally more troubling for family members than
    for the patient themselves.

    Management
    Conservative:
     Avoiding fluid overload - particularly stopping IV or subcutaneous fluids
     Educating the family that the patient is likely not troubled by secretions

    Medical:
     First-line: hyoscine butylbromide
     Second-line: glycopyrronium bromide
    SYRINGE DRIVERS
    A syringe driver should be considered in the palliative care setting when a patient is unable to take
    oral medication due to nausea, dysphagia, intestinal obstruction, weakness or coma. In the UK there
    are two main types of syringe driver:
     Graseby MS16A (blue): the delivery rate is given in mm per hour
     Graseby MS26 (green): the delivery rate is given in mm per 24 hours

    The majority of drugs are compatible with water for injection although for the following drugs
    sodium chloride 0.9% is recommended:
     granisetron
     ketamine
     ketorolac
     octreotide
     ondansetron

    Commonly used drugs


     nausea and vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide
     respiratory secretions: hyoscine hydrobromide
     bowel colic: hyoscine butylbromide
     agitation/restlessness: midazolam, haloperidol, levomepromazine
     pain: diamorphine is the preferred opioid

    Mixing and compatibility issues


     diamorphine is compatible with the majority of other drugs used including cyclizine*,
    dexamethasone, haloperidol, hyoscine butylbromide, hyoscine hydrobromide,
    levomepromazine, metoclopramide, midazolam
     cyclizine is incompatible with a number of drugs including clonidine, dexamethasone, hyoscine
    butylbromide (occasional), ketamine, ketorolac, metoclopramide, midazolam, octreotide,
    sodium chloride 0.9%

    *precipitation may be seen at higher doses

    You might also like