Palliative CarePart 1

Dr Christine HirschSchool of Pharmacy, Aston University, Birmingham B4 7ET

What is Palliative Care?

“Palliative care is an approach that improves quality of life of patients and their families facing the problems associated with life threatening illness, through prevention & relief of suffering by means of early identification, impeccable assessment and treatment of pain and other problems physical, psychosocial and spiritual.”

WHO 2004 www.who.int

Team Approach

Symptom prevalence patients with advanced cancerC. Faull and R. Woof .Palliative Care 2002 Oxford University Press

Symptom % Cancer

Pain 60

Anorexia 60

Fatigue / weakness 50

Sleep disturbance 50

Constipation 50

Depression 45

Nausea or vomiting 40

Trouble breathing 40

Incontinence 40

Anxiety 40

Confusion 30

Objectives Part 1- Pain

Develop an individualised, safe, rational and stepwise approach to pain management in palliative careBe able to advise on management of breakthrough painBe able to ‘convert with confidence’Understand the appropriate use of adjuvant analgesics

Part 1 Patient 1

Mr S is a 78 year old man with advanced prostate cancer and bone metastases. He has been admitted via casualty drowsy and confused. He has a supply of paracetamol 1g qds and tramadol 100mg qds which were his own medications brought with him on admission. The label on the tramadol indicates that it had been dispensed three days earlier.

Assessment of pain

An unpleasant sensory and emotional experienceIs what the patient says it isLocation – underlying pathology (related to cancer? Treatment?)Duration and timingIntensity and natureWhat if anything eases it or makes it go away.

Pain management in cancer patients

Visceral pain - usually opioid sensitive “deep ache”, “pressure”, “throbbing”Bone pain – localised, “aching” variable response to opioids, traditionally NSAID sensitive, radiotherapy or bisphosphonates may be appropriateNeuropathic pain – difficult to describe, dysaesthesia, may respond poorly to opioids, adjuvant analgesics may be helpfulIncident pain - episodic

Pain due to cancer

30% do not develop painPain may be:cancer relatedtreatment relatedrelated to consequent disabilitydue to concurrent disordermay be controlled in 80% of patients

Tramadol

Opioid and non-opioid actionMetabolised to M1(O-desmethyltramadol) in liver,

2-4 x more potent than tramadol via CYP2D65-10% caucasians lack CYP2D6Much lower affinity for opioid receptors than morphineInhibits re-uptake of noradrenaline and serotoninDrug interactions

Analgesic effect reduced by ondansetronWarfarin - may prolong INR

WHO three-step analgesic ladder

e.gParacetamol

NSAIDs

e.g. Codeine

DihydrocodeineTramadol

e.g. Morphine

DiamorphineFentanyl

OxycodoneHydromorphone

Methadone

Non-opioids +/- adjuvant/s

Opioid for mild to moderate pain +/-

non-opioid +/- adjuvant

Opioid for moderate to

severe pain +/- non-opioid +/-

adjuvant

1 2 3

Analgesia in advanced cancerWhere possible give analgesia:

Regularly

By mouth

By the WHO analgesic ladder

Initiating morphine as a ‘strong opioid’If previously on weak opioid give 10mg morphine 4-hourly or mr 20-30mg bdIf frail or elderly 5mg morphine 4-hourlyIn reduced renal function reduce dose or lengthen dose interval or both.If two or more prn doses taken in 24 hours increase by 30-50% every 2-3 days as long as pain is opioid responsive.If using mr morphine also provide ‘immediate release’ morphine liquid or tabletsGoal: pain free, mentally alert

Anticipate – ‘Rescue’ doses

Choose opioid prescribed for regular medication (exceptions may be fentanyl & methadone)

Dose = up to 1/6 of 24 hour dose of baseline analgesia

TOTAL PAIN

PHYSICAL

SOCIAL

PSYCHOLOGICAL

SPIRITUAL

Alternative opioids

When would you use ?Which would you use?

Patient 2 part 1

Mrs. B. A 65 year old lady with advanced ovarian carcinoma has had her pain controlled previously on Zomorph 60mg bd.Very unwell

vomiting for 3 days severe abdominal painUnable to take her usual modified release morphine because of the vomiting

Alternative Step 3 opioid analgesics:

Fentanyl - (transdermal patch – reservoir & matrix, transmucosal lozenge/ sl, buccal, alfentanil injection-sc infusion)Hydromorphone – (normal release capsules, modified release capsules,‘Special’ – injectable)Oxycodone – (normal release caps and liquid, modified release tabs, injection)Methadone - (liquid, caps/tabs, injection) - specialist use only.Transdermal buprenorphine- (place in palliative pain control still not determined)

‘Converting’ doses of opioid

Refer to tables- as guidance onlyNB : Opioid metabolism varies between individualsTitrate to individual requirementsNB: Compromised renal or hepatic function and concomitant drugs.

Episodic pain

Breakthrough pain – (exacerbations against a background on controlled pain or occurring before next opioid dose is due).Spontaneous pain - ‘idiopathic pain’ unpredictableIncident pain – (predictable) related to specific actions e.g. movement, dressing change, coughingEnd-of-dose failure

‘Any acute transient pain that is severe and has an intensity that flares over the baseline’ EAPC working group 2002

Patient 3 – Part 1

A 72 year-old manProstate cancer, diagnosed 2002Bone secondaries, March 2007Spinal cord compression recentlyHis assessment – ’20 year-old, locked in an old body’Problems: mobility, pain, constipation

Drug history on admission

Co-codamol 8/500 2 qds (not taken)Diethylstilbestrol 1mg odLansoprazole 30mg odDexamethasone 8mg bdCyclizine 50mg tdsAspirin 150mg odLactulose 10ml bd

Adjuvant analgesics

CorticosteroidsAntidepressantsAntiepilepticsBisphosphonatesMNDA receptor blockade

AntispasmodicsMuscle relaxantsTENS / AcupunctureRadiotherapy

Patient 4 Part 1 - BS 49 year old female

Bilateral carcinoma of breastLong standing back painSevere painStraining to pass urinePain lower abdomenNumbness in handsNIDDM

Prescribed drugs

Zomorph 60mg bdParacetamol 1g qdsLansoprazole 30mg odCo-danthramer 2 nocteDiclofenac 75mg MR bdSodium clodronate 1600mg odGabapentin 300mg tdsDexamethasone 2mg odGliclazide 40mg od plus BM measurement.

Temazepam 10mg prnHyoscine Hydrobromide 400mcg prnMidazolam 2.5mg prnLevomepromazine 6mg po prn/ 5mg scOromorph 20mg prnDiamorphine 5mg sc prn

Gold Standards Framework

CommunicationCo-ordination Control of symptoms Continuity out of hours

Continued learning Carer support Care in the dying phase

Availability of drugs in the community

AnticipationIn-hours availabilityOut of hours availability

Gold Standards FrameworkLiverpool Care Pathway

Communication

References:

West Midlands Palliative Care Physicians - Guidelines for the use of drugs in symptom control 4th Ed 2007.Faull C, Carter Y,Daniels, 2005 Handbook of Palliative Care Blackwells Oxford.Twycross R, Wilcock A. Palliative Care Formulary 3rd Ed. 2007.Dickman A,Schneider J, Varga J. The syringe driver in palliative care.2nd Ed, 2005 Oxford University Press. Oxford.Dickman A. Basics of managing breakthrough cancer pain. The Pharmaceutical Journal 2009;283,21

References cntd:

Fallon M, Hanks G. ABC of Palliative Care. 2nd Ed 2006. Blackwell Publishing.Dickman A. Chronic pain management: advances. Pharm J. 2007;279:354-356.Palliative drugs website: www.palliativedrugs.comScottish intercollegiate guidelines network website www.sign.ac.uk

Palliative CarePart 2

Dr Christine HirschSchool of Pharmacy, Aston University, Birmingham B4 7ET

Objectives Part 2

To advise on aspects of symptom control other than painTo understand the place of the syringe driver in symptom control in palliative care

PainNauseaAgitationSecretions

Pathway for care of the dying

Integrated care pathway e.g. Liverpool Care Pathway

Initial assessmentOngoing careCare after death

When should a syringe driver be started?

Persistent nausea & vomitingDifficulty swallowingPoor alimentary absorptionIntestinal obstructionUnconscious or profoundly weak

Opioids via syringe driver willNOTgive better analgesia

unless there is a problem withabsorption or administration

Patient 1 Part 2 Mrs BS 49 year old female

Bilateral carcinoma of breastLong standing back painSevere painStraining to pass urinePain lower abdomenNumbness in handsNIDDM

Prescribed drugs

Zomorph 60mg bdParacetamol 1g qdsLansoprazole 30mg odCo-danthramer 2 nocteDiclofenac 75mg MR bdSodium clodronate 1600mg odGabapentin 300mg tdsDexamethasone 2mg odGliclazide 40mg od plus BM measurement.

Temazepam 10mg prnHyoscine Hydrobromide 400mcg prnMidazolam 2.5mg prnLevomepromazine 6mg po prn/ 5mg scOromorph 20mg prnDiamorphine 5mg sc prn

Data on drug compatibility and stability is limited:

Generally dilute with water - unless 0.9% saline is specified – debate!

Avoid mixing more than two drugs in a syringe, unless stability data is available

Analgesia - usually diamorphine

Alternatives: Morphine, Oxycodone, Hydromorphone, AlfentanilDose conversions – consult local palliative care guidelinesConsider, renal failure, liver failure, stable painTiming

Antiemetics

First line agent - based on underlying cause: haloperidol, metoclopramide, cyclizineSecond line, add another first line or change to ‘broad spectrum e.g. LevomepromazineThird line, if other agents not controlling try 3 days 5HT3 receptor antagonist

Antiemetics - in syringe drivers

Cyclizine & levomepromazine (Nozinan) - irritation at infusion site.Try saline as diluent for levomepromazineDo not use saline to dilute cyclizineCyclizine / diamorphine mixture may precipitate if cyclizine conc >10mg/ml or either drug > 25mg/ml. Use larger volumeDo not mix cyclizine and oxycodone

Agitation and delirium

Consider causes; e.g. drugs (opioids), biochemistry (e.g. calcium) infection, constipationDelirium/psychosis:

Haloperidol Levomepromazine

Restlessness & agitation

Where agitation & anxiety are predominant features:

Midazolam Levomepromazine

Myoclonic jerking

May be exacerbated by drugs, rapid escalation of opioid dose and anticholinergics

Midazolam Clonazepam (specialist use only)

Terminal respiratory secretions

PositioningReassurance

Hyoscine hydrobromide -crosses blood brain barrier, absorbed transdermally, paradoxical agitation, sedation. Hyoscine butylbromide - for colic with intestinal obstruction, may be used to control secretions. Does not cross blood brain barrier. Glycopyrronium - for excessive respiratory secretions and bowel colic. Does not cross blood brain barrier. Unstable above pH6, avoid mixing with dexamethasone.

Prescribed drugs

Zomorph 60mg bdParacetamol 1g qdsLansoprazole 30mg odCo-danthramer 2 nocteDiclofenac 75mg MR bdSodium clodronate 1600mg odGabapentin 300mg tdsDexamethasone 2mg odGliclazide 40mg od plus BM measurement.

Temazepam 10mg prnHyoscine Hydrobromide 400mcg prnMidazolam 2.5mg prnLevomepromazine 6mg po prn/ 5mg scOromorph 20mg prnDiamorphine 5mg sc prn

BS syringe driver

Diamorphine 40mg over 24 hoursCyclizine 150mg over 24 hours

Increased by 10mg diamorphine after 3 days and to 60mg diamorphine after further 3 days.

High gastric output, obstruction, fistulae:

•Opioids, regular or continuous

•Octreotide 0.1-0.6mg per day (may be given as continuous infusion.)

Dyspnoea

Diazepam 2.5-10mgLorazepam 0.5mg sublinguallyMidazolam 2.5-5mg 4 hourly subcutaneouslyOpioids, 2.5-5mg diamorphine 4 hourly s.c. for opioid naïve patientsLevomepromazine 25-50mg 6-8 hourly if extreme agitation

Other symptoms: Mouth Care

•Water sips, ice chips, mouth swabs

•Emollients, paraffin jelly

•Artificial saliva - not glycerin

•Candidiasis

•Benzydamine

Use of drugs beyond licence-

‘a legitimate aspect of clinical practice’‘currently both necessary and common’‘..professionals should inform, change & monitor……… in light of evidence from audit and published research.’

Association for Palliative Medicine and the Pain Society – position statement 2001.

Gold Standards Framework

CommunicationCo-ordination Control of symptoms Continuity out of hours

Continued learning Carer support Care in the dying phase

Availability of drugs in the community

AnticipationIn-hours availabilityOut of hours availability

Gold Standards FrameworkLiverpool Care Pathway

Communication

References:

West Midlands Palliative Care Physicians - Guidelines for the use of drugs in symptom control 4th Ed 2007.Faull C, Carter Y,Daniels, 2005 Handbook of Palliative Care Blackwells Oxford.Twycross R, Wilcock A. Palliative Care Formulary 3rd Ed. 2007.Dickman A,Schneider J, Varga J. The syringe driver in palliative care.2nd Ed, 2005 Oxford University Press. Oxford.Dickman A. Basics of managing breakthrough cancer pain. The Pharmaceutical Journal 2009;283,21

References cntd:

Fallon M, Hanks G. ABC of Palliative Care. 2nd Ed 2006. Blackwell Publishing.Dickman A. Chronic pain management: advances. Pharm J. 2007;279:354-356.Palliative drugs website: www.palliativedrugs.comScottish intercollegiate guidelines network website www.sign.ac.uk