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PSA Prep Course Palliative Care DR CHANG KIM FY1 1Disclaimer We are a group of F1 doctors preparing this course to help prepare/as a supplement for your PSA. Please do not use this as your sole source of revision. None of the patients/cases are based on real-life scenarios, and any similarities are coincidental. Some drug concentrations/preparations may have been changed for ease of calculations, and may not resemble real-life clinical practice. Always consult your university for exam-related queries and support, and the BNF/Medicines Complete for up-to-date information on drugs and prescriptions. 2 Recruiting Now! •We are looking for a tutor to join our team •Nov 21 – Psychiatric Emergencies • MSE • Neuroleptic malignant syndrome • Serotonin syndrome • Lithium toxicity • Clozapine-induced agranulocytosis •If you are interested, shoot an email to icsm.amsa.academics@gmail.com 3 Learning Objectives •Analgesia & Drug Conversions •WHO Pain Ladder • (Neuropathic Pain) •Opioid Conversions •Palliative Medications 4 What is palliative care? •“Palliative care improves the quality of life of patients and that of their families who are facing challenges associated with life-threateningillness, whether physical, psychological, social or spiritual. The quality of life of caregivers improves as well.” -WHO Medical care that relieves pain, symptoms and stress caused by serious illnesses. 5 An 85-year-old man has been on your ward for the past 3 weeks. He was initially admitted following a CAP and is currently awaiting for his care package to be increased prior to discharge. He has a DNAR form in place. During your morning WR he complains of elbow pain and the consultant asks you to modify his analgesia. PMH: hypertension, BPH, MI 2004 Aspirin 75mg PO OD Which of the following options is the most suitable Ramipril 2.5mg PO OD next-line option? Simvastatin 10mg PO ON a. Codeine phosphate 60mg PO QDS Finasteride 5mg PO OD b. Oramorph 2.5mg PO 4-hourly c. Paracetamol 1g PO QDS Paracetamol 1g PO QDS d. Ibuprofen 400mg PO QDS PRN e. Paracetamol 1g IV QDS GTN spray 2 spraystopical PRN Apologies for the unclear question in the tutorial. Have changed the stem from back pain to elbow pain. Correct answer: C. This is because if the patient is already on paracetamol but on the PRN side. You would want to change it to regular rather than introducing a new medication, increasing the risk of drug reactions/increased side effects. 6 WHO Pain Ladder Step 1 Step 2 Step 3 Strong Opioids Morphine, Oxycodone, Fentanyl Weak Opioids Codeine, Dihydrocodeine, Tramadol, Co-codamol* Non-Opioid Paracetamol, Ibuprofen, Aspirin, Diclofenac etc Adjuvant Therapies BNF: Adjuvant analgesics include drugs such as antidepressants, antiepileptics, benzodiazepines and other muscle relaxants, bone-modulating drugs, corticosteroids, and topical capsaicin, lidocaine, and rubefacients. *Note co-codamol contains codeine and paracetamol. Co-dydramol has the same principle, but contains dihydrocodeine instead of codeine. Common questions involving non-opioid analgesia: -NSAIDs and renal disease -Paracetamol + co-codamol/co-dydramol prescription Entire guidelines and very detailed recommendations from WHO can be found here: https://www.who.int/publications/i/item/9789241550390 7 A 74-year-old man presents to the emergency department with a shortened and externally rotated left hip. An X-ray reveals a left neck of femur fracture. PMH: HTN, osteoporosis. Allergies: NKDA. DH: ramipril 10mg PO OD, denosumab 60mg SC every 6 months. He has been prescribed paracetamol 1g PO QDS by the ED team, however, is still complaining of pain. A. Aspirin B. Femoral nerve block C. General anaesthesia Which of the following would be the most suitable next-line D. Ibuprofen analgesia? E. Oramorph Not a “palliative”/end of life question but analgesia related Answer: E NICE CKS: Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended in hip fracture management. 8WHO Pain Ladder Step 1 Step 2 Step 3 Strong Opioids Morphine, Oxycodone, Fentanyl Weak Opioids Codeine, Dihydrocodeine, Tramadol, Co-codamol Non-Opioid Paracetamol, Ibuprofen, Aspirin, Diclofenac etc Adjuvant Therapies 9 Opioid Conversion Oral morphine management ◦ Immediate/modified release +/- rescue doses ◦ IR formulation: quicker release of medication ◦ Wear off quicker than MR medication Pain Level Morphine SulphatMorphine SulphatMorphine SulphatMorphine SulphatMorphine SulphatMorphine Sulphate t IR 10mg IR 10mg IR 10mg IR 10mg IR 10mg IR 10mg Immediate release tablets will work quickly but will quickly wear off 10Opioid Conversion Oral morphine management ◦ Immediate/modified release +/- rescue doses ◦ MR formulation: longer/slower release of medication Pain Level Morphine Sulphate Morphine Sulphate t MR 30mg MR 30mg 11Opioid Conversion Oral morphine management ◦ Immediate/modified release +/- rescue doses ◦ MR formulation: longer/slower release of medication ◦ Will need additional rescue doses to cover painful periods Pain Level Morphine Sulphate Morphine Sulphate MR 30mg MR 30mg a 12 Opioid Conversion Calculating up to regular analgesia 1. Establish the total amount of MORPHINE given over a 24h period 2. Convert total amount into regular medication dose E.g. Patient has had Morphine 20mg BD + 4 doses of Oramorph 5mg In a 24h period -> (20 x 2) + (5 x 4) 60mg total Morphine sulphate MR 30mg BD* *In clinical practice, and often in the PSA, you will be expected to convert the medication to a BD schedule. The official guidelines on the BNF state that MR preparations can be given as 12- hourly or 24-hourly preparations. 13 Opioid Conversion Calculating breakthrough pain rescue doses 1. Establish the total amount of MORPHINE given over a 24h period 2. Divide by 6 (or 10) E.g. Morphine sulphate MR 30mg BD In a 24h period -> 30 + 30 = 60mg total 60/6 = 10mg morphine oral solution (Oramorph) Typically Oramorph is prescribed with a cap on the maximum number of doses E.g. maximum 4 doses over 24 hours If a patient reaches the maximum dose, a review of the analgesia control would be required 14WHO Pain Ladder Step 1 Step 2 Step 3 Strong Opioids Morphine, Oxycodone, Fentanyl Weak Opioids Codeine, Dihydrocodeine, Tramadol, Co-codamol Non-Opioid Paracetamol, Ibuprofen, Aspirin, Diclofenac etc Adjuvant Therapies 15 Opioid Conversion Chart Key conversions to be aware of: Codeine PO to morphine PO (÷ 10) Morphine PO to morphine IM/IV/SC (÷ 2) This chart is taken directly from BNF 16 Example Question Re-prescribe analgesia for a patient currently taking 60mg codeine QDS and has had 3 doses of 5mg Oramorph into morphine sulphate MR 12- hrly tablets & Oramorph PRN. Total codeine dose: 60mg x 4 = 240mg 240mg codeine is equivalent to 24mg morphine (÷10) 24mg + 3x5mg = 39mg total Morphine sulphate MR 20mg BD 40mg ÷ 6 = 6.666 Should we prescribe Oramorph PRN as 5mg or 7.5mg? Answer: should ideally be prescribed as 7.5mg. Morphine sulphate is typically prepared as 2.5mg aliquots, as this allows for safe and uncomplicated drawing up of the drug to take place, reducing the risk of error. 5mg would be an under-dose and is likely to be ineffective. 7.5mg would therefore be more appropriate. 17Oramorph prescription Needs to be prescribed as drug name I.e. Morphine oral solution Always prescribe as dose, not volume Note 100mcg/mL, 10mg/5mL, 10mg/mL, 20mg/mL 1819During the WR you see a 74-year-old lady who was admitted on the ward following a community-acquired pneumonia. The patient complains of pleuritic chest pain and the consultant decides to escalate her analgesia to a fentanyl patch. You note that she has had 4 doses of her Oramorph in the last 24 hrs. PMHx: metastatic breast cancer, AF. DHx: Co-amoxiclav 500/125mg IV TDS, morphine sulphate MR 60mg PO BD, apixaban 5mg PO BD, Morphine oral solution 10mg PO QDS PRN Please write a prescription for a Fentanyl patch. (Medication, Dose, Route, Frequency) 20 During the WR you see a 74-year-old lady who was admitted on the ward following a community-acquired pneumonia. The consultant decides to escalate her analgesia to a fentanyl patch. You note that she has had 4 doses of her Oramorph in the last 24 hrs. PMHx: metastatic breast cancer, AF. DHx: Co-amoxiclav 500/125mg IV TDS, morphine sulphate MR 60mg PO BD, apixaban 5mg PO BD, Morphine oral solution 10mg PO QDS PRN Total dose: 60 x 2 + 10 x 4 = 160mg morphine Head to the BNF and search “Prescribing in palliative care” Fentanyl 75 mcg/hr patch, 1 application, topical, every 3 days Fentanyl‘XX’ patch indicates a fentanyl XX mcg/hr patch As mentioned in the first session, this is why I think it is important to have explored the PSA website, mess with the mock assessments, and use them as a reference point when answering questions supplied by other tutors/question banks. Using the official site is the best way to accurately practice prescribing medication. 21This graph has only been includedfor you to refer to as a point of reference. The only things I would recommend learning are the conversion rates for PO morphine to SC morphine, and PO codeine to PO morphine, and to convert PRN th doses by calculating to 1/6 . 22 You are the on-call FY1 who has just been bleeped by a nurse to prescribe some medication. A 74-year-old lady has admitted following a non-infective exacerbation of COPD. She was treated along the acute COPD management protocol, and despite some improvement in her clinical status, she still reports of breathlessness. This is her 5 presentation in the last year. She was reviewed by the palliative team on admission, who recommended the prescription of an opioid, but did not document which one to prescribe. Which medication should be prescribed to assist with her breathlessness? A. Morphine sulphate nebuliser 2.5mg 1-hourly PRN B. Morphine sulphate IR liquid (Oramorph) 5.0mg PO QDS PRN C. Morphine sulphate IR liquid (Oramorph) 5.0mg PO QDS D. Morphine sulphate injection 1.25 SC 1-hourly PRN E. Fentanyl patch 12 mcg/hr every 72hrs Answer: B Opioids have a respiratory suppression property, and are used often in palliative medicine for symptomatic control of breathlessness. Thank you to the person who corrected me on the session, BNF states that you would start at 5mg PO QDS. 23 Her dyspnoea becomes well controlled over the next few days, however she starts complaining of some chest pain. You are asked by your consultant to prescribe some regular morphine sulphate MR (12-hrly) for her, and change her Oramorph prescription if needed. You note that in the past 24hrs, she has had 8 doses of the 2.5mg Oramorph. A. What dose of morphine B. What dose of Oramorph should sulphate should be prescribed? be prescribed? A. 10mg BD B. 5mg PRN (3.33, better to overdose than underdose) 24 A 62-year-old man presents to the emergency department with a chronic headache and new onset seizures. PMH: small cell lung cancer. Allergies: NKDA. DH: nil. Investigations CT Head: multiple well-demarcated lesions, with extensive surroundingoedema. He has been started on carbamazepine 100mg BD for seizure prophylaxis. Write a prescription for ONE drug that is most appropriate to help manage the oedema. Dexamethasone 0.5-10mg daily Note the question specifically says OEDEMA not headache 25 During your on-call shift you are bleeped to review a 47-year-old woman who complains of worsening back pain. PMH: Metastatic breast cancer, Sjogren’s disease. Allergies: NKDA. DH: Codeine 60mg PO QDS, Hypromellose 1 drop topical PRN, Oramorph 7.5mg PO PRN 4-hrly, paracetamol 1g IV QDS. You note on her drug chart that she has had 2 doses of Oramorph in the last 24h. You decide to convert her analgesic medication to optimise her pain control. How much morphine sulphate (to the nearest 10mg) should be prescribed for her in a 24 hour period? 60*4 = 240 240 / 10 = 24 24 + 15 = 39 40mg morphine sulphate 26 One of the nurses asks you to review a palliative patient in the ward. She is a 92-year-old female who is receiving end-of-life treatment for metastatic breast cancer. She has a GCS of 9 and has no visible signs of distress. The family at the bedside say that she has started having laboured breathing and finds the rattling breath sounds upsetting. PMH: metastatic breast cancer, heart failure DH: Morphine 2.5mg SC 1-hourly PRN, Midazolam 2.5mg SC 1-hourly PRN, Haloperidol 1mg SC 12-hourly PRN Please prescribe one medication to help manage this patient’s condition. (Drug, Dose, Route, Frequency) Hyoscine hydrobromide – SC 400 mcg 4 hrly PRN, up to 1 hourly (more sedative) Hyoscine butylbromide –SC 20 mg 4 hrly PRN. Up to 1 hourly if required(less sedative) Glycopyrronium bromide – SC 200 mcg 4 hrly PRN up to 1 hourly Infusions would also be suitable but not full marks as they wouldn’t be first line Morphine: for pain/breathlessness, midazolam: for agitation, haloperidol: for nausea 27 You are bleeped to review an 87-year-old male who was admitted for bowel obstruction secondary to metastatic colon cancer. He is currently being treated by the palliative team for symptomatic relief only. The nurse tells you that he is constipated and has vomited twice this morning, which you suspect is secondary to his opioid therapy, and he is not tolerating oral medication. PMH: metastatic colon cancer, HTN, T2DM, Meniere’s disease DH: Morphine 2.5mg SC 1-hourly PRN, paracetamol 1g PO QDS PRN, senna 7.5 mg PO ON, docusate 250mg PO BD Please prescribe one medication to help manage this patient’s nausea. (Drug, Dose, Route, Frequency) Haloperidol 2.5-10mg SC infusion over 24hrs Cyclizine/levomepromazine are technically not wrong, but you wouldn’t score the full 5+5 marks, as you are aiming to treat the nausea which is likely secondary to opioid use. Metoclopramide 30-100mg SC infusion over 24hrs is incorrect, as it is a pro-kinetic anti-emetic, and thus would be contraindicated. Pro-kinetic antiemetics are contraindicatedin GI bleeds, obstructions, and perforations. 28 Antiemetics Metoclopramide: indicated for use in opioid-induced nausea, and has pro-kinetic properties, contraindicated in bowel obstruction/perforation Haloperidol: metabolic causes (hypercalcaemia, renal failure) Ondansetron: generally only used in N+V secondary to chemotherapy or radiotherapy Dexamethasone: used as an ADJUNCT in N+V in palliative care Levomepromazine: “broad-spectrum” antiemetic with high SE profile, typically reserved in multi-factorial emesis, or if others don’t work ◦ Can cause drop in postural BP, so not used typically in the elderly Cyclizine: used for nausea and vomiting due to mechanical bowel obstruction, raised intracranial pressure, and motion sickness. Apologies, this slide and the previous slide has been cut out from the recording, due to errors during the presentation. Many thanks to the students who pointed it out. 2930 Feedback •We are looking for a tutor for: •Nov 21 – Psychiatric Emergencies • MSE • Neuroleptic malignant syndrome • Serotonin syndrome • Lithium toxicity • Clozapine-induced agranulocytosis •If you are interested, shoot an email to icsm.amsa.academics@gmail.com 31
