Symptom Management. Program of Experience in the Palliative Approach (PEPA)- Workshop ( ) Palliative Care Services in NW Tasmania

Transcription

1 Symptom Management Program of Experience in the Palliative Approach (PEPA)- Workshop ( ) Palliative Care Services in NW Tasmania Dr Thiru Thirukkumaran CMO / Palliative care Palliative Care Services Northwest Tasmania Senior Lecturer in Palliative Medicine Rural Clinical School, Burnie, University of Tasmania

2 How this Session is planned? Introduction to Palliative care Symptom Management 2

3 Introduction to Palliative care Section - One 3

4 What is Palliative Care? An active and total approach to the care of a person with a life limiting illness that embraces physical, psychological, emotional, social, cultural and spiritual elements PCA 2005 Comfort Care / Supportive Care /holistic approach to care 4

5 What is Palliative Approach? An attitude to care that concentrates on quality of life for clients facing lifelimiting illness. Active treatment may be provided concurrently. This approach does not necessarily need to involve the specialist Palliative Care Services. There is an understanding that dying, death and bereavement are a part of life 5

6 How do we access to Palliative Care Services? The service can be accessed by phone, fax, from: The person/client Client s family GP Medical Specialist Hospital Staff Community Health Nurse Rural Aged Care Staff Other Health Care Professionals (allied health) 6

7 What palliative care can offer to Patient/family & carers? Palliative Care is offered to The unit of care. The service for Patient, and family/carers/friends Offers a support system to enable people to live as actively as possible until their death, in the environment of their choice 7

8 Palliative Care Team Medical Specialists Community Palliative Care Nurses Social workers. Liaison CNC at NWRH/MCH (currently suspended) Admin. & Management staff Hospice Care Association (NGO): Coordinator and Volunteers 8

9 Tasmanian Model for Palliative Care Service Delivery Level-4: Direct Care (including community & in-patient) by the Palliative specialist service. Level-3: Shared Care with PCS team and other primary care providers. Level-2: Consultation and advice for primary care providers, but primary provider remains first contact for client Level-1: Information / resources / training and professional development 1 9

10 Partnerships for Coordination of Care Community Nursing Hospice Care Association Rural Aged Care Facilities Allied Health Professionals e.g.: OT, Physiotherapist Holman Clinic GPs Public, Regional & District Hospitals Carer-Respite Centre and Family Based Care Private Hospitals & Medical Consultants 10

11 Contact Details: Palliative Care Services Northwest Tasmania Phone: Fax: Web: 11

12 Symptom Management Program of Experience in the Palliative Approach (PEPA)- Workshop Section - Two 12

13 Prevalence of 27 Symptoms in 400 patients referred to palliative care services Symptom All % Hospice % Community % Hospital % Outpatient % (n =400) (n =100) (n =100) (n =100) (n =100) 1. Pain Anorexia Constipation Weakness Dyspnoea Nausea Neuropsychiatric Tiredness Weight loss Low mood Vomiting Dry mouth Cough Dermatological Urinary Anxiety Oedema Sleep problem Loose stool Dyspepsia Numbness/tingling Dysphagia Haemorrhage Early satiety Sweating Hiccoughs Taste change J Potter et al. Palliative Medicine 2003; 17:

14 Pain 14

15 Question 64 years old, Mrs F referred for pain assessment. She was diagnosed with metastatic breast carcinoma with multiple liver metastasis. RUQ ache (pain score of 4-5/10) with sharp shooting exacerbations (pain score = 9-10/10) for few seconds on movements. She was given Norspan patch of 10mcg/hr and morphine mixture 5mg prn (4hourly) by her GP. Patient find patch give some relief to her constant ache (pain score = 2-3 /10) and top-ups are not helping for sharp pain. She is using 5 top-ups /day and it make her sleepy throughout the day. 1. What type / types of pain we consider here? 2. Why Morphine mixture is not helping on her sharp shooting pain? 3. What is her opioid requirement? How to calculate? 4. How do we manage this patient? 15

16 Answer 1. (a) A Constant ache likely to be Liver capsular pain (b) Sharp shooting pain (for few seconds) on movements likely be due to neuropathic element 2. Morphine mixture take minutes to work but this pain last for seconds 3. On multiple opioids! Morphine Total opioid / 24 hours = Norspan dose (mcg/hr) x 24 (hrs) x 60 (Conversion ratio) 1000 ( mcg to mg) = 10 x 24 x = 14.4 mg for 24 hours from Norspan patch = ( 5mg x 5) = 39.4 mg Using 39.4mg /24hours but still having pain 4. Fentanyl patch 12mcg/hr approx. equal to 45 mg of morphine (oral) My Management will be (a) Stop Norspan patch & start Fentanyl patch 12mcg/hr every 3 days (b) Top-up Morphine mixture 1/6 of total dose = 45mg/6 =7.5mg prn (4 hourly) (c) Dexamethasone 8mg po mane to reduce the size of enlarged liver ( capsular pain) (d) Reduce liver size may improve the sharp pain & if not, consider adding a neuropathic agent, if no response to above treatment 16

17 Pain Two types on the basis of the mechanism by which pain is produced Nociceptive Pain Visceral Pain Somatic Pain Capsular Bowel Cardiac Bone Soft Tissue Neuropathic Pain Nerve Compression Nerve Injury Peripheral Central Sympathetically maintained 17

18 Pain Evaluation & Pain history taking We need to know the pain response objectively to provide better pain control To measure the pain objectively we need pain measurement tools Numeric Rating Scale Faces Pain Scale Visual Analogue Scale Verbal Descriptor Scale 18

19 Pain Management Non Pharmaceutical management Heat pads; TENS; Massage therapy Cognitive Behavioural therapy (Relaxation, Guided imagery, music, prayer) MDT approach for Total Pain Pharmaceutical management WHO analgesic ladder approach Available medications for pain relief Opioid Management 19

20 Attitudes Extent of Nociceptive insult Beliefs Previous Pain Experiences Individual Pain Experience Current emotional status Cognitive Understanding Cultural factors Individual coping Strategies 20

21 WHO analgesic ladder 21

22 Non-opioid Pain Medications used in palliative care Paracetamol... NSAIDs... Biphosphonates... Antidepressants... Benzodiazepines... Anaesthetics... NMDA Antagonist... Anticonvulsant... Corticosteroids... Antibiotics... Skeletal muscle relaxants... Antispasmodics... Calcium-channel Blocker... Nitrates... Misc. others:... (as a pain adjuvant) (Iboprofen / Ketoralac for bone pain) (Zolendronic acid for bone pain) (Amitriptyline for nerve pain) (Clonazepam for Nerve pain) (Versalis topical patches for nerve pain) (Ketamine for complex nerve pain) (Carbamazepine for neuralgia pain) (Dexamethasone for liver capsular pain) (for Cellulitis pain / discomfort) (Baclofen for muscle spasms) (Buscopan for smooth muscle spasms) Nifidipine } for Oesophageal GTN spray } Spasms / Haemorrhoids Sucralfate suspension /PPI /Capsaicin cream 22

23 Issues in Opioid Management Opioid titration against pain How? (Back ground & Top-up opioid) Important points : Regular pain assessment, Patient/carer/ Family understanding of Pain Management & The concept of Total Pain 23

24 Morphine Oxycodone Methadone Hydromorphone Fentanyl / Buprenorphine/ Alfentanil Short acting: Oral Medications: Ordine Suspension [Morphine HCL] 1mg/ml 200mL [1] 2mg/ml 200mL[1] RPBS 5mg/mL200mL[1] RPBS 10mg/mL 200mL[1] RPBS Sevredol 10, 20mg tablets Anamorph 30mg tablet Short acting: Oral Medications: Oxynorm Liquid [HCL] Liquid 5mg/5ml [250 ml] PBS / RPBS Oxynorm capsules 5, 10, 20 mg[20] RPBS Endone tablet 5mg [20] PBS / RPBS Short acting: Oral Medications: Dilaudid Tablets [HCL] 2, 4, 8mg [20] PBS/RPBS Dilaudid oral liquid 1mg/mL 473mL [1] RPBS/PBS Short acting: Oral Medications: Actiq Lozenge Buccal route (200; 400; 600; 800; 1200;1600 mcg) Nasal Spray Instadyl nasal Fentanyl spray 50 mcg; 100 mcg; 200mcg /dose PenFent nasal Fentanyl spray 100; 400 mcg /dose Injectable Preparations: Morphine Sulphate inj 10mg/ml, 15mg/ml; 20mg/ml; 30mg/ml (1ml & 2 ml vials); 1mg/ml (50ml vials) Suppository Morphine Sulphate HCL Supps 10; 15; 20 & 30mg Long acting or Sustained Release: Oral Preparations: MS Contin tablets: 5, 10, 15, 30, 60, 100, 200mg MS Contin Suspension 20, 30, 100 mg sachet Kapanol Capsule 10, 20, 50, 100mg MS Mono Capsule 30, 60, 90, 120mg [Available Long Acting Morphine injections are Sulphate & Remember sulphate allergies!] Injection Preparation: Oxynorm Inj HCL 10mg/ml 1ml amp [5] 20mg/2ml amp [5] 50mg /ml amp Long acting or Sustained Release: Oral Preparations: Oxycontin tablet 5, 10; 20; 40; 80 mg [20] & [60] PBS /RPBS Targin Tablet 5/2.5; 10/5; 20/10; 40/20 Long acting : Methadone [HCL] 10mg tablet [20] PBS/RPBS Methadone Syrup 5mg/mL 200mL [1] (Authority PBS/RPBS for PALLIATIVE CARE one month supply) Injectable Preparations: Physeptone inj 10mg/mL 1mL [5] Injectable Preparations Dilaudid inj PBS / RPBS 2mg/mL 1mL[5] 10mg/mL 1mL[5] 50mg/mL 1mL[5] 500mg/mL 1mL[5] Long acting : Jurnista Tablet 4. 8,16, 32 mg tablets PBS/RPBS Injectable Preparations: Alfentanil Inj 500mcg/ml (2ml&10ml) + 5mg/ml (1ml vial) Long acting or Sustained Release: Oral Preparations: Nil Transdermal Preparations: Fentanyl Patch (72 hours) Durogesic DTrans 12; 25; 50; 75; 100 mcg/hr Buprenorphine Patch (weekly) BuTrans Matrix Patch 5; 10; 20 mcg/hr 24

25 Question: (a) Mr Lucas was diagnosed as Carcinoma of the prostate with bony metastasis. He was on Panadeine Forte 30/500 ❷ po qid. Last 3 days, he got more pain. How do you manage him? Codeine tablets 30mg 2 tabs qid = 240 mg of Codeine / 24 hours = 24 mg Oral morphine / 24 hours His pain is not controlled with 24 mg of Morphine /24 hours You need to give slightly higher & Therefore, Morphine SR preparation 15mg PO bd [ Total 30mg /24 hours] Or Morphine Mixture 5 mg PO 4 Hourly ( 4 Hourly means 6 times in 24 hours 5 x 6 = 30mg / 24 hours) 25

26 (b) You suggested Ordine Suspension 5mg (2.5ml) PO every 4 Hourly. Use of Ordine suspension reduced his pain.(his worst pain score was 9/10 & now the pain score is 4-5/10). On 2 nd visit, you increased the Ordine suspension dose to 10mg PO 4 hrly as he is sensitive to opioids. In two days you receive a panic call from wife regarding his drowsiness & confusion. How are we going to manage him now? 1. Look for toxicity symptoms; 2. See whether he has pain or not 3. Reduce or switch the opioid dose (Not to stop it completely; withdrawal can be equally troublesome! + it will also increase the pain levels) If you suspect opioid toxicity, what are the signs we look for? & how do you manage then? Look for any visual hallucinations / involuntary muscle jerks or any clinical evidence of respiratory depression [RR <10/min]), ± other symptoms like drowsiness / confusion / pin point pupils Management:- Opioid toxicity + No pain Reduce the opioids by 30-50% of total 24 hours dose Opioid toxicity + Have more pain Opioid Switch 26

27 Anorexia Cachexia 27

28 Anorexia Cachexia Anorexia is commonly part of cancer-induced anorexia- Cachexia syndrome. Always exclude or treat the other causes: Anorexia- Cachexia syndrome (1) Nausea (2) Painful mouth (3) Oral infection (4) Oesophagitis / Oesophageal spam (5) Dysphagia from narrowed / obstructed oesophagus Management - Corticosteroids can increase the general wellbeing / mood & enjoyment of food in many patients (No scientific evidence for steroids) Dex 4mg mane - If symptoms of gastric stasis with / without nausea Trial of Maxolon - New trials in progress Thalidaomide in the treatment of cancer cachexia (Reference: Gordon JN, et al. GUT 2005; 54: ) Progestational Steroids: Megestrol acetate & Medroxyprogesterone acetate No evidence at present! 28

29 Cancer Related Fatigue 29

30 Cancer Related Fatigue Fatigue in cancer patients is a subjective feeling of unusual tiredness, affecting the body (physical), emotions (affective) and mental functions and relief only partially or not at all with rest /sleep. Fatigue is multifactorial & multi-diamensional. Verhagen SP, et al. Determinants of chronic fatigue in disease free breast cancer patients: A cross-sectional study 2002; Annals of Oncology 2002; 13: Postulated Mechanisms: 1.Central: Mediated by serotonin levels affecting the Hypothalamic-pituitary-adrenal axis (Lots of evidence from other conditions: chronic fatigue syndrome & animal models) 2. Endocrine: HPA dysfunction reduce activity leads to unstimulated cortisol / adrenal under-function & limited feedback loop 3. Muscular: 4. Immunological: association with inflammatory makers or 5. Combination Evaluation of Fatigue Assess characteristics / Manifestations 1. Severity / Onset, duration, pattern, & Course 2. Exacerbating factors 3. Distress & impact 4. Manifestations include: Lack of energy / weakness / Somnolence / Impaired thinking / Low mood 5. Assess the related Constructs: Overall quality of life, Symptom distress & Goals of care Evaluation of predisposing factors Physiological: Underlying disease /Treatment / Inter-current disease process (infection / anaemia) / Sleep disorder / Possible poly-pharmacy Psychological: Mood disorder / Stress 30

31 Cancer Related Fatigue - Management Establish reasonable expectations & Periodical re-assessments Correction of reversible causes Exclude common causes of anaemia & treatment / Look for Depression & appropriate treatment Correction of fluids / electrolytes / Calcium; Thyroid or Corticosteroid replacement Treat any infection / Reduce or Eliminate the non-essential medications Medical Management 1.Using Steroids Trial of Low dose Dexamethasone 4mg to 6mg po mane for 1-2 weeks 2.Using Psycho-stimulants - Trial of Methylphenidate (on specialist advice please!) Non- Pharmacological interventions: Patient education / Low impact Exercise / Modify activity & rest (sleep)pattern / Stress mgt / Nutrition On- going research work: 1. Trial of Modafinil for the treatment of fatigue (Reference: Palliative Medicine 2009; 23: ) 2. A randomized, double blind, Placebo-controlled Trial assessing the impact on Dexamphetamine on Fatigue patients with advanced cancer (Reference: Journal of Pain and Symptom Management 2009; 37: Haemopoetic growth factors Erythropoetin & Darbopoetin - Conflicting evidence at present! 4. Progestational Steroids: Megestrol acetate & Medroxyprogesterone acetate No evidence at present! 5. Paroxetine: fatgue & mood are inter-related 6. Methylphenidate only two studies so far & large study underway! 31

32 Break for 15 minutes! 32

33 Nausea & Vomiting 33

34 Nausea & Vomiting-01 Multiple causes 1. Pain; pain medications & Pain medication S/E Severe pain can induce N/V, Opioid, Constipation 2. Oro-pharyngeal Narrowing/ Plaques Candida infection, sputum 3. GI narrowing due to internal compression Internal Bleeding, Ulcers, Tumour growth, due to external Compression Enlarged liver, pancreas, LN 4. Gastric Stasis Motility disorders 5. Biochemical Causes Renal Failure, Liver Failure, Hypercalcaemia, 6. Central causes ICP 7. Cancer Treatment Related: Acute N &V / Delayed N &V / Anticipatory N &V 8. Gastritis: NSAIDs / Steroid induced 9. Psychological / Emotional: Pain/Fear/Anger/Anxiety & Depression 34

35 Nausea & Vomiting-02 N / V Can be multi-factorial Example Cancer patient Cancer patient with pain induces N/V; Using Opioid induces N/V; Opioid S/E Constipation Leads to N / V Chemo / DXT Induces acute nausea/delayed nausea Anxiety of further chemo Leads to Anticipatory N /V Two Approaches > Mechanistic or Empirical Mechanistic Approach - Accurate identification of the cause - Understanding of pharmacological mechanism - Use of most effective drug 35

36 The emetic process pathways of emesis and the neurotransmitters involved from BMJ 36

37 Common Anti-emetic Medications Metoclopramide D 2 Antagonist, 5HT 3 at high doses + (5HT 4 - gut) For Prokinetic Activity (Gastric stasis) 10-20mg qid Haloperidol D 2 Antagonist For Biochemical Causes (Hypercalcaemia, RF) 1.5mg Nocte 6mg/24 hr Cyclizine H 1 Antagonist, For Central Causes 50mg tds Anticholinergic antagonist (Increased ICP) Levomepromazine D 2 + H 1 + 5HT 2 Antagonist + Acetylcholine Standard 2 nd drug due to its multiple receptor activity 6.25mg 25mg/24hr Ondansetron 5HT 3 Antagonist Chemo / DXT related (Acute & delayed) Nausea 4mg tds or 8mg bd Others used to for N / V PPI / Lorazepam / Steroids PPI Reflex disease associated N Lorazepam anxiety induced N / V Steroid Combination in Chronic N 37

38 Constipation 38

39 Constipation - 1 Causes 1. Malignancy: Directly due to tumour Intestinal obstruction due to (a) Tumour in the bowel wall (b) External compression Damage to lumbosacral spinal-cord, cauda-equina or pelvic plexus Hypercalcaemia Secondary effects of tumour Inadequate food intake, Dehydration, Weakness, Inactivity, Confusion, Depression 2. Drugs: Opioids, Drugs with anticholinergic effects (Hyoscine, TCAs), Antacids with calcium & aluminium compounds, Diuretics, Irons, Anticonvulsants, Antihypertensive agents. 3. Concurrent Illness: Hypothyroidism, Diabetes, Hypokalaemia, Hernia, Diverticular disease, Colitis, Rectocoele, Anal fissure / stenosis, Haemorrhoids. - Oxford Text Book of Palliative Medicine 39

40 Constipation - 2 Complications with constipation 1. Pain colic or constant abdominal discomfort 2. Intestinal obstruction 3. Overflow diarrhoea / faecal incontinence 4. Urinary Retention 5. Confusion / Restlessness Management 1. Maintain good general symptom control 2. Encourage activity 3. Maintain adequate fluid intake 4. Maximize the fibre content of the diet 5. Anticipate constipating effects of drugs & starting prophylactic laxative 6. Provide privacy / raised toilet seat for comfort Drugs Used (a) Oral: 1. Lactulose 10-20ml / Senna 10-20ml (or 1-2 tab) bd (Small volume!) & 2. Sodium Docusate commonly in obstruction 3. Movicol 1-8 sachets /day (usually bd) 4. Movicol + Senna ( if further stimulant/push needed) 5. Codanthramer 10-20ml ( or 1-2 tab) bd 6. Codanthramer forte 10-20ml bd (b) PR medications: 1. Polyethylene Glycol supps 2. Bisacodyl supps 3. Microlax enema 4. Phosphate enema 40

41 SOB 41

42 SOB The common reasons for Dyspnoea in cancer patients Anxiety Fatigue Muscle weakness ( cachexia; steroid myopathy) Phrenic nerve palsy Restrictive Chest wall Tumours 42

43 The Different approaches to SOB Heart Failure Anaemia Infection Pulmonary Embolism Bronchospasm Ascites Pleural Effusion Lung Tumour Lymphangitis Carcinomatosis Large Airway Obstruction Radiation-induced Pulmonary Fibrosis Treatment : Diuretics Treatment : Blood Transfusion Treatment : Antibiotics Treatment : Oxygen + Anti-coagulation Treatment : Bronchodilators + Corticosteroids Treatment : Paracentesis + Diuretics Treatment : Pleural Tap + Pleurodesis Treatment : Radiotherapy Diagnosis: Only by CXR & even this may not be diagnostic. Suspect when severe SOB at rest /on exertion & wide spread fine Crepitations Treatment : Corticosteroids + Diuretics + Bronchodilators Diagnosis: Clinically by SOB & Inspiratory Stridor Treatment : Radiotherapy + Stent + Laser Treatment +Brachytheraphy + Corticosteroids Corticosteroids SVC Obstruction Diagnosis: Clinically by dilated upper chest / neck veins + Swollen face/neck/arms Treatment : Corticosteroids + Radiotherapy 43

44 Dyspnoea-Symptomatic Management Low dose regular opioid Anxiolytics Short acting pams are helpful (Oxazepam 5-10mg/Lorazepam 1mg SL) These drugs can break SOB Anxiety cycle Oxygen therapy No clinical evidence (Only Fanning effect to patient) (if the patient is hypoxic SaO 2 < 90% Trial of Oxygen) Massage, aromatherapy or other relaxation methods Other methods: - Position Sitting upright rather than lying - Cool air from fan or open window Consider a trial of bronchodilators e.g. nebulisation with salbutamol (bronchospasm is not always associated with wheezes & bronchodilators can improve dyspnoea without measurable changes in lung function). MDT Approach (Feeling safe /open-up reduce anxiety levels Less SOB) 44

45 Death rattle / secretions 45

46 Death rattle / secretions Why secretions are more pronounced in terminally ill patients? - How much saliva produced /day? Approx. 1.5 L - Weak of swallowing muscles & Due to the positioning obstruction - Breathing through the collected saliva Death Rattle Medications used in in-patient units: Glycopyrronium or Hyoscine What is the Dose? Commonly used drug in the hospice is Glycopyrronium mg sc stats (max of 2mg/24hr) or SD start with 600mcg 1.2 mg/24hr Hyoscine: Buscopan 20mg sc stats (max 240mg/24h) or SD-Buscopan mg/24 hr 46

47 Cough 47

48 Cough Cough has a useful protective function but symptomatic treatment may be indicated when it is distressing or affecting sleep/ activity. Reversible causes should be identified and treated. Management Ensure adequate analgesia pain may be inhibiting effective coughing. Physiotherapy assessment if difficulty coughing retained secretions. Medication Step 1. Try Simple linctus BP 5-10ml 3 times daily. Step 2. Nebulised 0.9% sodium chloride 2.5-5ml can help loosen secretions (if any). Step 3 Using Opioid: titrate according to response, monitor for side effects (constipation). Codeine linctus BP (15mg/ 5ml) 5-10ml, 6-8 hourly and/or at bedtime. Oral morphine liquid 2mg, 6-8hourly or at bedtime. Methadone linctus (2mg/5ml) 2.5ml at bedtime (specialist advice only). Non Pharmaceutical management Posture - it is impossible to cough effectively when lying flat. Key References 1. Morrice AH. British Thoracic Society recommendations for the management of cough in adults. Thorax 2006; 61: Leach M. Cough. Oxford Textbook of Palliative Medicine, 3 rd Edition 2004, p

49 Hiccups 49

50 Hiccups -1 Hiccup results from (1) Diaphragmatic spasm caused by diaphragmatic irritation (2) In advanced cancer, is often associated with liver enlargement or gastric distension. (3) Phrenic nerve stimulation due to enlarged malignant mediastinal lymph nodes may also cause hiccups as may uraemia. (4) A more unusual cause is a brain stem tumour affecting the central nervous control of the diaphragm. Management of hiccup (a) Treat reversible causes The traditional remedies of pharyngeal stimulation (sucking a spoon of sugar) or splinting of the diaphragm (breath holding, re-breathing into a bag) may be of benefit in this often episodic condition. (b) The pharmacological management of hiccup It is based on case studies and clinical anecdote and deciding which medication to use will include consideration of potential side-effects 50

51 Hiccups 2 Treat gastric distension and gastro-oesophageal reflux disease if thought to be a cause. (1) Gastric distension: Reduced by a change to small frequent meals and the use of a defoaming antiflatulant with an antacid 5-10mL q.d.s. or A trial of a pro-kinetic drug e.g. metoclopramide 10mg or domperidone 10mg q.i.d (2) GORD Gastro-oesophageal reflux disease: Use a PPI or ranitidine 150mg b.d. (3) Suppress central irritation from intracranial tumour This may respond to dexamethasone (starting with 4-8mg daily) or to an anticonvulsant. (4) If hiccup is severe and not responding to other measures it may be necessary to try: - Haloperidol 1.5 to 3mg nocte - Gabapentin titrated up (as for neuropathic pain) - Nifedipine 5mg PRN or regularly three times daily, (either by mouth or sublingually, to relax smooth muscle) - Chlorpromazine 25mg PO followed by a maintenance dose of 10-25mg t.d.s - Baclofen (5mg b.d initially increase accordingly * ) - Midazolam 10mg up to 60mg CSCI may be effective as part of terminal care in the dying patient 51

52 Itch in Palliative Care 52

53 Itch in Palliative Care Itch may be localised or due to systemic disease. It can cause discomfort, frustration, poor sleep, anxiety and depression. Persistent scratching leads to skin damage excoriation and thickening. Patients with itch usually have dry skin. Assessment Examine the skin; look for local and systemic causes. May be multifactorial. Primary skin disease (eg. atopic dermatitis, contact dermatitis, psoriasis). Infection candidiasis, lice, scabies, fungal infection. Medication opioids (particularly morphine, diamorphine). Systemic diseases that can cause itch [include: Cholestatic jaundice / Hepatitis /Hepatoma Primary biliary cirrhosis / Chronic kidney disease / Thyroid disease / Diabetes / Lymphoma Iron deficiency +/- anaemia / Leukaemia / Multiple myeloma / Polycythaemia / Mycosis fungoides] Management Treat underlying cause(s). Review medication to exclude a drug reaction. Use an emollient or aqueous cream frequently as a moisturiser. Add an emollient to bath water and use aqueous cream as a soap substitute. 53

54 Itch in Palliative Care - 2 Topical Agents 1. Emollients 2. Aqueous cream (1% menthol can be added). 3. Crotamiton 10% cream (Eurax) or capsaicin (0.025%) cream for localised itch. 4. Topical corticosteroid (mild/moderate potency) once daily for 2-3 days if the area is inflamed but not infected. Medication 1. Antihistamine (stop if no benefit after a few days). Sedating antihistamine if poor sleep is a problem (eg. Chlorphenamine) Some non-sedating antihistamines can have an antipruritic effect (eg loratadine, cetirizine). 2. An antidepressant can help if the patient has associated anxiety or depression. 3. Cimetidine 400mg twice daily for itch in lymphoma or polycythaemia. (Check for drug interactions). 4. Biliary stenting: may relieve the symptoms of cholestatic jaundice. 54

55 Intestinal obstruction & Related issues 55

56 Intestinal obstruction & Related issues Symptoms depends on type & level of obstruction Types: Partial or Complete Level of obstructions: a) High Obstruction Predominantly frequent nausea/vomiting b) Low Obstruction Emptying (faecal) vomits, abdominal distension, discomfort / spasms Medications Partial obstruction If Complete obstruction If no colic try with gentle push with Prokinetic If colic (+) Stop Prokinetic & may need Buscopan use Haloperidol / Levomepromazine via SD + Trial of Dexamethasone (8-16mg OM SD/SC) No Prokinetic (Metoclopramide / Domperidone) [ X ] # To reduce the volume Octreotide via SD ( mcg /24hr) # To reduce the colic Buscopan (60-240mg/24hr) # To reduce the sickness Levomepromazine ( mg/24hrs) # Faecal softener Docusate sodium ( mg bd / tds) 56

57 Dry Mouth (Xerostomia) 57

58 Dry Mouth (Xerostomia) Common symptom among the terminally ill & can have profound negative effects on patients quality of life Why Dry mouth in Cancer? # Drugs: Opioids (morphine), antimuscarinic drugs (Buscopan), Antidepressants (TCA) Antipsychotics (Haloperidol, Levomepromazine), Diuretics # Oncology treatment: Chemo / head & neck radiotherapy # Rapid cancer cell multiplication uses water & energy Dehydration Dry mouth # Poor immunity leads to Candida infection (oral thrush) # Fatigue / Lethargy/ SOB mouth breathing Management # Salivary Stimulation Citrus products; pineapple # Chewing gum chewing induce saliva (Reduced mastication produces salivary atrophy) # sucking ice-cubes # Medications - Artificial Saliva (Saliva orthana spray, Glandosane, Oral balance gel) - Pilocarine HCL successfully used to induce saliva in carefully selected patients specially in radiotherapy induced xerostomia & Sjogrens syndrome (cardiovascular pulmonary SEs; C/I in asthma or COPD) Cook, C(1992) Xerostomia a review; Palliative Medicine; 10:

59 Sialorrhoea / Drooling of Saliva 59

60 Sialorrhoea / Drooling of Saliva Production of excessive saliva. Uncommon in cancer (but Oesophageal cancer / GORD) Common in patients with swallowing difficulties (MND; Tumours of head/neck; brain Tumours; Parkinson disease or drug induced parkinsonism) Management Antimuscarinic drugs will reduce saliva production. Most will not swallow tablets / capsules & many may have PEG tube. (a) Injection / CSCI: Glycopyrronium 0.2mg to 0.4mg sc stat or 0.4mg to 0.6mg via CSCI (b) Transdermal Patch Hyoscine transdermal patch (Scopoderm) # S/E can occur in elderly. (c) Oral / via PEG Glycopyrronium 0.6mg to 2mg 60

61 References Anorexia Cachexia Macmillan Cancer Support: Templeton A. Treating cancer patients with anorexia-cachexia syndrome. European J Palliative Care 2007; 14(5): Shragge J E. The management of anorexia by patients with advanced cancer: a critical review of the literature. Palliative Medicine 2006; 20: Poole K. Loss of weight & loss of appetite in advanced cancer: a problem for the patient, the carer or the health professional? Palliative Medicine 2002; 16: Fainsinger R. Clinical assessment & decision making in cachexia and anorexia. In Oxford Textbook of Palliative Medicine 3rd Edition 2004, p Bruera E. Pharmacological interventions in cachexia and anorexia. In Oxford Textbook of Palliative Medicine, 3rd Edition 2004, p Strasser F. Pathophysiology of the anorexia/cachexia syndrome. In Oxford Textbook of Palliative Medicine, 3rd Edition 2004, p Davis MP. Appetite and cancer associated anorexia: a review. Journal of Clinical Oncology 2004; 22 (8): Hiccups Porzio G, Aielli F, Narducci F, et al. Hiccup in patients with advanced cancer successfully treated with gabapentin: report of three cases. N Z Med J 2003;116(1182) Smith HS, Busracamwongs A. Management of hiccups in the palliative care population. (review) Am J Hosp Palliat Care 2003;20(2): Lipps DC, Jabbari B, Mitchell MH, et al. Nifedipine for intractable hiccups. Neurology 1990;40(3 ):531-2 Madanagopolan N. Metoclopramide in hiccup. Curr Med Res Opin 1975;3(6):371-4 Regnard C. Dysphagia, dyspepsia, and hiccup. Doyle DH, et al, eds. Oxford Textbook of Palliative Medicine. 3rd ed. Oxford: Oxford University Press, 2003: Woelk CJ. Palliative care file: Managing hiccups. Canadian Family Physician June 2011; Vol 57 : Other symptoms 1. Oxford Book of Palliative Medicine 2. Hand book of Palliative Medicine by I. N. Back 3 rd Edition, by pfizer

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