Srivieng Pairojkul, MD. Karunruk Palliative Care Center ......- Non-opioid co-analgesic:...
Transcript of Srivieng Pairojkul, MD. Karunruk Palliative Care Center ......- Non-opioid co-analgesic:...
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Srivieng Pairojkul, MD.Karunruk Palliative Care Center
Srinagarind HospitalFaculty of Medicine, Khon Kaen University
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• Is this an expected/unexpected manifestation of the disease?
• Is this an exacerbation of an intercurrent problem?
• Is this a new intercurrent problem?
• Can we do something about the problem?
• Whether the problem is likely to be reversible?
• What is the person’s wishes under these circumstance?
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• Clinical benefit?
• Benefit VS. burden?
• Reversible condition?
• How to get the patients back to best condition as possible?
• Time frame of recover VS. survival
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• “Whole person approach”
• Prevent and manage suffering symptoms
• Provides “specific disease modifying treatment”
• CMT, hormonal treatment, RT, restorative treatments
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• PC medications different from standard setting
Antipsychotic drug – haloperidol ใช้ใน N/V
Antidepressants รักษา neuropathic pain
Opioids รักษา dyspnea
• “Off-license” prescribing
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• Administration of medications at home
• When the patients could not swallow drugs
Subcutaneous route: MO, fentanyl, midazolam, hadol, metoclopramide,
buscopan, atropine
Sublingual route: lorazepam, fentanyl, ketamine, midazolam
Rectal suppository: MO, lorazepam, DZP
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• Simple regimen
• Minimized number of medications
• Long-acting form to reduce numbers of tablet
• Use medication with multiple actions:
eg. Haloperidol - anti-emetic & mild sedative
• Review, review, and review
• Provide written instruction to the patient
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• Metabolism: pharmacokinetics & dynamic of
drugs are unpredictable at EOL; polypharmacy
• Pathophysiology of death: systematic changes
rather than single organ failure.
• Prognostication.
• Measure of benefit NNTTertiary prevention of disease are likely to be
continued.
• Psychological concerns.
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Stevenson J, et al. BMJ 2008;329:909-12.
Prevention Strategy
Tertiary
(Disease with
Symptoms)
Secondary
(Disease with
No symptoms)
Primary
(No disease)
Inflammatory
arthritis
DM Phenylketonuria
Pulmonary
Rehabilitation in
COPD
Hypertension Influenza
vaccination
Osteoporosis Hyperlipidemia Some aspirin use
To elderly people
Treatment likely to be changed later Treatment to be changed earlier
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• Symptom never caused by physical or
psychological only
• Relationship between physical and
psychological is the principle of PC
• Goal of symptom management is the best
possible QoL
• Communication is the key
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74%
70%
70%
67%
46%
47%
28%
25%
Pain
Dyspnea
Constipation
Oral symp.
Cough
Insomnia
Delirium
N/V
Pain Dyspnea Constipation Oral symp. Cough Insomnia Delirium N/V
Karunruk Palliative Care Center 2012
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• Tissue inju ries• Easy to
localize•R esponse to opioids
•Difficult to localize• Liver capsule d istension
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D
C
B
A
Fracture from bone metastasis
Pressure sore
Constipation colic
Inflammation from IV site
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• By the clock
• By the mouth
• By the patient
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• Background pain – continuous pain Use WHO 3-step ladder guideline Continue around the clock
• Episodic pain:
-E nd-of-dose failure – pain occurs before next scheduled dose Increase dosage
- Breakthrough pain – sudden, intense, spikes of pain immediate released opioid
- Incident pain – pain which is predictable, associated with activities eg. bone metastasis, wound dressing
prevent with rapid short acting analgesic.
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Pain
Pain persists
or increases
Pain persists
or increases
Freedom from pain
Non-opioids for
mild - mod pain
± Adjuvant
Weak opioids for mild - mod pain± Non-opioid± Adjuvant
Strong opioids for mod–severe pain ± Non-opioid± Adjuvant
• Non-o pio ids: - Acetaminophen- NSAIDS
• Week opio ids: - Codeine- Tramadol
• Strong opio ids:- M orphine- Fentanyl- M ethadone
• Adjuvants: - An ticonvulsants- An tidepressants- Corticosteroids
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Low doses o f s tep III opioid m ay be used instead o f codiene or tramadol.
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Acetaminophen500-1000 mg. q4-6H. (not more than 6-8 gm/D)Acute over dose (150 mg/kg) hepatic necrosis
NSAIDs – anti-inflammatory action Effective in bone pain, liver pain, inflammatory pain SE : G I irritation, Plt dysfunction, avoid in RF, CHF
Drug Do sage Duration of Action (H)
Ibuprofen 400 m g bid, qid 4-6
Diclofenac 50 m g bid, tid 8
Celecoxib 100-200 m g od, bid 12
Acetaminophen + NSAID additive effect
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• Codeine: Derivative of morphinePotency 1/10 of MO, dosage: 30–60 mg q4h.
• Tramadol: weak μ agonistSerotonin & NE reuptake inhibitorSome anti-neuropathic effect
Potency 1/20 – 1/5 of MO
Adverse effect: N/V, constipationLess respiratory depression
Minimal use in cancer pain management
Dosage: 50-100 mg q 6-8H, max 400 mg/D
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• Morphine: Full μ agonistStandard opioid which others are compared
Metabolized by hepatic conjugation
– MO-3-glucuronide neurotoxic symptoms
– MO-6-glucuronide analgesic activity• Methadone
• Pethidine X
• Fentanyl: μ agonistPotency 100 X of morphine Injection - rapid onset, short duration of action
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Approxim ate dose conversion ratio; PO to POConversion Ratio Calculation Example
Codeine to MO 10:1 Divide 24h codeine dose by 10 Codeine 240mg/24h PO
morphine 24mg/24h PO
Tramadol to MO 5:1 Divide 24h tramadol dose by 5 Tramadol 400mg/24h PO
Morphine 80 mg/24h PO
MO to methadone Discuss with palliative medicine consultant
Approximate dose conversion ratio; PO to SC/IV
MO to MO 3:1 Divide 24h morphine dose by 3 Morphine 30mg/24h PO
morphine 10 mg/24h SC/IV
morphine 0.4mg/h SC/IV
Methadone to
methadone
2:1 Divide 24h methadone dose by 2 Methadone 30mg/24h PO
methadone 15 mg/24h SC/IV
MO to fentanyl Use same calculation as for transdermal patch
Approximate dose conversion ratio; PO to TD
MO to fentanyl 100:1 Multiply 24h morphine PO dose in
mg by 10 to obtain 24h fentanyl
dose; divide answer by 24 to
obtain mcg/hr patch strength
Morphine 120 mg/24h PO
Fentanyl 1,200 mcg/24h;
1,200/24= 50 mcg patch q
72h.
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oral morphine iv/sc hourly infusions td patchmorphine normal morphine tab morphine fentanyl fentanyl
release minture sustained release infusion infusion patch
(MST)
mg mg mg/hr mcg/hr mcg/hr
4hrly 12 hrly continuous continuous every 72 hrs
2.5 10 0.2 4 - 6
5 10 or 20 0.4 8 - 12 12
10 30 0.8 17 - 25 25
15 40 or 50 1.2 25 - 37 37
20 60 1.6 33 - 50 50
25 70 or 80 2.1 42 - 62 62
30 90 2.5 50 - 75 75
35 100 2.9 58 - 87 87
40 120 3.3 67 - 100 100
50 150 4.1 83 - 125 125
60 180 5 100 - 150 150
80 240 6.7 133 - 200 200
90 270 7.5 150 - 225 225
100 300 8.3 167 - 250 250
120 360 10 200 - 300 300
140 420 11.7 233 - 350 350
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• No ceiling effect, no max dose, titrate until effect• Conversion PO:IV = 3:1• Severe hepatic impairment – reduce freq (q6-8H.)• Renal impairment- ovoid if possible
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Preparations & administration:
• Immediate-released – duration 4H.- MO syrup (2mg/ml) - Immediate released tablet 10 mg (MO-IR)
• Slow-released: MST (10, 30, 60, 100 mg/tab) q8-12H. Kapanol (20, 50, 100 mg/cap) q12-24H.
• IV injection (10mg/ml)
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• MO naive - start with low dose and titrate to effect
• Needs 2-3 days for titration
• Use immediate released for titrationGive background dose q4H + PRN q2H
• If pain not controlled - Increase dose 30-100% according to pain severity Severe 100%
Moderate 50% Mild 30%
- Readjust dose Total MO required in 24H Regular + PRN in 24H
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MO naïve - start with
• Oral 0.15-0.3 mg/kg PO 5 mg (max 10-15 mg) q4H
• Injection 0.05-0.1 mg/kg IV/SC 3 mg (max 5-10 mg) q4H
Example
• 5 mg immediate released MO MO-IR (10 mg) ½ tab or MO syr (2mg/cc) 2.5 cc PO q4H.
or 10 mg controlled release tab (MST) q8H.
• Break through dose = dose q4H (or 24H MO ÷ 6) MO-IR ½ tab or MO syr 2.5 cc PRN for BTP q2H
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MO-IR (10 mg) ½ tab at 6, 10, 14, 18, 1 tab at 22.and ½ tab MOIR PRN for BTP q2H (MO syr. 2.5 cc.)
Patient required 4 PRN doses in past 24HAdjusted dose = regular 30 + BTP 20 50 mg/d 50/6 ~7.5 mg/dose ¾ tab of MO-IR q4h + ¾ tab of MO-IR PRN for BTP q2H (MO syr 3.5 cc)
• Dose adjustment on the next day (regular + PRN)
• Adjust dose by increasing dose 30-100%
24h MO = 5 mg x 6 doses = 30 mg (PS - moderate) Increase 50% =15 mg 30+15 = 45 mg/d 45/6 7.5 mg/dose ¾ tab of MO-IR q4h.
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• Mr.A received MO 3 mg IV q4H, required 1 BTP 3mg Pain well controlled, plan for discharge MO 3 mg x 6 + BTP 3 mg =21 mg MO inj 21 mg = MO oral 21 x 3 = 63 mg MST (30mg) 1 tab q12H + BTP (60÷6) = 10 mg PRN q2H (MO-IR 1 tab orMO syr 5 ml BTP q2H)
• Follow up 2 months later, required 3 BT doses/D. MO adjustment? MO (background) 60 + PRN (10x3) 30mg = 90 mg MST(30 mg)1 tab q8H +MOIR (10mg)1.5 tab PRN
or MO syr 7.5 ml PRN q2H
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• Constipation (90%) will not tolerance to this SE needs to prescribe laxative continuously
• Nausea/vomiting (30%)
• Sedation on the first few dayssedation score recorded
0 = alert 2 = very sleepy, easily awakened1 = sligh t drowsy 3 = deep sleep, unable to wake up
If sedation score >2 decrease dose 30-50%Score >3 skip next dose and decrease 30-50%
• Itchy (7%) Rx antihistamine
• Dry mouth, urinary retention, delirium- rare
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• Potent synthetic opioid agonist
• Less SE profile (constipation, CNS)
• Transdermal route, slow onset (12-24H)
• Difficult titration/conversion factor
• Peak onset 24H, cont controlled release for 72H
• Breakthrough analgesia is difficult
• Transdermal patch 25 ug/H= ~60mg oral/24H = ~20-30mg SC/24H
• When take off, effect still last for 24H
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Common in:
• Bone metastases
• Neuropathic pain
• Wound dressing, debridement
• Urinary catheterization
• Evacuation feces Use quick onset and short duration analgesic
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• Fentanyl inj 12.5 mcg (0.25 cc) SL 5-10 min
onset of action ~ 5-15 min, max ~ 20 min,
duration ~ 45 min.
• If not controlled repeat same dose 1-2 times in
5-10 min.
• Increase dosage to 25 50 100 mcg if pain
not well controlled
http://onco -prn .blogspo t.com/2010/02/fentanyl-citra te-sublingua l-dosing-and.html
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• NeuropathicCommon in advanced cancerInvasion, compression of neural structuresIatrogenic: from CMT, surgery
• Bone painCommon in advance cancer Reponses to opioidsDifficult to management bone pain: weight bearing bone, impending fracture, nerve compression
• Visceral painPancreatic painPelvic pain: Bladder spasms, rectal pain
Cherny NI, Ann Onco 2005;16(Supp 2):ii79
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• Opioids are used more frequently in cancer-related NP- NP may not exist in isolation but with another
pain which can be highly opioid responsive
- NP may linked with a painful mass which requires opioid treatment
- Some patients may achieve a better analgesia/side-effect profile with an opioid rather than an adjuvant for NP
• Opioid NNT in NP 2.6 to 5.1, TCAs NNT 2.1 to 2.8, G abapentin NNT 4.2 to 6.4
Brit J Anaesthesia 2013;111:105-11
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Management• Responsive to opioids• Radiotherapy - overall response 58-59% • NSAIDS opioids• Bisphosphonate less effective than opioids/RT
second line therapy
Characteristics:• Moderate/severe background pain• Breakthrough pain - common• Incident pain - common
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Cognitive and behavioral methods:
• Distraction
• Imagery
• Hypnosis
• Relaxation Techniques
– Deep breathing
– Progressive relaxation
– Meditation
Physiological methods
– Warm baths
– Massage
– Acupuncture
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1. Consider primary therapies of underlying causes: RT in bone pain
CMT - reduce tumor size
Surgery - relieve obstruction
AB – Occult infection of fungating tumor in head
neck CA
2. Titrate opioids until controlled with tolerable SE
3. Medical treatment of SE , if not tolerate opioid switching
Cherny NI, Ann Onco 2005;16(Supp 2):ii79
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4. Use adjuvant analgesics- Non-opioid co-analgesic: Paracetamol, NSAID
- Dexamethasone in: ICP, spinal cord compression, SVC obstruction, bone pain, neuropathic pain
- Non-pharmacological interventions
- Tropical local anesthetics
5. Regional anesthesia
6. Invasive neuroablative interventions
7. Last resource - Palliative sedation
Cherny NI, Ann Onco 2005;16(Supp 2):ii79
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• Severe pain associated with movement fracture of a long bone vertebral collapse
• Severe pain that disturb sleep
Parenteral Medication
• Intravenous morphine
• Sublingual ketamine
• Sublingual fentanyl
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Morphine is the first-line d rug used
1. Starting dose Opioid Naïve MO 2-5 mg IVOpioid Tolerant 10-20% of the total opioid requirement in the previous
24 hours (around the clock/scheduled doses plus as-needed doses)
2. Re-assess in 15 minutes (60 minutes if oral)- PS unchanged/higher increase 50-100% - PS decreased to 4-6 repeat same dose- PS 0-3 continue at current dose q4h
From: Shoenbe rge r J. Malignant pa in . In : Pa llia tive aspects of eme rgency ca re . Oxfo rd 2013
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• COPD 90-95%
• Heart disease 60-90%
• AIDS and renal disease 10-60%
• Last few weeks of life 70%
**Breathlessness at rest is an independent predictor o f surviva l second only to performance s tatus**
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• n = 80, Last week of life
• 50% had severe/very severe dyspnea
less than ½ of these were offered effective treatment
Dying from cancer: the views of bereaved family and friends
about the experience of terminally ill patients. Addington -Ha ll JM, et al. Palliat Med, 1991 5:207-214.
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• Direct tumor effects
• Indirect tumor effects
• Treatment-related
• Unrelated to cancer
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• Only on exertion? At rest?
• Comfortable position?
• Interference with daily activities or sleep? How?
• Relieved/improved with oxygen?
• Onset and progression?Rapid changes often provide an opportunity for corrective treatment,
eg. effusion, pneumonia• Meaning , patient’s knowledge, beliefs
Meaning : terminal, choking to death• Oxygen saturation has poor correlation with the sensation of
breathlessness!
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Correct the correctable
Symptomatic drug treatmentNon-drug treatment
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In fe ction An tibiotics , PT
COP D/asthma Bronchodilators, s teroids, PT
Obstruction o f trachea/bronchus/S VC Steroids, radiotherapy, laser therapy, s tenting, chemotherapy
Ly mphangitis carcinomatosis Steroids, d iuretics , bronchodilators
Pleural e ffusion Drainage +/-P leurodesis
Pericardial e ffusion Paracentesis, s teroids
Ascites Diuretics , paracentesis
Anemia Blood transfusion
Pulmonary embo lism An ticoagu lation
Heart fa ilure Diuretics , AC E inhibitors, opioids
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• Positioning - leaning forward, arms resting on table- Sleep with the normal lung up
• Use electric fan or stay near open window
• Gentle physiotherapy (rebreathing techniques, aid expectoration)
• Relaxation techniques, breathing exercise
• Discussion and reassurance
• Information & support for patient and family
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• Bronchodilators for bronchospasm (COPD, asthma)
• Mucolytics or NSS nebulizer if tenacious sputum is contributing to breathlessness
• Opioids for symptom management
• Benzodiazepines
• Corticosteroids for lymphangitis carcinomatosis or lung mets
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MildSco re 1-3
Mo derateSco re 4-7
SevereSco re 8-10
Re fracto ry
Fan
Position
Breathing exercise
Relaxation
Education
Short-acting MO prn. for dyspnea attack
Long-acting schedule MO
Sedation
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• Breathing training, walking aids, neuro-electrical muscle stimulation and
chest wall vibration appear to be effective non-pharmacological interventions
for relieving breathlessness in advanced stages of disease
(C ochrane Da tabase of Systema tic Reviews 2008, Issue 2)
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• Opioids reduce ventilatory response to hypercapnia, hypoxia, and exercise decrease respiratory effort and breathlessness
• Opioids are more beneficial in patients who are breathlessness at rest than on exertion
• Non-drug measures are of primary importance in breathlessness on exertion
• Improvement is seen at doses that do not cause respiratory depression
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• Reduced bronchoconstriction
• Improved gas exchange due to higher CO2 and lower O2 concentrations- Reduction in responses to hypoxia and hypercapnia- Reduction in the drive to breath- Reduction in total ventilation
• Less oxygen required at rest or to exercise
• Vasodilatation of pulmonary vasculature
• Attenuate limbic responses to dyspnea.
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• Several RCTs supported use of opioids in cancer patients (Ann In tern Med 1993, J Pain Sympt Manag 1990 ,
Sou th Med J 1991 , Ann Oncol 1999)
• Systematic reviews (18 RCTs) showed opioids reduced dyspnea symptom in cancer patients
(C ochrane Da tabase of Systema tic Reviews 2001, Issue 3)
• Current evidence does not support nebulized opioids for dyspnea management
(Annals of P harmacotherapy 2005)
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• Positive e ffect o f opioids on breathlessness (p=0.0008)• Greater e ffect for o ral/parenteral than nebulized opioids• Subgroup o f COPD showed same results.
Breathlessness Exercisetolerance
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• Endogenous opioids in COPD
• Meta-analysis - oral & parenteral opioids relief dyspnea.(Bruera E. J Pain Symptom Manage 2005)
• NNT 1.5 (Currow DC . J Pain Symptom Manage 2011;42 :388)
• Recommended dose in clinical trials low dose sustained-released 10-20 mg/d in opioid –naïve or 30% increment if receiving opioids
(Abernethy AP . BMJ 2003;327:523)
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• In opioid-naïve patient:
- Start with 2.5-5 mg PO PRN.
- If > 2 doses/24 h are needed give regularly and titrate according to response
• In patients already taking opioids:
- 30% increase of current MO- As with pain, individual titration is required
• Slow titration in type 2 respiratory failure
Actions: perception of dyspnea, anxiety & pain
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Actions: Decrease anxiety, act as muscle relaxants, reduce anxiety and panic attacks
Drug Dose Comments
Diazepam 2 -5mg PO up to TDS
Long acting (T2 = 20-100h)
Lorazepam 0.5 - 1mg SL/PO q 8h PRN
Shorter acting (T2= 12–15h) Fast onset of action
Midazolam 2.5 - 5 mg SC q 4h Short acting (T2= 2-5h) For intractable breathlessness
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MO = morphine 3 mg Mi = midazolam 2 mg MM = MO + midazolam
Navigante et al, J Pain Symptom Manage 2010;39:820
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• Review treatment after 5 days.
• If improved, reduce dose to the lowest effective dose
• If not improved, stopped or reduced to previous maintenance dose.
• If taken steroids for < 14 days stop abruptly.
Indication Dexamethasone dose SVC obstruction 16 mg Stridor 8-16 mg Lymphangitis carcinomatosisPost - Radiotherapy Bronchospasm
8mg
Action: Reduce inflammatory edema
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• Calm down
• Rest on a chair, elbows on thighs
• “Purse lip breathing”
• If not improved take morphine syrup 2 cc. Takes 20-30 min before action.
• Lorazepam tab 0.5 mg SL rapid onset.
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• Breathlessness is a complicated sensation
great variation in oxygen response
• In patient with SaO2 <90% oxygen may be benefit
• Advance cancer patients who were hypoxemic on room air benefited from oxygen therapy
(Lance t 1993, J Pain Symptom Manage 1992 , Palliat Med 2003)
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• Sudden onset / rapid worsening of dyspnea
• Often imminently terminal situation
Pulmonary embolism
Fulminant pneumonia
Upper airway obstruction
Hemoptysis
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• Aggressively pursue comfort• Ideally use intravenous route
• G enerally employ non-specific measures:
» Calm reassurance
» Oxygen
» Opioids
» Possibly sedatives: benzodiazepines (lorazepam, midazolam)
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IV push with escalating doses q 10 min
MO 3-5 mg IV
MO 5-10 mg IV
MO 10-15 mg IV
No t im prove in 10 m in
No t im prove in 10 m in
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Ellershaw, Care of the dying: A pathway to excellence
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+ 2 6 6
/ . . / . / .
5 2 6 6 . 6 6 )
· , D65 2 6 2 6 2 6 2 4 2 2 2
) ) ) ) ( )
· 1 1 1 1 1 1 1 . 00 0
5 2 6 6
+ 2 6 6 0 2 9 2 3 5 3 9 0 9 9. 5. 9 2
·
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- / 52F 2 . 00 44 44
·
·
ยาที่ผสมรวมกนัได้ Compatibility ตัวท ำละลำย
Morphine, Haloperidol / NSS SWI
Morphine, Metocloplamide / NSS SWI
Morphine, Midazolam / NSS SWI
Morphine, Metoclopramide, Midazolam
/ NSS
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• Positioning
• Antisecretory agents
-H yoscine H Br (Buscopan) 20 m g Q6h .
- Atropine 0.4 - 0.8 mg SC q1h prn- Atropine eye drop 1% 4 drops SL q 4h prn
• Consider suctioning if secretions are:
- Distressing, proximal, accessible- Not responding to antisecretory agents
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Etiology of Nausea & Vomiting
• Chemical causes
• Gastrointestinal causes
• Cranial causes
• Other causes
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Neuro transmitters:S erotonin, dopaminehistamine
Serotonin receptor antagonistsOn dansetronProkinetic/dopamine antagonistsMetoclo promide , ha lo perido l
Benzodiazepines Lo razepamDexam ethasone
Prokinetic drug for s tasis/partial obstruction: Metoclo pramideSurge ry/co rticosteroids for in testinal obstructionOctreotide , Busco pan to decrease secretions
Drugs : opioids, chemoTxBiochem: hyperCa, renal/liver fa ilure
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• Oral hygiene care - essential
• Small, frequent meals
• Avoid strong smells
• Acupuncture/acupressure
• Relaxation and imagery
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MedicationCla ss
Drug s
Dopamine An tagonists
Metoclopramide 10-20m g po/iv/sc/pr q4-8h
Haloperidol 0.5-1 m g po/sc/iv q6-12h
Domperidone 10 m g po q4-8h
Prokinetic Metoclopramide 10-20 m g po/sc/pr q4-8h
Domperidone 10 m g po q4-8h
Serotonin An tagonists
Ondansetron 4-8 m g b id-tid po/sc/iv
Granisetron 0.5–1 m g po/sc/iv OD - b id
H1 An tagonists Dim enhydrinate 25-100 m g po/iv/pr q4-8h
Promethazine 25 m g po/iv q4-6h
Misce llaneous Dexam ethasone 2-4 m g po/sc/iv OD-qid
Lorazepam 0.5 - 1 m g po/s l/iv q4-12h
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• Drugs (70-100%): opioid, anticholinergic drugs, TCA, diuretics, iron, 5HT3 antagonists
• Advance cancer:
Bowel obstruction
Spinal cord compression
Hyper Ca• Comorbids: hypothyroidism
• Debility:
- Fatigue, decreased mobility, bed bound - Dehydration
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History: bowel pattern (frequency, consistency , difficulty) pain, N/V,
neurological symptoms
Frequent soiling following severe constipation
overflow diarrhea
Beware
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PR:
• PR rectal tone? impact stool?
• Hard loading stool softeners
• Soft loading senna, bisacodyl
• Empty with ballooning rectum
high fecal impaction vs. gut obst. plain film
abdomen and treat accordingly.
** Abdominal exam & PR**
Abd. exam: distension, sausage-like mass LLQ,
visible peristalsis, bowel sounds
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Score >7 aggressive treatment
Dalal s. J Pall Med, 2006
Rectal treatment for
• Impact feces evacuate
Metoclopramide & abdominal massage
SSE, Unison enema, laxative + stool softener• Paraplegic/bedbound patient patients.
0 = No feces
1 = Stool occupy <50% of lumen
2 = Stool occupy >50% of lumen
3 = Stool completely occupy
the lumen
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• Stimulants
Senna (Senokot)
Bisacodyl (Dulcolax)
• Softeners
Lactulose
Magnesium salts
• Fibre*psyllium (Metamucil)
* Avoid fibre laxatives in
palliative care
• Suppositories & enemasGlycerin / bisacodyl
Bisphosphanate (Unison enema)
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Class Medication Dose Route SE
Stimulants Senna 2-4 tab HS PO Nausea,
cramping
Bisacodyl
5mg/tab
5-15 mg OD PO
PR
Nausea,
clamping
Stool Lactulose
15g/10 ml
15-30 ml PO Diarrhea,
nausea
Docusate
100mg/tab
50-200 mg/d
divide 1-4
PO Diarrhea,
nausea
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• Address any reversible causes.
• Good oral fluid intake (2 L/d).
• Review diet.
• Increase mobility
• Toilet training.
• Explain importance of preventing constipation.
• Ensure privacy and access to toilet facilities.
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• Avoid bulk forming laxatives fecal impact
• Lactulose needs a high fluid intake; can causes
flatulence and clamps.
• Almost all PC patients on opioid need a regular
laxative.
• Review laxative regimen when opioid medication
or dose is changed.
• If maximal laxative therapy fails, consider
changing opioid to fentanyl
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• Common finding in palliative patient
– Not improve with rest
– Not related to activities
• Become more severe at last few months of life
• Effected quality of life
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Ph ys ical
• CA, HF, COPD, E SRD
• Poor symptom control
• Side effect of medications: CMT, RT, diuretics
• Cachexia
• Anemia
• Fluid-electrolyte imbalance
• Insomnia
Ps ychosocial
• Anxiety
• Depression
• Family issues
• Psychosocial & spiritual
problems
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• Information giving• Rehabilitation program• Effectively treat symptoms• Review mediations• Assess fluid-electrolytes, intake• Blood transfusion for anemia• Treated anxiety and depression• Psychosocial & spiritual support
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• Dexamethasone (in patients with <4 w survival)
Feeling of well-being
Effects wean after 4-6 weeks.
• CNS stimulants: methylphenidate
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• Unavoidable in PC patients especially CA, HF
• Caused by hormonal dysregulation, inflammatory mediators
• Other causes: - Drugs and treatment eg. Diuretics - Poor control of symptoms: Pain, constipation, dyspepsia, gastric stasis
dry/sore-mouth, mucositis, candidiasis- Psychosocial & E motional distress
• Severity associated with survival
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Non-pharm R x
• Finding cause and treatment
• Provided information
• Small frequent meals
• Eating with family
Pharm R X
• Nutritional support in G I obst
patients.
• Appetite stimulants
- Progestogens
(Megestrol acetate)
- Dexamethasone in patients with
< 4wks survival
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• Reduce suffering
• Maximize comfort
• Preserve function
• Prevent complications
• Prolong survival