Michael Sobell House & Hillingdon Specialist Palliative Care Teams. Symptom control guidelines for health care professionals

Transcription

1 Michael Sobell House & Hillingdon Specialist Palliative Care Teams Symptom control guidelines for health care professionals Version

2 These principles are intended for guidance only and do not cover all aspects of an individual patient s care. If uncertain please contact your Specialist Palliative Care Team (SPCT) for advice. PAIN CONTROL WHO guidelines are well established as a robust and simple means of controlling pain in >80% patients with cancer. Give analgesia REGULARLY. Proceed UP and DOWN the ladder in response to symptoms. Give drugs via the oral route wherever possible. Converting weak opioids to equivalent dose of strong opioid Conversion for most step 2 drugs is 10:1 Example 1: Codeine 60mg = Morphine 6mg oral Example 2: Tramadol 100mg = Morphine 10mg oral (but can be equivalent to up to 15mg depending on the individual) 3-step WHO ladder Step-1 Non-opioids Paracetamol 1g qds, NSAIDs Step-3 Opioids Morphine see below for conversion and examples. No MAX dose, titrate to symptoms Step-2 opioids Tramadol 100mg qds (max) Codeine 30-60mg qds Co-codamol 30/500 i - ii qds Adjuvants: NSAIDs, neuropathic agents may be added at any step. Keep step 1 (unless contraindicated)

3 Morphine Morphine sulphate (immediate release) is 1st line: e.g. Oramorph liquid or Sevredol 5 10mg 4-6 hourly (opioid naïve 2.5-5mg 4-6 hourly) Titrate to pain; increase dose by 30% every 1-2 days if needed to achieve pain control. When pain controlled convert to slow release Morphine sulphate e.g. MST Continus 12 hourly (eg 60mg po in total in 24 hours: convert to 30mg MST Continus bd) Always prescribe regular laxatives and PRN anti-emetic For patients on regular step-3 opioids always prescribe an opioid for breakthrough pain PRN 1/6th of the total 24 hour opioid dose e.g. for MST Continus 30mg b.d. breakthrough dose is 10mg Oramorph or Sevredol PRN For opioid conversions e.g. to Oxycodone, Fentanyl patches, etc seek advice from SPCT Fentanyl patches 2nd line step-3 opioid; For stable pain only: in patients who have already been titrated on morphine. Indications: non-oral route required, side effects from morphine, poor compliance. Peak plasma concentrations achieved at hrs; depot remains in skin 24 hrs after patch removed. Patches should be changed every 72 hrs. Fentanyl patch strength (micrograms/hr) Approximate equivalent total 24 hour oral morphine dose (mg) Approximate 4 hourly oral morphine dose (mg) 12 <60 <10 25 <135 < For Fentanyl patch over 100 mcg/hr seek SPCT advice; 12 mcg/hr Fentanyl patch is licensed for stepping up between patches For pain relief at the end of life or when patient has dysphagia or intractable nausea and vomiting see syringe driver section TRANSTEC Buprenorphine patches seek advice from specialist palliative care team BU-TRANS Buprenorphine patches seek advice from specialist palliative care team

4 NAUSEA AND VOMITING Consider potentially reversible factors (correction may not be indicated if the patient is dying imminently) For any given cause prescribe the first line anti-emetic regularly and the second line for PRN use Review the efficacy of anti-emetic medication every 24 hours Review the patient s regular oral medication and consider an alternative route in order to maintain absorption (e.g. syringe driver) First line Cyclizine 50mg orally/sc tds or mg CSCI/24 hrs (continuous subcutaneous infusion) for nausea associated with raised intracranial pressure and bowel obstruction Haloperidol 1-2.5mg orally once daily or 2.5mg CSCI/24 for nausea associated with: hypercalcaemia, opioid induced nausea (usually a temporary phenomenon), uraemia. Second line Levomepromazine mg orally nocte (avoid if patient has severe risk of having an epileptic fit) or mg CSCI/24 hrs Also consider use of antacid or proton pump inhibitor 5HT3 antagonists (Ondansetron, Granisetron) are primarily used for nausea and vomiting secondary to chemotherapy and should not be used without advice from SPCT in nonchemotherapy regimens. They can cause constipation. Metoclopramide 10mg/sc/oral tds or Domperidone 10-20mg oral qds or Metoclopramide 30mg CSCI/24 hrs for nausea associated with gastric stasis

5 CONSTIPATION Most patients on opioids require regular laxatives. Use a softener AND a stimulant. Rectal intervention is sometimes required in addition. Laxatives in palliative care Type of laxative Name Dose Osmotic Movicol 1 sachet od-bd Softener Liquid paraffin & 5 20ml od magnesium hydroxide oral emulsion Stimulant Senna mg od-bd Stimulant Bisacodyl 5-10mg od Combination Docusate sodium mg / day capsules (for patients at risk of partial intestinal obstruction) Combination Co-danthramer susp 5 10ml od bd (danthron and Co-danthramer capsules i-ii od-bd poloxamer 25/200) BREATHLESSNESS Can be very frightening Try physical measures: open a window, use a fan Assess need for oxygen (either requires it or desires it) Treat underlying causes infection, bronchospasm, pleural effusions, etc. Discuss with SPCT and consider: Morphine sulphate 2.5-5mg oral PRN or up to 4hourly (can convert to MST) Benzodiazepines Lorazepam 0.5mg sublingually PRN or Diazepam 2mg PRN/tds oral (useful in panic/anxiety from breathlessness)

6 AGITATION Ensure calm and comfortable environment Treat reversible causes e.g. pain, urinary retention, constipation May still be appropriate to use sedation even if reversible causes are present First line Diazepam 2mg PRN tds oral OR Lorazepam 0.5 1mg PRN tds sublingual Midazolam 2.5mg sc 6 hrly PRN or 10-50mg over 24 hour CSCI OR Levomepromazine is both sedative and anti-emetic. Use mg sc 6 hrly PRN or mg over 24 hrs CSCI (Diazepam 10mg oral Lorazepam 1mg oral/ sublingual Midazolam 5mg subcut) Second line Seek SPCT advice LAST 48 HOURS Ensure that staff and carers are aware patient is dying. Stop unnecessary drugs and interventions (e.g. BP, glucose monitoring, IV fluids etc). Some patients can be managed with PRN medication and good nursing care only. Assess patient for symptoms: - Symptom control in the last 48 hours Symptom Drug via 24 hour PRN drugs given CSCI syringe driver via subcut (SC) route Pain Morphine sulphate Morphine (opioid naive) 10mg/24hr sc for opioid sulphate 2.5mg sc naïve (5mg starting dose for elderly frail) Pain Convert analgesia to Breakthrough dose (already on equivalent dose of is 1/6 of total of opioids) 24 hr sc 24hr opioid dose (Morphine oral:sc 2:1) (Morphine oral:sc 2:1) Nausea Cyclizine 150mg/24hr 2nd line Or Haloperidol Levomepromazine 2.5mg/24hr 6.25mg sc bd Agitation Midazolam Midazolam (exclude reversible 10 30mg/24hr sc 2.5 5mg sc up causes e.g. urinary (5mg starting dose to qds Or retention) for elderly frail) second line Levomepromazine mg sc bd Bronchial Glycopyrronium Glycopyrronium secretions mg/24hr sc 0.2mg sc tds Or Or Hyoscine Hyoscine hydrobromide hydrobromide mg/24hr sc mg sc qds

7 SYRINGE DRIVERS Device used to deliver drugs via continuous subcutaneous infusion (CSCI). Commonly used in terminal phase in hospital and community setting, but also indicated for dysphagia, intractable vomiting, or in those who are too weak to swallow drugs. General guidelines: Maximum 3 drugs in a syringe (occasionally 4 drugs but discuss with SPCT first) Check compatibility Drugs that cannot be given sc: Diazepam, Prochlorperazine, Chlorpromazine Use separate syringe driver for: Dexamethasone, Phenobarbital, Ketamine, Ketorolac, Diclofenac Standard diluents are water for injection (WFI) or Normal Saline (but must use WFI with Cyclizine and diamorphine >40mg/ml; use N/Saline with Ketamine and Diclofenac) Morphine sulphate is compatible with: Haloperidol, Metoclopramide, Cyclizine, Levomepromazine, Midazolam, Glycopyrronium, Hyoscine hydrobromide The following 7 drugs are all compatible (except for Cyclizine with Metoclopramide) in various combinations (max 3 drugs): Diamorphine, Haloperidol, Metoclopramide, Levomepromazine, Hyoscine hydrobromide, Midazolam, Cyclizine Drug conversions oral to subcut: Oral Morphine to subcut Morphine 2:1 E.g. 24 hour oral Morphine 60mg = 30mg subcut Morphine in 24 hours Oral Morphine to subcut Diamorphine 3:1 E.g. 24 hour oral Morphine 60mg = 20mg subcut Diamorphine in 24 hours Oral Oxycodone to subcut Oxycodone 2:1 E.g. 24 hour oral Oxycodone 60mg = 30mg subcut Oxycodone in 24 hours

8 WHEN TO ASK FOR HELP FROM SPECIALIST PALLIATIVE CARE TEAM Complex pain: neuropathic pain, pain due to bone metastases, ischaemic pain, physical pain complicated by psychological or existential issues, poorly opioid responsive pain Using opioids in patients with significant renal or liver impairment Opioid conversions Malignant inoperable bowel obstruction Extreme distress or terminal agitation REFERENCES M Watson, C Lucas, A Hoy. Palliative Care Guidance nd Edition. M Watson, C Lucas, A Hoy, I Back. Oxford Handbook of Palliative Care. 1st Edition: Oxford University Press. British National Formulary 53, March BMJ & RPS Publishing. R Twycross, A Wilcock, S Charlesworth, A Dickman. Palliative Care Formulary. 2nd Edition Radcliffe Medical Press. Poor symptom control at the end of life Vomiting unresponsive to 1st line anti-emetics Severe constipation Patient/carer request You would like to discuss treatment/ management plan Planning for community care

9 AUTHORS Dr Yolande Saunders, Consultant in Palliative Medicine, Hillingdon. Dr Humaira Jamal, Consultant in Palliative Medicine, Mount Vernon Cancer Centre & Michael Sobell House Specialist Palliative Care Unit. ACKNOWLEDGEMENTS Hillingdon Hospital: Specialist Palliative Care Team, Acute Pain Team, Jitendra Kachela (pharmacist), Iain McKay (formatting). Further information In Hours: Hillingdon SPCT (Hillingdon Hospital & Community) Michael Sobell House Specialist Palliative Care Unit Out of Hours: Palliative Care Advice Line Version Published: May 2008 Review Date: May 2011