Batting order of anti-emetics:
Oxycodone may cause fewer central SEs than morphine. Different patients can have different levels of response to morphine & oxycodone.
For breakthrough pain, use buccal, sublingual, or intranasal medication – oral takes too long to work, and increasing the background dose in the absence of rest pain is going to lead to too many side-effects.
Note that there’s a high incidence of VTE in palliative care patients, associated with pain and suffering – prophylaxis with LMWH is frequently recommended, though I’m rather boggled by thoughts of the cost-effectiveness.
Although dexamethasone can be very useful, be aware of the side-effects of ongoing use – proximal myopathy can interfere with mobility, fractures can be a problem, steroid-induced psychosis is rare but horrible.
For malignant spinal cord compression, as well as arranging urgent admission and radiotherapy, start immediate dexamethasone 16 mg od.
(Pulse on-line learning module)