Palliative care

(From BMJ learning module)

Palliative Care Adult Network Guidelines Plus are a useful resource.

Opiates in renal impairment

Some good ones:

  • Oxycodone, which is 90% excreted by the liver and only needs dose reduction in CKD5
  • Fentanyl – fine down to CKD3, adjustments needed in patients with more severe impairment.
  • Alfentanil
  • Buprenorphine

General principles:

  • Immediate-release preparations rather than controlled-release
  • Smaller doses
  • Longer interval

(There’s also a bit on prescribing in liver disease, but it’s really not all that helpful and I haven’t made notes on it.)

Vomiting

Central causes: drugs, biochemistry, cranial radiotherapy

Peripheral causes: localised radiotherapy, bowel tumour/inflammation/bleed. Puzzlingly, the module also lists infection and RICP, which I would have thought were central causes, especially the latter (I suppose ‘infection’ may be meant to refer to gastrointestinal infection rather than general sepsis – it isn’t very clear).

Anyway, the point of all this is to help pick an effective antiemetic:

Cyclizine, haloperidol and dexamethasome are centrally-acting antiemetics

Metoclopramide and ondansetron are peripherally-acting antiemetics.

Levomepromazine has a combined effect.

So, in a recalcitrant case of N&V, it may be possible to reach the desired effect by combining antiemetics. However, do note that cyclizine is not a good one for combination in a syringe driver as it tends to precipitate.

Subacute malignant bowel obstruction

Options for management include:

  • If death imminent and only small volumes of vomiting, manage with an antiemetic such as cyclizine in a syringe driver.
  • If flatus being passed and no abdominal colic, try prokinetic plus lots of stool softener.
  • If colic present, stop all prokinetics and use centrally-acting antiemetic (see above), Buscopan for the colic, and stool softener to keep the bowel contents as liquid as possible.
  • If large volumes of vomiting, consider octreotide syringe driver or nasogastric tube.
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About Dr Sarah

I'm a GP with a husband and two young children.
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