Prescribing for Palliative Patients; a primary care approach

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Prescribing for Palliative Patients a primary
care approach

• Dr Laura Smith
• GP ST1

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Contents

• The role of the GP in palliative care
• Out of hours out of ideas?
• Pain
• Assessment
• Analgesia
• Which one?
• When?
• Which Route?
• Quiz

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The role of the GP in palliative care

• Palliative care 'the active, holistic care of
  patients with advanced, progressive illness'
• Why is the GP ideal to facilitate this?
• long-established relationships with their
  patients
• used to dealing with co-morbidity and uncertainty
• trained to treat patients holistically
• Care needs to be PROACTIVE

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When should we think about palliative care?

• If a patient is diagnosed with cancer?
• If a patient needs a syringe driver?
• If a patient has hours to live?
• ...When a patient is in the last year of their
  life (GSF)

Identify
GP
Assess
Plan
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Imagine you are a GP...

• How many of your patients are in the last year of
  their life?
• 10
• 1
• 0.1
• On average, each GP has 20 deaths per year
• How many of these will be from cancer?
• How many will be from organ failure?
• How many from dementia/frailty or MOF?
• How many will be sudden/unexpected?

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Out of hours out of ideas?

• Groups of 2-3
• Imagine you are working as the OOH GP you are
  called out to a patient who is near the end of
  life suffering with cancer.
• His wife is concerned because...
• ...he won't stop hiccuping doctor, it has been
  going on for hours!
• What would you prescribe?

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Pain in Palliative Care

• How many patients with cancer suffer pain?
• 10
• 30
• 50
• 70
• 100
• How many patients dying with non malignant
  disease suffer pain?
• 25
• 45
• 65
• 85

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Pain tolerance
Sleep
Listening
Physio
Social inclusion
Relief of symptoms
Relaxation
Boredom
Diversion
Mental isolation
Understanding
Insomnia
Depression
Elevated mood
Explanation
Discomfort
Finding meaning
Insomnia
Fatigue
Anger
Sadness
Fear
Anxiety
Pain is a complex subjective phenomenon and is
affected by the emotional context in which it is
endured
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History taking

• SOCRATES
• Physical effects or manifestations
• Functional impact of pain
• Psychosocial factors
• Spiritual aspects
• Self assessment important as pain subjective
• Help patient to actively manage their pain
• What is causing the pain?

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The WHO pain ladder
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Adjuvants
Drugs Indications
NSAIDS Bone pain Hepatomegaly Soft tissue infiltration
Corticosteroids Raised ICP Nerve compression Hepatomegaly Soft tissue infiltration
Antidepressants/Anticonvulsants Nerve compression Paraneoplastic neuropathies
Bisphosphonates Bone pain
Ketamine Neuropathic pain Ischaemic limb pain
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Non Opiates

• Paracetamol
• Weak
• Few side effects
• NSAIDS
• Good for bone pain
• SE GI Bleed

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Opiates

• Weak opioids
• Codiene
• Tramadol
• Use with non-opioids
• Strong opioids
• Morphine
• For patients with no renal or hepatic
  comorbidities, offer a typical total daily
  starting dose schedule of 20-30 mg of oral
  morphine plus 5 mg oral immediate-release
  morphine for rescue doses during the titration
  phase NICE

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Converting between oral preparations
Converting from Converting to
Codeine Morphine Divide by 10
Tramadol Morphine Divide by 5
Morphine Oxycodone Divide by 2
Example Mr Jones takes 60mg of codeine qds for
his bony mets but is still in agony what dose
of morphine would you start him on? Answer 60 x
4 240mg in 24 hours of codeine 240 / 10
24mg morphine needed in 24 hours Therefore try
5mg every four hours 30 mg in 24 hours
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Breakthrough pain

• 1/6th of total 24 hour dose can be given as a
  rescue dose for pain between doses of regular
  morphine
• This can be repeated every 4 hours
• AIM Prevent pain, not relieve pain

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Parental route of administration

• When should this be used
• Patient unable to swallow, vomiting, weakness,
  dysphagia
• IM/SC morphine ½ oral morphine dose
• IM/SC diamorphine 1/3 oral morphine dose

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Transdermal route of administration

• NOT for acute pain, or for patients whose
  analgesic requirements change rapidly
• Use if problems with oral route, constipation,
  subacute obstruction or morphine intolerance

Oral Morphine Dose Patch equivalent
45mg daily Fentanyl 12 patch
90mg daily Fentanyl 25 patch
180mg daily Fentanyl 50 patch
270mg daily Fentanyl 75 patch
360mg daily Fentanyl 100 patch
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Poor kidney function preventing and managing
opioid toxicity

• Consider dose reduction /- increased dose
  interval
• Use immediate-release oral formulation
• Switch to alfentanil, buprenorphine or fentanyl,
  which are the opioids of choice where eGFR
  lt30ml/minute
• Frequent monitoring and review
• Seek specialist advice

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Top Tips

• Continuous pain regular analgesia NOT prn
• Take breakthrough analgesia before undertaking a
  potentially pain-provoking activity
• KISS Minimum number of drugs in the most
  acceptable form and dose intervals possible
• Written guidance for patients and families
• Regular review of effectiveness and side effects
• Adequate prn medications

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Quiz

• Mr Smith comes to see you in your morning
  surgery.
• 18 months ago he was diagnosed with bowel cancer.
• He underwent surgery and chemotherapy but 1 month
  ago was diagnosed with recurrence with spread to
  the liver.
• He comes to see you as he is getting worsening
  continuous abdominal pain.
• You take a careful history and you wish to change
  his pain relief.

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Question 1

• Mr Smith currently takes
• Paracetamol 1g po qds
• Ibuprofen 400mg po tds
• Codeine 60mg qds
• Oral morphine 20mg immediate release tablets
  twice daily
• You wish to convert him to a higher dose of
  morphine and stop the codeine what dose of
  immediate release morphine tablets will you
  prescribe?
• A) 10mg prn
• B) 10mg 4 hourly
• C) 5mg 4 hourly
• D) 20mg 4 hourly

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Question 2

• What breakthrough dose of oromorph does he need?
• A)10mg
• B) 5mg
• C) 6mg
• D) 10ml

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Question 3

• Mr Smith returns to the surgery later that week.
  You review his analgesia use
• He has taken 10mg four hourly regularly but most
  days has needed a breakthrough dose before bed
  and when taking his dog for a walk (twice a day).
• How would you alter his morphine dose?
• A) 45mg four hourly with 10mg breakthrough
• B) 15mg four hourly with 10mg breakthrough
• C) 15mg four hourly with 15mg breakthrough
• D) 20mg four hourly with 20mg breakthrough

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Question 4

• As a good GP what else might you prescribe Mr
  Smith when you prescribe his morphine?
• A)Naloxone
• B)Phosphate enema
• C)Lactulose and senna
• D)Ondansetron

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Question 5

• Mr Smith comes the following week his pain much
  better controlled and he is not needing any
  breakthrough treatment, but is concerned that he
  feels he is taking medication all the time.
• What could you do?
• A)Tell him to skip some doses and see how he
  feels
• B)Convert him to a twice daily morphine slow
  release dose of 45mg bd
• C)Convert him to a twice daily morphine slow
  release dose of 90mg bd
• D)Prescribe a fentanyl 25 patch

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Question 6

• 2 months later you are asked to see Mr Smith on a
  home visit.
• He has been reviewed by your colleagues and is
  now taking 75mg bd or MR morphine sulphate
  tablets.
• He now describes a burning and tingling type
  pain in his feet which is making it difficult to
  walk. It started 14 months ago after the
  chemotherapy but is now worsening.
• What would you prescribe?
• A) MR MST 90mg bd
• B) Amitriptiline 10mg po nocte
• C) Gabapentin 600mg tds
• D) Crutches

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Question 7
Unfortunately several weeks later Mr Smith is
admitted to hospital overnight unwell with
confusion. When discharged home the EDS notes for
GP state Please alter medication as found to
have renal impairment. On his last repeat
prescription he was on 90mg bd MR MST, ibuprofen
400mg tds, amitriptiline 10mg nocte with 30mg
oromorph as breakthrough prn, lactulose 10ml bd,
senna TT po nocte. Which of his medicines needs
to be altered? A)Reduce ibuprofen only B)Stop MST
only C)Stop ibuprofen, change MST to fentanyl
patch D)Reduce ibupofen, change MST to fentanyl
patch
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Question 8

• What dose of fentanyl patch will you prescribe
  and when should it be started?
• A) Fentanyl 50 apply at same time as last dose
  of MR MST given
• B) Fentanyl 25 apply 12 hours after last dose
  MR MST given
• C) Fentanyl 75 apply at same time as last dose
  of MR MST given
• D) Fentanyl 12 apply 12 hours after last dose
  MR MST given

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Question 8

• Luckily whilst you are working this out the
  receptionist receives a phone call from the
  oncall FY1 who sent the EDS in error the
  patient does not have renal failure but has
  deteriorated so could you do a home visit to
  check on him?
• On visiting the patient you confirm that he has
  quickly deteriorated, but he wishes to die at
  home, with his family supporting him. He is too
  weak to swallow tablets, and seems in pain.
• You wish to convert his 90mg bd MR MST to subcut
  diamorphine - what is the daily dose?
• A) 45mg
• B) 30mg
• C) 90mg
• D) 60mg

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Question 9

• The Macmillan nurse telephones you to let you
  know that no diamorphine is in stock they only
  have sub cut morphine can you re-prescribe it?
• What daily dose do you use now?
• A) 45mg
• B) 30mg
• C) 90mg
• D) 60mg

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Question 10

• You visit Mr Smith on a home visit 3 days later.
  He is in bed, and is asleep. His breathing has
  slowed but is very noisy due to secretions. His
  wife is upset thinking that he is in distress.
  You think he may be entering the last few hours
  of life.
• What might you prescribe?
• A) Increase his morphine to speed up his death
  and lessen the agony for his wife.
• B) Hyoscine hydrobromide 400 microgram subcut
• C) Midazolam 2.5-5mg subcut
• D) Cyclizine 50mg subcut

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Summary

• The role of the GP in palliative care
• Pain
• Assessment
• Analgesia
• Which one?
• When?
• Which Route?

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References

• Pain Control in Palliative Care Patient.co.uk
• Liverpool Care Pathway for the Dying Patient
  (LCP)
• Palliative Care Guidelines NHS Scotland
• Opioids in palliative care safe and effective
  prescribing of strong opioids for pain in
  palliative care of adults NICE guidelines

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Final thoughts

• Mr Smith passes away peacefully that night. His
  family are happy with the care he has received
  and thank you for not putting him on that awful
  death pathway like they do in Liverpool!
• How do you respond?