Yorkshire Cancer Network

and

North East Yorkshire and Humber Clinical Alliance

A GUIDE TO SYMPTOM MANAGEMENT IN PALLIATIVE CARE Version 5.1
Public !ion " !e# $ebru r% &'1& Re(ie) " !e# $ebru r% &'1*

The Humber and Yorkshire Coast Cancer Network (HYCCN) was formed in 2000 in response to the NHS Cancer Plan !ollowin" or"anisational chan"e in !ebruar# 20$2 HYCCN became part of the North %ast Yorkshire and Humber Clinical &lliance (N%YHC&) The work on this document was completed prior to this date' therefore' the document references data and or"anisational names in use prior to the official name chan"e

YOR+S,IRE AND ,UM-ER . YOR+S,IRE COAST CANCER NET/OR+S

PALLIATIVE AND END O$ LI$E CARE GROUPS

A GUIDE TO SYMPTOM MANAGEMENT IN PALLIATIVE CARE

CONTENTS P 0e In!ro"uc!ion inclu"in0# (seful resources (nlicensed use of licensed medicines Principles of S#mptom )ana"ement P in M n 0e2en! inclu"in0# Principles &ssessment * +e,iew (includin" anal"esic ladder) +ecommended -ru"s N use n" Vo2i!in0 In!es!in l Obs!ruc!ion Cons!i6 !ion D%s6noe Deliriu2 P lli !i(e C re E2er0encies inclu"in0# )etastatic Spinal Cord Compression * .ertebral )etastases Superior .ena Ca,al /bstruction H#percalcaemia L%269oe"e2 T9e L s! D %s o: Li:e S%rin0e Pu26 Princi6les Subcu! neous Me"ic !ions A66en"i; /pioid anal"esic e0ui,alences with oral morphine sulphate 7 * * 5 1 3415 3 1' 1& &' && &* &1 &5 71473 71 71 78 75 *1 *8 *3 5'457

INTRODUCTION Au!9ors9i6 These s#mptom mana"ement "uidelines ha,e been produced b# the Sub1re"ional Palliati,e and %nd of 2ife Care 3roups of the Yorkshire Cancer Network and the Humber and Yorkshire Coast Cancer Network The# were updated in No,ember 20$$ and reflect a consensus of opinion from specialists workin" in the field of palliati,e care in hospitals' hospices and in the communit# Discl i2er# These "uidelines are the propert# of the Yorkshire Cancer Network and Humber and Yorkshire Coast Cancer Network Palliati,e and %nd of 2ife Care 3roups 4t is intended that the# be used b# 0ualified medical and other healthcare professionals as an information resource' in the clinical conte5t of each indi,idual patient6s needs The Palliati,e and %nd of 2ife Care 3roups take no responsibilit# for an# conse0uences of an# actions taken as a result of usin" these "uidelines +eaders are stron"l# ad,ised to ensure that the# are actin" in keepin" with current accepted practice and le"islation' as these ma# chan"e !or e5ample' new N4C% "uidance on the prescription of opioids is e5pected in 20$2' and the Palliati,e Care !ormular# (PC!) is updated at re"ular inter,als No le"al liabilit# is accepted for an# errors in these "uidelines' or for the misuse or misapplication of the ad,ice presented here 4n difficult situations' please seek ad,ice from #our local Specialist Palliati,e Care ser,ice Use:ul Resources -etails are "i,en here of selected widel# used dru"s See also 7+4T4SH N&T4/N&2 !/+)(2&+Y (7N!) sections on 8Controlled -ru"s9 and 8Prescribin" in Palliati,e Care9 Check 7N! for formulations' dose recommendations' side effects and contra1 indications /ther useful resources are

1 2 3

2ocal intranet "uidelines The latest ,ersion of: 8The Palliati,e Care formular# (PC!) 9 Tw#cross +' and ;ilcock &' +adcliffe )edical Press 2td and website www palliati,edru"s com< ;est Yorkshire Cardio,ascular Network' 8S#mptom )ana"ement 3uidelines for patients in the later sta"es *

of heart failure and criteria for referral to specialist palliati,e care9' www #orksandhumberhearts nhs uk

1 2 3

;ebsites for Yorkshire Cancer Network (www #cn nhs uk) and Humber * Yorkshire Coast Cancer Network (www h#ccn nhs uk) as appropriate to #our area N4C% website' www nice or" uk<"uidance 3)C "uidelines' 8Treatment and care towards the end of life: "ood practice in decision makin"9' (20$0)' www "mc1uk or"

Unlicense" Use o: License" Me"icines <=O:: l bel> use? The unlicensed use of medicines is necessar# when clinical need cannot be met b# the licensed medicines a,ailable The recommendations in this "uide do include unlicensed use of licensed medicines These recommendations are based on current accepted palliati,e care practice in the (= 4n practice' appro5imatel# 2>? of prescribed medicines for palliati,e care patients are used in an unlicensed wa# (e " "i,en b# subcutaneous in@ection when licensed for 4) or 4. use' or for the treatment of nausea and ,omitin" when onl# licensed as an antips#chotic) !urther information re"ardin" unlicensed use of indi,idual palliati,e care medicines can be found in the current ,ersion of the PC! Prescribin" unlicensed medicines or those outside the marketin" authorisation ma# carr# si"nificant risks The prescriber si"nin" the prescription takes full responsibilit# ;hen prescribin" licensed medicines for unlicensed use' it has been su""ested that the prescriber should: document in the patient6s records the reason wh# the# are usin" the medicine 8off label9A where appropriate' "ain informed consent from the patientA inform nurses and pharmacists to a,oid misunderstandin"s where necessar#A and "i,e the patient a written leaflet where appropriate (a suitable leaflet ma# be downloaded from www britishpainsociet# or"<bookBusin"dru"sBpatient pdf) 4n practice' recordin" e,er# unlicensed use ma# be impractical and "ainin" informed consent in e,er# instance ma# lead to unnecessar# an5iet# for the patient or carer Practitioners must follow their clinical @ud"ment on the balance of potential burden and benefit and their own or"anisation6s polic# on the unlicensed use of licensed medicines 5

Princi6les o: S%26!o2 M n 0e2en!

1.

+emember to consider the Cwhole patient6 S#mptoms are ne,er purel# ph#sical or purel# ps#cholo"ical' and all s#mptoms and treatments will ha,e an impact on the patient' their famil# and friends %,aluate s#mptoms thorou"hl# Consider potential causes and remember to consider causes other than cancer Consider the impact of the s#mptom on the patient6s 0ualit# of life %ffecti,e communication is essential %5plain in simple terms and a,oid medical @ar"on -iscuss treatment options with patients and their families' and in,ol,e them in the mana"ement plan Correct the correctable' as lon" as the treatment is practical and not o,erl# burdensome +emember non1dru" treatments e " palliati,e radiotherap# for metastatic bone pain ;hen usin" dru" treatments for persistent s#mptoms' "i,e re"ularl# and also Cas needed6 =eep dru" treatment as simple as possible +e,iew re"ularl# and ad@ust treatment +emember to consider non1pharmacolo"ical strate"ies to help relie,e s#mptoms e " simple repositionin"' or the use of a T%NS machine ma# help painA complementar# therapies ma# help ps#cholo"ical distress &lthou"h the e,idence base for such treatments is not robust' some patients find them helpful Plan in ad,ance 3ood communication is essential in establishin" patients6 wishes for their future care and treatment Patients ma# want to document their wishes D the Preferred Priorities for Care document (a,ailable from www endoflifecareforadults nhs uk) or an &d,ance -ecision to +efuse Treatment ma# be helpful =eep other staff informed &sk for help +efer to local "uidelines or speak to the local Specialist Palliati,e Care team (SPCT) +efer to 3)C "uidelines (see (seful +esources)

2.

3.

4. 5. 6. 7.

8.

9. 10.

This brief "uidance co,ers some of the commonest s#mptoms in cancer and ad,anced pro"ressi,e disease !or the mana"ement 1

of other s#mptoms not included here' includin" fati"ue' cou"h' sweatin"' anore5ia and oral problems please see an introductor# palliati,e care te5t' such as CS#mptom )ana"ement in &d,anced Cancer (Eth edition)6 + Tw#cross' & ;ilcock and C Stark Toller (eds)' and refer to the other useful resources listed in the introduction

PAIN MANAGEMENT SECTION A# PRINCIPLES

1.

Pain is a total' personal e5perience with ph#sical' ps#cholo"ical' social and spiritual dimensions /ptimal pain mana"ement will be compromised if an# of these aspects are ne"lected Pain is common in ad,anced cancer and non1mali"nant conditions' and mana"ement can be difficult Not all pain e5perienced b# a patient with cancer is caused b# the cancer itself /ften se,eral pains coe5ist' and an accurate dia"nosis of the cause or mechanism of each pain must precede effecti,e treatment +e"ular re,iew is ,ital for "ood pain control 4n "eneral' successful relief of pain in palliati,e care patients re0uires:

2. 3.

4.

(1) +e"ular' as well as p r n

(as re0uired) dose

(2) Titration of dosa"e a"ainst effect with no ri"id upper limit for
most opioids e5cept buprenorphine' codeine and tramadol

(3) &ppropriate time inter,al between doses (4) Sufficient dose to pre,ent return of pain before ne5t dose is
due

(5) ;illin"ness

to "i,e stron" opioids earl# when other anal"esics fail

(6) %arl# consideration of co1anal"esics and non1

pharmacolo"ical approaches

(7) +e"ular re,iew and assessment (8) Prescribers follow the 8anal"esic ladder9 (see pa"e $$) (9) &ppropriate (10)
patient e5planation and information and medication taken as prescribed +eferral for anaesthetic anal"esic

inter,entions as necessar#

5.

)orphine sulphate orall# (or diamorphine or morphine subcutaneousl#) is the 83old Standard9 anal"esic in ad,anced 3

cancer and other end1sta"e conditions' althou"h other anal"esics such as paracetamol or a weak opioid ma# suffice &lternati,e opioids ma# be re0uired in patients with renal impairment (seek specialist ad,ice)

6.

3i,e morphine orall# if the patient can swallow and absorb the dru" /nl# consider other routes if the patient has d#spha"ia' "astric stasis' intractable nausea or ,omitin" or impaired consciousness 4f parenteral opioids are re0uired' a continuous subcutaneous infusion (CSC4) b# portable s#rin"e pump and<or p r n subcutaneous (SC) in@ections should be used )orphine sulphate or diamorphine are the first line dru"s of choice' dependin" on local polic# and practice !or hi"her doses' diamorphine ma# be ad,anta"eous because its hi"h solubilit# allows lar"er doses to be "i,en in small ,olumes /pioid side effects include:

7.

8.

1 2 3 4

constipation (,er# common) nausea and ,omitin" (a common but controllable and transient side effect that usuall# impro,es after appro5imatel# > da#s) drowsiness (often dose1related and temporar#) respirator# depression (clinicall# rarel# a problem if dose is titrated correctl#) &lwa#s prescribe la5ati,es and consider prescribin" p r n or re"ular anti1emetics Neither tolerance nor addiction are si"nificant problems in palliati,e care practice

9.

Some pains are onl# partiall# opioid1responsi,e These include tension headache' post1herpetic pain' muscle spasms' ner,e dama"e< compression' bone pain' ,isceral distension' tenesmoid pain and acti,it# pro,oked pain These ma# re0uire other measures includin" co1anal"esics' ner,e blockade or specific oncolo"ical treatments Co1anal"esics include non1steroidal anti1inflammator# dru"s (NS&4-s)' anti1con,ulsants' anti1depressants'

10.

benFodiaFepines and corticosteroids 5

11. +e,iew use of p r n

medication 4f patients are re0uirin" se,eral p r n doses a da#' assess whether this is due to inade0uatel# controlled back"round pain or the presence of break1throu"h (episodic) pain This term is used to describe a transient e5acerbation of pain in someone who has relati,el# stable and ade0uatel# controlled back"round pain (PC!G) Consider whether such break1throu"h pain is predictable (incident pain) e " on mo,ement' or unpredictable (spontaneous) and how lon" the break1throu"h pain lasts Such assessment will determine how p r n anal"esics are tailored for the indi,idual patient' specificall# in terms of dose and duration of action 4nade0uatel# controlled back"round pain usuall# re0uires the back"round dose to be titrated' whereas planned use of p r n medication ma# be acceptable for incident or spontaneous pain !urther "uidance is a,ailable in the PC!' and seekin" specialist ad,ice would also be appropriate

SECTION -# ASSESSMENT AND REVIE/ /9 ! is !9e 6 in "ue !o@ Consider: &natom# H site of ori"in &etiolo"# H cause of pain 7e in0uisiti,e ;hat helpsI ;hat makes it worseI +e,iew and re,iew a"ain 4n,esti"ate appropriatel# Think of J1ra# for patholo"ical fracture or bone metastasesA ultrasound or CT scan for deep soft tissue tumours +emember common non1mali"nant causes e " arthritis' tension headache' infections includin" oral thrush 4n ad,anced' pro"ressi,e disease there are usuall# multiple causes of pain and a mana"ement plan will be needed for each of these

1'

/9ic9 n l0esic@ Di 0r 2 o: !9e n l0esic l ""er Stron" opioids K<1 Paracetamol K<1 co anal"esics Step G ;eak opioid K<1 Paracetamol K < 1 co anal"esics Step 2 Paracetamol K < 1 co anal"esics Step $ The anal"esic ladder pro"resses lo"icall# from a non1opioid ,ia a weak opioid to a stron" opioid Start at the bottom of the ladder and work up as necessar# (se the dru"s at the optimal dose re"ularl# i e b# the mouth' b# the clock' b# the ladder +emember:

1 2 3

;eak opioids include codeine and dih#drocodeine Co1codamol is a,ailable in three stren"ths containin" paracetamol and either Lm"' $>m" or G0m" of codeine 4n elderl# or frail patients a lower stren"th ma# be re0uired Codeine is a pro1dru" of morphine 4ts anal"esic effect is ,ia its con,ersion to morphine' which ,aries between patients and there is a small proportion of the population in whom codeine is ineffecti,e Paracetamol has a different anal"esic effect to opioids and can pro,ide additional benefit for patients takin" stron" opioids Tramadol is "enerall# not used in cancer related pain Stron" opioids include morphine' diamorphine' o5#codone'

4 5 6

11

fentan#l' alfentanil' h#dromorphone' buprenorphine' and methadone (specialist use onl#)

To consider the aetiolo"# of the pain<s and select anal"esics accordin"l# (see Section C' Co1&nal"esics' pa"e $M)

SECTION C# RECOMMENDED DRUGS 1. O6ioi" n l0esics 3eneral Principles

1. 2. 3.

4mmediate and modified (slow) release preparations are a,ailable &ll patients takin" re"ular anal"esics should also ha,e anal"esics prescribed for Cbreakthrou"h pain6 to take Cas re0uired6 (p r n ) P r n immediate release opioids should be indi,iduall# titrated Commonl# this is $<N of the total dail# dose' but a ran"e of $<N to $<$0 ma# be appropriate !or a patient on G0m" )ST b d $<N of their total 2E hour morphine dose would be $0m" immediate release morphineA a patient on G0m" slow release o5#codone (e " /5#continO) b d would re0uire $0m" immediate release o5#codone (e " /5#normO) )a5imum fre0uenc# and dose of p r n opioids in 2E hours should be clearl# stated +emember to prescribe re"ular la5ati,es and p r n anti1 emetics and discuss side effects of opioids with the patient ;hen usin" opioid anal"esics titrate doses upwards b# G01 >0? increments to relie,e pain' or until unacceptable side effects occur Hal,e the usual startin" doses if the patient is elderl# or frail Some anal"esics ma# accumulate in renal or hepatic impairment and specialist ad,ice ma# be re0uired Careful indi,idual tailorin" of opioid dose is also re0uired in patients with respirator# failure 4t is ad,isable to seek specialist palliati,e care ad,ice re"ardin" patients recei,in" hi"her doses of opioids' especiall# when

4. 5. 6. 7. 8.

9.

undertakin" con,ersions to alternati,e dru"s or routes of administration 1&

1.1 Or l Pre6 r !ions 1.1.1 Mor69ine sul69 !e !ormulations a,ailable Immediate release tablets and li0uids would be e5pected to be effecti,e after 20 minutes and to last up to E hours %5amples include /ramorphO and "eneric /ral )orphine Sulphate Solution (stren"th $0m"<>mls) 1 both of which are colourlessA /ramorph Concentrate 2i0uid (stren"th 20m" in $ml 1 pink in colour) and Se,redolO tablets (morphine sulphate immediate release tablets 1 $0m"' 20m" and >0m") Modified/slow release tablets' "ranules and capsules would be e5pected to be effecti,e after E hours and to last for $2 hours or 2E hours' dependin" on the preparation %5amples include )ST ContinusO tablets and suspension sachets' PomorphO capsules and )orph"esicO tablets Startin" re"imen

1 2

4f a patient is not takin" an# weak (step 2) opioids it is usual to commence these first before considerin" morphine 4f the optimal dose of weak opioid plus or minus paracetamol and<or an ad@u,ant dru" does not control the pain' the patient should be switched to morphine at a dose which is e0ui,alent to or sli"htl# "reater than the dose of the weak opioid that the# are takin" The weak opioid must then be stopped (see &ppendi5 $ for con,ersions) % " a patient who has been takin" stron" Co1 codamol G0<>00 (Codeine phospate G0m"' paracetamol >00m") 2 tablets 0 d s re"ularl#' could be commenced on slow release morphine sulphate (e " )STO) $>m" to 20m" b d with immediate release morphine for breakthrou"h pain and the dose titrated b# G01>0? increments or until unacceptable side effects occur 4f there are concerns about medicines adherence' opioid sensiti,it# or absorption of slow release products' start with between 2m" and $0m" of immediate release morphine E hourl# and p r n (start with >m" E hourl# if opioid naQ,e or not reliabl# takin" pre,iousl# prescribed anal"esics' and with 2 or Gm" E hourl# in the frail or elderl#) See point L on pa"e $2 re"ardin" or"an failure /nce a stable dose is achie,ed it is usual to transfer to modified 17

release preparations' e " a patient on $0m" oral morphine immediate release (e " /ramorphO) E hourl# recei,es a total of N0m" morphine in 2E hours This is e0ui,alent to G0m" $2 hourl# of morphine sulphate (modified release) tablets e " )STO' PomorphO Patients bein" initiated on morphine b# either method' should ha,e their doses re,iewed e,er# 2E hours and titrated up b# G01 >0? increments as necessar# if back"round pain remains inade0uatel# controlled' takin" into account both the re"ular dose of morphine and the number of p r n doses that the# ha,e re0uired in the pre,ious 2E hours (&lso see pa"e $0' Pain )ana"ement Principles no $$) &ll patients bein" titrated on morphine should be monitored for si"ns of to5icit# (confusion' drowsiness' hallucinations' @erkin") 4f the patient has moderate to se,ere renal impairment' morphine metabolites will accumulate and specialist ad,ice ma# be re0uired re"ardin" alternati,e opioids 7reakthrou"h pain &ll patients on modified release morphine should ha,e immediate release morphine a,ailable p r n for breakthrou"h pain C&2C(2&T% 1 the total m" of modified release morphine prescribed in 2Ehrs and di,ide b# N to "i,e p r n immediate release morphine dose % " )ST R0m" b d H $L0m" morphine <2Ehours di,ided b# N H G0m" /ramorph (immediate release morphine) p r n 1.1.& O;%co"one /5#codone is a stron" opioid with pharmacolo"ical properties similar to morphine 4t is a useful second line stron" opioid for patients who ha,e not tolerated morphine 4t is a more e5pensi,e option /ral o5#codone is $ > to 2 times more potent than oral morphine Consult a dose con,ersion chart when startin" o5#codone or ask ad,ice from #our local palliati,e care team or pharmac# !ormulations a,ailable 4t is a,ailable as immediate release o5#codone (e " /5#NormO) with duration of action E1N hours' or modified (slow release) o5#codone (e " /5#ContinO) with duration of action of $2 hours 1*

7reakthrou"h pain 4mmediate release o5#codone should be a,ailable p r n ' at a dose which is usuall# $<N of the 2E hour dose of o5#codone 1.& P ren!er l Pre6 r !ions This section contains information needed for prescribin" continuous subcutaneous infusions ,ia s#rin"e pump 1.&.1 Di 2or69ine n" Mor69ine inAec!ions 7oth diamorphine and morphine sulphate can be "i,en p r n subcutaneousl# (SC) with duration of action of up to E hours &lternati,el# the# can be "i,en as a continuous subcutaneous infusion ,ia a portable s#rin"e pump !or an opioid naQ,e patient' start with morphine sulphate or diamorphine' 2 or Gm" SC p r n or between > and $0m" morphine or diamorphine o,er 2E hours as a continuous SC infusion 4t is usual practice across the Yorkshire and Humber networks to use the followin" con,ersion ratios:

Parenteral morphine and diamorphine are between 21G times more potent than oral morphine (refer to local polic#)

So' for e5ample' to switch a patient pre,iousl# on oral morphine to a continuous subcutaneous infusion of diamorphine: -i,ide the total 2E hour dose of oral morphine b# G % " if a patient is on )ST G0m" b d ' the# will re0uire 20m" subcutaneous diamorphine o,er 2E hours 4t is e5tremel# important that p r n anal"esia is prescribed 3i,e $<N of their total 2E hour subcutaneous opioid dose e " in the abo,e e5ample' the SC p r n dose would be between 2 and >m" diamorphine 1.&.& O;%co"one InAec!ion Patients on oral o5#codone who ha,e been intolerant of oral morphine can be con,erted to a subcutaneous infusion of parenteral o5#codone To con,ert to subcutaneous o5#codone from oral o5#codone' di,ide the total dail# dose of oral o5#codone b# 2 There are two concentrations of parenteral o5#codone a,ailable These are $0m"<ml and >0m"<ml 15

1.7 Tr ns"er2 l 6re6 r !ions Transdermal preparations are mainl# suitable for patients with chronic pain alread# stabilised on other opioids The# ma# be useful in patients with poor compliance with oral opioids or swallowin"<absorption problems Some patients ma# e5perience less ad,erse effects than with oral morphine The# should not usuall# be started in the last da#s of life 7oth fentan#l and buprenorphine ha,e less ad,erse effects than morphine in patients with renal failure N 7 &ll patients usin" transdermal patches should also be prescribed an immediate release preparation for breakthrou"h pain' the dose of which is dependent on the patch stren"th Transdermal fentan#l patches ha,e a M21hour duration of action Transdermal buprenorphine patches are a,ailable as:

1 2

2ow dose patches (7uTransO) which ha,e a duration of action of M da#s These ma# be helpful in patients with poor compliance who re0uire a low dose opioid Hi"her stren"th patches (TranstecO)' which ha,e a duration of action of RN hours but are desi"ned to be replaced twice a week

Consult dose con,ersion chart (see PC! or &ppendi5 $) when startin" transdermal opioids or ask for ad,ice from #our local palliati,e care team or pharmacist 1.* O!9er rou!es o: "2ins!r !ion o: s!ron0 o6ioi"s !ormulations of sublin"ual' buccal and nasal fentan#l are a,ailable 1.5 /9 ! i: o6ioi"s "onB! )orC@

1)

Are o6ioi"s !9e n l0esic o: c9oice@ Consi"er e!iolo0%. -on6t for"et palliati,e radiotherap# for bone secondaries' which can be "i,en as a sin"le treatment 4n >1$0? of patients some kind of ner,e block will help (e " coeliac ple5us block in pancreatic pain) -iscuss with palliati,e care or pain clinic collea"ues

2)

Is !9e "ose 9i09 enou09@ 4f there is a partial response or inade0uate duration of pain 11

relief i e pain returns in under E hours after immediate release oral morphine or in under $2 hours after modified release morphine' increase the dose b# G01>0? increments rather than shortenin" the inter,al between doses +emember to check that the p r n dose prescribed is still ade0uate and bein" taken for pain mana"ement rather than breathlessness

3)

Is "ru0 bein0 bsorbe"@ 4f there is uncontrolled ,omitin"' d#spha"ia or hi"h stoma output' consider alternati,e routes of deli,er# (e " subcutaneous' rectal' intra,enous' transdermal) Is 6 in bre Cin0 !9rou09 )i!9 2o(e2en! or 6 in:ul 6roce"ures@ 4dentif# and minimise pro,okin" factors Consider pre1empti,e doses of immediate release opioid' consider NS&4-s -iscuss with palliati,e care team Are co n l0esics reDuire"@ Please see ne5t section for indications /9o 2i09! be ble !o 9el6@ -on6t be afraid to ask a more e5perienced collea"ue for help Your hospital palliati,e care team' local hospice or communit# palliati,e care team will "ladl# offer ad,ice

4)

5) 6)

&. Co4An l0esics Choice of co1anal"esic will be determined b# the aetiolo"# of the pain )ore detailed information about NS&4-s is "i,en in section 2 >' pa"e $R &.1 Dru0s :or -one 6 in Consider NS&4-s' bisphosphonates' palliati,e radiotherap# and corticosteroids &.& Dru0s :or Neuro6 !9ic 6 in The decision to use an antidepressant or an anticon,ulsant depends on a patient6s s#mptoms and the ad,erse effect profile (anti1 choliner"ic side1effects with amitript#line' namel# dr# mouth' urinar# hesitanc#' postural h#potension and constipation' or sedation and "astro1intestinal effects with "abapentin or pre"abalin) Patients ma# de,elop ad,erse effects before benefit' and effecti,e anal"esia ma# take up to a week to be achie,ed 18

&.&.1 An!i"e6ress n!s Start with low dose' usuall# "i,en at ni"ht' and "raduall# increase e,er# 21> da#s if ad,erse effects allow &mitript#line $0 to M>m" at ni"ht (lower than usual antidepressant doses) &.&.& An!icon(uls n!s Slower titration is recommended in the frail and elderl#' often slower than stated in the 7N! (se with caution in renal impairment and seek ad,ice if necessar# G b 6en!in 7etween $00 and $L00m" in di,ided doses Pre0 b lin 7etween 2> and G00m" twice dail# 4n addition' for ner,e root compression consider de5amethasone' between L and$Nm"' NS&4-s' palliati,e radiotherap#' and pain team inter,entions &.7 Dru0s :or r ise" in!r 4cr ni l 6ressure De; 2e!9 sone $Nm"<da# Corticosteroid of choice with hi"h anti1inflammator# potenc#' hi"h solubilit# and low mineralocorticoid effect (less salt and fluid retention) (se at the lowest effecti,e dose for shortest possible time -e5amethasone $m" H Prednisolone Mm" Taper the dose slowl# when stoppin" (not usuall# necessar# if duration of treatment is one week or less) Prescribe doses to be "i,en in the mornin" to a,oid causin" insomnia &.* Dru0s :or o!9er 6 in Painful muscle spasms Di Ee6 2 ni"ht - clo:en >m" t d s 2i,er capsule pain Consider NS&4-s (see bone pain for su""estions)' de5amethasone between E and Lm" o m 13 7etween 2 and >m"' L1$2 hourl# or once' at

)usculoskeletal pain Consider NS&4-s (oral or topical)' T%NS machine 4ntestinal colic &nti1spasmodicsA h#oscine but#lbromide 20m" SC or h#oscine h#drobromide' between $>0 and G00micro"rams S2 See also 4ntestinal /bstruction section' pa"e 22 Pel,ic pain Consider NS&4-S' corticosteroids' antispasmodics for colic &.5 Non4S!eroi" l An!i4In:l 22 !or% Dru0s <NSAIDs? )ost patients with cancer ha,e risk factors for si"nificant "astrointestinal ad,erse effects therefore consider use of an H21 receptor anta"onist or a proton1pump inhibitor alon"side NS&4use (se NS&4-s with caution in patients with renal impairment' uncontrolled h#pertension or heart failure 7alance short and lon" term risks and benefits Ibu6ro:en ! ble!s E00m" L hourl# Diclo:en c ! ble!s )a5imum dail# dose $>0m" or su66osi!ories N 6ro;en ! ble!s 7etween >00m" and $" dail#' or su66osi!ories in di,ided doses

15

NAUSEA n" VOMITING

1 Nausea and ,omitin" can be difficult to control 2 4t is important to consider all possible causes 3 Causes are often multifactorial and ma# re0uire more than one
dru"

4 Consider re,ersible causes

e " "astritis 1 treat with H2 1 receptor anta"onist or a proton pump inhibitorA oral thrush 1 treat with antifun"als

5 4f patient has se,ere nausea or ,omitin"' parenteral anti1emetics

ma# be re0uired

6 4f initial ad,ice in -ru" )ana"ement Table is not effecti,e

contact the Palliati,e Care Team

7 Prescribe dru"s re"ularl# as well as p r n 8 C#cliFine and other antimuscarinic dru"s block the final common
pathwa# throu"h which metoclopramide acts' therefore concurrent administration should be a,oided

9 C#cliFine and 7uscopan ma# cr#stalliFe when mi5ed in a s#rin"e

pump and should onl# be used to"ether on s6eci lis! "(ice

&'

RECOMMENDED DRUG MANAGEMENT O$ NAUSEA AND VOMITING CAUSE $IRST4LINE STAT DOSE &* ,R DRUG <PO or SC? RANGE
G s!ric s! sis n" irri! !ion )etoclopramid e K<1 proton pump inhibitor< H2 1receptor anta"onist )etoclopramid e $0 1 20m" G0 1 N0m" P/ or SC

-o)el obs!ruc!ion /IT,OUT colic -o)el obs!ruc!ion /IT, colic

$0 1 20m" SC onl#

G0 1 N0m" SC onl#

C#cliFine K<1

>0m" SC onl# $ > D >m" SC onl# 20m" SC onl#

$001$>0m" SC onl# $ > D >m" SC onl# N0 D $20m" SC onl#

Haloperidol K<1 H#oscine 7ut#lbromide (7uscopanO) C9e2ic l e" S dru"s S h#percalcaemi a S uraemia R ise" in!r cr ni l 6ressure Haloperidol

$ > 1 >m"

$ > 1 >m" P/ or SC

-e5amethaso ne plus C#cliFine K<1 /ndansetron or 3ranisetron H#oscine h#drobromide /+ C#cliFine

L 1 $Nm" >0m" See 7N! G00micro"rams S2 E00micro"rams SC

L 1 $Nm" $>0m" See 7N!

Mo!ion

G00micro"rams S2 0 d s L00micro"rams 1 $ 2m" SC $00 1$>0m" P/ or SC

>0m"

In"e!er2in !e F Mul!i: c!ori l

2e,omepromaF ine

N 1 $2 >m" Nm" tablet a,ailable on named patient basis or 2>m" tablet can be 0uartered

N 2> 1 2>m" P/ or SC

&1

INTESTINAL O-STRUCTION IN ADVANCED CANCER INTRODUCTION 4ntestinal obstruction in ad,anced cancer is fre0uentl# incomplete' intermittent' at multiple sites or due to motilit# disturbance There is a hi"h incidence in o,arian and bowel cancer CLINICAL $EATURES S#mptoms ,ar# dependin" on the le,el and de"ree of obstruction and ma# include an# or all of the followin":

1 2 3 4 5 6 7 8 9

Nausea and ,omitin" Colick# pain &bdominal distension -ull achin" pain -iarrhoea and<or constipation

DIAGNOSIS Histor# is most useful &bdominal J1ra#s ma# help but 8normal appearances9 do not e5clude bowel obstruction -ifferential dia"nosis is constipation but this ma# also co1e5ist with bowel obstruction Passa"e of flatus stops in complete obstruction

MANAGEMENT &ll patients will re0uire s#mptom mana"ement Sur"ical inter,ention should also be considered earl# in appropriate cases (see below) SURGICAL MANAGEMENT Selectin" patients who are likel# to benefit from a sur"ical procedure (e " bowel resection or b#1pass K<1 stoma formation) is difficult These decisions are best made with an e5perienced sur"ical collea"ue and careful discussion with the patient Patients likel# to benefit are those with no other life1threatenin" disease and sin"le1site obstruction /ther factors to consider include patient

performance status' co1morbidit#' nutritional status and options for further treatment such as chemotherap# &&

SYMPTOM MANAGEMENT ;ith appropriate s#mptomatic treatment patients ma# sur,i,e se,eral weeks or occasionall# months 3ood s#mptom mana"ement can usuall# be achie,ed and "reatl# impro,es 0ualit# of life )edication should "enerall# be "i,en b# subcutaneous in@ection or continuous subcutaneous infusion (CSC4)

1.

IV $lui"s n" NG !ube These re"imens are indicated while sur"er# is bein" considered or as a short1term inter,ention but are rarel# appropriate for lon"1 term mana"ement N3 tube ma# occasionall# be used as a ,entin" mechanism to relie,e ,omitin" in "astric outlet or hi"h small bowel obstruction N use n" (o2i!in0

2.

1 2 3.

Set realistic "oals Nausea can usuall# be reduced si"nificantl# but ,omitin" ma# continue once or twice dail# 3i,e anti1emetics parenterall# and re"ularl# Subcutaneous infusion is often helpful (see nausea and ,omitin" section' pa"e 20)

P in ColicC% 6 in

1 2 3
S

Stop stimulant la5ati,es and prokinetic dru"s' e " metoclopramide (se antispasmodics (h#oscine but#lbromide' between N0 and L0m"<2E hours b# CSC4) -iamorphine<morphine -iamorphine<morphine

Dull c9in0 6 in
No!e# -e5amethasone' hi"h dose metoclopramide and octreotide ma# also be used under specialist ad,ice

4.

On0oin0 nu!ri!ion n" 9%"r !ion

1 2

4. fluids and total parenteral nutrition (TPN) are rarel# necessar# in far ad,anced cancer /ral intake of food and drink can continue for the patient6s en@o#ment and is often surprisin"l# well tolerated 1 the patient will decide if the risk of ,omitin" outwei"hs the pleasure of eatin"

No!e# Patients with a hi"h obstruction without other life1threatenin"

complications re0uire special consideration re"ardin" s#mptom mana"ement' h#dration and nutrition e " ,entin" "astrostom#' subcutaneous fluids TPN ma# be considered in indi,idual cases

&7

CONSTIPATION Constipation is ,er# common in palliati,e care patients due to a combination of factors includin" immobilit#' reduced food and fluid intake' dru"s' bowel patholo"# and sometimes h#percalcaemia -ia"nosis is usuall# made on the basis of histor# and e5amination &bdominal J1ra# is rarel# re0uired Consider patient education and information about the causes of constipation' increasin" fluid intake and makin" appropriate dietar# chan"es to help impro,e s#mptoms Gui"elines on !9e use o: l ; !i(es in cons!i6 !ion

1 &ssess cause and treat where possible 2 &

combination of stool softener and stimulant la5ati,e is usuall# re0uired

3 %5amples of stool softeners include:

-ocusate Polo5amer 2actulose )o,icolO )a"nesium salts

1 %5amples
Senna

of stimulant la5ati,es include:

-antron 7isacod#l

Sodium picosulphate

2 %5amples of combination preparations include:

Codanthramer (polo5amer and dantron) Codanthrusate (docusate and dantron)

3 2ocal units ma# ha,e their own "uidelines on first line

la5ati,es

4 &,oid stimulant la5ati,es if colic is present

5 Note that dantron stains urine red and can cause contact
&*

dermatitis -o not use preparations containin" dantron in incontinent patients

1 Note 2 4n

that lactulose ma# cause si"nificant flatulence and bloatin" complete bowel obstruction' do not prescribe la5ati,es without seekin" ad,ice the patient whether the# prefer la5ati,e in li0uid or tablet

3 &sk
form

4 +e,iew la5ati,es e,er# 2 da#s 5 4f

patients are currentl# mana"in" well on their la5ati,e re"imen' there is no need to chan"e la5ati,es

6 4f bowels ha,en6t mo,ed in G da#s' do a rectal e5amination and

follow local "uidelines on rectal measures

7 Subcutaneous meth#lnaltre5one ma# be indicated in rare cases

for opioid1induced constipation resistant to optimal la5ati,e re"imens <seeC "(ice :ro2 s6eci lis! 6 lli !i(e c re !e 2?

&5

DYSPNOEA De:ini!ion o: "%s6noe # uncomfortable awareness of breathin" -#spnoea occurs ,er# commonl# in ad,anced cancer' cardiorespirator# and neurolo"ical disease 2ook for re,ersible causes as listed below Is "%s6noe o: su""en onse!@ Possible c use &sthma Consi"er

7ronchodilators' corticosteroids' ph#siotherap#

Pulmonar# oedema -iuretics' diamorphine<morphine Pneumonia &ntibiotics' ph#siotherap# -iamorphine<morphine Consider anticoa"ulants

Pulmonar# embolism

Pneumothora5 , s "%s6noe Possible c use

Chest draina"e' o5#"en risen o(er se(er l " %s@ Consi"er &ntibiotics' bronchodilators'

%5acerbation of C/Pcorticosteroids Pneumonia

&ntibiotics' ph#siotherap# -e5amethasone $Nm" o m

7ronchial obstruction

b# tumourearl# radiotherap# (+T)' laser or stents Superior ,ena ca,al -e5amethasone $Nm" o m obstruction Ur0en! stentin"

D%s6noe o: 2ore 0r "u l onse! Possible c use Consi"er

Con"esti,e cardiac -iuretics' di"o5in' &C% inhibitors failure

&naemia &s a chronic condition unlikel# to be the ma@or cause of d#spnoea Transfusion ma# help if HbTL"<dl /ral iron is ineffecti,e in chronic normochromic normoc#tic anaemia &1

Pleural effusion

Consider pleural aspiration and follow with pleurodesis if appropriate These procedures ma# be distressin" for frail patients Consider palliation 1 see o,er

Pulmonar# fibrosis Possible if histor# of c#toto5ics (esp bleom#cin)' or lun" +T Palliati,e mana"ement D see below
&scites

Paracentesis if appropriate

Primar#<secondar# +esection' +T or chemotherap# as carcinoma lun" Carcinomatous l#mphan"itis appropriate -e5amethasone between L and $2m" o m S!o6 if not effecti,e within one week 7ronchodilators ma# help

Re(ers l o: c use o: "%s6noe in "eDu !e or i26ossible G P lli !i(e M n 0e2en!

1 -#spnoea is fri"htenin" to patient' famil# and staff

+eassurance and e5planation are ,ital parts of the treatment whate,er the cause

2 )odification of lifest#le' breathin" retrainin" and rela5ation ma#

be beneficial if instituted earl# enou"h

3 Consider referral to ph#siotherapist or occupational therapist 4 & portable<table fan directed onto the face often eases
d#spnoea

5 3ood

oral care is important if there is persistent mouth breathin"

6 Humidified o5#"en ma# help acute d#spnoea but should be used

alon"side other measures and its use re,iewed re"ularl#

7 2on"

term o5#"en therap# for chronic respirator# illness should onl# be insti"ated b# respirator# ph#sicians

8 )an# patients re0uirin" palliation for breathlessness will not

benefit from o5#"en therap# )easurement of o5#"en saturation le,els usin" a pulse o5imeter ma# aid decision makin" in assessin" whether or not o5#"en is of benefit &8

Dru0s !o consi"er &ll dru"s for s#mptomatic relief of d#spnoea are respirator# sedati,es ;hen prescribed' their use should be monitored carefull# 4n the conte5t of distressin" d#spnoea in the terminal sta"es of illness the benefits usuall# outwei"h the risks

1 O6ioi"s
/ral morphine (immediate release) 2 to Gm" E hourl# 3raduall# titrate dose upward accordin" to response or until unacceptable side effects occur This can be con,erted to a lon" actin" morphine preparation if effecti,e 4f alread# takin" stron" opioid for anal"esia contact palliati,e care team for ad,ice

2 -enEo"i

Ee6ines

2oraFepam between >00micro"rams and $m" S2 ma# "i,e rapid relief durin" panic attacks !or lon"er1term mana"ement consider oral diaFepam 2m" once at ni"ht or twice dail# )idaFolam 2 >m" SC ma# benefit patients that cannot tolerate oral<sublin"ual route These dru"s can be continued in the terminal phase See section on C2ast -a#s of 2ife6 (pa"e E$)

&3

DELIRIUM -elirium is e5tremel# common in patients with ad,anced disease 4t is a source of increased morbidit# and distress and interferes with the abilit# to communicate effecti,el# at the end of life 4t is often unreco"nised or treated inappropriatel# and can be misdia"nosed as dementia' depression' an5iet# or ps#chosis Clinic l :e !ures

1. 2.

-isturbance of consciousness (i e reduced clarit# of awareness of the en,ironment) with reduced abilit# to focus' sustain' or shift attention & chan"e in co"nition (such as memor# deficit' disorientation' lan"ua"e disturbance) or the de,elopment of a perceptual disturbance that is not better accounted for b# a pre1e5istin"' established' or e,ol,in" dementia The disturbance de,elops o,er a short period of time (usuall# hours to da#s) and tends to fluctuate durin" the course of the da# There is e,idence from the histor#' ph#sical e5amination or laborator# findin"s that the disturbance is caused b# the direct ph#siolo"ical conse0uences of a "eneral medical condition

3. 4.

Subt#pes of delirium are based on the t#pe of arousal disturbance: o o o H#peracti,e H#poacti,e )i5ed (with alternatin" features of h#per and h#poacti,it#)

Assess2en! /btain a thorou"h histor# to determine the patient6s pre1morbid le,el of functionin"' their use of alcohol and illicit substances and the chronolo"# of the onset of the chan"es in their mental state Co"niti,e assessment tools such as the abbre,iated mental test score should be used to "au"e the patient6s co"niti,e state but will not differentiate delirium from other causes of co"niti,e impairment 4dentif# an# re,ersible causes: medication (e " dru"s with anticholiner"ic side effects such as c#cliFine' corticosteroids)A infectionA biochemical abnormalitiesA alcohol withdrawal &5

M n 0e2en!

4n,esti"ations appropriate to o,erall "oals of care Non1 pharmacolo"ical measures are the mainsta# and include: o &ddressin" re,ersible causes o )aintainin" ade0uate fluid balance and nutrition the patient6s en,ironment to reduce confusion and distress e "

15 )ana"in"

1~ .isible clock to aid orientation 2~ %ncoura"e

e5planation famil# to ,isit and pro,ide them with a full

3~ Consistent nursin" 4~ 3ood li"htin" durin" da#time 2

Pharmacolo"ical inter,entions:

15 Consider usin" haloperidol 1~ /ral

between >00micro"rams and $ >m" b d with additional doses e,er# four hours as needed

2~ SC between >00micro"rams and $m"' obser,e for

G01N0 minutes and repeat if necessar#

3~ +e,iew at least e,er# 2E hours * seek further ad,ice

from SPC if not workin"

4~ -iscontinue within M da#s if s#mptoms resol,e 15 7enFodiaFepines

should be used with caution due to their abilit# to sedate and increase confusion

7'

PALLIATIVE CARE EMERGENCIES METASTATIC SPINAL CORD COMPRESSION <MSCC? n" VERTE-RAL METASTASES <V-M? INTRODUCTION

1 Spinal cord compression

metastatic cancer

is a well1reco"nised complication of

2 This can be a catastrophic e,ent leadin" to paral#sis below

the le,el of the compression' urinar# retention and faecal incontinence

3 4f treated earl# these problems can usuall# be pre,ented or at

least partiall# re,ersed

4 )SCC and .7) occur more fre0uentl# in some tumour t#pes'

when there is metastatic disease (especiall# bone) and in the later sta"es of a cancer tra@ector# 2un"' breast and prostate cancers account for o,er >0? of casesA l#mphoma and m#eloma account for 20? Patients at hi"h risk ma# ha,e been identified b# treatin" clinical teams and informed both of features to look out for and what to do if the# suspect that the# ma# be de,elopin" .7) or )SCC Such patients should ha,e been pro,ided with an )SCC information booklet

5 )an# of the features of )SCC (back pain' weakness' bladder

and bowel chan"e) are non1specific features of ad,anced cancer so the patient6s s#mptoms and si"ns in the Cconte5t6 of their cancer must be considered

6 )SCC and .7) are suspected clinicall# but can onl# be pro,en
b# ima"in" ()+4 is the 3old Standard)

7 Patients should onl# be referred for )+4 if the# are fit enou"h to
tolerate an )+4 scan (E0 minutes of flat bed1rest) and tra,el to 2eeds or Hull (dependin" on the location of the patient) for therap# if the )+4 is positi,e

8 Patients with suspected )SCC should ha,e an )+4 within 2E

hours

9 Patients with suspected .7) should ha,e an )+4 within M

da#s

10

4nitial )+4 ima"in" will be performed at the patient6s local cancer unit and is accessed ,ia the local cancer unit pathwa#' 71

usuall# ,ia their &cute /ncolo"# contact point !or YCN patients' treatment of )SCC and .7) is deli,ered in 2eeds (+adiotherap# at SU4/ or Sur"er# at 234) A for HYCCN patients' treatment takes place in Hull (+adiotherap# at CHH or Sur"er# at H+4) althou"h if bein" treated conser,ati,el# this will be done in local hospitals rather than the cancer centre Please refer to N4C% Clinical 3uideline M> on )SCC for additional information and back"round SYMPTOMS S%26!o2s su00es!i(e o: s6in l 2e! s! ses#

1. 2. 3. 4. 5. 1.

Pain in thoracic or cer,ical spine Pro"ressi,e lumbar spinal pain Spinal pain a""ra,ated b# strainin" 2ocalised spinal tenderness Nocturnal spinal pain pre,entin" sleep

S%26!o2s su00es!i(e o: MSCC Pain

(1) 7ack

pain or ner,e root pain either unilateral or bilateral' particularl# if associated with alteration in "ait

(2) )a# be a""ra,ated b# mo,ement' cou"hin" or l#in" flat (3) )a# precede other s#mptoms b# up to N weeks (4) )a# be absent in appro5imatel# $0? of patients 2.
;eakness )otor weakness below le,el of lesion This ma# be rapid or slow in onset and can be subtle in the earl# sta"es -escriptions of percei,ed chan"es in stren"th are important Sub@ecti,e sensor# disturbance /ften precedes ob@ecti,e ph#sical si"ns' e " 84 feel like 4 am walkin" on cotton wool9 Propriocepti,e chan"es ma# lead to "ait d#sfunction percei,ed as Cpoor balance6

3.

4.

7ladder<bowel d#sfunction (rinar# retention often de,elops insidiousl# 3enerall# occurs late 7&

SIGNS The absence of si"ns does not e5clude earl# spinal cord compression 4n,esti"ations should be considered on the basis of histor# alone in a patient who is at risk

1 2 3 4 5 6

;eakness<paraparesis<paraple"ia Chan"e in sensation below le,el of lesion (not alwa#s complete loss of sensation) +efle5es D absent at le,el of lesion D increased below it Clonus Painless bladder distension 2oss of anal tone

N 7 Sensor# and refle5 chan"es ma# occur secondar# to other disease processes or pre,ious neuroto5ic chemotherap# INVESTIGATIONS . MANAGEMENT The followin" "eneral principles appl# to the in,esti"ation and mana"ement of .7) and )SCC The detailed )SCC and .7) clinical pathwa#s for YCN and HYCCN and other supportin" information are a,ailable from #our local cancer network website (see useful resources' pa"e >) In(es!i0 !ions URGENT

1 Contact 2/C&2 cancer unit &cute /ncolo"# Team ,ia their

dedicated number to discuss case and need for further assessment<e,aluation

2 ;hole spine )+4 1 in,esti"ation of choice and shows full e5tent of

disease This should be done within 2E hours if )SCC is suspected

3 -o not use

plain radio"raphs to dia"nose or e5clude spinal metastases or )SCC no neurolo"#) then whole spine )+4 within M da#s is indicated -iscuss with the patient6s Consultant Clinical /ncolo"ist (if the# ha,e one)' the

4 4f suspected .7) onl# (i e

Consultant Clinical /ncolo"ist linked to the appropriate site1 specific )-T (if #ou don6t know who this is contact the 77

site1specific )-T coordinator) or' if all other a,enues fail' the Clinical /ncolo"# Sp+ on1call Please note that s#mptomatic .7) is not an emer"enc# in the same wa# as suspected )SCC M n 0e2en! Cor!icos!eroi"s 1 can be commenced if there is stron" clinical suspicion of cord compression and no contraindications' pendin" definiti,e in,esti"ations 3i,e de5amethasone $Nm" stat then o d )a# "i,e short term impro,ement while arran"ements are bein" made for in,esti"ations and treatment &fter sur"er# or radiotherap#' de5amethasone can be reduced o,er >1M da#s unless neurolo"ical function deteriorates )onitor blood "lucose le,els while patient is on corticosteroids (peak would be e5pected in earl# e,enin" after a mornin" dose) Sur0er% 1 Sur"ical treatment can be appropriate in certain situations The Clinical /ncolo"# team will undertake appropriate assessment and tria"e of patient with pro,en )SCC on )+4 -4+%CT &PP+/&CH T/ TH% S(+34C&2 T%&) !/+ P&T4%NTS ;4TH
P+%1%J4ST4N3 P+/.%N )&243N&NT -4S%&S% &N- )SCC SH/(2-

N/T 7% (N-%+T&=%N 4n most cases sur"er# should be followed b# hi"h dose radiotherap# R "io!9er 6% 1 forms the mainsta# of treatment in most cases The Clinical /ncolo"# team will arran"e deli,er# of this once )+4 re,iew and patient tria"e ha,e been undertaken b# them C9e2o!9er 6% 1 is ,irtuall# ne,er used in acute mana"ement of )SCC but ma# be indicated in onward disease mana"ement as )SCC<.7) alwa#s reflect a back"round of pro"ressi,e cancer No c!i(e n!i4c ncer !9er 6% 1 ma# be appropriate for patients in the late sta"es of their cancer tra@ector#' in those who are unfit for tra,el' )+4 scannin" or radiotherap# treatment or who ha,e established paraparesis and are pain free P in relie: 1 offer to all patients as per the ;H/ anal"esic ladder (pa"e $$) Su66or!i(e c re 1 full holistic care assessment should be made Venous !9ro2boe2bolis2 6ro69%l ;is 1 should be undertaken followin" assessment accordin" to local polic# 7*

Re9 bili! !ion 1 Patient positionin" and mobilisation should be undertaken accordin" to patient abilit#<deficit !lat bed rest is not indicated b# default and patients ma# sit inclined as their pain and sittin" balance permit 4f safel# ambulant then this should be encoura"ed Patients should ha,e ph#siotherap#< occupational therap# assessment to a"ree an initial rehabilitation plan &""ressi,e rehabilitation is often not appropriate (as it will be hampered b# pro"ressi,e back"round mali"nanc# with fati"ue and limited abilit# to compl#) but fitter patients with residual but reduced function and at an earlier phase of their cancer tra@ector# ma# benefit from onward referral to local rehabilitation teams (thou"h a,ailabilit# of local ser,ices ma# ,ar#) PROGNOSIS Neurolo0ic l 1 &mbulator# status post1treatment is linked to that pre1treatment ;here pre1treatment' the patient is walkin" without help' R0? will be ambulator# post1treatmentA where walkin" with help' N0?A not walkin" but with residual power' E0?A no residual power at all' $0? Patients with a slower onset of weakness (V$E da#s) ha,e a better likelihood of re"ainin" ambulator# function O(er ll sur(i( l 1 Patients who under"o resectional sur"er# would normall# ha,e an anticipated minimum sur,i,al duration of N months and median sur,i,al of $L months Patients who ha,e radiotherap# and ha,e further s#stemic anti1cancer treatment options ha,e a median sur,i,al of $ #ear Those who recei,e radiotherap# but who ha,e no s#stemic anti1cancer options remainin" (i e are late1 tra@ector#) ha,e a median sur,i,al of N weeks

75

SUPERIOR VENA CAVAL O-STRUCTION <SVCO? INTRODUCTION

1 2 3 1. 2. 3. 4. 5.

)ost commonl# seen in lun" cancer Consider l#mphoma' particularl# in #oun" patients +e"ard as emer"enc#' as patient6s condition ma# deteriorate rapidl#

SYMPTOMS AND SIGNS Swellin" or discolouration of the face and neck !eelin" of fullness in the head -#spnoea' worse on l#in" flat Non1pulsatile raised @u"ular ,enous pulse WU.PX -ilated anterior chest wall ,eins

INVESTIGATIONS -iscuss with radiolo"ist re"ardin" local polic#:

1 2

Chest J1ra# Thoracic CT

MANAGEMENT .ascular stentin" is usual treatment of choice althou"h radiotherap# or chemotherap# ma# be "ood alternati,es Chemotherap# ma# be the treatment of choice in l#mphoma and small cell lun" carcinoma (if dia"nosis pre,iousl# established) The e,idence for the use of corticosteroids as a holdin" measure before definiti,e treatment is lackin" ;here used this should be for a limited duration -iscussion with local respirator# team<oncolo"ist is recommended Recurren! su6erior (en c ( l obs!ruc!ion +adiotherap# ma# be considered .ascular stent ma# be replaced Thrombol#sis ma# be considered if a stent is blocked b# thrombus OUTCOME Treatment often "i,es useful s#mptomatic relief

4f untreatable S.C/' patient has a pro"nosis of da#s 71

,YPERCALCAEMIA INTRODUCTION

1 2 3 4 5

&ffects appro5imatel# $0120? of patients with ad,anced cancer )ost commonl# seen in multiple m#eloma' breast' renal and s0uamous carcinomas Consider in une5plained nausea' ,omitin"' confusion or constipation )ore commonl# due to tumour secretion of parath#roid hormone1related protein than to bone metastases )a# de,elop insidiousl#

SYMPTOMS AND SIGNS Se,erit# of s#mptoms is more related to the speed of rise of the serum calcium rather than the absolute le,el

1 2 3 4 1 2

Non1specific earl# s#mptoms: lethar"#' malaise' anore5ia Common s#mptoms: nausea and confusion /ther s#mptoms: constipation' thirst and deh#dration 2ate features: drowsiness' fits' coma

INVESTIGATIONS Corrected serum calcium (rea and electrol#tes

MANAGEMENT Treat if serum calcium ele,ated' s#mptomatic and clinicall# appropriate

1 2

4ntra,enous bisphosphonateY e " pamidronate between G0 to R0m"' Foledronic acid Em" or ibandronate between 2 to Em" Choice depends on local "uidelines and renal function Pre and post dose reh#dration with 0 R? sodium chloride tailored to the patient6s renal function' cardio,ascular status

and oral intake

YN 7 7isphosphonates ma# also be used for treatment of bone pain and pre,ention of skeletal e,ents 1 see full prescribin" "uidelines for doses

78

$OLLO/ UP +echeck calcium if s#mptoms ha,e not impro,ed after G1E da#s

1 2 3 4

)a5imal response to bisphosphonates is seen after N1$$ da#s 4f appropriate' repeat the same or a different bisphosphonate if calcium le,el has not decreased Consider in,esti"atin" for h#perparath#roidism in selected patients !or recurrent h#percalcaemia consider intermittent intra,enous bisphosphonates 4f repeated doses of bisphosphonates are anticipated' patients should ha,e a dental assessment and their dental practice informed' to minimise the risk of osteonecrosis of the @aw

OUTCOME

1 2 3

&,era"e duration of response is G1E weeks Patients should be informed that h#percalcaemia ma# recur and to monitor for s#mptoms Pro"nosis depends on the underl#in" patholo"#' but refractor# h#percalcaemia is a poor pro"nostic indicator

73

LYMP,OEDEMA INTRODUCTION 2#mphoedema is a chronic pro"ressi,e swellin" due to the inabilit# of the l#mphatic s#stem to maintain normal tissue homeostasis This results in an accumulation of protein1rich fluid in the subcutaneous tissues 2#mphoedema is one form of chronic oedema 4n patients with cancer' l#mphoedema is usuall# secondar# to the underl#in" cancer or pre,ious cancer treatment C,ARACTERISTIC $EATURES

1 2 3 4 5 6

/edema Chronic inflammation Skin chan"es e " dr# skin' thickened tissues (Stemmer6s si"n) Hea,iness and achin" in the affected limb %5cess fibrosis 4n the earl# sta"es of l#mphoedema pittin" is demonstrated ;ith time' this feature is lost due to the oedema ha,in" a hi"h protein content

GENERAL MANAGEMENT ;here a,ailable' patients should be referred to specialist l#mphoedema clinics The core treatment elements are:

1 2 3 4

Skin care 1 keep skin clean and moisturised with non1perfumed emollient (e " a0ueous cream' -iprobaseO) Compression<support )o,ement and e5ercise Simple l#mph draina"e' self1massa"e techni0ues

&,oid affected limb for an# medical procedure e " in@ection' ,enepuncture' blood pressure measurement

75

MANAGEMENT O$ CELLULITIS IN LYMP,OEDEMA Comprehensi,e ad,ice is a,ailable in the Consensus document from the 2#mphoedema Support Network and 7ritish 2#mpholo"# Societ# (www thebls com &u"ust 20$0) Treat earl#' monitor closel# and continue antibiotics for at least $E da#s after clinical impro,ement is obser,ed

1. 2. 3.

/ral amo5icillin >00m" t d s (clarithrom#cin >00m" $2 hourl# or er#throm#cin >00m" 0 d s if penicillin aller"ic) 4f e,idence of Staph#lococcus &ureus infection add in or substitute fluclo5acillin !ollow "uidance on the 7ritish 2#mpholo"# website' www thebls com

&cute infection is usuall# painfulA re,iew anal"esics &,oid compression "arments and NS&4-s in acute attack 4f patient de,elops s#stemic s#mptoms' 4. antibiotics ma# be re0uiredA seek specialist ad,ice Recurren! celluli!is &ntibiotic proph#la5is is needed if patient has had 2 or more attacks of cellulitis per #ear Penicillin . >00m" dail# (er#throm#cin >00m" dail# if penicillin aller"ic) first line Please consult www thebls com and refer for specialist ad,ice $ur!9er in:or2 !ion The 2#mphoedema Support Network: www l#mphoedema or"<lsn The 7ritish 2#mpholo"# Societ#: www thebls com

*'

T,E LAST DAYS O$ LI$E +eco"nition of imminent death is important 4t allows withdrawal of unnecessar# treatments and preparation of the patient and famil#<carers for death This phase is often heralded b# a more rapid deterioration in the patient6s "eneral condition and can be difficult to reco"nise 4f all potentiall# re,ersible causes for the patient6s condition ha,e been considered and appropriatel# mana"ed' the followin" s#mptoms and si"ns in patients ma# indicate that the pro"nosis is short:

1 2 3 4 5 6 7 1. 2.

Profound weakness Confined to bed for most of the da# -rows# for e5tended periods -isorientated Se,erel# limited attention span 2oss of interest in food and drink Too weak to swallow medication

ACTIONS Sensiti,el# check the awareness of patient and famil#<carers and e5plain the plan of care Ne"otiate appropriate treatment and ad,ance care plans with the patient' if the# ha,e capacit# Check if an &d,ance -ecision to +efuse Treatment (&-+T) has been made or a 2astin" Power of &ttorne# (2P&) for welfare appointed 4f the patient does not ha,e capacit#' clinical decisions must be made in the patient6s best interest in line with the )ental Capacit# &ct !amil#' carers and other healthcare professionals should be consulted The role of the famil# is to ad,ise on what the patient would ha,e wanted for his<herself %stablish the patient6s preferred place of care This should take into account the needs and wishes of the patient and the famil#<carers !ast Track<Continuin" Care !undin" !orm or e0ui,alent needs to

3.

4. 5.

be si"ned for patients wishin" to be cared for in a home or care home settin" *1

6.

CP+ status should be re,iewed 4n accordance with local polic#' either complete a transferable re"ional -N&CP+ form or -N&CP+ forms in all rele,ant settin"s and prior to ambulance transfers 4f at home<care home ensure an /ut of Hours Hando,er !orm has been completed and the patient and famil#<carers ha,e the NHS -irect Palliati,e Care 2ine number Professional carers ma# need to acknowled"e and share their own feelin"s )utual support and teamwork are important

7. 8.

P9%sic l c re /9 ! nursin0 c re n" su66or! is nee"e"@

1. 2. 3. 4. 5. 6.

4f a patient is to be dischar"ed home from hospital ensure the "eneral practitioner' district nurse and where appropriate' the communit# palliati,e care team are aware &de0uate da# and ni"ht nursin" support needs to be arran"ed Consider ni"ht sitters %nsure the patient is not left alone for lon" periods and preferabl# not at all 4n,ol,e famil#<carers in practical care as much as the# wish and discuss the plan of care ;hen the patient is in the last da#s<hours of life consider an inte"rated care pathwa# for the d#in" e " 2CP' where a,ailable Priorities of care include:

1 2 3 4

&ssess re"ularl# for common s#mptoms at the end of life: pain' a"itation' respirator# secretions' nausea and ,omitin" and breathlessness Treat dr# mouth with "ood re"ular mouth care (minimum hourl#) 4mmobilit# and pressure areas 1 bed' mattress' positionin" needs to be assessed Continence 1 consider catheter' con,ene' pads and monitor

for si"ns of retention

7owel care 1 assess for bowel problems that ma# cause *&

discomfort' such constipation or diarrhoea

&ssess the ps#cholo"ical' reli"ious' cultural and spiritual care needs of the patient and famil#

/9 ! bou! :oo" n" :lui"s@ & reduced need for food and fluids is part of the normal d#in" process and patients should be supported to take food and fluids b# mouth for as lon" as tolerated S#mptoms of thirst < dr# mouth are often due to mouth breathin" or medication < o5#"en therap# and "ood mouth care is essential !or man# patients' the use of clinicall# assisted (artificial) h#dration will not be of benefit and decisions about their use should be made in a patient6s best interest 4f clinicall# assisted artificial h#dration or nutritional support is in place' re,iew rate < ,olume < route accordin" to indi,idual need Possible benefits of withdrawin" or reducin" clinicall# assisted h#dration<nutrition include reduced ,omitin" and incontinence' reduced painful ,enepuncture /9 ! bou! 2e"ic !ion@ +eassess indications and potential benefits in the conte5t of the terminal phase for &22 medications /nl# continue medication needed for s#mptom mana"ement 4f the oral route is not appropriate the subcutaneous route or the rectal route can be used for man# s#mptom mana"ement dru"s ;hen in the last da#s<hours of life refer to local inte"rated care pathwa# for the d#in" s#mptom mana"ement "uidelines where a,ailable %nsure anticipator# medications are prescribed and a,ailable for the fi,e common s#mptoms which ma# de,elop in the last hours or da#s of life: pain' terminal restlessness' respirator# tract secretions' nausea and ,omitin" and breathlessness Ter2in l res!lessness &ssess the patient carefull# +estlessness can occur at the end of life but there ma# be a precipitant' therefore look for e,idence of:

1 2

Ph#sical discomfort 1 pain related to underl#in" condition' urinar# retention' faecal impaction or new e,ent e " haemorrha"e' malfunctionin" s#rin"e pump +espirator# distress 1 d#spnoea' cou"h' tracheal obstruction *7

1 2

Neurolo"ical problems 1 fits' hallucinations' m#oclonic @erks' motor restlessness +emember an# of these ma# be caused b# dru"s (includin" opioids and anti1emetics) Ps#cholo"ical distress (see below)

4f there are no re,ersible precipitatin" factors or ps#chosis' midaFolam is the dru" of choice (see s#rin"e pump section' pa"e EM) Haloperidol is useful for delirium Res6ir !or% !r c! secre!ions or HDe !9 R !!leB This is a rattlin" noise produced b# the mo,ement of secretions in the upper airwa#s in patients who are too weak to e5pectorate effecti,el# +elati,es and carers ma# find this distressin" 4t is important to e5plain to the relati,es<carers that this is unlikel# to be causin" distress to the patient

1 2 3

+epositionin" of the patient and postural draina"e ma# help &nti1secretor# dru"s can be used (see s#rin"e pump section or local inte"rated care pathwa# for the d#in" s#mptom mana"ement "uidelines) Prompt dru" treatment is re0uired

!or resistant s#mptoms consider other causes e " "astric or chest secretions and mana"e accordin"l# Dis!ressin0 !er2in l e(en!s %,ents such as haemorrha"e' fits or tracheal obstruction are unusual and can often be anticipated and a mana"ement plan discussed with nursin" staff in ad,ance Prescribe appropriate p r n medication (e " diamorphine or morphine and midaFolam) to relie,e distress and sedate if necessar# Seek ad,ice from palliati,e care team if unsure Do no! !!e26! c r"io6ul2on r% resusci! !ion <DNACPR? or"ers 4f a patient is in the last da#s of life' cardiopulmonar# resuscitation (CP+) is hi"hl# unlikel# to be of clinical benefit The resuscitation status of the patient should be discussed within the clinical team and documented as per local polic# 4t is "ood practice to e5plain to the patient and their carers: wh# CP+ will not be attemptedA that the focus of care is on palliation and comfortA in the home settin"' that famil# members know what to do when the patient dies

**

Ps%c9olo0ic l n" s6iri!u l c re o: 6 !ien! n" : 2il% -ecisions about the plan of care should be communicated to the patient where appropriate and to the relati,e or carer The patient' relati,e and carer should be "i,en the opportunit# to discuss what is important to them at this time The patient ma# be an5ious for themself or others and addressin" ps#cholo"ical and spiritual needs ma# contribute to alle,iatin" s#mptoms of a"itation Consider barriers to communication such as hearin"' ,ision and speech difficulties' learnin" disabilities' dementia' neurolo"ical conditions and confusion The relati,e or carer ma# know how specific si"ns indicate distress if the patient is unable to articulate their own concerns %ncoura"e open communication and e5plore fears and concerns:

1 2 3 4

!acilitate e5pression of emotions 4n,ol,e children and those with learnin" disabilities +emember spiritual care and reli"ious needs (offer to contact chaplain' priest' rabbi etc if appropriate) Consider music' art' poetr#' readin"' photo"raphs or somethin" else that has been important to the well1bein" of the patient

C re :!er "e !9 Pr c!ic l n" le0 l s6ec!s !o !!en" !o :!er "e !9 &rran"ements ma# ,ar# dependin" on place of death and local berea,ement ser,ice pro,ision

1 2 3 4

;arn relati,es when Coroner6s referral mi"ht be necessar# (e " mesothelioma) 4t is preferable to do this before the patient6s death %nsure prompt ,erification of death' personal care after death and pro,ision of death certificate Pro,ide information about the role of the undertaker' how to re"ister a death' common feelin"s of "rief and a,ailable support !or deaths not occurrin" in the patient6s own home' ensure

patient6s 3P is informed within 2E hours *5

1 !or

deaths occurrin" at home' ensure planned ,isits are re,iewed and arran"ements made to return e0uipment

2 %nsure hospital appointments (and transport) are cancelled and

hospitals<consultants in,ol,ed with the patient6s care are informed -ere (e2en! 4t is "ood practice after someone has died to pro,ide written information about common feelin"s of "rief and a,ailable support and to identif# those at increased risk in berea,ement +isk factors include:

1 pre,ious multiple losses or recent losses 2 ambi,alent relationship 3 dependent children in,ol,ed 4 berea,ed parent 5 pre,ious ps#cholo"ical problems or substance abuse 6 people li,in" alone or feelin" unsupported
Seek ad,ice from collea"ues and relati,e6s 3P (with their permission)' if one or more of these risk factors are present 4t is "ood practice to re,iew how someone is copin" N1L weeks after the berea,ement

*1

SYRINGE PUMP PRINCIPLES 4n palliati,e care a s#rin"e pump or dri,er is an alternati,e wa# of administerin" medication continuousl# ,ia the subcutaneous route when the patient is unable to swallow or absorb oral dru"s due to an# of the followin":

persistent ,omitin"' intestinal obstruction' d#spha"ia' weakness' unconsciousness or mouth' throat and oesopha"eal lesions ;here indicated' s#rin"e pumps can be used for a short period for s#mptom control' or for lon"er in the terminal phase The rationale for use should be e5plained to the patient and their relati,es

Considerations:

1 2

-oses of medication are calculated on the basis of patients6 pre,ious re0uirements !ollowin" commencement of a s#rin"e pump it will be se,eral hours before therapeutic le,els are achie,ed' so consider "i,in" a stat dose of medication e0ui,alent to the normal breakthrou"h dose S#rin"e pumps re0uire careful monitorin" and should be prescribed on prescription< s#rin"e pump charts as per local Trust s#rin"e pump policies 4nade0uate s#mptom control is not an indication for s#rin"e pump use unless there is reason to belie,e oral medications are not bein" absorbed +ecommended sites for insertion of the cannulae are the anterior chest wall' upper arms' abdominal wall and thi"hs

3 4 5

N/T%: & ,ariet# of models of ambulator# infusion de,ices (s#rin"e pumps) are in use 3raseb# ambulator# s#rin"e dri,ers no lon"er meet )H+& safet# re0uirements and are bein" phased out &s a result' )c=inle# TGE s#rin"e pumps are now widel# used in the re"ion &lternati,e )H+& appro,ed s#rin"e pumps ma# also be a,ailable Please follow #our local s#rin"e pump polic# *8

COMMON DRUG DOSAGES $OR SU-CUTANEOUS MEDICATIONS AND IN$USIONS

1 2 3 4
* 3

&ll the dru"s on this pa"e and opposite can be "i,en as subcutaneous infusions in a s#rin"e pump +emember to prescribe subcutaneous p r n medication 4f usin" more than one dru" in a s#rin"e pump' check compatibilities with current PC!' pharmac#' or Specialist Palliati,e Care Team To con,ert from oral morphine see section $ 2 $ (pa"e $G) !or other opioids' ' seek specialist ad,ice 4f s#mptoms are not controlled' other re"imens ma# be needed Seek specialist ad,ice Haloperidol and c#cliFine can be effecti,e in combination C#cliFine and metoclopramide are anta"onistic
Usu l &* 9our "ose r n0e Usu l s! r!in0 sFc 6rn "ose <. 2 ; :reDuenc% ini!i ll%I )9ere rele( n!?
$<Nth of the 2E hour SC dose

Co22onl% use" sub4cu! neous 2e"ic !ions

Use:ul 26oule siEe in:or2 !ion

Co22en!s

ANALGESICS -iamorphine < )orphine

7etween > and$0m"<2E hours if opioid naQ,e /therwise: S $<G of pre,ious 2E hour oral morphine dose as diamorphine<2E hours SC S $<G to Z of pre,ious 2E hour oral morphine dose as morphine<2E hours SC (see local "uidelines)

-iamorphine: -r# powder: >m"' $0m"' G0m"' $00m"' >00m" )orphine sulphate: $0m"<$ml' $>m"<$ml' 20m"<$ml' G0m"<$ml' 20m"<2ml' G0m"<2ml' E0m"<2ml' N0m"<2ml

Seek ad,ice if: S patient re0uirin" rapidl# escalatin" doses S patient in renal failure

$<Nth of the 2E hour SC dose

$<Nth of the 2E hour SC dose

NS&4-s

ANTIEMETICS Haloperidol C#cliFine 2e,omepromaFine )etoclopramide ANTISECRETOR Y DRUGS H#oscine h#drobromide

7etween $ > and >m"

$ >m" (ma5 b d ) >0m" (ma5 t d s ) N 2>m" (ma5 0ds) 7etween $0 and 20m" (ma5 0 d s ) E00micro"ram (ma5 0 d s ) 20m" (ma5 t d s ) E00 micro"ram (ma5 t d s ) 7etween 2 >m" and >m"

>m"<$ml >0m"<$ml 2>m"<$ml $0m"<2ml

7etween $00 and $>0m" (ma5 dose $>0m" in 2E hours) 7etween N 2> and $2 >m" 7etween G0 and N0m"

7etween $ 2 and 2 0m" (ma5 dose 2 Em" in 2E hours) 7etween N0 and $20m" 7etween N00micro"rams and$ 2m" 7etween $0 and 20m" (startin" dose) )a# be increased accordin" to patient response Seek SPCT ad,ice

E00micro"rams<$ml N00micro"rams<$ml 20m"<$ml

* 5

H#oscine but#lbromide 3l#cop#rronium SEDATIVES Mi" Eol 2

200micro"rams<$ml N00micro"ram<Gml $0m"<2ml

ANTICONVULSA NT Mi" Eol 2

$0m" 7etween 20 and N0m"<2E hrs to replace oral anti1con,ulsants ma# be re0uired

/ther preparations a a,ailable' howe,er' use should be restri to minimise the risk unintended o,erdos $0m"<2ml /ther preparations a a,ailable' howe,er' use should be restricted minimise the risk of unintende o,erdose $m"<ml

Clon Ee6 2

7etween $ and Lm"<2E hours

>00micro"rams

Also see n use . (o2i!in0 sec!ion.

Haloperidol has an5iol#tic and sedati,e properties C#cliFine incompatible with h#oscine but#lbromide 2e,omepromaFine doses abo,e $2 >m" ma# be sedatin" E rl% in!er(en!ion :or ="e !9 r !!le> is reDuire". H#oscine h#drobromide is sedatin" H#oscine but#lbromide is:

incompatible with c#cliFine 3l#cop#rronium is not sedatin" )uscle rela5ant' an5iol#tic and anticon,ulsant (see below) D short actin" so essential to "i,e as a continuous subcutaneous infusion 4f ineffecti,e seek specialist ad,ice Seek SPCT ad,ice re mana"ement of prolon"ed fits

1 2

not sedatin"

2on"er actin" than midaFolam when used p r n and sedatin" Seek SPCT ad,ice re mana"ement of prolon"ed fits

A66en"i; 1 S!e6 & O6ioi" n l0esic eDui( lences )i!9 or l 2or69ine sul69 !e in P lli !i(e C re Gener l Princi6les

1) 2) 3) 4)

2/C&2 /+3&N4S&T4/N&2 /P4/4- C/N.%+S4/N CH&+TS for opioid use in palliati,e care )(ST be used in preference to these tables 4f there is an# uncertaint# re"ardin" the safe prescribin" of opioids seek specialist ad,ice before doin" so 4t is ad,isable to double check calculations and document method used in the patient record' includin" for appropriate p r n opioid Clinical @ud"ement should also be applied' considerin": underl#in" clinical situationA comorbidit# and concomitant dru"sA nature of pain and its opioid responsi,enessA to5icit# of current opioidA pre,ious opioid doses and adherenceA rapidit# of opioid escalationA reason for switchin" 1 if pain is controlled' switchin" due to ad,erse effects or con,enience is usuall# less problematic than switchin" if the pain is uncontrolled (seek specialist ad,ice) 2ar"er doses of opioid ma# re0uire an empirical decrease in the dose of the replacement opioid and re1 titration !or doses "reater than $20m" oral morphine e0ui,alence a da# it is ad,isable to seek ad,ice Specialist ad,ice is stron"l# recommended for doses "reater than 200m" oral morphine e0ui,alence a da# &rran"ements for anal"esic re,iew and monitorin" for ad,erse effects' includin" consideration of patient6s place of care' need to be considered' documented in the patient record and communicated onwards

5)

6)

5'

T9ese ! bles s9oul" onl% be use" in !9e con!e;! o: !9ese 0ui"elines s )9oleI n" use" lon0si"e !9e su22 r% Ce% 6rinci6les ou!line" o66osi!e.
S!e6 & <=)e C>? o6ioi"s 4 "ose con(ersion !o or l 2or69ine sul69 !e N 7 Some people cannot efficientl# metabolise codeine or tramadol to the acti,e metabolite and therefore the# ma# re0uire a lower dose of stron" opioid on titration to step G Or l =/e C> o6ioi" To! l MAJ " il% "ose Con(ersio n : c!or A66ro;i2 !e &* G 9ourl% or l 2or69ine sul69 !e "ose eDui( lence /ral Codeine phosphate /ral -ih#drocodeine Tramadol h#drochloride (also weak noradrenaline and serotonin reuptake inhibitor) Y +eference: Palliati,e Care !ormular# Grd %d TRANSDERMAL $ENTANYL PATC,ES 1 dose con,ersion to oral morphine sulphate (suall# chan"ed e,er# M2 hours 4f possible patients should not be switched between brands when on stable dose $en! n%l 6 !c9es micro"rams< hr &* G 9ourl% or l 2or69ine sul69 !e "ose (7ased on -uro"esic SPC &pril $$) *49ourl% n" bre C!9rou09 or l 2or69ine sul69 !e "ose <roun"e" !o 6r c!ic l 2oun!s? > to $0m" $0 to $>m" $> to 2>m" 2> to G> m" E00m"<da# [ $0Y E0m"<da# 2E0m"<da# [ $0Y 2Em"<da# 2E0m"<da# [ $0Y 2Em"<da#

Y $2 2> \ GM >0

Y TE>m" TR0m" R0 to $GE m" $G> to $LR m"

\ N2 M>

$R0 to 22Em" 22> to G$E m"

G> to E0m" E0 to >0 m"

$OR LARGER SIKE PATC,ES SEE+ SPECIALIST ADVICE

Y -uro"esic -TransO ' and /smanilO $2mc"<hr fentan#l patches are onl# licensed for dose titration steps indicated b# \' not as startin" dose )eFolar )atri5O patch SPC states startin" doses should not e5ceed $2 to 2> mc"<hr and )atrifenO patch SPC states startin" dose should not e5ceed 2>mc"<hr (see indi,idual SPCs) No,ember 20$$ /wner: YCN and HYCCN Palliati,e * %nd of 2ife Care 3roups

51

A66en"i; 1 <Con!".? S!e6 & O6ioi" n l0esic eDui( lences )i!9 or l 2or69ine sul69 !e in P lli !i(e C re <con!".? Gener l Princi6les

1) 2) 3) 4)

2/C&2 /+3&N4S&T4/N&2 /P4/4- C/N.%+S4/N CH&+TS for opioid use in palliati,e care )(ST be used in preference to these tables 4f there is an# uncertaint# re"ardin" the safe prescribin" of opioids seek specialist ad,ice before doin" so 4t is ad,isable to double check calculations and document method used in the patient record' includin" for appropriate p r n opioid Clinical @ud"ement should also be applied' considerin": underl#in" clinical situationA comorbidit# and concomitant dru"sA nature of pain and its opioid responsi,enessA to5icit# of current opioidA pre,ious opioid doses and adherenceA rapidit# of opioid escalationA reason for switchin" 1 if pain is controlled' switchin" due to ad,erse effects or con,enience is usuall# less problematic than switchin" if the pain is uncontrolled (seek specialist ad,ice) 2ar"er doses of opioid ma# re0uire an empirical decrease in the dose of the replacement opioid and re1 titration !or doses "reater than $20m" oral morphine e0ui,alence a da# it is ad,isable to seek ad,ice Specialist ad,ice is stron"l# recommended for doses "reater than 200m" oral morphine e0ui,alence a da# &rran"ements for anal"esic re,iew and monitorin" for ad,erse effects' includin" consideration of patient6s place of care' need to be considered' documented in the patient record and communicated onwards

5)

6)

5&

T9ese ! bles s9oul" onl% be use" in !9e con!e;! o: !9ese 0ui"elines s )9oleI n" use" lon0si"e !9e su22 r% Ce% 6rinci6les ou!line" o66osi!e.
TRANSDERMAL -UPRENORP,INE PATC,ES 1 morphine sulphate dose con,ersion to oral

There is no re"ional consensus re"ardin" con,ersion ratios !ollow local "uidance where a,ailable $:M> ratio in cancer pain (+ef: )ercadante S and Caraceni &' Palliati,e )edicine Uul# 20$$ 2>(>) >0E1>$>) reflects more closel# pre,ious clinical practice in some specialist ser,ices' howe,er (= SPC for TranstecO Patch 0uotes a ran"e of $:M> to $:$$> based on multiple sin"le dose studies and chronic pain data 7uTransO Patch (Chan"e once a week (se in cancer pain is unlicensed) -uTr nsL P !c9es 2icro0r 2sF9r &*G9ourl% or l 2or69ine sul69 !e "ose eDui( lence (con,ersion ratio $:M> (ratio ran"e $:M> to $:$$> appro5imated)) > $0 20 Rm" ($0m" to $>m") $Lm" (20m" to G0m") GNm" (G>m" to >>m") *49ourl% n"

bre C!9rou09 or l 2or69ine sul69 !e "ose (rounded to practical amounts) $m" to 2 m"YY Gm" (to >m") >m" (to $0m")

YY /r use e0ui,alent dose of oral codeine phosphate and check efficac# TranstecO Patches (Chan"e twice a week on same da#s 2icensed for use in cancer pain) Dose Con(ersion Tr ns!ecL P !c9es 2icro0r 2sF9r &*49ourl% or l 2or69ine sul69 !e "ose eDui( lence (con,ersion ratio $:M> (ratio ran"e $:M> to $:$$> appro5imated)) G> NGm" (N0 to R>m") *49ourl% n"

bre C!9rou09 or l 2or69ine sul69 !e "ose (rounded to practical amounts) $0m" ($0 to $>m")

>2 >

R>m" (R> to $E>m") $2Nm" ($2> to $R0m")

$>m" ($> to 2>m")

M0

20m" (20 to G0m")

$OR LARGER SIKE PATC,ES SEE+ SPECIALIST ADVICE

No,ember 20$$ /wner: YCN and HYCCN Palliati,e * %nd of 2ife Care 3roups

57

NOTES

5 *

NOTES

5 5

Yorkshire Cancer Network Palliati,e and %nd of 2ife Care 3roup Yorkshire Cancer Network' 2$ ;etherb# +oad' Harro"ate' H32 M+Y Tel: 0$E2G >>>M0> www #cn nhs uk .ersion > $ Publication date: !ebruar# 20$2 +e,iew date: !ebruar# 20$E

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