Palliative care medicines

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PALLIATIVE CAREPALLIATIVE CARE

Think Clinical ServicesThink Clinical Services

Last Updated: January 2009

22Think Clinical ServicesThink Clinical Services 22

What is Palliative Care?What is Palliative Care?

The goal of palliative care is to achieve the The goal of palliative care is to achieve the best possible quality of life for patients best possible quality of life for patients and their families and friends. and their families and friends.

Palliative care:Palliative care:

- provides relief from pain and other - provides relief from pain and other distressing symptoms distressing symptoms

- affirms life and regards dying as a normal - affirms life and regards dying as a normal process process

- intends neither to hasten nor postpone - intends neither to hasten nor postpone deathdeath


What is Palliative Care?What is Palliative Care?

- offers a support system to help - offers a support system to help patients live as actively as possible patients live as actively as possible

- offers a support system to help the - offers a support system to help the family and carers cope during the family and carers cope during the patient’s illness patient’s illness

- avoids futile interventions. - avoids futile interventions.

The patient should have a central role The patient should have a central role in decision-making.in decision-making.


PBS ListingPBS Listing

A new and separate section has been introduced in the Schedule of Pharmaceutical Benefits for palliative care medications. For the purposes of prescribing under the Palliative Care Section of the PBS, a palliative care patient is defined as:

a patient with an active, progressive, far-advanced disease for whom the prognosis is limited and the focus of care is the quality of life.

Authority required for all palliative care listings

(up to 4 months supply)


Palliative Care SectionPalliative Care Section

The Palliative Care Section adds to the medicines that were already available on the PBS (such as opioid analgesics) for use in patients typically with malignant neoplasia.

The following medicines are listings in the Palliative Care Section:

• Carmellose mouth spray (Aquae) as a saliva substitute.

• Clonazepam 500 micrograms and 2 mg tablets (Paxam, Rivotril); 2.5 mg/mL oral liquid (Rivotril) for preventing epilepsy.

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Palliative Care SectionPalliative Care Section

New Palliative Medicines.• Hyoscine butylbromide 20 mg/mL inj

(Buscopan) for colicky pain.• Paracetamol 500 mg suppositories

(Panadol) for analgesia.• Promethazine hydrochloride 10 mg and

25 mg tablets; 5 mg/5 mL elixir (Phenergan) for nausea and vomiting.


LaxativesLaxatives

A number of laxative products are included in the new Palliative Care Section. These include:

• Bisacodyl 5 mg tablets and 10 mg in 5 mL enemas (Bisalax); 10 mg suppositories (Durolax, Fleet Laxative Suppositories, Petrus Bisacodyl Suppositories)

• Docusate sodium with bisacodyl 100 mg/10 mg suppositories (Coloxyl)

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LaxativesLaxatives

Laxatives• Glycerol suppositories 700 mg (for

infants), 1.4 g (for children), 2.8 g (for adults) (Petrus)

• Sorbitol, sodium citrate and sodium lauryl sulfoacetate enemas (Microlax)

• Sterculia with frangula bark granules (Granocol, Normacol Plus).


AnalgesicsAnalgesics

Many different analgesics are used in Many different analgesics are used in the management of pain. These may the management of pain. These may include:include:

- Paracetamol- Paracetamol

- NSAIDs- NSAIDs

- Opioids- Opioids

- Adjuvants (control symptoms that - Adjuvants (control symptoms that may worsen pain)may worsen pain)


FENTANYL PATCHES FENTANYL PATCHES for Chronic Painfor Chronic Pain

Severe chronic painSevere chronic pain– Oral morphine preferredOral morphine preferred

Ease of dose adjustmentEase of dose adjustment

Ease of availabilityEase of availability

– Reserve Fentanyl UseReserve Fentanyl UseCannot take oral morphineCannot take oral morphine

Vomiting or swallowing difficultyVomiting or swallowing difficulty

Severe renal impairmentSevere renal impairment


FENTANYL PATCHES FENTANYL PATCHES for Chronic Painfor Chronic Pain

CautionCaution– Delayed onset of actionDelayed onset of action– Prolonged duration of actionProlonged duration of action– Opioid ADEs are difficult to controlOpioid ADEs are difficult to control

Monitor serious ADEs for 24 hrs after patch Monitor serious ADEs for 24 hrs after patch removalremoval

Serum concentrations Serum concentrations ↓ ↓ slowlyslowly

Ensure safe disposalEnsure safe disposal


Anticholinergic drugsAnticholinergic drugs

Hyoscine butylbromideHyoscine butylbromide is used to treat is used to treat painful colic resulting from malignant bowel painful colic resulting from malignant bowel obstruction, and to reduce gastrointestinal obstruction, and to reduce gastrointestinal secretions. It does not cross the blood–brain secretions. It does not cross the blood–brain barrier so does not cause drowsiness or barrier so does not cause drowsiness or delirium. Its duration of action is less than 2 delirium. Its duration of action is less than 2 hours. It can be used subcutaneously.hours. It can be used subcutaneously.

Belladonna alkaloids such as Belladonna alkaloids such as atropineatropine have have been used in palliating accumulated been used in palliating accumulated secretions and noisy breathing at the end of secretions and noisy breathing at the end of life. life.


AntiemeticsAntiemetics

Antiemetics are often used prophylactically to Antiemetics are often used prophylactically to counteract the emetic adverse effects of other counteract the emetic adverse effects of other drugs, especially opioids. However, care should drugs, especially opioids. However, care should be taken with this practice as all the commonly be taken with this practice as all the commonly used antiemetics can themselves cause used antiemetics can themselves cause significant adverse effects.significant adverse effects.

In the palliative setting, nausea and vomiting are In the palliative setting, nausea and vomiting are common symptoms.common symptoms.

Examples include: Metoclopramide (Maxolon, Examples include: Metoclopramide (Maxolon, Pramin), Prochlorperazine (Stemetil), Pramin), Prochlorperazine (Stemetil), Domperidone (Motilium), Odansetron (Zofran)Domperidone (Motilium), Odansetron (Zofran)


Principles for managementPrinciples for management

Know the person who is being treated and Know the person who is being treated and the impact that their illness is having on the impact that their illness is having on them.them.

Know the disease that is being treated Know the disease that is being treated (reverse whatever can be reversed and (reverse whatever can be reversed and treat symptoms simultaneously).treat symptoms simultaneously).

Know the overall therapeutic aim of each Know the overall therapeutic aim of each intervention being introduced or ceased.intervention being introduced or ceased.

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Principles for managementPrinciples for management

Work as a team, because it is unlikely that Work as a team, because it is unlikely that one person will have all of the solutions one person will have all of the solutions (and if you don’t have the answer to a (and if you don’t have the answer to a particular problem, ensure that you particular problem, ensure that you involve the person who does); this involve the person who does); this includes working with subspecialists.includes working with subspecialists.

Actively recognise periods of transition Actively recognise periods of transition (rehabilitation, deterioration, terminal (rehabilitation, deterioration, terminal care).care).

Health & Medicine

Palliative care medicines