Dr Enam Khan St Clare Hospice - PowerPoint Presentation

1. Dr Enam Khan St Clare HospiceGASTROINTESTINAL SYMPTOMS IN PALLIATIVE CARE

2. St Clare Hospice

3. Sarah 39 year old lady diagnosed with stage 3b Ovariancancer. Treatment involved surgery followed by Chemotherapy.Sarah contacted the St Clare Hospice advice line to report a three day history of : Nausea & vomiting large amounts after eating and drinking Cramping abdominal pain Feeling bloated in the abdomen Constipation St Clare HospiceCASE – 1

4. John, 78 year old gentleman with Metastatic Prostate cancerwas seen at home by his GP after suffering a fall.Family reported that John had been more confused latelyand complaining of abdominal pain and nausea.Family Members were also concerned that he had notopened his bowels for 7 days.John is taking Zomorph 30mg BD with Oramorph 10 to15mgprn.John is not currently taking any form of laxatives.St Clare HospiceCASE – 2

5. Lee, 62 year old lorry driver diagnosed with cancerof the Rt. Parotid gland. After diagnosis, he hadsurgical treatment. Then his cancer recurred and he developedfungating lesion over Rt. Parotid gland. He was admitted at the SCH for symptom control ofPain, Malodour, Discharge from wound and Drymouth. Lee was due for radiotherapy treatment.St Clare HospiceCASE – 3

6. Affect 60% patients with cancer.Common problems :Coated tongueDry mouth (70%)Painful mouth and stomatitis: 46%Infection : fungal infection-candidiasisDrooling: MND (40%)Halitosis: (50%) offensive odour from the mouthTaste Disturbance : (44%)St Clare HospiceOral problems

7. Subjective sensation of Dryness of the mouth.1.5 lt of saliva are produced daily.Cause profound negative impact on life. Impacts on the ability to eat, sleep speak and swallow. Recurrent oral infectionsCauses:Commonest drug treatment.Disease or damage to salivary glands.Dehydration and Malnutrition.St Clare HospiceDry Mouth

8. General : Daily assessment and Comprehensive mouth care.Review Medications.Correct dehydration and treat infections.Non Pharmacological management: Sipping semi-frozen drinks, sucking ice cube, Pineapplepieces, sugar free chewing gum, vitamin C tablet.Pharmacological:Saliva substitutes : Use every 30-60 minute, before and during meals.Mucin based product (Saliva Orthana): pork based which might notbe suitable for patients with Jewish, Islamic faith, Vegans. Cellulose based product : Glandosane spray.Saliva Stimulant: Pilocarpine Tablet 5mg TDS. Max.30mg/day.Pilocarpine 4% eye drop solution (2-3 drops orally t.d.s.) unlicensed use. St Clare HospiceManagement

9. Definitions:NAUSEA: An unpleasant sensation experienced in the back of the throat and the epigastrium that may or may not culminate in vomiting.VOMITING: Forceful expulsion of the contents of the stomach through the oral or nasal cavity.RETCHING: Unsuccessful attempt to vomit.St Clare HospiceNausea & Vomiting in Palliative Care

10. Incidence: Nausea- 20-30% with advance cancer Increase upto 70% in last days of life. Vomiting – develops in 20% patients. N&V are highest in gynaecological cancers (42%) and gastric cancer (36%). St Clare HospicePrevalence

11. St Clare HospiceNausea & Vomiting: Pathways, Receptors & Anti-emetics

12. Through assessment : History, Examination, Investigations, Review medications. Identify the likely cause & pathway(s) and neurotransmitters involved. Choose the most potent receptor antagonist Choose the appropriate route Titrate the dose or it may be necessary to combine anti-emetics If symptoms persist re-assess.St Clare HospiceMANAGEMENT STRATEGY

13. Gastro-Intestinal : Constipation, gastric stasis,Bowel obstruction, Radiotherapy.Chemical/Metabolic : Drugs, Renal failure,Hypercalcaemia, Chemotherapy.Intracranial disease : Tumour, Brain Metastasis.Vestibular : Movement related.Anxiety InducedSt Clare HospiceCauses

14. St Clare HospiceCAUSES – DRUGS MechanismsDrugsCTZ activation Opioids, digoxin, cytotoxics, antibiotics, anticoagulantsGastric irritation NSAIDs, iron, cytotoxics, antibioticsGastric stasis Opioids, tricyclics, phenothiazines, anticholinergics

15. St Clare HospiceCauses & TreatmentCauseManagementHypercalcaemiaRehydration / bisphosphonatesInfectionAntibioticsRaised intracranial pressure CorticosteroidsGastric irritation Stop NSAIDs, H2 antagonist, PPIConstipation Rectal measures / laxativesAnxietyExplanation, reassurance, anxiolytics

16. Blocks Histamine receptors in vomiting centre USES: Intestinal Obstruction Raised intra-cranial pressure Dose: Oral: 50 mg TDS PRN:50 mg oral / SC SD:50–150 mg / 24 hoursSt Clare HospiceCYCLIZINE

17. Blocks Dopamine receptors in the Gut USES: Gastric stasis & ileus Squashed Stomach Syndrome Dose: Oral:10 mg – 20 mg TDS PRN:10 mg SD: 30 – 120 mg / 24 hoursSt Clare HospiceMETOCLOPRAMIDE

18. Blocks Dopamine receptors in the CTZ USES: Chemical induced N&V e.g., opiates Dose: Oral:0.5 mg TDS – 3 mg TDS PRN:1.5 – 3 mg SD: 3 – 5 mg / 24 hoursSt Clare HospiceHALOPERIDOL

19. Blocks serotonin receptors in Vomiting centre and Gut USES: Chemo / Radio-therapy Dose: Oral:4 mg TDS PRN:4 mg SD:8–12 mg / 24 hoursSt Clare HospiceONDANSETRON

20. Blocks Dopamine, Serotonin, Histamine, Acetylcholine receptors USES: Second-line General anti-emetic Dose: Oral:6 mg OD–50 mg TDS PRN:6–25 mg SD:12.5 –100 mgSt Clare HospiceLEVOMEPROMAZINE

21. DrugOral dose PRNSDIndicationsDomperidone 10-20mg tds/qdsGastric stasisHyoscine butylbromide 20mg qds 20mg20 – 100 mg / 24 hoursBowel ObstructionHyoscine hydrobromide 150-300mcg bd/tds400 – 1200 mcg / 24 hoursDexamethasone4 mg BD8 – 12 mgCerebral OedemaObstructing TumoursOctreotide100 – 900 mcg / 24 hoursMalignant Bowel ObstructionLansoprazole30 – 60 mg ODDyspepsia St Clare HospiceOTHER DRUGS

22. Defined as ‘Passage of small hard feaces infrequently and with difficulty.’ Common in patients with advanced cancer. 50% patients admitted at SPC unit report constipation 80% need Laxatives. Constipation can cause pain, bowel obstruction, overflow diarrhoea and urinary retention, confusion and restlessness. St Clare Hospice CONSTIPATION

23. Constipation is a Symptom not usually a primary disorder.Complex pathophysiology : Alterations of Gut Transit Luminal fluid BalanceSt Clare Hospice

24. Cancer related : Bowel cancer, pelvic tumour, Hypercalcaemia, DepressionDrugs - Opioids - NSAIDs - Antimuscurinics e.g., Tricyclics - 5 HT3 receptor antagonists- Ondansetron,Granisetron Diuretics, Octreotide Ferrous sulphateSt Clare HospiceCAUSES

25. Patients are embarrassed to talk about itDebility - Inactivity - Poor nutrition - Poor fluid intake - Dehydration - Weakness - Inability to reach toiletConcurrent : Hemorrhoids, Fissure, Neurological disorder.St Clare HospiceCAUSES

26. No standardised assessment tool.Constipation means different things to different people.In advance cancer patient : 70% Constipated 60% receives inadequate treatment.St Clare HospiceAssessment

27. Proper Assessment with full history an examination(abdomen, rectal & neurological) To differentiate between current and normal pre- illness bowel pattern. To identify possible causes.Aim of management is to re-establish comfortablebowel habits to the satisfaction of the patient , not anyparticular frequency of bowel action. St Clare HospiceAssessment

28. St Clare Hospice41 year old ladyCa oesophagusPoor oral intakeTPNPoor compliance with laxativesDid not speak EnglishDenied being constipated

29. St Clare Hospice63 year old man renal cell caPain in base of spine and rectumDifficulty sitting on chair / bed

30. General measures: - Stop or decrease the dose of drugs - Mobilise if possible - Ensure privacy & access to toilet facilities - Diet Increase food/fibre intake Encourage Fluid intake. St Clare HospiceManagement

31. Pharmacological management ofConstipation in palliative careAim of Treatment :Regular soft bowel motion.Minimal medication BurdenMinimal Drug side effects/interactionsRational prescribingSt Clare Hospice

32. St Clare Hospice“Lack of evidence regarding whether individual laxatives are more effective than others or cause fewer side effects.”What laxative is best?

33. Oral :Stimulant laxatives: (Senna, Bisacodyl, Danthron, Picosulphate)Softening Laxatives: Lubricant :Liquid Paraffin Surface wetting agents: Docusate, Co-danthramer Osmotic laxatives: (Lactulose, Macrogols, Magnesuim sulphate) Rectal measures : Suppositories and Enemas. St Clare HospiceLaxatives

34. Always prescribe laxatives with Opioids. A combination of Stimulant and Softener laxative is recommended. Laxative dose should be titrated up against the response on a daily or alternate day basis. St Clare HospicePharmacological Management

35. St Clare HospiceOpioid Induced Constipation-PAMORAsCentral opioid receptors AnalgesiaPeripheral opioid receptors Constipation

36. Oral naloxoneOral naloxone / oxycodone : Targinact MR TabletNaloxegol -Tablet : 25mg OD Recommended by NICE, following a failure of a four week trial of conventional laxative. Methylnaltrexone-Methylnaltrexone Inj (Relistor) Opioid antagonist S/C 8-12mg act within 30-60min. NaldemedineAlvimopanSt Clare HospicePAMORAs

37. Thank YouSt Clare Hospice