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Constipation
Constipation is a very common cause of
distress and is almost invariable after administration of
an opioid analgesic. It should be prevented if possible by
the regular administration of laxatives; a faecal softener
with a
peristaltic
stimulant
(e.g.
co-danthramer)
or
lactulose solution with a senna preparation should be
used (section 1.6.2 and section 1.6.3). Methylnaltrexone
(section 1.6.6)
is licensed for the treatment
of
opioid-
induced constipation.
Convulsions
Patients with cerebral
tumours or urae-
mia may be susceptible to convulsions.
Prophylactic
treatment
with phenytoin or
carbamazepine (section
4.8.1)
should be considered.
When oral
medication is
no longer possible, diazepam as suppositories 10–20 mg
every 4 to 8 hours,
or phenobarbital
by injection 50–
200 mg twice daily is continued as prophylaxis.
For the
use of
midazolam by subcutaneous infusion using a
continuous infusion device,
see below.
Dry mouth
Dry mouth may be relieved by good mouth
care and measures such as chewing sugar-free gum,
sucking ice or pineapple chunks,
or the use of artificial
saliva (section 12.3.5); dry mouth associated with candi-
diasis can be treated by oral preparations of nystatin or
miconazole (section 12.3.2);
alternatively,
fluconazole
can be given by mouth (section 5.2.1).
Dry mouth may
be caused by certain medications
including opioids,
antimuscarinic drugs
(e.g.
hyoscine),
antidepressants
and some antiemetics;
if
possible,
an alternative pre-
paration should be considered.
Dysphagia
A corticosteroid such as dexamethasone
8 mg daily may help, temporarily, if there is an obstruc-
tion due to tumour.
See also Dry Mouth,
above.
Dyspnoea
Breathlessness at rest may be relieved by
regular oral morphine in carefully titrated doses, starting
at 5 mg every 4 hours. Diazepam 5–10 mg daily may be
helpful for dyspnoea associated with anxiety. A cortico-
steroid, such as dexamethasone 4–8 mg daily, may also
be helpful
if there is bronchospasm or partial
obstruc-
tion.
Fungating tumours
Fungating tumours can be trea-
ted by regular dressing and antibacterial drugs; systemic
treatment
with metronidazole (section 5.1.11)
is often
required to reduce malodour but topical metronidazole
(section 13.10.1.2) is also used.
Hiccup
Hiccup due to gastric distension may be helped
by a preparation incorporating an antacid with an anti-
flatulent
(section 1.1.1).
If
this fails,
metoclopramide
10 mg every 6 to 8 hours by mouth or by subcutaneous
or intramuscular injection can be added; if this also fails,
baclofen 5 mg twice daily,
or
nifedipine 10 mg three
times daily,
or
chlorpromazine (section 4.2.1)
can be
tried.
Hypercalcaemia
see section 9.5.1.2
Insomnia
Patients with advanced cancer
may not
sleep because of
discomfort,
cramps,
night
sweats,
joint
stiffness,
or
fear.
There should be appropriate
treatment
of
these
problems
before
hypnotics
are
used.
Benzodiazepines,
such as
temazepam (section
4.1.1),
may be useful.
Intractable cough
Intractable cough may be relieved
by moist inhalations or by regular administration of oral
morphine in an initial
dose of
5 mg every 4 hours.
Methadone linctus should be avoided because it has a
long duration of action and tends to accumulate.
Nausea and vomiting
Nausea and vomiting are
common in patients with advanced cancer.
Ideally,
the
cause should be determined before treatment with an
antiemetic (section 4.6) is started.
Nausea and vomiting may occur with opioid therapy
particularly in the initial stages but can be prevented by
giving an antiemetic such as haloperidol
or
metoclo-
pramide. An antiemetic is usually necessary only for the
first 4 or 5 days and therefore combined preparations
containing an opioid with an antiemetic are not recom-
mended because they lead to unnecessary antiemetic
therapy (and associated side-effects when used long-
term).
Metoclopramide has a prokinetic action and is used in a
dose of
10 mg 3 times daily by mouth for nausea and
vomiting associated with gastritis,
gastric stasis,
and
functional bowel obstruction. Drugs with antimuscarinic
effects
antagonise prokinetic drugs
and,
if
possible,
should not be used concurrently.
Haloperidol is used by mouth in an initial dose of 1.5 mg
once or twice daily (can be increased if necessary to 5–
10 mg daily in divided doses) for most metabolic causes
of vomiting (e.g.
hypercalcaemia,
renal failure).
Cyclizine is given in a dose of 50 mg up to 3 times daily
by mouth.
It
is used for nausea and vomiting due to
mechanical
bowel
obstruction,
raised intracranial pres-
sure,
and motion sickness.
Antiemetic therapy should be reviewed every 24 hours;
it may be necessary to substitute the antiemetic or to
add another one.
Levomepromazine can be used if
first-line antiemetics
are inadequate; it is given by mouth in a dose of 6–50 mg
daily (6-mg tablets available from ‘special-order’ manu-
facturers or specialist importing companies, see p.
988)
in 1–2 divided doses.
For
the dose by subcutaneous
infusion,
see p.
23.
Dexamethasone 8–16 mg daily by
mouth can be used as an adjunct.
For the administration of antiemetics by subcutaneous
infusion using a continuous infusion device,
see below.
For the treatment
of
nausea and vomiting associated
with cancer chemotherapy,
see section 8.1.
Pruritus
Pruritus, even when associated with obstruc-
tive jaundice,
often responds to simple measures such
as application of emollients (section 13.2.1). In the case
of
obstructive
jaundice,
further
measures
include
administration of colestyramine (section 1.9.2).
Raised intracranial
pressure
Headache due to
raised intracranial
pressure often responds to a high
dose of a corticosteroid, such as dexamethasone 16 mg
daily for 4 to 5 days,
subsequently reduced to 4–6 mg
daily if possible; dexamethasone should be given before
6 p.m.
to reduce the risk of insomnia.
Restlessness and confusion
Restlessness and con-
fusion may require treatment with haloperidol
1–3 mg
by mouth every 8 hours. Levomepromazine is also used
occasionally for restlessness.
For the dose by subcuta-
neous infusion using a continuous infusion device,
see
p.
23.
22
Prescribing in palliative care
BNF 61
Prescribing in palliative care