if possible, an alternative preparation should be considered.
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, dry mouth
associated with candidiasis can be treated by oral
preparations of nystatin p. 710 or miconazole p. 516 ,
alternatively,fluconazole p. 374 can be given by mouth.
DysphagiaA corticosteroid such as dexamethasone p. 439
may help, temporarily, if there is an obstruction due to
tumour. See alsoDry mouth, above.DyspnoeaBreathlessness at rest may be relieved by regular
oral morphine p. 282 in carefully titrated doses. Diazepam
p. 220 may be helpful for dyspnoea associated with anxiety.
Sublingual lorazepam p. 222 or subcutaneous or buccal
midazolam p. 223 are alternatives. A nebulised short-acting
beta 2 agonist or a corticosteroid, such as dexamethasone or
prednisolone p. 442 , may also be helpful for bronchospasm
or partial obstruction.Excessive respiratory secretionExcessive respiratory
secretion (death rattle) may be reduced by hyoscine
hydrobromide patches or by subcutaneous or intravenous
injection of hyoscine hydrobromide p. 266 , however, care
must be taken to avoid the discomfort of dry mouth.
Alternatively, glycopyrronium bromide p. 751 may be given.
Hyoscine hydrobromide can be administered by
subcutaneous or intravenous infusion using a continuous
infusion device.Fungating tumoursFungating tumours can be treated by
regular dressing and antibacterial drugs; systemic treatment
with metronidazole p. 333 is often required to reduce
malodour, but topical metronidazole is also used.Gastro-intestinal painThe pain of bowel colic may be
reduced by loperamide hydrochloride p. 49. Hyoscine
hydrobromide p. 266 may also be helpful in reducing the
frequency of spasms; it is given sublingually asKwells®
tablets and also by subcutanous infusion.
Gastric distension pain due to pressure on the stomach may
be helped by a preparation incorporating an antacid with an
antiflatulent and a prokinetic such as domperidone before
meals.HiccupHiccup due to gastric distension may be helped by a
preparation incorporating an antacid with an antiflatulent.InsomniaChildren 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 p. 821 , may be useful.
Intractable coughIntractable cough may be relieved by
moist inhalations or by regular administration of oral
morphine p. 282 every 4 hours. Methadone hydrochloride
linctus p. 299 should be avoided because it has a long
duration of action and tends to accumulate.
Mucosal bleedingMucosal bleeding from the mouth and
nose occurs commonly in the terminal phase, particularly in
a child suffering from haemopoeitic malignancy. Bleeding
from the nose caused by a single bleeding point can be
arrested by cauterisation or by dressing it. Tranexamic acid
p. 82 may be effective applied topically or given systemically.
Muscle spasmThe pain of muscle spasm can be helped by a
muscle relaxant such as diazepam p. 220 or baclofen p. 649.
Nausea and vomitingNausea and vomiting are common in
children with advanced cancer. Ideally, the cause should be
determined before treatment with an antiemetic is started.
Nausea and vomiting with opioid therapy are less common in
children than in adults but may occur particularly in the
initial stages and can be prevented by giving an antiemetic.
An antiemetic is usually necessary only for thefirst 4 or
5 days and therefore combined preparations containing anopioid with an antiemetic are not recommended because
they lead to unnecessary antiemetic therapy (and associated
side-effects when used long-term).
Metoclopramide hydrochloride p.^262 has a prokinetic action
and is used 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 therefore be
used concurrently.
Haloperidol p. 245 is used by mouth or by continuous
intravenous or subcutaneous infusion for most metabolic
causes of vomiting (e.g. hypercalcaemia, renal failure).
Cyclizine p. 260 is used for nausea and vomiting due to
mechanical bowel obstruction, raised intracranial pressure,
and motion sickness.
Ondansetron p. 264 is most effective when the vomiting is
due to damaged or irritated gut mucosa (e.g. after
chemotherapy or radiotherapy).
Antiemetic therapy should be reviewed every 24 hours; it
may be necessary to substitute the antiemetic or to add
another one.
Levomepromazine p. 268 can be used iffirst-line antiemetics
are inadequate. Dexamethasone p. 439 by mouth can be used
as an adjunct.
SeeContinuous subcutaneous infusions, below, for the
administration of antiemetics by subcutaneous infusion
using a continuous infusion device.PruritusPruritus, even when associated with obstructive
jaundice, often responds to simple measures such as
application of emollients. Ondansetron p. 264 may be
effective in some children. Where opioid analgesics cause
pruritus it may be appropriate to review the dose or to switch
to an alternative opioid analgesic. In the case of obstructive
jaundice, further measures include administration of
colestyramine p. 129.Raised intracranial pressureHeadache due to raised
intracranial pressure often responds to a high dose of a
corticosteroid, such as dexamethasone p. 439 ,for 4 to 5 days,
subsequently reduced if possible; dexamethasone should be
given before 6 p.m. to reduce the risk of insomnia.
Treatment of headache and of associated nausea and
vomiting should also be considered.Restlessness and confusionRestlessness and confusion
may require treatment with haloperidol p. 245.
Levomepromazine p. 268 is also used occasionally for
restlessness.Continuous subcutaneous infusions
Although drugs can usually be administeredby mouthto
control symptoms in palliative care, the parenteral route
may sometimes be necessary. Repeated administration of
intramuscular injectionsshould be avoided in children,
particularly if cachectic. This has led to the use of portable
continuous infusion devices such as syringe drivers to give a
continuous subcutaneous infusion, which can provide good
control of symptoms with little discomfort or inconvenience
to the patient.
Indications for theparenteral routeare:
.inability to take medicines by mouth owing tonausea
and vomiting,dysphagia,severe weakness,orcoma;
.malignant bowel obstructionfor which surgery is
inappropriate (avoiding the need for an intravenous
infusion or for insertion of a nasogastric tube);
.refusal by the child to take regular medication by
mouth.
Syringe driver rate settingsStaff using syringe drivers
should beadequately trainedand different rate settings
should beclearly identifiedanddifferentiated; incorrect
use of syringe drivers is a common cause of medication
errors.22 Prescribing in palliative care BNFC 2018 – 2019
Prescribing in palliative care