Pain
Remember that pain has physical, emotional, and spiritual components: all aspects need to be addressed. Diagnose and monitor each pain separately.
Opiates
Diamorphine PO: 2mg 3mg morphine. SC: 1mg diamorphine 1.5mg morphine. Sustained release morphine is available, eg MST-30 (30-100mg/12h PO) or MXL (lasts 24h). Syringe drivers or suppositories can be used when dysphagia or vomiting make oral drugs useless, eg oxycodone 30mg suppositories (eg 30mg/8h, 30mg morphine). If crystallization occurs with drugs mixed in syringe drivers, either increase the dilution, or use 2 syringe drivers. Transdermal patches are also useful, eg fentanyl (Durogesic patches last 72h: typical starting dose for someone needing the equivalent of 90mg morphine/day would be one Durogesic-25 patch (the 25 means 25 fentanyl/h; 50 135-224mg MST, 75 225-314mg MST and 100 315-404mg MST). Use non-irritated, non-irradiated, non-hairy skin on trunk or upper arm; remove after 72h and replace by another patch at a different site.
Non-opiate analgesia may especially help bone pain (ibuprofen 400mg/8h PO or diclofenac + misoprostol (Arthrotec), 1 tablet/12h PO.) Pamidronate may also relieve pain from bony secondaries (OHCM p 696).
Nerve destruction pain
Amitriptyline 25-50mg PO at night clonazepam 0.5-1mg/24h PO nocte, increased slowly to 1-2mg/8h. Resistant pain Nerve blocks are useful.
Gut symptoms
Diarrhoea (post radiotherapy)
Low residue diets.
Constipation
Co-danthramer capsules or liquidbisacodyl 5-10mg nocte.
Gastric irritation eg associated with gastric carcinoma H2 antagonists (eg cimetidine 400mg/12h PO or proton pump inhibitors (omeprazole).
Itch in jaundice Cholestyramine 4g/6h PO (1h after other drugs).
Pain with dysphagia or vomiting:
Buprenorphine sublingual 0.2-0.4mg/8h. Not a pure agonist. Ceiling effects negate dose increases.
Foul rectal discharges Betadine vaginal gel.
Vomiting
Cyclizine 50-150mg/4-8h PO, IM, SC. Haloperidol 0.5-2mg PO. If from inoperable GI obstruction, try hyoscine hydrobromide 0.4-0.6mg SC/8h or 0.3mg sublingual. Octreotide, max 600/24h via a syringe driver may remove the need for palliative surgery, IVIs and NGTs.
If from gastric stasis
Metoclopramide 10mg/8h PO or SC. If this fails, try domperidone 60mg/8h rectally.
Lung symptoms
Pleural effusion
Thoracocentesis (bleomycin pleurodesis).
Air hunger
Chlorpromazine (eg 12.5mg IV).
Bronchial rattles
Hyoscine (as above) 0.4-0.6mg/8h SC or 0.3mg sublingual.
Dyspnoea
(hypoxic) Table fans supplemental humidified oxygen.
Haemoptysis
Diamorphine, above, IV if massive.
Pleural pain
Intercostal nerve blocks may bring lasting relief.
Cardiovascular symptoms
Distension from ascites often causes distressing symptoms. Try spironolactone 100mg/12h PO + bumetanide 1mg/24h PO.
Genitourinary symptoms
Foul vaginal discharges
Betadine vaginal gel.
Massive bladder bleeding Alum irrigation (1%) by catheter (in hospital).
Others Coated tongues may be cleaned by 6% hydrogen peroxide, chewing pineapple chunks to release proteolytic enzmes, sucking on ice, or butter.
Superior vena cava or bronchial obstruction, or lymphangitis carcinomatosa Steroids; dexamethasone is most useful: give 8mg IV stat. Tabs are 2mg ( 15mg prednisolone) NB: dexamethasone given at night can prevent sleep.
Psychological symptoms
Agitation Try diazepam 10mg suppositories (eg 10mg/8h), or haloperidol (p 360) 0.5-2mg PO (may help nightmares, hallucinations, and vomiting too). Or midazolam in syringe drivers (eg 5-100mg/24h) or levomepromazine (Nozinan) 12.5-50mg IM stat or 25-200mg/24h SC via a syringe driver.
Appetite low, or headache due to ICP Steroids; most useful is dexamethasone, eg 4mg/12-24h PO to stimulate appetite, reduce ICP, and in some patients induce a satisfactory sense of euphoria.
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