Nausea and Vomiting, Constipation - Palliative Care

What can be some causes of nausea and vomiting in palliative care (not exhaustive)?

• Drugs e.g., chemotherapy

• Tumours

• Increased intracranial pressure

• Radiotherapy

• Hepatomegaly

• Peptic ulceration

• Biochemical e.g., hypercalcaemia

• Psychological causes e.g., anxiety, fear

• GI motility disorder

• Ileus/bowel obstruction

• Cerebral oedema or skull metastases

• Pain

How many steps are in the nausea and vomiting treatment layer?

3

What does treatment of nausea and vomiting dependent on?

Cause and patient’s response

What is the first step in the WHO ladder for nausea and vomiting?

Cause specific anti-emetic e.g., metoclopramide, haloperidol and cyclizine

What is step 2 in the WHO nausea and vomiting ladder?

Broad spectrum anti-emetic e.g., levomepromazine

What is the MHRA warning for metoclopramide?

NOT for under 18s due to risk of adverse neurological conditions

What is the 3rd line treatment in the WHO nausea and vomiting ladder?

Dual therapy e.g., levomepromazine and 5HT3 agonist

What drugs should be used for gastritis, gastric stasis and functional bowel obstruction?

Pro kinetic drugs e.g., domperidone, metoclopramide

What anti-emetics are used for chemical causes e.g., morphine, hypercalcaemia, renal failure?

Centrally acting anti-emetics e.g., haloperidol or metoclopramide

What anti-emetic is used for raised intracranial pressure or for vestibular symptoms?

Cyclizine + dexamethasone for intracranial pressure

What anti-emetics are used for unknown causes?

Haloperidol or metoclopramide

What can be some causes of constipation in palliative care?

• Drugs

• Opioid analgesics, anticholinergic e.g., TCAs, chemotherapy, antiemetics, diuretics

• Metabolic disturbances

• Neurological disorders

• Tumours

• Decreased fluid intake

• Age

• Reduced mobility

• Lack of privacy

What is the effect of opioids on the bowel?

• Increased circular muscle contraction causing cramps

• Reduced coordinated peristalsis and causes slow bowel transit

• Reduced secretion of fluids and electrolytes causes a dry hard stool

What are the treatment aims for treating constipation?

• A comfortable passage of stool

• Re-establish comfortable bowel habits

• Relieve discomfort and/or pain

• Avoid laxative dependence

• Prevent GI symptoms

How should laxatives be prescribed for all patients taking opioids?

Prophylaxis as most patients develop constipation

What is the 1st line laxative for constipation in palliative care?

Stimulant laxative e.g., senna or bisacodyl

What is the 2nd line laxative for constipation in palliative care?

Osmotic laxative e.g., lactulose, macrogol 3350

What is the 3rd line laxative for constipation in palliative care or first line for patients with bowel colic?

Stool softener e.g., docusate

What is the 4th line laxative for constipation in palliative care?

Bisacodyl or glycerin suppository or sodium citrate micro-enema

What is the 5th line laxative for constipation in palliative care?

Phosphate enema - sodium acid phosphate with sodium phosphate

How do stimulant laxatives work?

Increases peristalsis and irritates mucosa lining to increase motility

How do osmotic laxatives work?

Increase fluid content of stools - fluid drawn in by osmotic force and the increase in volume triggers peristalsis

What is a drug only indicated in palliative care for constipation in patients who are terminally ill due to their carcinogenic risk, containing a faecal softener and peristaltic stimulant?

Co-danthramer

What is the drug licensed for opioid induced constipation, only to be used if other laxatives were ineffective?

Methylnaltrexone

Why are bulk-forming laxatives not suitable for opioid induced constipation due to patients not being able to maintain a sufficient fluid intake for them to be effective and can cause bowel obstruction?

Bulk-forming laxatives e.g., ispaghula husk