Palliative Care

$ Question 1 of 27 !
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An 88-year-old woman with advanced, metastatic colon cancer is put onto

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the end-of-life care pathway after long discussions between the patient,
family and healthcare team.
The palliative care team have extensive input and are asked to review the
patient after she describes significant oral pain.
Which of the following would be a useful medication to alleviate this?
Benzydamine mouthwash
Chlorhexidine mouthwash
Oral glycopyrronium
Soluble aspirin as a mouthwash
Transdermal hyoscine
Submit answer
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, Question 1 of 27 # $ % Search Score:
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An 88-year-old woman with advanced, metastatic colon cancer is put onto
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the end-of-life care pathway after long discussions between the patient,
1 #
family and healthcare team.
) Google search on
The palliative care team have extensive input and are asked to review the "Palliative care
prescribing: pain"
patient after she describes significant oral pain.
Which of the following would be a useful medication to alleviate this?

Links
Benzydamine mouthwash 56%
NICE * 16 + 6
Chlorhexidine mouthwash 25%
2012 Opioids in palliative
care guidelines
Oral glycopyrronium 7%
Soluble aspirin as a mouthwash 7%

BNF * 13 + 6
Prescribing opioids in
Transdermal hyoscine 5%
palliative care
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Benzydamine hydrochloride mouthwash or spray may be useful in Report broken link
reducing the discomfort associated with a painful mouth that may
occur at the end of life
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From the options above, the best answer is benzydamine mouthwash. This,
or a spray formulation, may be useful in reducing the discomfort and pain in
the mouth that can often occur towards the end of life. Benzydamine is a
non-steroidal anti-inflammatory drug which acts topically.
Complete Guide to
Chlorhexidine mouthwash may be useful to treat secondary infections or Palliative Care for Medical
when pain is limiting other mouth care methods such as toothbrushing. It is Students
not known to reduce mouth pain significantly. MedFlix -
* 9 + 2
YouTube
Oral glycopyrronium is often used at the end of life to reduce excessive

drooling and secretions. It does not play a role in the alleviation of oral pain. + Suggest media
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Soluble aspirin, used as a mouthwash, provides no topical relief from pain

and so is not recommended. If benzydamine mouthwash is not sufficient,
systemic analgesia may be needed.
Transdermal hyoscine is another medication used to reduce oral secretions

at the end of life; it does not alleviate oral pain.
& ' ( Discuss Improve
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Palliative care prescribing: pain "

NICE guidelines
In 2012 NICE published guidelines on the use of opioids in palliative care.

Selected points are listed below. Please see the link for more details.
Starting treatment
when starting treatment, offer patients with advanced and
progressive disease regular oral modified-release (MR) or oral
immediate-release morphine (depending on patient preference), with
oral immediate-release morphine for breakthrough pain
if no comorbidities use 20-30mg of MR a day with 5mg morphine for
breakthrough pain. For example, 15mg modified-release morphine
tablets twice a day with 5mg of oral morphine solution as required
oral modified-release morphine should be used in preference to
transdermal patches
laxatives should be prescribed for all patients initiating strong opioids
patients should be advised that nausea is often transient. If it persists
then an antiemetic should be offered
drowsiness is usually transient - if it does not settle then adjustment
of the dose should be considered
SIGN guidelines
SIGN issued guidance on the control of pain in adults with cancer in 2008.
Selected points
the breakthrough dose of morphine is one-sixth the daily dose of
morphine
all patients who receive opioids should be prescribed a laxative
opioids should be used with caution in patients with chronic kidney
disease
oxycodone is preferred to morphine in palliative patients with
mild-moderate renal impairment
if renal impairment is more severe, alfentanil, buprenorphine and
fentanyl are preferred
metastatic bone pain may respond to strong opioids,
bisphosphonates or radiotherapy. The assertion that NSAIDs are
particularly effective for metastatic bone pain is not supported by
studies. Strong opioids have the lowest number needed to treat for
relieving the pain and can provide quick relief, in contrast to
radiotherapy and bisphosphonates*. All patients, however, should be
considered for referral to a clinical oncologist for consideration of
further treatments such as radiotherapy
Other points
When increasing the dose of opioids the next dose should be increased by
30-50%.
In addition to strong opioids, bisphosphonates and radiotherapy,

denosumab may be used to treat metastatic bone pain.
Opioid side-effects
Usually transient Usually persistent
Nausea Constipation
Drowsiness
Conversion between opioids
From To Conversion factor
Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 10**
Oxycodone generally causes less sedation, vomiting and pruritis than

morphine but more constipation.
Oral morphine Oral oxycodone Divide by 1.5-2***
The current BNF gives the following conversion factors for transdermal
perparations
a transdermal fentanyl 12 microgram patch equates to approximately
30 mg oral morphine daily
a transdermal buprenorphine 10 microgram patch equates to
approximately 24 mg oral morphine daily.
Oral morphine Subcutaneous morphine Divide by 2
Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5
*BMJ 2015;350:h315 Cancer induced bone pain
**this has previously been stated as 5 but the current version of the BNF
states a conversion of 10
***historically a conversion factor of 2 has been used (i.e. oral oxycodone is

twice as strong as oral morphine). The current BNF however uses a
conversion rate of 1.5
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! Question 2 of 27 " #
Jean is an 85-year-old lady who is currently suffering from metastatic ovarian cancer. She is currently being treated with palliative
intent. She has deteriorated further and her husband calls you for a home visit. She is currently taking 60 mg BD of MST (morphine
slow release tablet) but is no longer able to tolerate oral medications. What dose of subcutaneous morphine over 24 hours would you
prescribe?
60 mg
30 mg
120 mg
20 mg
90 mg
Submit answer
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# Question 2 of 27 $ % &
Jean is an 85-year-old lady who is currently suffering from metastatic ovarian cancer. She is currently being treated with palliative
intent. She has deteriorated further and her husband calls you for a home visit. She is currently taking 60 mg BD of MST (morphine
slow release tablet) but is no longer able to tolerate oral medications. What dose of subcutaneous morphine over 24 hours would you
prescribe?
60 mg 82%
30 mg 9%
120 mg 4%
20 mg 3%
90 mg 2%
Jean is having a total of 120 mg of morphine over 24 hours currently via an oral route.
Given that we are converting her from an oral to subcutaneous morphine we must divide by 2.
Therefore the correct dose of subcutaneous morphine over 24 hours is 60 mg.
The following website (see below) by North Yorkshire and York NHS Trust is an excellent reference for how to convert between
opioids and route of administration.
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NICE guidelines
In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below. Please see the link for
more details.
Starting treatment
when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral
immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release
morphine tablets twice a day with 5mg of oral morphine solution as required
oral modified-release morphine should be used in preference to transdermal patches
patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
SIGN guidelines
SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
the breakthrough dose of morphine is one-sixth the daily dose of morphine
opioids should be used with caution in patients with chronic kidney disease
oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment
if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred
metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The assertion that NSAIDs are
particularly effective for metastatic bone pain is not supported by studies. Strong opioids have the lowest number needed to
treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates*. All patients, however,
should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy
Other points
When increasing the dose of opioids the next dose should be increased by 30-50%.
In addition to strong opioids, bisphosphonates and radiotherapy, denosumab may be used to treat metastatic bone pain.
Opioid side-effects
Nausea Constipation
Drowsiness
Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation.
The current BNF gives the following conversion factors for transdermal perparations
a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily
a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily.

**this has previously been stated as 5 but the current version of the BNF states a conversion of 10
***historically a conversion factor of 2 has been used (i.e. oral oxycodone is twice as strong as oral morphine). The current BNF
however uses a conversion rate of 1.5
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Links
NICE + 16 , 6
2012 Opioids in palliative care guidelines
BNF + 13 , 6
Prescribing opioids in palliative care
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Complete Guide to Palliative Care for Medical Students
MedFlix - YouTube + 9 , 2
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Score: 50%
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A 79-year-old female with a history of COPD and metastatic lung cancer is admitted with increasing shortness of breath. Following
discussion with family it is decided to withdraw active treatment, including fluids and antibiotics, as the admission likely represents a
terminal event. Two days after admission she becomes agitated and restless. What is the most appropriate management?
Subcutaneous midazolam
Intramuscular haloperidol
Oral lormetazepam
Oral haloperidol
Recommence fluids and antibiotics
Submit answer
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2 &
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A 79-year-old female with a history of COPD and metastatic lung cancer is admitted with increasing shortness of breath. Following
discussion with family it is decided to withdraw active treatment, including fluids and antibiotics, as the admission likely represents a
terminal event. Two days after admission she becomes agitated and restless. What is the most appropriate management?
Subcutaneous midazolam 67%
Intramuscular haloperidol 18%
Oral lormetazepam 1%
Oral haloperidol 11%
Recommence fluids and antibiotics 2%
Next question !
Palliative care prescribing: agitation and confusion "
Underlying causes of confusion need to be looked for and treated as appropriate, for example hypercalcaemia, infection, urinary
retention and medication. If specific treatments fail then the following may be tried:
first choice: haloperidol
other options: chlorpromazine, levomepromazine
In the terminal phase of the illness then agitation or restlessness is best treated with midazolam
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Score: 33.3%
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A 70-year-old man with metastatic lung cancer comes in for review. His pain is not currently controlled with MST 100 mg bd. He also
takes paracetamol 1g tds and diclofenac 50mg tds. What is the most appropriate next step?
Increase MST to 140 mg bd
Add codeine 60mg qds
Submit answer
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Score: 33.3%
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A 70-year-old man with metastatic lung cancer comes in for review. His pain is not currently controlled with MST 100 mg bd. He also
takes paracetamol 1g tds and diclofenac 50mg tds. What is the most appropriate next step?
Increase MST to 140 mg bd 42%
Add codeine 60mg qds 11%
In palliative patients increase morphine doses by 30-50% if pain not controlled

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NICE guidelines
more details.
Starting treatment
SIGN guidelines
Other points
Opioid side-effects
Nausea Constipation
Drowsiness

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NICE + 16 , 6
BNF + 13 , 6
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A 72-year-old man with metastatic colon cancer is reviewed. He currently takes co-codamol 30/500 2 tablets qds for pain relief.
Unfortunately this is not controlling his pain. What is the most appropriate change to his medication?
Switch to MST 15mg bd + paracetamol 1g qds
Switch to MST 35mg bd + paracetamol 1g qds
Add tramadol 50-100mg 1-2 qds
Switch to MST 25mg bd
Switch to MST 15mg bd
Submit answer
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Score: 50%
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A 72-year-old man with metastatic colon cancer is reviewed. He currently takes co-codamol 30/500 2 tablets qds for pain relief.
Unfortunately this is not controlling his pain. What is the most appropriate change to his medication?
Switch to MST 15mg bd + paracetamol 1g qds 51%
Switch to MST 35mg bd + paracetamol 1g qds 13%
Add tramadol 50-100mg 1-2 qds 7%
Switch to MST 25mg bd 13%
Switch to MST 15mg bd 16%
His total codeine dose is 30 * 2 * 4 = 240 mg/day. Converting this to oral morphine = 24 mg/day. It is therefore reasonable to start
MST 15mg bd as his pain is not currently controlled. Paracetamol should be continued as it has been shown to give benefits even to
patients on large doses of morphine
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NICE guidelines
more details.
Starting treatment
SIGN guidelines
Other points
Opioid side-effects
Nausea Constipation
Drowsiness

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NICE + 16 , 6
BNF + 13 , 6
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Score: 40%
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A 69-year-old man with terminal lung cancer is reviewed. He currently takes MST (oral, modified-release morphine) 60mg bd for
pain. He has become unable to take oral medications and a decision is made to set-up a syringe driver. What dose of diamorphine
should be prescribed for the syringe driver, to cover a 24-hour period?
60 mg
40 mg
120 mg
30 mg
20 mg
Submit answer
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Score: 40%
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A 69-year-old man with terminal lung cancer is reviewed. He currently takes MST (oral, modified-release morphine) 60mg bd for
pain. He has become unable to take oral medications and a decision is made to set-up a syringe driver. What dose of diamorphine
should be prescribed for the syringe driver, to cover a 24-hour period?
60 mg 26%
40 mg 58%
120 mg 4%
30 mg 7%
20 mg 6%
To convert from oral morphine to diamorphine the total daily morphine dose (60 * 2 = 120mg) should be divided by 3 (120 / 3 =
40mg)
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NICE guidelines
more details.
Starting treatment
SIGN guidelines
Other points
Opioid side-effects
Nausea Constipation
Drowsiness

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A 55-year-old male with sickle cell anaemia enters the emergency department. He is suffering another episode of extreme pain,
particularly in his hands. He has a past medical history of type 2 diabetes, chronic kidney disease stage 4 and previous a DVT.
Which of the following analgesia would be most appropriate for the patient?
Co-codamol
Codeine
Diamorphine
Morphine
Oxycodone
Submit answer
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Score: 50%
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A 55-year-old male with sickle cell anaemia enters the emergency department. He is suffering another episode of extreme pain,
particularly in his hands. He has a past medical history of type 2 diabetes, chronic kidney disease stage 4 and previous a DVT.
Which of the following analgesia would be most appropriate for the patient?
Co-codamol 6%
Codeine 3%
Diamorphine 9%
Morphine 12%
Oxycodone 71%
Oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment

Clinicians should take care in prescribing opioids in the elderly and those with renal failure. Morphine, diamorphine, codeine and
other renally excreted drugs will accumulate in patients with poor kidney function. These should be avoided unless in certain
circumstances.
Oxycodone and alfentanil are two examples of analgesics which are mainly metabolised in the liver and thus can safely be used in
patients with kidney failure.
Sickle cell patients can experience many acute and chronic complications. Sickle cell crisis (where severe anaemia occurs) can be
extremely painful and solely codeine or co-codamol will likely not control the pain.
Longer-term patients may develop sickle cell nephropathy where hemolysis and vascular occlusion leads to loss of tubular function.
Patients can further develop chronic kidney disease and later end-stage renal disease.
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more details.
Starting treatment
SIGN guidelines
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Opioid side-effects
Nausea Constipation
Drowsiness

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Score: 42.9%
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A 65-year-old man on palliative treatment for metastatic oesophageal cancer is finding it increasingly difficult to take his morphine
and as such is in increasing discomfort. His current prescription is for 60 mg BD oral.
Which of the following is the most appropriate option to manage his pain?
Switch to subcutaneous morphine infusion at 120 mg/24hrs
Switch to gabapentin
Switch to fentanyl ‘100’ patch (100 micrograms/hour)
Switch to subcutaneous morphine infusion at 60 mg/24hrs
Increase oral morphine solution to 90 mg BD
Submit answer
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Score: 42.9%
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A 65-year-old man on palliative treatment for metastatic oesophageal cancer is finding it increasingly difficult to take his morphine
and as such is in increasing discomfort. His current prescription is for 60 mg BD oral.
Which of the following is the most appropriate option to manage his pain?
Switch to subcutaneous morphine infusion at 120 mg/24hrs 8%
Switch to gabapentin 1%
Switch to fentanyl ‘100’ patch (100 micrograms/hour) 11%
Switch to subcutaneous morphine infusion at 60 mg/24hrs 78%
Increase oral morphine solution to 90 mg BD 3%
Divide by two for oral to subcutaneous morphine conversion

This patient’s daily dose of oral morphine is 120 mg in total. Based on the history provided, his increasing pain is a result of his
inability to swallow, rather than a change in his condition. As such the most appropriate option is to switch to an equivalent dose of
an opioid via a more tolerable route.
1) The ratio of oral to parenterally administered morphine is 2:1, that is to say, subcutaneous or intravenous doses are half that of the
oral dose. This dose is, therefore, double his current requirements.
2) There has been no change in his condition or nature of his pain. As such, it would not be appropriate to switch to a different class
of pain relief.
3) Transdermal patches are suitable for those with stable levels of pain who will not require regular titration of their pain relief. This
will not always be the case in a palliative cancer patient. They should also not be given to opioid naïve patients. At this dose, a
fentanyl 100 patch will deliver 2400 micrograms or 2.4 mg of fentanyl per 24 hours. The conversion of oral morphine to transdermal
fentanyl is however 1:100, and as such this is equivalent to 240 mg oral morphine per 24 hours, double his current requirements.
4) This is correct as a subcutaneous dose of 60 mg/24 hours is equivalent to 120 mg of oral morphine.
5) This option would be inappropriate as it is the patient’s difficulty in taking his pain relief that is causing his pain, not an increase in
his pain requirements.
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more details.
Starting treatment
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Opioid side-effects
Nausea Constipation
Drowsiness

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A 67-year-old man with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral morphine solution should he
be prescribed for breakthrough pain?
5 mg
10 mg
15 mg
20 mg
30 mg
Submit answer
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Score: 50%
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A 67-year-old man with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral morphine solution should he
be prescribed for breakthrough pain?
5 mg 24%
10 mg 65%
15 mg 5%
20 mg 3%
30 mg 3%
Breakthrough dose = 1/6th of daily morphine dose

The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of this, 10 mg
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NICE guidelines
more details.
Starting treatment
SIGN guidelines
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Opioid side-effects
Nausea Constipation
Drowsiness

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Score: 44.4%
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You review a palliative care patient at home. They are currently on 30mg MST bd. This is controlling the pain but the patient is no
longer able to swallow. After discussion with all concerned you agree to switch to morphine through a syringe driver. What would be
the most appropriate dose to start on?
60mg over 24 hours
30mg over 24 hours
40mg over 24 hours
10mg over 24 hours
6mg over 24 hours
Submit answer
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Score: 44.4%
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You review a palliative care patient at home. They are currently on 30mg MST bd. This is controlling the pain but the patient is no
longer able to swallow. After discussion with all concerned you agree to switch to morphine through a syringe driver. What would be
the most appropriate dose to start on?
60mg over 24 hours 7%
Source: Clinical Knowledge Summary - Palliative cancer care (last reviewed April 2015)
When changing the route of administration of one strong opioid to another, the most common switch is from oral morphine sulphate
to subcutaneous diamorphine or morphine.
Diamorphine is much more soluble than morphine and therefore easier to administer in higher doses. It is also compatible with most
other drugs which may need to be administered by a subcutaneous infusion. However, morphine is preferred in most cases as most
people do not require doses large enough to cause solubility issues:
Parenteral diamorphine is approximately three times as potent as oral morphine, so the total daily dosage of oral morphine
should be divided by three to obtain the 24-hour subcutaneous dose of diamorphine.
The oral to subcutaneous potency ratio of morphine is between 1:2 and 1:3 (that is, the subcutaneous dose is one third to one
half of the oral dose). In practice, most centres divide the oral dose by two and re-titrate as necessary.
See also the British National Formulary section: Prescribing in palliative care - continuous subcutaneous infusions for further
information and a table showing equivalent does of morphine sulphate and diamorphine hydrochloride given over 24 hours.
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Starting treatment
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A 72-year-old man with metastatic small cell lung cancer is admitted to the local hospice for symptom control. His main problem at
the moment is intractable hiccups. What is the most appropriate management?
Chlorpromazine
Codeine phosphate
Diazepam
Methadone
Phenytoin
Submit answer
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Score: 50%
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A 72-year-old man with metastatic small cell lung cancer is admitted to the local hospice for symptom control. His main problem at
the moment is intractable hiccups. What is the most appropriate management?
Chlorpromazine 74%
Codeine phosphate 8%
Diazepam 12%
Methadone 4%
Phenytoin 2%
Hiccups in palliative care - chlorpromazine or haloperidol

Haloperidol may also be used
Next question !
Palliative care prescribing: hiccups "
Management of hiccups
chlorpromazine is licensed for the treatment of intractable hiccups
haloperidol, gabapentin are also used
dexamethasone is also used, particularly if there are hepatic lesions
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Score: 54.5%
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You are asked to review a 62-year-old man with castrate-resistant prostate cancer. He is known to have widespread bony
metastases in multiple lumbar vertebrae, his left ilium and left proximal femur. He is complaining of increased hip pain on his current
dose of modified release morphine sulphate tablets (MST Continus). He is currently taking 50mg twice daily. He has taken an extra
40mg of PRN oramorph for breakthrough pain in the last 24 hours.
What is the best course of action to manage his pain?
Ensure that he is taking regular paracetamol
Increase MST to 60mg twice daily
Add in ibuprofen three times daily with a proton pump inhibitor
Submit answer
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Score: 54.5%
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" Question 12 of 27 # $ %
You are asked to review a 62-year-old man with castrate-resistant prostate cancer. He is known to have widespread bony
metastases in multiple lumbar vertebrae, his left ilium and left proximal femur. He is complaining of increased hip pain on his current
dose of modified release morphine sulphate tablets (MST Continus). He is currently taking 50mg twice daily. He has taken an extra
40mg of PRN oramorph for breakthrough pain in the last 24 hours.
What is the best course of action to manage his pain?
Ensure that he is taking regular paracetamol 7%
Increase MST to 60mg twice daily 17%
Add in ibuprofen three times daily with a proton pump inhibitor 7%
In palliative patients increase morphine doses by 30-50% if pain not controlled

The correct answer is to increase MST to 70mg twice daily. In palliative patients, the total daily dose of morphine should be increased
by 30-50% if pain is not controlled. This dose change increases the dose by 40%, and is therefore correct. The appropriate dose can
also be worked out by calculating the total daily dose of required morphine:
50 + 50 + 40 = 140mg daily total
140 / 2 = 70mg twice daily
If the dose increase using this calculation gave a value over 50% greater than the previous day's dose, the dose should ideally be
increased only be 50%. For example:
If the patient had taken 70mg PRN morphine, this would give a daily total of 170mg (50+50+70). However, the modified release
morphine should only be increased to a daily total of 150mg to prevent adverse effects.
Whilst paracetamol is an appropriate adjunct to improve pain control in patients taking opiate medications, this is unlikely to be a
significant enough intervention to manage this patient's pain.
Increasing MST to 60mg daily would be unlikely to get the pain under control considering 140mg total was needed in the previous
day. This also only constitutes an increase of 20%.
As below, the assertion that NSAIDs are particularly effective for metastatic bone pain is not supported by studies.
Increasing MST to 80mg twice daily would be an increase of over 50% of total daily dose and would therefore be inappropriate and
likely increase risk of adverse effects.
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Palliative care prescribing: pain )
NICE guidelines
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Starting treatment
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Nausea Constipation
Drowsiness

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BNF + 13 , 6
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Score: 58.3%
1 #
2 -
3 -
4 #
5 -
6 #
7 -
8 #
9 -
10 #
11 #
12 #
You are reviewing an elderly man with prostate cancer. Unfortunately his pain is not currently controlled by co-codamol 30/500 2
tablets qds and diclofenac 50mg tds. You decide to switch him to oral morphine. What is the conversion factor between oral codeine
and oral morphine?
Divide by 4
Divide by 15
Divide by 6
Divide by 20
Divide by 10
Submit answer
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Score: 58.3%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 -
You are reviewing an elderly man with prostate cancer. Unfortunately his pain is not currently controlled by co-codamol 30/500 2
tablets qds and diclofenac 50mg tds. You decide to switch him to oral morphine. What is the conversion factor between oral codeine
and oral morphine?
Divide by 4 8%
Divide by 15 2%
Divide by 6 8%
Divide by 20 1%
Divide by 10 81%
Codeine to morphine - divide by 10

' ( ) Discuss Improve
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Score: 61.5%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
A 76-year-old female with stage 4 endometrial cancer is admitted to a hospice for end-of-life care. She has her nausea managed
with cyclizine, any agitation managed with midazolam and her increased respiratory secretions managed with hyoscine
hydrobromide. Her pain has been self-reported as well-controlled on 240mg a day of oral codeine phosphate tablets.
The hospice has decided that all the medications can stay at the same doses, but wish to convert the codeine phosphate to an
equivalent dose of oral morphine.
What dose of morphine per day should be prescribed?
12mg
24mg
60mg
80mg
120mg
Submit answer
Reference ranges $
Score: 61.5%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 -
A 76-year-old female with stage 4 endometrial cancer is admitted to a hospice for end-of-life care. She has her nausea managed
with cyclizine, any agitation managed with midazolam and her increased respiratory secretions managed with hyoscine
hydrobromide. Her pain has been self-reported as well-controlled on 240mg a day of oral codeine phosphate tablets.
The hospice has decided that all the medications can stay at the same doses, but wish to convert the codeine phosphate to an
equivalent dose of oral morphine.
What dose of morphine per day should be prescribed?
12mg 2%
24mg 78%
60mg 9%
80mg 4%
120mg 6%

24mg is the correct answer as oral codeine to oral morphine is a divide by 10 calculation, thus 240/10 = 24mg.
12, 60, 80 and 120mg are all incorrect conversions for the 240mg daily dose of codeine phosphate.
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Score: 64.3%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
A 67-year-old with chronic kidney disease stage 4 and metastatic prostate cancer presents as his pain is not controlled with co-
codamol. Which one of the following opioids is it most appropriate to use given his impaired renal function?
Buprenorphine
Morphine
Hydromorphone
Diamorphine
Tramadol
Submit answer
Reference ranges $
Score: 64.3%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 -
A 67-year-old with chronic kidney disease stage 4 and metastatic prostate cancer presents as his pain is not controlled with co-
codamol. Which one of the following opioids is it most appropriate to use given his impaired renal function?
Buprenorphine 68%
Morphine 4%
Hydromorphone 7%
Diamorphine 9%
Tramadol 12%
Alfentanil, buprenorphine and fentanyl are the preferred opioids in patients with chronic kidney disease.
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Score: 60%
Score: 60%
1 -
2 $
3 $
4 -
5 $
6 -
7 $
8 -
9 $
10 -
11 -
12 -
13 -
14 -
15 $
A 60-year-old veteran with a background of metastatic lung cancer and CKD stage 4 is deteriorating and complains of a chronic
generalised pain in his chest. Which regular pain relief would be the most appropriate option for him?
Morphine sulphate liquid
Morphine sulphate tablets
Diamorphine
Naproxen
Oxycodone
Submit answer
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Score: 60%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 -
A 60-year-old veteran with a background of metastatic lung cancer and CKD stage 4 is deteriorating and complains of a chronic
generalised pain in his chest. Which regular pain relief would be the most appropriate option for him?
Morphine sulphate liquid 6%
Morphine sulphate tablets 8%
Diamorphine 9%
Naproxen 3%
Oxycodone 74%
Oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment

Morphine sulphate liquid - This is the wrong answer for two reasons: 1. It is short-acting so would be better for PRN use 2. It is not
recommended in patients with renal failure as its active metabolites are renally excreted. Immediate release Oxycodone liquid would
be the preferred choice for PRN use.
Morphine sulphate tablets - Active metabolites are renally cleared so not recommended in patients with renal failure.
Diamorphine - As above however if a patient is imminently dying, it may be used in a syringe driver preferably after discussion of the
risk/benefits with the palliative care team.
Naproxen - Not recommended as it would be nephrotoxic in this case and also unlikely to provide adequate pain relief for this
gentleman.
Oxycodone - A relatively safer opioid to use as it is mostly cleared by the liver. Other options options include fentanyl,
buprenorphine, alfentanil and methadone although it is best to discuss with palliative care team first.
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Score: 62.5%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
15 -
16 $
You are asked to review an 85-year-old man who was admitted 5 days ago with community acquired pneumonia. He has a past
medical history of type 2 diabetes mellitus, angina, chronic obstructive pulmonary disease (COPD) and spinal stenosis.
Unfortunately, despite optimal ward-based treatment including IV co-amoxiclav, the patient has continued to deteriorate. He current
scores 11 on the Glasgow coma scale. His pupils are 3mm bilaterally and reactive to light. He has been unable to take his morning
medications which include morphine sulphate modified release (Zomorph) 30mg twice daily, oramorph 10mg as required, and
metoclopramide 10mg three times a day. In the past 24 hours, he has used 4 doses of PRN oramorph.
He is reviewed on the consultant ward round and the decision is made that he should be for end of life care. He is currently
comfortable, with no evidence of hallucinations, pruritis or myoclonus. The nurse asks you to convert his medications to a syringe
driver.
What will you prescribe?
Metoclopramide 30mg s/c + morphine 50mg s/c
Metoclopramide 30mg s/c + oxycodone 100mg s/c
Metoclopramide 30mg s/c + oxycodone 50mg s/c
Submit answer
Reference ranges $
Score: 62.5%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 %
17 -
You are asked to review an 85-year-old man who was admitted 5 days ago with community acquired pneumonia. He has a past
medical history of type 2 diabetes mellitus, angina, chronic obstructive pulmonary disease (COPD) and spinal stenosis.
Unfortunately, despite optimal ward-based treatment including IV co-amoxiclav, the patient has continued to deteriorate. He current
scores 11 on the Glasgow coma scale. His pupils are 3mm bilaterally and reactive to light. He has been unable to take his morning
medications which include morphine sulphate modified release (Zomorph) 30mg twice daily, oramorph 10mg as required, and
metoclopramide 10mg three times a day. In the past 24 hours, he has used 4 doses of PRN oramorph.
He is reviewed on the consultant ward round and the decision is made that he should be for end of life care. He is currently
comfortable, with no evidence of hallucinations, pruritis or myoclonus. The nurse asks you to convert his medications to a syringe
driver.
What will you prescribe?
Metoclopramide 30mg s/c + morphine 50mg s/c 76%
Metoclopramide 30mg s/c + oxycodone 100mg s/c 2%
Metoclopramide 30mg s/c + oxycodone 50mg s/c 6%

This question is asking you to convert oral morphine to subcutaneous morphine for use in a syringe driver - also known as a
continuous subcutaneous infusion (CSCI).
The first step to calculate doses for use in a CSCI is to calculate the total 24-hour usage of the drug. We are told this patient is taking
both zomorph (modified release morphine), and oramorph (immediate release) - we need to include both of these medications in our
calculation.
The patient is taking 30mg zomorph twice daily = 60mg/24 hours.

He has also taken 4 doses of 10mg oramorph = 40mg/24 hours.
This gives us a total of 60mg + 40mg = 100mg/24 hours of oral morphine. In order to convert this to subcutaneous morphine, we
must divide by two. Therefore the amount of morphine needed in the CSCI is 100mg/2 = 50mg/24 hours.
The patient is comfortable, with no evidence of opioid toxicity, and so there is no indication to change to oxycodone at the moment.
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Score: 64.7%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
15 -
16 $
17 $
A 65-year-old man is reviewed on the inpatient ward round by the palliative care team. He has a past medical history of metastatic
lung cancer and has been admitted for optimization analgesia due to worsening chest wall pain. He has been commenced on oral
paracetamol 1g four times daily, oral codeine phosphate 60mg four times daily and oral immediate-release morphine 5mg four times
daily and his pain is now well controlled.
A decision is made to rationalize his opiate medication into a modified-release regimen.
From the list below, what dosing schedule is most appropriate?
Modified release oral morphine 5mg twice daily
Submit answer
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Score: 64.7%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 %
17 %
18 -
A 65-year-old man is reviewed on the inpatient ward round by the palliative care team. He has a past medical history of metastatic
lung cancer and has been admitted for optimization analgesia due to worsening chest wall pain. He has been commenced on oral
paracetamol 1g four times daily, oral codeine phosphate 60mg four times daily and oral immediate-release morphine 5mg four times
daily and his pain is now well controlled.
A decision is made to rationalize his opiate medication into a modified-release regimen.
From the list below, what dosing schedule is most appropriate?
Modified release oral morphine 5mg twice daily 4%

Modified release oral morphine 20mg twice daily is the correct answer. He is taking 240mg codeine daily and 20mg oral morphine
daily. 240mg codeine is equivalent to 24mg of morphine. 24mg + 20mg = 44mg of total daily morphine. The closest approximation
to this dose is 20mg twice daily of oral modified release morphine.
All of the other options are incorrect as they are worse approximations of his current medication regimen, which is controlling his
pain. (10mg, 20mg, 30mg, 60mg).
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Score: 66.7%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
15 -
16 $
17 $
18 $
A 69-year-old man with metastatic prostate cancer presents with worsening pain. He currently takes oral modified-release morphine
sulphate 60mg bd but it is decided to convert this to subcutaneous administration as he is frequently vomiting. What is the most
appropriate dose of morphine to give over a 24 hour period using a continuous subcutaneous infusion?
20mg
30mg
40mg
60mg
120mg
Submit answer
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Score: 66.7%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 %
17 %
18 %
19 -
A 69-year-old man with metastatic prostate cancer presents with worsening pain. He currently takes oral modified-release morphine
sulphate 60mg bd but it is decided to convert this to subcutaneous administration as he is frequently vomiting. What is the most
appropriate dose of morphine to give over a 24 hour period using a continuous subcutaneous infusion?
20mg 5%
30mg 10%
40mg 9%
60mg 71%
120mg 6%
The BNF recommend half the oral dose of morphine in this situation:
The equivalent parenteral dose of morphine (subcutaneous, intramuscular, or intravenous) is about half of the oral dose. If the
patient becomes unable to swallow, generally morphine is administered as a continuous subcutaneous infusion
This patient is on 60mg bd = 120mg. Divided by 2 = 60mg of subcutaneous morphine.
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Media
Score: 68.4%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
15 -
16 $
17 $
18 $
19 $
A 76-year-old female with multiple myeloma is experiencing acute back pain. Her oral regular analgesic medications include 7.5mg
morphine QDS and 1g paracetamol QDS.
What breakthrough dose of morphine should be given?
3mg
5mg
7.5mg
10mg
15mg
Submit answer
Reference ranges $
Score: 68.4%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 %
17 %
18 %
19 %
20 -
A 76-year-old female with multiple myeloma is experiencing acute back pain. Her oral regular analgesic medications include 7.5mg
morphine QDS and 1g paracetamol QDS.
What breakthrough dose of morphine should be given?
3mg 8%
5mg 81%
7.5mg 3%
10mg 4%
15mg 3%
Breakthrough dose = 1/6th of daily morphine dose

The total daily dose of morphine is equal to 30mg (7.5*4). The breakthrough dose is 1/6 of the total daily dose of morphine which is
5mg (30/6).
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Score: 70%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
15 -
16 $
17 $
18 $
19 $
20 $
A 63-year-old woman with breast cancer with newly diagnosed spinal metastases is reviewed on the oncology ward. She is currently
taking codeine 60mg QDS regularly for her pain, which she says provides an adequate background level of analgesia. However, she
does report exacerbations of her pain between doses, and has asked about the possibility of additional analgesic doses for these.
She also states that she is fed up with taking tablets, and has asked whether she could take liquid morphine instead.
Which of the following would be the most appropriate breakthrough dose of oral morphine for this patient?
2.5mg of oral morphine
5mg of oral morphine
Submit answer
Reference ranges $
Score: 70%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 %
17 %
18 %
19 %
20 %
21 -
A 63-year-old woman with breast cancer with newly diagnosed spinal metastases is reviewed on the oncology ward. She is currently
taking codeine 60mg QDS regularly for her pain, which she says provides an adequate background level of analgesia. However, she
does report exacerbations of her pain between doses, and has asked about the possibility of additional analgesic doses for these.
She also states that she is fed up with taking tablets, and has asked whether she could take liquid morphine instead.
Which of the following would be the most appropriate breakthrough dose of oral morphine for this patient?
2.5mg of oral morphine 12%
5mg of oral morphine 61%

This patient is taking a total of 240mg of regular codeine (the maximum licensed dose) per day. The dose conversion of codeine to
oral morphine can be performed by dividing the oral codeine dose by 10, i.e. 24mg of morphine per day. As she reports an adequate
background level of analgesia, it would be reasonable to aim for an equivalent total amount of regular background morphine. For her
episodes of breakthrough pain, the 2008 SIGN guidelines advocate giving a dose of morphine equivalent to 1/6th of her total daily
dose of regular morphine. This is equivalent to 4mg or oral morphine, thus making 5mg the closest, and best answer (erring on the
side of giving her adequate rather than inadequate symptomatic relief). In practice, this patient may well be changed to twice daily
15mg modified release oral morphine capsules, with 5mg oramorph for breakthrough pain.
2.5mg of oral morphine is unlikely to provide adequate analgesia for her breakthrough pain given her daily codeine requirements.
10mg, 15mg and 20mg of oral morphine are all too high doses for the management of breakthrough pain for someone who requires
the equivalent of 24mg regular morphine per day. If the dose of 5mg failed to improve her symptoms, or she was getting more
regular pain exacerbations, it would be advisable to increase her background regular morphine, rather than simply increasing her
breakthrough dose.
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Score: 71.4%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
15 -
16 $
17 $
18 $
19 $
20 $
21 $
You review a 65-year-old woman in oncology clinic. She has known metastatic breast cancer, and has received a mastectomy,
chemotherapy and radiotherapy.
She has complained of headaches and nausea for the last 7 days, which are worse in the mornings. A CT head showed multiple brain
metastases, with compression of the ventricles and sulci.
Your patient declines further chemotherapy or radiotherapy. She is currently taking opioid painkillers.
Which of the following medications can be used as an adjunct to further relieve her symptoms?
Ondansetron
Cyclizine
Dexamethasone
Haloperidol
Sumatriptan
Submit answer
Reference ranges $
Score: 71.4%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 %
17 %
18 %
19 %
20 %
21 %
22 -
You review a 65-year-old woman in oncology clinic. She has known metastatic breast cancer, and has received a mastectomy,
chemotherapy and radiotherapy.
She has complained of headaches and nausea for the last 7 days, which are worse in the mornings. A CT head showed multiple brain
metastases, with compression of the ventricles and sulci.
Your patient declines further chemotherapy or radiotherapy. She is currently taking opioid painkillers.
Which of the following medications can be used as an adjunct to further relieve her symptoms?
Ondansetron 17%
Cyclizine 8%
Dexamethasone 70%
Haloperidol 3%
Sumatriptan 2%
Headache caused by raised intracranial pressure due to brain cancer (or metastases) can be palliated with dexamethasone
Dexamethasone is used to reduce oedema around brain metastases, to palliate symptoms of raised intracranial pressure.
Ondansetron, cyclizine and haloperidol are all effective agents for nausea, but would not treat the root cause.
Sumatriptan is a treatment for migraines and has no role here.
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Score: 72.7%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
15 -
16 $
17 $
18 $
19 $
20 $
21 $
22 $
A 72-year-old male with metastatic lung cancer is referred to the palliative care team for end of life care. Currently, he takes 10mg
oral morphine daily which effectively controls his pain. Anticipatory medications are prescribed in a syringe driver.
How much daily subcutaneous morphine needs to be given?
3.3mg
5mg
6.7mg
10mg
15mg
Submit answer
Reference ranges $
Score: 72.7%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 %
17 %
18 %
19 %
20 %
21 %
22 %
23 -
A 72-year-old male with metastatic lung cancer is referred to the palliative care team for end of life care. Currently, he takes 10mg
oral morphine daily which effectively controls his pain. Anticipatory medications are prescribed in a syringe driver.
How much daily subcutaneous morphine needs to be given?
3.3mg 8%
5mg 84%
6.7mg 2%
10mg 5%
15mg 1%

Switching the route and choice of opioid requires dose adjustment. Oral morphine is half as strong as subcutaneous/intravenous
morphine mainly due to first-pass metabolism.
Fentanyl, buprenorphine and other opioids have varying conversion ratios for different routes.
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Score: 73.9%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
15 -
16 $
17 $
18 $
19 $
20 $
21 $
22 $
23 $
A 69-year-old man with terminal lung cancer is reviewed. He currently takes MST 60mg bd for pain. He has become unable to take
oral medications and a decision is made to set-up a syringe driver. What dose of diamorphine should be prescribed for the syringe
driver?
60 mg
40 mg
120 mg
30 mg
20 mg
Submit answer
Reference ranges $
Score: 73.9%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 %
17 %
18 %
19 %
20 %
21 %
22 %
23 %
24 -
A 69-year-old man with terminal lung cancer is reviewed. He currently takes MST 60mg bd for pain. He has become unable to take
oral medications and a decision is made to set-up a syringe driver. What dose of diamorphine should be prescribed for the syringe
driver?
60 mg 26%
40 mg 51%
120 mg 4%
30 mg 9%
20 mg 9%
To convert from oral morphine to diamorphine the total daily morphine dose (60 * 2 = 120mg) should be divided by 3 (120 / 3 =
40mg)
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Score: 75%
1 $
2 -
3 -
4 $
5 -
6 $
7 -
8 $
9 -
10 $
11 $
12 $
13 $
14 $
15 -
16 $
17 $
18 $
19 $
20 $
21 $
22 $
23 $
24 $
A 68-year-old woman has been investigated as an inpatient for a six month history of cough and weight loss. Following a CT scan of
her chest she is diagnosed with lung cancer. Biopsy and further imaging confirm this to be metastatic small cell lung cancer. After
discussion at the multi-disciplinary team meeting and subsequently with the patient it is agreed that her treatment be palliative.
On the ward she has been taking codeine sulphate 60mg four times a day for pain however this is still poorly controlled. The decision
is made to convert this to oral morphine.
What is the equivalent dose of oral morphine daily?
6mg
20mg
24mg
80mg
120mg
Submit answer
Reference ranges $
Score: 75%
1 %
2 &
3 &
4 %
5 &
6 %
7 &
8 %
9 &
10 %
11 %
12 %
13 %
14 %
15 &
16 %
17 %
18 %
19 %
20 %
21 %
22 %
23 %
24 %
25 -
A 68-year-old woman has been investigated as an inpatient for a six month history of cough and weight loss. Following a CT scan of
her chest she is diagnosed with lung cancer. Biopsy and further imaging confirm this to be metastatic small cell lung cancer. After
discussion at the multi-disciplinary team meeting and subsequently with the patient it is agreed that her treatment be palliative.
On the ward she has been taking codeine sulphate 60mg four times a day for pain however this is still poorly controlled. The decision
is made to convert this to oral morphine.
What is the equivalent dose of oral morphine daily?
6mg 7%
20mg 3%
24mg 79%
80mg 4%
120mg 6%

This woman is taking 240mg of codeine per day (60mg x 4). To convert to morphine, this figure needs to be divided by 10. This gives
a daily dose of 24mg.
6mg represents 1/10th of her codeine dose, however as she takes these four times daily the daily dose of morphine required needs
to be 4 times this figure.
20mg would be 1/12th of the daily dose which is incorrect.
80mg is 1/3rd of her daily codeine dose which is an incorrect conversion. Converting oral morphine to subcutaneous diamorphine
requires dividing by 3.
120mg is half of her daily codeine dose which is an incorrect conversion. Converting oral morphine to subcutaneous morphine
requires dividing by 2.
Next question !
NICE guidelines
more details.
Starting treatment
SIGN guidelines
Other points
Opioid side-effects
Nausea Constipation
Drowsiness
Next question !
! " # $ % & ' ( ) * +
Save my notes
Search

Links
NICE + 16 , 6
BNF + 13 , 6
Media
Score: 76%
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25 $
You are called to see an 85-year-old man on the general medical ward as the nurses are worried about him. He has become
progressively more drowsy in the last 12 hours and they have now noticed odd jerky movements of his arms.
He was admitted 14 days ago with severe pneumonia on a background of metastatic lung cancer. Treatment was eventually stopped
and he is now on the end of life care pathway and is awaiting discharge to a hospice.
His current medication includes 15 mg morphine sulfate twice daily with no recent use of his breakthrough medication. The nursing
staff tells you that despite being drowsy he is still responding when spoken to, eating, and drinking small amounts.
His last blood test was taken two days ago and the results are shown below:
Na+ 145 mmol/L (135 - 145)
K+ 4.9 mmol/L (3.5 - 5.0)
Bicarbonate 22 mmol/L (22 - 29)
Urea 12 mmol/L (2.0 - 7.0)
Creatinine 340 µmol/L (55 - 120)
What changes would you make to his medications?
Decrease his dose of morphine sulfate
Stop morphine sulfate and start a fentanyl patch
Stop morphine sulfate and start as required oxycodone
Stop oral morphine sulfate and start a subcutaneous syringe driver with morphine sulfate
Stop morphine sulfate and start buccal fentanyl four times daily
Submit answer
Reference ranges $
Score: 76%
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! Question 26 of 27 " # $
You are called to see an 85-year-old man on the general medical ward as the nurses are worried about him. He has become
progressively more drowsy in the last 12 hours and they have now noticed odd jerky movements of his arms.
He was admitted 14 days ago with severe pneumonia on a background of metastatic lung cancer. Treatment was eventually stopped
and he is now on the end of life care pathway and is awaiting discharge to a hospice.
His current medication includes 15 mg morphine sulfate twice daily with no recent use of his breakthrough medication. The nursing
staff tells you that despite being drowsy he is still responding when spoken to, eating, and drinking small amounts.
His last blood test was taken two days ago and the results are shown below:
Na+ 145 mmol/L (135 - 145)
K+ 4.9 mmol/L (3.5 - 5.0)
Bicarbonate 22 mmol/L (22 - 29)
Urea 12 mmol/L (2.0 - 7.0)
Creatinine 340 µmol/L (55 - 120)
What changes would you make to his medications?
Decrease his dose of morphine sulfate 9%
Stop morphine sulfate and start a fentanyl patch 40%
Stop morphine sulfate and start as required oxycodone 38%
Stop oral morphine sulfate and start a subcutaneous syringe driver with morphine sulfate 7%
Stop morphine sulfate and start buccal fentanyl four times daily 6%
Buprenorphine or fentanyl are the opioids of choice for pain relief in palliative care patients with severe renal impairment, as
they are not renally excreted and therefore are less likely to cause toxicity than morphine
This man has deteriorating renal function and is experiencing opioid toxicity due to poor renal clearance of morphine sulfate. This is
evidenced by his drowsiness and myoclonic jerks. Ideally, his medications should have been changed far earlier.
Opioids of choice in renal failure include alfentanil, buprenorphine, and fentanyl.
Decreasing his dose of morphine sulfate is incorrect as his kidney function is clearly causing him to have side effects from his
morphine sulfate. In this situation, the opioid must be switched.
Stopping the morphine sulfate and starting a fentanyl patch is the correct answer. A transdermal fentanyl 12 microgram patch
equates to approximately 30mg oral morphine daily, so this should be his starting dose.
Stopping the morphine sulfate and starting as required oxycodone is incorrect as this does not offer a long-acting solution for his
pain relief.
Starting a syringe driver with morphine sulfate is incorrect as the opioid must be changed in this situation. Starting a syringe driver
with alfentanil would be a potential solution in this case. However, the patient is still communicating, eating, and drinking. Therefore a
patch is more appropriate. A syringe driver may be used at a later stage.
Stopping morphine sulfate and starting buccal fentanyl four times daily is incorrect. Buccal fentanyl in the form of lozenges is used
for incident pain. It is rapidly absorbed and has a short half-life therefore should not be used to provide background pain.
Next question %
Palliative care prescribing: pain &
NICE guidelines
more details.
Starting treatment
SIGN guidelines
Other points
Opioid side-effects
Nausea Constipation
Drowsiness
Next question %
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NICE + 16 , 6
BNF + 13 , 6
Media
Score: 76.9%
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! Question 27 of 27 " $
You review a 72-year-old man with metastatic bowel cancer who is in the terminal phase and has a syringe driver. Unfortunately he
has developed intestinal obstruction and is suffering with bowel colic. What is the most appropriate drug to add to the syringe
driver?
Metoclopramide
Morphine
Levomepromazine
Haloperidol
Hyoscine butylbromide
Submit answer
Reference ranges #
Score: 76.9%
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" Question 27 of 27 # $ (
You review a 72-year-old man with metastatic bowel cancer who is in the terminal phase and has a syringe driver. Unfortunately he
has developed intestinal obstruction and is suffering with bowel colic. What is the most appropriate drug to add to the syringe
driver?
Metoclopramide 20%
Morphine 11%
Levomepromazine 8%
Haloperidol 3%
Hyoscine butylbromide 57%
Syringe drivers: respiratory secretions & bowel colic may be treated by hyoscine hydrobromide, hyoscine butylbromide, or
glycopyrronium bromide
% & ' Discuss Improve
Syringe drivers !
A syringe driver should be considered in the palliative care setting when a patient is unable to take oral medication due to nausea,
dysphagia, intestinal obstruction, weakness or coma. In the UK there are two main types of syringe driver:
Graseby MS16A (blue): the delivery rate is given in mm per hour
Graseby MS26 (green): the delivery rate is given in mm per 24 hours
The majority of drugs are compatible with water for injection although for the following drugs sodium chloride 0.9% is recommended:
granisetron
ketamine
ketorolac
octreotide
ondansetron
Commonly used drugs

nausea and vomiting: cyclizine, levomepromazine, haloperidol, metoclopramide
respiratory secretions/bowel colic: hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide.
agitation/restlessness: midazolam, haloperidol, levomepromazine
pain: diamorphine is the preferred opioid
Mixing and compatibility issues

diamorphine is compatible with the majority of other drugs used including cyclizine*, dexamethasone, haloperidol, hyoscine
butylbromide, hyoscine hydrobromide, levomepromazine, metoclopramide, midazolam
cyclizine is incompatible with a number of drugs including clonidine, dexamethasone, hyoscine butylbromide (occasional),
ketamine, ketorolac, metoclopramide, midazolam, octreotide, sodium chloride 0.9%
*precipitation may be seen at higher doses
! " # $ % & ' ( ) * +
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Syringe drivers
+ Suggest media
Score: 74.1%
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$ Question 1 of 27 !

" Reference ranges #

An 88-year-old woman with advanced, metastatic colon cancer is put onto

Which of the following would be a useful medication to alleviate this?

Soluble aspirin as a mouthwash

Which of the following would be a useful medication to alleviate this?

Benzydamine mouthwash 56%

Soluble aspirin as a mouthwash 7%

Oral glycopyrronium is often used at the end of life to reduce excessive

Soluble aspirin, used as a mouthwash, provides no topical relief from pain

Transdermal hyoscine is another medication used to reduce oral secretions

& ' ( Discuss Improve

Palliative care prescribing: pain "

In 2012 NICE published guidelines on the use of opioids in palliative care.

In addition to strong opioids, bisphosphonates and radiotherapy,

Usually transient Usually persistent

Conversion between opioids

From To Conversion factor

Oral codeine Oral morphine Divide by 10

Oral tramadol Oral morphine Divide by 10**

Oxycodone generally causes less sedation, vomiting and pruritis than

From To Conversion factor

Oral morphine Oral oxycodone Divide by 1.5-2***

From To Conversion factor

Oral morphine Subcutaneous morphine Divide by 2

Oral morphine Subcutaneous diamorphine Divide by 3

Oral oxycodone Subcutaneous diamorphine Divide by 1.5

*BMJ 2015;350:h315 Cancer induced bone pain

***historically a conversion factor of 2 has been used (i.e. oral oxycodone is

! " # $ % & ' ( ) * +

Therefore the correct dose of subcutaneous morphine over 24 hours is 60 mg.

' ( ) Discuss (2) Improve

Palliative care prescribing: pain "

Usually transient Usually persistent

Conversion between opioids

From To Conversion factor

Oral codeine Oral morphine Divide by 10

Oral tramadol Oral morphine Divide by 10**

From To Conversion factor

Oral morphine Oral oxycodone Divide by 1.5-2***

From To Conversion factor

Oral morphine Subcutaneous diamorphine Divide by 3

Oral oxycodone Subcutaneous diamorphine Divide by 1.5

*BMJ 2015;350:h315 Cancer induced bone pain

! " # $ % & ' ( ) * +

* Google search on "Palliative care prescribing: pain"

2012 Opioids in palliative care guidelines

Prescribing opioids in palliative care

+ Suggest link Report broken link

Complete Guide to Palliative Care for Medical Students

+ Suggest media Report broken media

Recommence fluids and antibiotics

Subcutaneous midazolam 67%

Intramuscular haloperidol 18%

Oral haloperidol 11%

Recommence fluids and antibiotics 2%

' ( ) Discuss (4) Improve

Palliative care prescribing: agitation and confusion "

! " # $ % & ' ( ) * +