Pharmacotherapy in Palliative Care

• If no treatable causes can be identified or when treatments do not completely alleviate distressing symptoms, opioids are first-line agents for treating dyspnea. ,

• Opioids suppress respiratory awareness, decrease response to hypoxia and hyper-capnia, vasodilate, and have sedative properties.

• Low-dose opioids (e.g., starting oral dose of morphine approximately 5 mg) have been shown to be safe and effective in the treatment of dyspnea. Doses should be titrated judiciously.

• As anxiety can exacerbate dyspnea, benzodiazepines and antidepressants that have

anxiolytic properties can be beneficial.

• Once an effective dose of an opioid has been established, converting to an extended-release preparation may simplify dosing.

• When using opioids, anticipate side effects and prevent constipation by initiating a stimulant laxative/stool softener combination.

• Nebulized opioids for treatment of dyspnea are controversial. Study results have

• Nonrandomized studies, case reports, and chart reviews describe anecdotal improvement in dyspnea using nebulized opioids; however, several controlled studies using nebulized opioids have provided inconclusive or negative results.

• Nebulized opioids may be advantageous in patients that are not able to or willing to take an oral agent or cannot tolerate adverse effects of systemic administration.

• Fentanyl appears to be the safest nebulized opioid.

• Nebulized furosemide appears effective for dyspnea refractive to other convention-

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al therapies.

• Hypothesized mechanism of action of nebulized furosemide is its ability to enhance pulmonary stretch receptor activity, inhibition of chloride movement through the membrane of the epithelial cell, and its ability to increase the synthesis of bronchodilating prostaglandins.

• Oxygen therapy may be useful to patients with dyspnea and can reverse hypoxemia.

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• For known etiologies of dyspnea, consider the following: ' '

• Bronchospasm or COPD exacerbation: Albuterol, ipratropium, and/or oral steroids should be used for symptoms management. Nebulizing bronchodilators are more effective than using handheld inhalers in patients who are weak and have difficulty controlling their breathing.

• Thick secretions: If cough reflex is strong, loosen secretions with guaifenesin or nebulized saline. If the cough is weak, hyoscyamine, glycopyrrolate, or scopolam-ine patch can effectively dry secretions.

• Anxiety associated with dyspnea: Consider benzodiazepines (e.g., diazepam, lorazepam).

• Effusions: Thoracentesis will be necessary.

• Low hemoglobin: Red blood cell transfusion (controversial) or erythropoietin (rarely used in hospice, but might have a larger role in palliative care patients).

• Infections: Antibiotic therapy as appropriate.

• Pulmonary emboli: Anticoagulants for prevention and treatment or vena cava filter placement (rarely used in hospice, but might have a larger role in palliative care patients).

• Rales due to volume overload: Reduction of fluid intake or diuretic therapy as appropriate.

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