5th November 2024

Managing physical symptoms other than pain

Nausea and vomiting

Nausea and vomiting are common but not always well managed. The underlying cause should always be considered. Mode of delivery is also key: a patient who is actively vomiting is unlikely to benefit from an oral antiemetic.

Main causes of nausea and vomiting, alongside clinical features and management options, are as follows:

Anxiety can also be a cause of nausea and vomiting. Management options include cognitive behavioural therapy, benzodiazepines and levomepromazine, and the decision depends very much on the specific clinical context.

Sometimes, the cause of the vomiting is unknown. In this case, levomepromazine is usually the first antiemetic to be trialled. Second-line options include metoclopramide, haloperidol and cyclizine. If these are ineffective, a trial of dexamethasone can be considered.

Pharmacology notes on antiemetics

There are a few things that might cause your pharmacist to come knocking regarding antiemetics.

Long QT: metoclopramide, haloperidol, levomepromazine and domperidone can all prolong the QT interval, increasing the risk of arrhythmias. This is a consideration, especially when a patient is on other medications that may also have this side effect. At the very end of life, the risks of this need to be balanced with the benefits gained from the medications.

Cancelling out: prokinetics (e.g. metoclopramide) and antimuscarinics (e.g. cyclizine) should not be prescribed together as the antimuscarinics will block the prokinetic effect.

Extrapyramidal side effects: avoid dopamine antagonists (in particular metoclopramide and haloperidol) in those at increased risk of extrapyramidal side effects, e.g. patients with Parkinson’s disease. Domperidone does not cross the blood-brain barrier and so is safe in patients with Parkinson’s disease.

Breathlessness

Reversible causes should always be considered and treated if present – for example, furosemide for pulmonary oedema, blood transfusions for anaemia, etc.

Non-pharmacological management techniques include use of a fan, opening a window, keeping the room cool, breathing techniques, posture and repositioning, encouragement to exercise and adaptation of the environment (e.g. setting up single-floor living or a micro-environment) to make living with breathlessness whilst carrying out daily activities easier.

Pharmacological management options include the following:

• Low-dose strong opioid (immediate-release preparation)
• Benzodiazepine if associated with acute anxiety (short-term use)
• Bronchodilator if partial airway obstruction, e.g. compressing tumour
• Oxygen may be considered in symptomatic hypoxia or in specific cases such as pulmonary hypertension, but there is limited evidence otherwise

Noisy secretions

Often, noisy secretions cause more distress to relatives than to the patient themselves. NICE guidelines recommend treatment if they are causing distress to the patient or to their carers.

Infection should be considered as a possible reversible cause.

The main conservative measure is to reposition the patient onto one side with their upper body elevated.

Pharmacological management options include:

• Glycopyrronium bromide
• Hyoscine butylbromide
• Hyoscine hydrobromide (although this may cause sedation or confusion)

It is important to monitor and treat side effects – dry mouth, delirium, sedation – and to consider stopping medications if the side effects outweigh the benefits.

Constipation

Common causes of constipation in the palliative care context include drugs, direct effects of the disease and secondary effects of the disease.

When initiating a drug likely to cause constipation (e.g. an opioid), a pre-emptive prescription of a stimulant laxative (e.g. senna) should be considered.

Reversible contributing factors include diet, dehydration, environment (particularly privacy and bedpan use), haemorrhoids or fissures and local tumour.

Management includes:

• Stimulant laxative (senna)
• Addition of a stool softener if needed – osmotic (lactulose, macrogol) or stool-softening laxatives (docusate)
• Consider rectal treatments if the rectum is full:
  • Soft loading – bisacodyl or sodium citrate
  • Hard loading – glycerol

Although phosphate enemas are commonly used, NICE guidelines advise to avoid them as they cause water and electrolyte imbalances.

Rectal interventions should not be carried out on those on chemotherapy who may be neutropenic, those with thrombocytopenia, and those with rectal or anal disease.

Terminal restlessness

Common causes of delirium should be considered and ruled out if needed: infection, drugs, anaemia, constipation, urinary retention, etc.

Conservative measures include reassurance, orientation with clocks and written messages, encouraging friends and family to be around, and ensuring the patient has their glasses and/or hearing aids if appropriate.

Medical management includes midazolam.

References

• Greater Manchester Health and Social Care Partnership. Palliative Care Pain & Symptom Control Guidelines For Adults [Internet]. 2019 Nov [cited 2022 Feb 13]. Available from: https://www.england.nhs.uk/north-west/wp-content/uploads/sites/48/2020/01/Palliative-Care-Pain-and-Symptom-Control-Guidelines.pdf
• Hardinge M, Suntharalingam J, Wilkinson T. Guideline update: The British Thoracic Society Guidelines on home oxygen use in adults. Thorax. 2015 Apr 27;70(6):589–91
• National Institute for Health and Care Excellence. Palliative care – constipation [Internet]. NICE. 2021 [cited 2022 Feb 13]. Available from: https://cks.nice.org.uk/topics/palliative-care-constipation/
• National Institute for Health and Care Excellence. Scenario: Noisy respiratory secretions at the end of life [Internet]. NICE. 2021 [cited 2022 Feb 13]. Available from: https://cks.nice.org.uk/topics/palliative-care-secretions/management/noisy-respiratory-secretions-at-the-end-of-life/
• National Institute for Health and Care Excellence. Palliative care – dyspnoea [Internet]. NICE. 2021 [cited 2022 Feb 13]. Available from: https://cks.nice.org.uk/topics/palliative-care-dyspnoea/
• National Institute for Health and Care Excellence. Palliative care – nausea and vomiting [Internet]. NICE. 2021 [cited 2022 Feb 13]. Available from: https://cks.nice.org.uk/topics/palliative-care-nausea-vomiting/
• NHS Scotland. Scottish Palliative Care Guidelines – Nausea and vomiting [Internet]. Scottish Palliative Care Guidelines. 2021. [cited 2022 Feb 13] Available from: https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/nausea-and-vomiting.aspx