HIVManagement.org

Constipation
"What's worse than being in pain?  Being in pain AND constipated!"

1.  Avoiding the development of constipation is the best strategy.  Exercise/body motion and adequate fluid intake (48 ounces or more) are essential for good bowel action in normal humans.  When providing therapy for constipation, always address the cause of the constipation, e.g., hypothyroidism.

2.  Laxatives that are safe and effective for prophylaxis or for obtaining bowel movement on a chronic or occasional basis include the following: lactulose 30-90 cc per day, Go-Lytely or Miralax (PEG-3350) at whatever dosage is effective (start with one heaping tablespoon in 8 ounces of fluid,) sorbitol 30-60 cc per day, or mineral oil dosed to allow for good bowel action.

3.  A fiber laxative taken at the high end of the dosage spectrum may be helpful.  For example, fine powdered psyllium at 2 tablespoons per day in 8-16 ounces of fluid should be considered.  Flatulence is the main side effect.

4.  Consider a trial of senna tablets up to 8-10 per day or SenoKot when one initiates opiate therapy for chronic pain although the alternatives above are preferable.
 

Nausea
Of all the palliative care issues, nausea may be the most debilitating and deadly in and of itself by acting as a barrier to necessary hydration, nutrients, and even medications.

1.  As in all other symptomatic states, always address the etiology of the nausea (e.g., medication related, CNS, renal/uremia, GI tract, hepatic, pancreas).  History, physical and a minimum lab evaluation (CBC, comprehensive metabolic profile, lipase) should be considered for evaluation of all acute or chronic nausea.  Nausea may be multifactorial, e.g., due to several different medications.

2.  As with many other symptoms, prevention of nausea is often easier to achieve than treatment once nausea and vomiting have developed.  For example, the use of oral antiemetics may be impossible in someone who is actively vomiting.

3.  Hydration is pivotal.  If nausea/vomiting precludes fluid intake, the patient may require emergency evaluation and/or parenteral fluid administration.

4.  Medications that may be useful for prophylaxis and/or treatment of nausea include the following:  promethazine 25-50 mg orally or per rectal suppository up to 4 times per day, perchlorperazine 5-10 mg orally or by suppository up to 4 times per day, metoclopropamide 10 mg orally 3-4 times per day, dranabinol 5-20 mg orally 3-4 times per day, lorazepam 1-2 mg orally 3-4 times per day.  Most of these medications may be very sedating and the phenothiazines are associated with tardive dsykinesia infrequently.

5.  For refractory nausea, consider corticosteroids or haloperidol or inapsine.

Sedation/Fatigue

The correct and appropriate use of analgesics and other therapies such as interferon/ribavirin may produce excessive sedation and fatigue.  Stated another way, appropriate dosing of analgesics for pain control or therapies such as interferon may lead to deterioration in quality of life due to severe fatigue.  In the author's mind, the most appropriate use of antidepressants and/or psychostimulants is in this setting.

1.  Determine the impact that sedation and fatigue have on the patient's quality of life.

2.  Look carefully at the impact of inadequate pain control on the sleep cycle.  Poor analgesia can result in frequent awakenings and sleep that is not restful.  Therefore, almost paradoxically, increasing analgesia may result in less fatigue.

3.  Look carefully at the sleep cycle in general.   Consider sleep apnea, urinary frequency, and other possible sleep disturbances.  Normalization of the sleep cycle may be critical.

4.  Certain medications such as amitriptyline or trazodone may be associated with excess sedation.  Substitution for these medications may be very helpful.

5.  If severe fatigue is due to medical therapy such as opiates or interferon therapy, consider the following options: modafinil (Provigil) 100-200 mg per day or Ritalin 5-10 mg three times per day.  Tolerance to Ritalin seems to develop more rapidly than to modafinil.  Sleep disturbance is thought to be less with modafinil.  Modafinil is more expensive, and there is less longterm data to support its efficacy and safety.
6.  Depression which is very commonly encountered in palliative care can be a very potent cause of sedation and fatigue.  Consider activating antidepressants such as buproprion.

Updated 10.27.2005