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CHRONIC PANCREATITIS
Like a Shot to the Gut . . . . . . . . . . . . . . . . . . . . . . . . . . . Level II
Janine E. Then, PharmD, BCPS
CASE SUMMARY
A 35-year-old woman with no known past medical history presents with GI complaints consistent with an acute exacerbation of
chronic pancreatitis. Initial management is directed toward alleviation of the patient’s pain and resolution of the acute process. This
patient has not been on enzyme replacement therapy previously.
Because there are a variety of enzyme preparations available, patient
and product factors should be considered in selecting the best regimen for a particular individual.
QUESTIONS
Problem Identification
1.a. Create a list of this patient’s drug therapy problems.
• Inadequate analgesia.
• Uncontrolled nausea and vomiting.
• Diarrhea, steatorrhea, and malabsorption.
• Dry eyes and mucous membranes are present and are not
associated with dehydration as she has a normal urine volume,
BUN/SCr ratio is <20, and she has normal skin turgor. These
symptoms are consistent with an autoimmune etiology of pancreatitis (eg, Sjøgren syndrome).
1.b.What subjective and objective information is consistent
with the diagnosis of chronic pancreatitis?
• Contrast-enhanced abdominal CT results indicate inflammation of the common bile duct.
• Elevated alkaline phosphatase and elevated total bilirubin consistent with inflammation of common bile duct.
• Malodorous watery green stool (this may indicate steatorrhea,
which does not occur until 90% of pancreatic secretory capacity is lost).
• Chronic abdominal pain for several years.
1.c. What signs, symptoms, and test results indicate that the
patient is experiencing an acute exacerbation of chronic
pancreatitis?
• Abdominal pain with radiation to her back.
• Nausea and vomiting with increased frequency and intensity.
• Increase in frequency of diarrhea and change in the consistency and fatty content of her stool.
• Decreased bowel sounds.
• Voluntary guarding.
1.d.Which of the patient’s problems are amenable to drug
therapy?
• Inadequate analgesia.
• Dry eyes and mucous membranes.
1.e.What additional information is needed to satisfactorily
assess the patient?
• The patient has a normal WBC count and is afebrile. A WBC
differential is useful to confirm a left shift and provide justification for antimicrobial therapy. Leukocytosis may be a normal
physiologic stress response. While evidence supports the use of
antimicrobials for severe necrotizing pancreatitis, it does not
support antimicrobials as empiric treatment for acute exacerbation of chronic pancreatitis.1
• A triglyceride level would be useful to identify hypertriglyceridemia, which is often associated with chronic pancreatitis
and acute exacerbation. Elevated triglycerides would prompt
alteration in the pharmacotherapeutic care plan.
• A rheumatologic and/or immunologic workup is prudent
at this point given the association of chronic pancreatitis,
in various forms, with immunologic deficiency (eg, Sjögren
syndrome, isolated autoimmune chronic pancreatitis, irritable
bowel-associated chronic pancreatitis). Serum immunoglobulins and antinuclear antibodies are a reasonable starting point.
• An MRCP can be performed to aid in diagnosis and rule out
structural abnormalities. An ERCP may be considered if an
intervention (ie, endoscopic dilation or stenting) is deemed to
be beneficial.
Desired Outcome
2.What are the goals of pharmacotherapy in this case?
• Chronic pancreatitis cannot be cured; treatment is directed
toward alleviation of presenting symptoms.
• Resolution of pain with adequate analgesia.
• Control of nausea and vomiting.
• Control of malabsorption and steatorrhea.
• Prevention of further disease-associated complications.
• Prevention of discomfort associated with dry eyes and
xerostomia.
Therapeutic Alternatives
3.a. What nondrug therapies could be useful in this patient?
• This patient will be admitted for acute hospital care.
• The patient should initially receive nothing by mouth. Cautious
advancement of oral intake and transition to oral medications
should be done as symptoms of pain, nausea, and vomiting
resolve.
• Psychological assessment may be required to identify any special needs regarding the patient’s avoidance of medical care for
15 years despite having significant recent symptoms.
• Financial counseling or social work assessment to determine
the patient’s insurance coverage with her new plan, and to
navigate regulations around preexisting conditions and coinsurance requirements.
• Sugarless mints, gum, or saliva substitutes may be helpful for
xerostomia.
3.b. What feasible pharmacotherapeutic alternatives are available
for treating this acute exacerbation of chronic pancreatitis?
• Analgesics. Pain is the predominant symptom causing patients
to seek treatment. Both opioid and nonopioid agents are used.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Chronic Pancreatitis
Heather M. Teufel, PharmD, BCPS
• Diarrhea, steatorrhea, and malabsorption.
CHAPTER 49
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• Uncontrolled nausea and vomiting.
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SECTION 4
Gastrointestinal Disorders
Adjunctive agents, such as tricyclic antidepressants (TCAs)
and gabapentin, may also be considered, although TCAs may
exacerbate this patient’s xerostomia. Although pain may be
intermittent during the acute exacerbation, it is a disabling
symptom that is challenging to manage. Because of the nature
of the illness, physical dependence, pseudoaddiction, and
psychological addiction are real concerns. Opioid tolerance
and physical dependence are to be expected with long-term
opioid use and should not be confused with psychological
dependence. Patients need to have aggressive pain management included in the treatment plan for acute exacerbation.
The use of oral agents is limited by the severity of pain, gastric
irritation, and the need to keep the patient NPO. Patients will
usually require parenteral analgesics for acute pain control and
can be transitioned to oral therapy as tolerated.
✓Morphine is now recommended as first-line therapy in
evidence-based pain management guidelines for patients
who require strong opioid therapy. It does lead to a histamine
release and may cause flushing and hypotension. Caution
should be used in hemodynamically unstable patients.
✓Hydromorphone is an acceptable alternative agent due to
less flushing and hypotension. Place in therapy may depend
upon institution preferences.
✓Meperidine is no longer recommended as first-line therapy.
Although meperidine does not exhibit as profound of an
effect on pressure in the sphincter of Oddi or the ductal
system, its active metabolite normeperidine is a central nervous system (CNS) irritant. The metabolite can accumulate
and cause CNS toxicity ranging from dysphoria to seizures.
Meperidine should be reserved for short-term treatment in
patients who have experienced prior therapeutic response or
those with allergies or therapy-limiting intolerance to other
opioids such as morphine or hydromorphone. It is contraindicated in patients with renal impairment or patients taking
monoamine oxidase inhibitors. Meperidine should be used
cautiously in patients with a history of seizures. It should
not be used for more than 48 hours or in doses in excess of
600 mg per 24-hour period.
✓Butorphanol and nalbuphine are mixed opioid agonist/
antagonists that are not as potent as pure opiate agonists
but cause less sedation and euphoria. Either agent could be
considered in patients who are elderly, have substance abuse
problems, or have respiratory compromise.
✓Ketorolac is an injectable nonsteroidal anti-inflammatory
drug (NSAID) that does not produce euphoria, respiratory
depression, or sedation. When combined with an opioid
agonist, it may allow for lower narcotic doses in some
patients. However, ketorolac can cause gastric irritation,
bleeding complications, and renal impairment. It should be
used with caution in patients with a history of peptic ulcer
disease or gastrointestinal bleeding, patients with or at risk
for advanced renal disease, and patients with thrombocytopenia. For optimum effect, ketorolac should be given on
a scheduled basis rather than as needed. The duration of
therapy should not exceed 5 days. The oral formulation of
ketorolac or other oral NSAID agents should not be considered while the patient remains NPO.
✓Ibuprofen is available in an injectable formulation and may
be considered for the treatment of acute pain seen in pancreatitis. It must be further diluted to a concentration of
<4 mg/mL and infused over at least 30 minutes. Similar to
ketorolac, ibuprofen should be avoided in patients with a
history of peptic ulcer disease or gastrointestinal bleeding,
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patients with or at risk for renal impairment, patients with
thrombocytopenia, and patients with heart failure. Patients
may benefit from taking ibuprofen on a scheduled basis for a
period of time especially if they are requiring opioid therapy
to control their pain.
✓Acetaminophen is also available in an injectable formulation.
It may be administered undiluted over 15 minutes. Patients
experience more of a benefit from taking acetaminophen on
a scheduled basis than taking it as needed.
✓COX-2 selective inhibitors may provide analgesia and target
the overexpression of COX-2 seen in chronic pancreatitis.
Celecoxib is the only agent available in the United States.
COX-2 selective inhibitors are considerably more costly than
traditional NSAIDs, have no advantage over nonselective
agents in patients without risk factors for NSAID-associated
complications, and may increase the risk of cardiovascular
complications (eg, myocardial infarction and stroke) in predisposed individuals. The lack of clinical evidence and lack
of an injectable form argue against use in this patient.
✓TCAs may target concomitant depressive symptoms and
neuropathic pain in patients presenting with symptoms
of both depression and chronic pancreatitis.2,3 Use in this
patient may be limited by the anticholinergic adverse effects
of TCAs.
✓Gabapentin and pregabalin have been used to target neuropathic pain. At this time pregabalin has only been used in
short-term studies and it is unknown if it is appropriate for
long-term pain management.2,4
• Antiemetics. Nausea and vomiting contribute to dehydration,
electrolyte abnormalities, and poor nutritional status. There
are a variety of agents available as both the injectable and rectal
forms for convenient and flexible administration.
✓Promethazine, prochlorperazine, and trimethobenzamide are
commonly used. Any of these agents in an appropriate dose
would be acceptable.
✓Metoclopramide may be effective in minimizing nausea and
vomiting, but it has prokinetic effects and may not be acceptable as first-line therapy. The adverse effect profile may also
be unacceptable in some patients due to motor effects.
✓Nausea should be treated cautiously mostly through IV
fluids and bowel rest. Once nausea has resolved, enteral
nutrition should be reintroduced. If treatment for nausea is
necessary, no one antiemetic medication has been shown to
be superior to another.
• IV fluids. Vomiting, diarrhea, nasogastric aspiration, and
decreased oral intake may contribute to dehydration and electrolyte disturbances. Maintenance of fluid balance is essential
to prevent further organ system compromise. Repletion of
intravascular volume deficits is best accomplished with lactated Ringer’s or other isotonic fluid. Dextrose-containing
solutions should be used cautiously with careful attention to
blood glucose monitoring. If hypokalemia is present, it should
be corrected by adding potassium chloride to maintenance
fluids.
• Nutrition supplementation. During acute exacerbations, oral
intake should be reintroduced slowly. Enteral nutrition is preferred and can be accomplished through a nasogastric tube.
Consideration may be given to postpyloric feeding and formulations that contain medium-chain triglycerides if tolerance
remains a concern.5 In patients unable to tolerate enteral feeding for more than a week or with signs malnutrition parenteral
nutrition may be considered.
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• Insulin. Insulin release in response to a glucose load is
impaired early in the disease process. Consistent nutrition and
correction of malabsorption may assist with glucose control.
Regular human insulin or rapid-acting insulins such as insulin
lispro or aspart are acceptable choices to be used with a sliding scale. These insulins have a shorter onset of action and a
shorter duration of effect.
3.c. What additional care is required for a patient who has not
seen a physician in about 15 years?
• Additional care for such a patient could be extensive but
should be limited to her current situation right now; less
urgent care that she did not receive in previous years can be
addressed on an outpatient basis after her acute illness has
resolved and she has been discharged from the hospital. For
example, vaccination assessment, Pap test and complete pelvic
examination, complete lipid profile, and skin cancer screen are
suggested after the patient is discharged and follows up with a
primary care physician.
Optimal Plan
4.What drug, dosage form, and duration of therapy are best for
this patient?
Analgesia:
• Examples of reasonable regimens for the initial treatment of
pain in this patient include:
✓Parenteral morphine 2–10 mg every 2–4 hours as determined by individual patient needs.
✓Morphine patient-controlled analgesia (PCA) 3 mg loading
dose with a 1 to 2 mg PCA dose and a 10-minute lockout
period. If the patient requires frequent bolus dosing without
pain relief, careful consideration of a basal rate or additional
analgesics may be necessary.
✓Parenteral hydromorphone 0.5 mg every 1–2 hours as
needed is an alternative to morphine. It should be reserved
for refractory pain or for patients who are not tolerating
morphine.
✓Parenteral hydromorphone PCA 1 mg IV loading dose followed by 0.4 to 0.6 mg PCA dose with a 10-minute lockout
period. If the patient requires frequent bolus dosing without
pain relief, careful consideration of a basal rate may be
necessary.
• All opioid dose adjustments should be individualized based on
a thorough patient assessment using a pain scale. An appropriate pain management strategy should include the evaluation
of scheduled versus as-needed dosing. The use of scheduled
dosing may help to achieve desired analgesia with less drug
use. Therapy duration should be reviewed with the initiation
of dose-tapering strategies in patients at risk for withdrawal
syndromes.
• If the patient is experiencing neuropathic pain, the addition
of a TCA, gabapentin, or pregabalin may decrease the need
for opioids. The use of TCAs in this patient may worsen her
xerostomia and alternative agents may be preferred.
Antiemetics:
• Parenteral or rectal promethazine 12.5–25 mg every 4–6 hours
as needed for nausea and vomiting may be used. Therapy
should be initiated cautiously at the lower end of the dosing
range with dose increases as clinically indicated and tolerated.
Promethazine can be sedating and may cause anticholinergic
effects, including xerostomia, which may not be tolerated in
this patient. Extravasation of promethazine injection can cause
severe tissue injury and necrosis.
• Prochlorperazine may be administered parenterally at a dose
of 2.5–10 mg every 3–4 hours or 25 mg rectally twice daily as
needed for nausea and vomiting. It is also sedating and may
cause hypotension on administration.
• Antiemetics can have additive sedative effects when combined
with opioids. Patients should be closely monitored when both
therapies are required.
Nutrition:
• After the nausea has been controlled, clear liquids should be
tried. If tolerated, the diet should be advanced slowly as she
continues to tolerate nutrition. If unable to tolerate eating,
discuss placement of a nasogastric tube and the initiation of
tube feeds at a low rate with the patient. The tube feeding could
contain medium-chain triglycerides to lessen the need for PES
and improve tolerance.
• Some experts recommend advancing the feeding tube into the
duodenum, past the sphincter of Oddi to minimize stimulation
of the pancreas.
• If the patient does not tolerate enteral feeding due to severe
abdominal pain, nausea, and/or vomiting, parenteral nutrition
may be initiated. Parenteral nutrition shall only be utilized if
the patient is expected to have inadequate nutrition for more
than 7 days.
• Enteral or parenteral nutrition shall provide 25–30 kcal/kg per
day with 1–2 g/kg per day of protein. IV lipid emulsion is contraindicated if the patient has hypertriglyceridemia.
• Parenteral nutrition increases the patient’s risk for infection,
hyperglycemia, thrombosis of the central line, and electrolyte
abnormalities.
• Patients who have had a prolonged course of decreased nutrition should be monitored closely for refeeding syndrome.
Potassium, magnesium, and phosphorus should be monitored
at least twice daily when reinitiating nutrition. Thiamine
may be administered to decrease the risk of Wernicke’s
encephalopathy.
• Multivitamins are supplemented in total parenteral nutrition
solution. The patient should start ADEK vitamin PO once
daily when the total parenteral nutrition is discontinued.
Glucose control:
• Subcutaneous rapid- or short-acting insulin adjusted by sliding scale is one method of maintaining glucose control when
it is unknown how much insulin will be required. Bedside
glucose checks should be performed every 4–6 hours while on
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Chronic Pancreatitis
• Lipid-soluble vitamin replacement. This patient should receive
vitamins A, D, E, and K (ADEK tablets) to replace the lipidsoluble vitamins lost with steatorrhea.
• If the patient’s acute pain is not controlled despite use of opiates, one may consider addition of adjunctive therapy with
a parenteral NSAID (ketorolac or ibuprofen) or parenteral
acetaminophen.
CHAPTER 49
• Pancreatic enzyme replacement. Use of oral pancreatic
enzyme replacement should be evaluated when nausea and
vomiting are controlled and oral nutrition is initiated. There
are various pancreatic enzyme supplements (PES) commercially available. All contain different amounts of amylase,
lipase, and protease enzymes and dosing should be titrated
to effect. The normal starting dose is lipase 500 units/kg/meal
and titrated based on the amount of steatorrhea the patient
experiences.
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SECTION 4
nutrition support. An example of an acceptable sliding scale
regimen follows.
• If blood glucose level is:
✓≤150 mg/dL → give 0 units regular insulin
✓151–200 mg/dL → give 3 units regular insulin
✓201–250 mg/dL → give 6 units regular insulin
✓251–300 mg/dL → give 9 units regular insulin
✓301–350 mg/dL → give 12 units regular insulin
Gastrointestinal Disorders
✓351–400 mg/dL → give 15 units regular insulin
✓>400 mg/dL → call prescriber
Enzyme replacement:
• A number of different pancreatic enzyme replacement products are available (refer to the textbook chapter on pancreatitis
for more detailed information). A common starting dose is
based on the lipase component of 500 units/kg/meal with half
of the mealtime dose administered with snacks.6 The dose
may be titrated every few days based on the patient’s clinical
symptoms and stool fat content. Many patients will require
several capsules with each meal and snacks that may affect
patient compliance. Doses of lipase >6000 units/kg/meal are
associated with increased risk of colonic stricture and are not
recommended.6
• Theoretically, delivery of sufficient enzyme should eliminate
malabsorption. In reality, it is rarely possible to eliminate
steatorrhea, but improvement in fat absorption is achievable
in most patients.
• Patient factors that should be considered when selecting a dosing regimen for enzyme replacement therapy include dietary
habits, concurrent medications that could alter intestinal pH,
gastric emptying function, and concurrent medications that
could alter GI motility. A simple regimen should be selected to
maximize the likelihood of patient adherence. Patients often
find it difficult to comply with even a simple regimen.
• Product factors that should be considered when selecting a
regimen include differences in enzyme content, potency, product formulation, and bioavailability. Cost is also an important
consideration, since the patient will likely require lifelong therapy. Unfortunately, all these products are relatively expensive.
Xerostomia:
• When sugarless mints or gums are not sufficient to stimulate
saliva production, a saliva substitute may be used.
• Pilocarpine 5 mg by mouth three to four times daily or cevimeline 30 mg three times daily may also be considered. However,
diarrhea is a common adverse effect and may prevent use in
this patient’s situation. The underlying etiology of xerostomia
should be explored pending the results of the autoimmune
testing as the above agents are used for xerostomia in the setting of Sjøgren syndrome.
Dry eyes:
• Hydroxypropyl methylcellulose—one to two drops in each eye
as needed for dryness.
Outcome Evaluation
5.What clinical and laboratory parameters are necessary to
evaluate the therapy for achievement of the desired therapeutic
outcome and to detect or prevent adverse events?
• Effectiveness of analgesics: A thorough baseline pain assessment using a pain scale should be performed on initiation of
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
therapy. This assessment should include a discussion with the
patient to identify an acceptable level of pain and desired level
of pain control. Further assessment using these desired targets
will provide a rational basis for dose modification of analgesic
therapy. Sleep patterns and the use of as-needed analgesics
for breakthrough pain should also be included as part of
the follow-up pain assessment. This information should be
included in the decision for dose modification of the analgesic
or the addition of adjunctive therapy for sleep and/or anxiety.
• Adverse effects of analgesics: The patient should be monitored
for decreases in respiratory rate, heart rate, blood pressure,
and wakefulness. Focused attention should be paid to these
parameters early in therapy. The opirate-narïve, elderly, and
otherwise compromised patients may be especially at risk
for opioid-related adverse events. The occurrence of opioidassociated nausea and vomiting may prompt the need for antiemetic therapy. Itching may simply be a histamine-mediated
reaction that can be treated with antihistamines. If accompanied by rash or other evidence of an allergic reaction, a change
in therapy may be warranted. Constipation is an expected
event with opioid use. Laxatives should be considered early in
therapy and included as clinically indicated.
• Effectiveness of antiemetics: The patient should be monitored
for subjective symptoms as well as objective evidence of emesis.
• Adverse events of antiemetics: Initiation of therapy at the low
end of the dosing range with careful titration should minimize
the potential for adverse events. CNS and respiratory depression are more prevalent with higher and cumulative doses.
Extrapyramidal symptoms have been reported with promethazine and prochlorperazine.
• Effectiveness of nutritional support: Monitoring of nutrition
support includes serum electrolytes, prealbumin, nitrogen
balance, metabolic parameters, and fluid status (eg, intake
and output). Normalization of these parameters is desirable.
Changes in these parameters guide adjustment in nutrition
regimen. A positive weight change toward the targeted goal
is desirable.
• Adverse effects of nutrition support: Abnormalities in serum
electrolytes, glucose, triglycerides, liver function tests, blood
urea nitrogen, and serum creatinine could occur. Prealbumin
and transferrin can be monitored to demonstrate short-term
improvement. In addition to laboratory values, the patient
should be monitored for elevated residuals, elevated temperature (which may indicate infection), and signs and symptoms of electrolyte imbalances, organ failure, fluid overload
(eg, monitor intake and output), and pulmonary or peripheral
edema. Diarrhea should also be monitored to ensure absorption of enteral feeds. If the patient experiences significant,
noninfectious diarrhea while on enteral feeds, addition of an
antidiarrheal such as loperamide may be considered.
• Adverse effects of insulin: Insulin must be used with caution,
as unpredictable hypoglycemia may occur with small doses.
The secretion of glucagon and insulin is impaired in patients
with long-standing chronic pancreatitis. Blood glucose levels
should be monitored routinely and insulin adjusted based on
the results.
• Effectiveness of PES: Stool is examined for changes in fecal fat
as indicated by decreasing odor and normalization of consistency. Dosage should be titrated to the minimum required.
• Adverse effects of PES: Impaired folic acid absorption, increased
uric acid levels, nausea, dyspepsia, abdominal cramps, and
diarrhea may occur.
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• Adverse effects of saliva substitutes: None; proper dental care
is required.
• Effectiveness of pilocarpine: Sensation of dry mouth should
decrease. Patient should notice greater ease in swallowing.
• Adverse effects of pilocarpine: Flushing, headache, tachycardia,
urinary frequency, diarrhea, and blurred vision.
• Adverse effects of hydroxypropyl methylcellulose: None.
Patient Education
6.Ms Jane wants information on her inpatient medication
regimen and the nurse refers her to you, the floor-based pharmacist. What information will you provide to enhance her
understanding of the medications, maximize compliance with
the new medication regimen, enhance the chance of success,
and minimize adverse effects?
• Continue to eat a low-fat diet (dietary fat <20 g per day).
• Eat small, frequent meals, such as six meals per day.
• If taking pancreatic enzyme replacement capsules with entericcoated spheres, swallow them whole; do not crush or chew
them before swallowing.
• Take the required number of tablets (or capsules) with all
meals and snacks.
• Pancreatic enzymes may cause nausea, upset stomach, abdominal cramps, and diarrhea.
• You will probably need to continue your enzyme therapy
indefinitely.
• For pain control we have started you on morphine PCA.
If you are experiencing pain, please press the button and it
• Contact your doctor if you notice any change in your stool
color, consistency, or odor.
• You will not need to be on insulin at home. I have discussed
the symptoms of high blood sugar with you. Contact your doctor if you notice any symptoms of high blood sugar.
• Use sugarless mints or lozenges as needed to decrease symptoms associated with dry mouth. Saliva substitutes as needed
will further alleviate symptoms that are not otherwise controlled. It is important to maintain routine dental care because
your lack of saliva will predispose you to dental caries
(cavities).
REFERENCES
1. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol 2013;108:1400–1415.
2. DiMagno MJ, DiMagno EP. Chronic pancreatitis. Curr Opin Gastroenterol 2012;28:523–531.
3. Berry AJ. Pancreatic enzyme replacement therapy during pancreatic
insufficiency. Nutr Clin Pract 2014;29:312–321.
4. Puylaert M, Kapural L, Van Zundert J, et al. Pain in chronic pancreatitis. Pain Pract 2011;11:492–505.
5.Trikudanathan G, Vavaneethan L, Vege SS. Modern treatment of
patients with chronic pancreatitis. Gastroenterol Clin North Am
2012;41:63–76.
6.Giuliano CA, Dehoome-Smith ML, Kale-Pradhan PB. Pancreatic enzyme products: digesting the changes. Ann Pharmacother
2011;45:658–666.
Copyright © 2017 by McGraw-Hill Education. All rights reserved.
Chronic Pancreatitis
• Effectiveness of hydroxypropyl methylcellulose: Sensation of dry
eyes should decrease.
will deliver a dose of the analgesic. If you feel that you are
requiring multiple doses of the medication without adequate
control of your pain, let us know and we can adjust the dosing.
Morphine may cause constipation; please continue to monitor
your stools.
CHAPTER 49
• Effectiveness of saliva substitutes: Sensation of dry mouth should
decrease. Patient should notice greater ease in swallowing.