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Opioid Rotation for Persistent Nausea — SCE Palliative Medicine MCQ

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ModeratePain ManagementOpioid Rotation for Persistent NauseaSCE Palliative Medicine

A 68‑year‑old man with advanced pancreatic cancer has pain controlled on morphine MR 60 mg BD but develops severe opioid‑induced nausea persisting despite 1 week of therapy, despite optimized antiemetic treatment (including a dopamine antagonist, a 5‑HT₃ antagonist, and levomepromazine). What management strategy targets the underlying cause of opioid‑induced nausea?

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Correct answer: D — Rotate to an alternative opioid (e.g. oxycodone or fentanyl), exploiting incomplete cross‑tolerance to provide equivalent analgesia with lower nausea risk

Option D is correct. Once anti‑emetic therapy has been optimized across receptor classes and nausea persists, UK guidance supports opioid rotation to address the mechanism (incomplete cross‑tolerance) rather than just symptoms. NICE evidence indicates morphine may cause more nausea compared with oxycodone in a small trial, although data are limited; rotation can therefore offer equivalent pain control with lower nausea risk. Option A is incorrect because anti‑emetics are already optimized. Option E does not modify the underlying central mechanism. Option B abandons effective analgesia. Option C is false—higher opioid doses typically worsen, not reduce, nausea. This hierarchy reflects UK palliative‑care prescribing priorities.

Reference: NICE Clinical Guideline 140: Opioids in palliative care – Managing side effects and evidence summary on nausea; 2012 (last reviewed 2016). See 'Managing side effects – Nausea' section and evidence appraisal on side‑effect differences. https://www.nice.org.uk/guidance/cg140/documents/opioids-in-palliative-care-full-guideline2