TABLE 6.

Summary of therapies for palliative management of dyspnea, muscle cramps, pruritus, and nausea

Symptom	Nonpharmacotherapies	Pharmacotherapies
Dyspnea	• Manage reversible causes (e.g., volume overload, asthma, sleep apnea) • Bedside fans • Supplemental oxygen therapy • Mindfulness, meditation, guided imagery • Paracentesis • Thoracentesis • Placement of drains (usually in the setting of hospice care)	• Opioids can be used cautiously in select cases, typically at the end of life (example: starting dose i.v. hydromorphone 0.2 mg every 3 h as needed, titrated to symptom relief) • Anxiolytics can be considered for dyspnea-associated anxiety (typically at the end of life when focus of care is comfort)
Muscle cramps	• Correct electrolytes	• Taurine (2–3 g daily) • Vitamin E (300 mg three times a day) • Baclofen (5–10 mg three times a day)
Pruritis	• Moisturizing creams • Avoid hot baths and harsh soaps and detergents • Use loose-fitting clothing • Cool humidified air	• Cholestyramine (4 g/d, titrated to 16 g/d if needed) • Sertraline (25 mg/d, titrated to 75–100 mg if needed) • RIF and naltrexone may improve pruritus, but their use is limited in palliative treatment of patients with DC. • Antihistamines (e.g., diphenhydramine and hydroxyzine) may help with pruritis-associated sleep disturbance given their sedating properties
Nausea and vomiting	• Correct electrolytes • Evaluate and treat adrenal insufficiency • Manage constipation • Review medications and eliminate potential triggers (e.g., lactulose, opioids) • Ginger • Mindfulness, relaxation • Acupuncture (use caution if platelets <50,000)	• Antacids (if contributing reflux) • Ondansetron, up to 8 mg/d is preferred • Metoclopramide up to 60 mg/d (very preliminary safety data; potential adverse reactions) • May consider alternatives (e.g., prochlorperazine, haloperidol) depending on goals of care