Palliative Care Nurse Practitioner Sydney Adventist Hospital. DRUG FORMULARY for JULIE EDWARDS. Palliative Care Nurse Practitioner

Transcription

1 Palliative Care Nurse Practitioner Sydney Adventist Hospital DRUG FORMULARY for JULIE EDWARDS Palliative Care Nurse Practitioner Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 1 of 27

2 The formulary provides for the poisons and restricted substances that may be possessed, used, supplied or prescribed by JULIE EDWARDS as a Nurse Practitioner under Section 17A of the Poisons and Therapeutic Goods Act 1966 (1) and the Poisons and Therapeutics Goods Regulation 2008 (2) It is the Nurse Practitioners responsibility to use this formulary in conjunction with the most recent MIMS/MIMS Online (3), Australian Medicines Handbook (4) and Therapeutic Guidelines: Palliative Care (5). Any alteration must be submitted to the Chief Nursing and Midwifery Officer (CNMO) NSW for approval. This document is invalid if any alterations or amendments are made without the approval from the CNMO NSW.. Introduction: The Palliative Care Nurse Practitioner (PCNP): Has the authority to prescribe, administer, use, supply and possess medications detailed in this PCNP Drug Formulary. Will utilise the most recent and appropriate resources to obtain information on compatibilities of drugs used in continuous subcutaneous infusions. May prescribe end of life medications on the community medication chart prior to discharge, for patients returning home, after consultation with and approval from the patients treating specialist. May convert routes of administration Will document in the medical records whenever a medication change is made. A physical assessment will be included as part of the documentation process. Will seek advice from the palliative care consultant to discuss appropriate management for complex patients and for those patients not responding as expected to treatment changes. Acknowledgement:This Formulary has been adapted from previous work developed by Judith Jacques - Nurse Practitioner Palliative Care - CCLHD; Pauline Davis Nurse Practitioner Palliative Care SWSLHD;Debbie White Nurse Practitioner Palliative Care MNCLHD; Pauline Wilson - Palliative Care Nurse Practitioner SWCN. Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 2 of 27

3 Dosages are in accordance with the Therapeutic Guidelines Palliative Care and Australian Medicines Handbook. = Oral; SL = Sublingual; SC = Subcutaneous; IM = Intramuscular; IV = Intravenous; PR = Per Rectum; TOP = Topical. Drug (Generic name) Route Therapeutic Class Clinical Presentation Poisons Analgesia Non-opioid Paracetamol Simple analgesic 1. Mild pain S2 / caplet Antipyretic 2. Co-analgesic 500mg 3. Fever Paracetamol Simple analgesic 1. Mild to moderate pain S2 Antipyretic 2. Osteoarthritis (modified release 665mg) Paracetamol PR Simple analgesic 1. Mild to moderate pain (when oral route not available) S2 Suppositories Antipyretic 2. Co-analgesic 500mg 3. Fever Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 3 of 27

4 Analgesia Opioid Paracetamol/Codeine Phosphate Combination Simple Analgesic Mild to moderate pain S3 500mg/ 8mg Paracetamol/Codeine Phosphate Opioid analgesic Moderate Severe Pain 500mg/ 30mg Fentanyl Opioid Analgesic Moderate severe breakthrough pain S8 Lozenge Various strengths Fentanyl Transdermal Patch Various strengths TOP Opioid Analgesic Severe pain Patient education on placement and changing of patch. S8 Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 4 of 27

5 HYDROmorphone Liquid Opioid Analgesic 1. Severe pain 2. Breakthrough pain S8 HYDROmorphone Opioid Analgesic 1. Severe pain S8 Sustained release tablet HYDROmorphone Injection SC Opioid Analgesic 1. Severe pain 2. Breakthrough pain 3.Pain management; end of life care S8 Morphine (Immediate Release) Liquid / Morphine (Sustained Release) / Granules Opioid Analgesic 1. Moderate to severe pain 2. Breakthrough pain 3. Dyspnoea Opioid Analgesic 1. Moderate to severe pain 2. Dyspnoea S8 S8 Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 5 of 27

6 Morphine Sulphate Injection SC Opioid Analgesic 1.Moderate to severe pain 2. Breakthrough pain 3. Dyspnoea S8 Morphine Tartrate Injection SC Opioid Analgesic 1. Moderate to severe pain S8 Morphine 0.1% Infused hydrogel Oxycodone IR (immediate release) / capsule/ liquid Various strengths 2. Breakthrough pain 3. Dyspnoea TOP Opioid Analgesic 1. Painful wound 2. Painful pressure area Opioid Analgesic 1. Moderate to severe pain 2. Breakthrough pain S8 S8 Oxycodone Opioid Analgesic Moderate to severe pain S8 SR (sustained release) Various strengths Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 6 of 27

7 Oxycodone hydrochloride and naloxone hydrochloride dehydrate (Targin) Opioid Analgesic Moderate to severe pain S8 Various strengths Opioid Antagonist Naloxone Injection Anti-infectives IM/SC/ IV Opioid Antagonist Reversal of opioid overdose; opioid induced respiratory depression: respirations < 8 min NB: Before use consider other causes of sedation or delirium (eg: sepsis) (American Pain Society) Amphotericin Antifungal Oral/oesophageal candidiasis Lozenge Fluconazole Antifungal Systemic candidiasis Capsule Miconazole 20mg/ ml Antifungal Oropharyngeal candidiasis S3 Gel (Daktarin) Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 7 of 27

8 Nystatin 100,000 units/ml Antifungal Oral / oesophageal candidiasis S3 Suspension Sodium Bicarbonate Mouthwash Sodium Hyaluronate Gel TOP Mouthwash Oral candidiasis Unscheduled TOP Antifungal oral lesions, oral mucositis/stomatitis S3 (Gelclair) Clotrimazole TOP Antifungal Vulvovaginal candidiasis S3 Vaginal Cream Clotrimazole 1% Hydrocortisone 1% TOP Antifungal Fungal infections, dermatitis S3 Metronidazole Gel TOP Antibacterial Malodorous malignant wounds Amoxycillin Penicillin Exacerbation chronic bronchitis; pneumonia; sinusitis Capsule, suspension Broad spectrum Amoxycillin with Clavulanic Acid ; suspension Penicillin Broad spectrum URTI; Pneumonia, sinusitis, UTI Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 8 of 27

9 Cephalexin Capsule; suspension Cephalosporin Moderate Spectrum Staphylococcal and streptococcal infection in people with mild moderate penicillin allergy UTI Metronidazole / suspension Antibacterial Systemic management of malignant malodorous wounds Roxithromycin Macrolides Upper and lower respiratory tract infection Trimethoprim Antibacterial Acute uncomplicated urinary tract infection. Anticholinergics Glycopyrrolate Injection SC Anticholinergic 1. Patients not responding or unlikely to respond to Hyoscine; for management of respiratory secretions in the terminal phase. 2. Management of respiratory secretions in conscious and alert patients. 3. Management of drooling in MND patients Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 9 of 27

10 HyoscineButylbromide Injection SC Antispasmodic Anticholinergic 1. Management of respiratory secretions in the conscious patient. 2. Management of painful colic in malignant bowel obstruction 3. Reduction of gastric secretions HyoscineHydrobromide SC Anticholinergic Management of terminal respiratory secretions Injection Antidiarrhoeals Diphenoxylate 2.5 mg Antidiarrhoeal Diarrhoea S3 Atropine Sulphate 25mcg Loperamide Antidiarrhoeal Diarrhoea S2 Capsules Antiemetics Cyclizine / SC Antihistamine Nausea and Vomiting Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 10 of 27

11 Dexamethasone /SC Corticosteroid Nausea and vomiting / Injection Domperidone Antiemetics Nausea and vomiting Reflux Haloperidol /SC/ IV Antipsychotic Nausea and vomiting / Injection Butyrophenone Lorazepam SL Anxiolytic Anticipatory Nausea and vomiting D Levomepromazine Injection SC Antipsychotic, antiemetic 1. Nausea and Vomiting 2. Terminal agitation Metoclopramide / Injection / SC/ IV Antiemetic 1. Nausea and vomiting 2. Persistent hiccups 3. Reflux Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 11 of 27

12 Prochlorperazine / Suppositories / PR/ SC/ IM Antiemetic Nausea and vomiting Antihistamine Promethazine / IM/ SC Antihistamine 1. Pruritis 2. Nausea and vomiting S3 Anti-inflammatory Steroidal Dexamethasone Injection / SC/ IV Corticosteroid 1. Pain associated with tumour related oedema 2. Cerebral Oedema 3. Spinal cord compression 4. Superior vena cava obstruction 5. Acute airways obstruction / dyspnoea 6. Malignancy related gastrointestinal obstruction 7. Appetite stimulant and feeling of well being Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 12 of 27

13 Prednisone Anti-inflammatory Non steroidal Corticosteroid 1. Airways obstruction / dyspnoea 2. Inflammatory disease 3. Appetite stimulate Celecoxib Non-steroidal anti-inflammatory 1. Pain Capsule Selective COX-2 Inhibitor 2. Co-analgesic Cyclizine / SC Antihistamine nausea and vomiting Diclofenac Non-steroidal anti-inflammatory 1. Pain Nonselective 2. Co-analgesic Diclofenac PR Non-steroidal anti-inflammatory 1. Pain Suppository Nonselective 2. Co-analgesic Ibuprofen Non-steroidal anti-inflammatory 1. Pain S2 Nonselective 2. Co-analgesic. 3. Fever Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 13 of 27

14 Ketoralac SC/ IM Non-steroidal anti-inflammatory Severe pain Injection Nonselective Always cover with PPI. Avoid if renal impairment, peptic ulcer, oesophagitis, GORD Meloxicam COX 2 inhibitor Pain Non-steroidal anti-inflammatory Naproxen / PR Non-steroidal anti-inflammatory Pain co-analgesic Nonselective Related to inflammation, bony pain Antipsychotics Haloperidol Antipsychotic Delirium / Injection Antispasmodics Hyoscinebutylbromide SC Antispasmodic and motility agent Colic related to bowel obstruction Injection Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 14 of 27

15 Hyoscinebutylbromide Antispasmodic and motility agent Colic related to bowel obstruction Anxiolytics Benzodiazepines Alprazolam Anxiolytic Anxiety or panic associated with dyspnoea Anticipatory nausea D Clonazepam SL/ SC Anticonvulsant 1. Anxiety D Liquid/ injectable Anxiolytic 2. Myoclonus Sedative 3. Seizure prophylactic and acute treatment 4. Terminal agitation Diazepam Anxiolytic 1. Anxiety D s Muscle relaxant 2. Pain associated with skeletal muscle spasm Anticonvulsant 3. Seizure Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 15 of 27

16 Lorazepam / SL Anxiolytic 1. Anxiety or panic associated with dyspnoea 2. Agitation related to delirium not responding to Haloperidol alone D Midazolam SC Anxiolytic 1. Terminal restlessness D Injection Hypnotic 2. Seizure Sedative 3. Myoclonus 4. Agitation related to delirium 5. Sudden catastrophic event 6. Dyspnoea Laxatives Always prescribed with Opioids Prophylaxis and Treatment of Constipation Bisacodyl Laxative Constipation Unscheduled Stimulant Bisacodyl PR Laxative Constipation Unscheduled Suppository Stimulant Soft faeces on rectal examination not responding to oral laxatives Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 16 of 27

17 Docusate Laxative Constipation Unscheduled Stool softener Docusate + sennoside B tablets (Coloxyl with Senna) Laxative Softener+ stimulant Constipation Unscheduled Glycerol PR Laxative Constipation Unscheduled Suppositories Osmotic Hard faeces on rectal examination Lactulose Laxative Constipation Unscheduled Syrup Osmotic Liquid Paraffin Laxative Constipation Unscheduled (Agarol) Softener Macrogol 3350, Potassium Chloride, Sodium Bicarbonate, Sodium Chloride Laxative Polyethylene glycol 1. Constipation 2. Faecal Impaction Unscheduled (Movicol) Powder Macrogol 3350 Laxative 1. Constipation Unscheduled (Osmolax) Osmotic 2. Faecal impaction Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 17 of 27

18 Methylnaltrexone Injection SC Laxative Opioid induced constipation that has not responded to other laxatives Sorbital 3.125g, sodium citrate 450mg, sodium lauryl sulfoacetate 45mg;(Microlax enema) PR Laxative Osmotic 1. Constipation 2. Faecal impaction Unscheduled Sodium Phosphate PR Laxative Constipation unresponsive to other treatments Unscheduled (Fleet ready-to-use enema) Osmotic Neuropathic Agents Gabapentin Antiepileptic 1. Refractory neuropathic pain 2. Uraemic pruritus 2 to renal failure 3. Restless legs syndrome 2 to renal failure Nortriptyline Antidepressant Neuropathic Pain Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 18 of 27

19 Pregabalin Antiepileptic Neuropathic pain Sodium Valproate Anticonvulsant Neuropathic Pain Protein-pump inhibitors Esomeprazole / Injection Omeprazole / Injection / IV Proton Pump Inhibitor 1. Gastro-oesophageal reflux disease 2. Protection from gastrointestinal irritation from antiinflammatory medication / IV Proton Pump Inhibitor 1. Gastro-oesophageal reflux disease 2. Protection from gastrointestinal irritation from antiinflammatory medication Pantoprozole / Injection / IV Proton Pump Inhibitor 1. Gastro-oesophageal reflux disease 2. Protection from gastrointestinal irritation from antiinflammatory medication Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 19 of 27

20 Miscellaneous Baclofen s Normal Saline 0.9% For infusion Normal Saline 0.9% KCL 30 mmol For infusion Skeletal muscle relaxant 1.Pain associated with skeletal muscle spasm particularly in MND 2. Hiccups SC/ IV 1. Dehydration 2. Comfort measures SC/ IV 1. Rehydration 2. Physiological K+ replacement Oxygen Dyspnoea, breathlessness Tranexamic Acid Antifibrinolytic 1. Profuse bleeding from malignant wound 2. Haemoptysis; vaginal or rectal bleeding secondary to local tumour invasion Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 20 of 27

21 Notes: 1. Patients in the terminal phase of their disease will have the reduced ability or inability to swallow medications. The Palliative Care Nurse Practitioner will reduce or cease oral medications and change to an alternate route as appropriate. This process is undertaken in an informative, collaborative manner with the patient, family, carers and the treating Medical Practitioner(s). The same approach will also be taken for the cessation of artificial nutrition and/or hydration. References: 1. Poisons and Therapeutic Goods Act (1966) Section 17A 2. Poisons and Therapeutic Regulation (2008) 3. MIMS Online: 4. Australian Medicines Handbook (2011) AMH Adelaide 5. Therapeutics Guidelines, Palliative Care Version 3 (2010) eviq Opioid Calculator Therapeutic Guidelines, Analgesia Version 5 (2007) Therapeutic Guidelines, Psychotropic Version 6 (2008) Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 21 of 27

22 Available Opioid Formulations and Equivalency The following is a list of the currently available opioid formulations in Australia. Preparations are available as immediate release or as modified released formulations. Modified-release formulations should never be crushed or chewed, as this destroys their release properties and can result in a large dose being absorbed over a short period. Please note that all conversions listed are a guide only and may vary according to the clinical situation, condition of the patient and previous analgesic requirements. Opioid Trade name Release Rate Formulation Oral morphine () equivalent dose* Buprenorphine Norspan Slow Release 5, 10 and 20 mcg/hr transdermal (TD) patch 50 mg morphine = 20 mcg TD patch Codeine Immediate 30 mg tablets 7.5 mg morphine = 60 mg codeine Codeine Codeine/Paracetamol eg.panadeine Forte ** Immediate 30/500 mg tablets 2 tablets = 7.5 mg morphine Codeine/Paracetamol eg.panadeine ** Immediate 8/500 mg tablets 2 tablets = 2 mg morphine Fentanyl Durogesic Fentanyl Sublimaze Slow Release 12, 25, 50, 75 and 100 mcg/hr transdermal (TD) patch Conversions from transdermal fentanyl to other opioids are imprecise and poorly studied. The calculator uses conversion figures provided by the manufacturer. Immediate 50 mcg/ml injection 25 mg morphine= 100 mcg fentanyl Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 22 of 27

23 2, 4 and 8 mg tablets 10 mg morphine = 1.67 mg Dilaudid Dilaudid Immediate 1 mg/ml oral liquid 10 mg morphine = 1.67 mg Dilaudid Hydromorphone 2 mg/ml and 10 mg/ml injection 20 mg morphine = 1 mg IV Dilaudid Dilaudid-HP Immediate 10 mg/ml injection 20 mg morphine= 1 mg IV Dilaudid Jurnista *** Slow Release 4, 8, 16, 32 and 64 mg tablets 4 mg Jurnista = 24 mg morphine Sevredol Immediate 10 and 20 mg tablets Direct equivalent Anamorph Immediate 30 mg tablets Direct equivalent Ordine Immediate 1mg, 2mg, 5mg and 10mg/ml oral solution Direct equivalent Kapanol Slow Release 10, 20, 50 and 100 mg capsules Direct equivalent Morphine Momex-SR Slow Release 10, 30, 60, 100 mg tablets Direct equivalent MS Mono Slow Release 30, 60, 90 and 120 mg capsules Direct equivalent MS Contin Suspension Slow Release 20, 30, 60, 100 and 200 mg sachets Direct equivalent MS Contin Slow Release 5, 10, 15, 30, 60, 100 and 200 mg tablets Direct equivalent Morphine sulfate Immediate 5, 10, 15, 30 mg/ml injection 25 mg morphine = 10 mg IV morphine Morphine tartrate Immediate 80 mg/ml injection 25 mg morphine = 10 mg IV morphine Endone Immediate 5 mg tablets 15 mg morphine = 10 mg Endone Oxycodone OxyNorm Immediate 5, 10, and 15 mg capsules 1 mg/ml oral solution 15 mg morphine = 10 mg OxyNorm OxyContin Slow Release 5, 10, 15, 20, 30, 40 and 80 mg 15 mg morphine = 10 mg OxyContin Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 23 of 27

24 tablets OxyNorm Immediate 10 mg/ml and 20 mg/2ml injection 20 mg morphine = 8 mg IV OxyNorm Tramal Zydol Immediate 50 mg capsules 10 mg morphine = 50 mg Tramadol Tramal Immediate 50 mg/ml injection 10 mg morphine = 50 mg Tramadol Tramadol Tramal SR Zydol 12 hour Slow Release 50, 100, 150 and 200 mg tablets 10 mg morphine = 50 mg Tramadol Durotram XR 24 hour Slow Release 100, 200 and 300 mg tablets 10 mg morphine = 50 mg Tramadol * Based on the conversions used in the eviq Opioid Calculator ** Combination products are not in the eviq calculator as there is no conclusive evidence that combination analgesics containing lower doses of codeine with paracetamol, aspirin or ibuprofen have any benefits over these non-opioids alone. *** The safety and efficacy of Jurnista in children and adolescents under the age of 18 has not been established. Until further experience is gained, Jurnista must not be used in this population Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 24 of 27

25 CONVERSION OF MORPHINE Q4H TO A FENTANYL PATCH Oral morphine range q4h Fentanyl dose mcg/hr < 20mg 25mcg patch 20-35mg 35-50mg 50-65mg 65-80mg 80-95mg mg mg mg mg 50mcg patch 75mcg patch 100mcg patch 125mcg patch 150mcg patch 175mcg patch 200mcg patch 225mcg patch 250mcg patch Ensure patch is calculated using q4h morphine dose To determine the appropriate Fentanyl patch, divide the 24hr oral dose by 3 Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 25 of 27

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27 NURSE PRACTITIONER FORMULARY ENDORSEMENT: Approved By: Name Signature Date: Nursing Council Chairperson Moran Wasson Pharmacy and Drug Committee Chairperson Dr Jeanette Conley Palliative Care Specialist (Collaborative arrangement) Dr Gillian Rothwell Medical Advisory Committee Chairperson Executive Committee Chairperson Dr L Giutronich Dr Leon Clark Julie Edwards Palliative Care Nurse Practitioner Drug Formulary SAH Page 27 of 27