ANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL IMPAIRMENT

Transcription

1 ANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL Doses of opiates must be proptional to current analgesic medication Please refer ALL patients on Methadone Ketamine to SPCT f advice. Patients on fentanyl patch should continue patch in addition to the following guidelines Do not stop opiates in patients who are taking them regularly PAIN Patient has pain which is not controlled Patient has no pain pain which is well controlled Is patient already taking al opiates? Is patient already taking al opiates? YES NO YES NO 1) If patient is already taking strong opiates start syringe driver as per conversion chart contact the Specialist Palliative Care Team f advice Administer ALFENTANIL micrograms PRN SC 1-2 hourly. If ALFENTANIL unavailable prescribe: OXYCODONE 1-2 milligrams SC stat and 2-4 hourly PRN MORPHINE milligrams SC stat 2-4 hourly 1) If patient is already taking strong opioids it is essential to convert to syringe driver as per conversion chart contact the Specialist Palliative Care Team f advice 1) Prescribe ALFENTANIL micrograms SC stat and PRN 1-2 hourly. If AFENTANIL unavailable prescribe OXYCODONE 1-2 milligrams SC stat and PRN 2-4 hourly MORPHINE milligrams SC stat and PRN 2-4 hourly 2) Start ALFENTANIL 500 micrograms 1 milligram in a syringe driver over 24 hrs. PRN dose should be approx. 1/6 th of the 24 hr dose of ALFENTANIL in syringe driver and this dose should be prescribed 1-2 hourly. 3) OXYCODONE 5 milligrams in a syringe driver over 24 hrs, PRN dose should be 1/6 th of the 24 hr dose of Oxycodone in syringe driver 2) If two me doses are required over 24 hours start a syringe driver of ALFENTANIL 500 micrograms 1 milligram/24 hrs SC. PRN dose of Alfentanil should be equal to 1/6 th of the 24 hr dose of Alfentanil in syringe driver every 1-2 hours. Many opioid analgesics and their metabolites may accumulate in renal failure causing toxicity. To convert from other strong opioids to Alfentanil contact Palliative Care Team Pharmacy f advice. Renal anticipaty flow charts 1

2 Contact NNUH Palliative Care Team 7 days / week 9-5 on Ext 3227 DECT 7181 Out of hours contact Palliative Care Advice Line OPIOID CONVERSION TABLE Opioid equivalent doses (Note: There is no exact equivalence between opioids therefe starting low and titrating upwards is recommended safe practice) N.B. Please refer ALL patients on Methadone Ketamine to the palliative care team f advice Approximately equivalent opioid doses f PRN ( as required ) use ORAL MORPHINE 4 milligrams ally 8 milligrams ally DIAMORPHINE 1.25 milligrams 2.5 milligrams MORPHINE 2 milligrams 4 milligrams ALFENTANIL 125 micrograms 250 micrograms Note: Alfentanil has a very sht half life and doses may only last 1-2 hours OXYCODONE 1 milligram 2 milligrams Note: Do not use these equivalent doses f larger doses without specialist palliative advice, as the small numbers entailed have been rounded up Approximately equivalent opioid doses f starting doses in continuous subcutaneous infusions Starting doses should be based on pri opioid requirements, and titrated upwards accding to the amount of subsequent PRN doses required in addition to the continuous infusion there is no upper limit provided the pain is responding well to the opioid, and there are no symptoms signs of adverse effects toxicity. Most patients with renal failure require only low doses if the dose is escalating, advice should be sought from the Palliative Care Team DIAMORPHINE 5-10 milligrams Do not use Diamphine in continuous infusion because of the high risk of accumulation and adverse effects MORPHINE 8-16 milligrams Do not use Mphine in continuous infusion because of the high risk of accumulation and adverse effects ALFENTANIL 500 micrograms-1 milligram OXYCODONE 4-8 milligrams Renal anticipaty flow charts 2

3 D ANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL Doses must be proptional to current benzodiazepine medication TERMINAL RESTLESSNESS AND AGITATION 1) Give a stat dose of MIDAZOLAM 2.5 5mg SC and prescribe this to be used 2-4 hourly PRN. 1) Prescribe PRN dose of MIDAZOLAM 2.5 5mg SC 2-4 hourly 2) Start MIDAZOLAM 10mg in a syringe driver/24 hrs SC 3) Review the required medication after 24hrs and, if the patient has needed breakthrough doses, then consider increasing the MIDAZOLAM in the syringe driver by at least the amount of PRN medication required in the last 24 hours. 4) Continue to give PRN doses accdingly. 2) If two me doses required PRN, consider use of a syringe driver over 24hrs incpating the amount given in the last 24 hours If patient unable to tolerate benzodiazepines use Levomepromazine 6.25mg stat SC and 2-4hrly PRN SC. If > 2 doses required in 24 hours start syringe driver of Levomepromazine 12.5mg/24 hrs F further advice please contact the Palliative Care Team Pharmacy f advice Contact NNUH Palliative Care Team 7 days / week 9-5 on Ext 3227 DECT 7181 F out of hours advice contact the Palliative Care Advice Line Renal anticipaty flow charts 3

4 ANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL RESPIRATORY TRACT SECRETIONS 1) Give a stat dose of HYOSCINE BUTYLBROMIDE 20mg SC 2) Start HYOSCINE BUTYLBROMIDE 60mg/24 hrs SC in a syringe driver 3) Continue to give PRN dose HYOSCINE BUTYLBROMIDE 2-4 hourly if needed 1) Prescribe PRN HYOSCINE BUTYLBROMIDE 20mg SC 2-4 hourly 2) If two me doses of PRN HYOSCINE BUTYLBROMIDE required, then start a syringe driver with 60mg SC over 24 hours 4) Increase total 24hr dose to 120 mg equivalent to the PRN doses administered in previous 24 hours. Avoid using Hyoscine in patients with severe cardiac failure as this can increase arrhythmias. F patients with severe cardiac failure use Glycopyronium Bromide 200 micrograms stat SC and 600 micrograms/24 hours in syringe driver if required F further advice please contact the Palliative Care Team Pharmacy f advice. Contact NNUH Palliative Care Team 7 days /week 9-5 on Ext 3227 DECT 7181 Renal anticipaty flow charts 4

5 F out of hours advice contact the Palliative Care Advice Line ANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL Doses must be proptional to current anti-emetic medication NAUSEA AND VOMITING 1) Give a stat dose of LEVOMEPROMAZINE 6.25mg 2) Start LEVOMEPROMAZINE 12.5mg /24hrs SC via a syringe driver. 3) Prescribe LEVOMEPROMAZINE 6.25mg SC PRN 2-4 hourly. 1) Prescribe LEVOMEPROMAZINE sc 6.25mg 2-4 hourly PRN 2) Review after 24 hours if 2 me doses administered please start syringe driver of mg LEVOMEPROMAZINE / 24hrs SC 4) Review dosage after 24hrs. If the patient is still nauseated/vomiting has required breakthrough doses, then consider increasing the dose of LEVOMEPROMAZINE in the syringe driver to a maximum of 25mg. Alternative anti-emetics HALOPERIDOL 2.5mg SC STAT and 5mg/ 24 hrs via a syringe driver SC CYCLIZINE 50mg SC PRN and mg / 24 hrs via syringe driver SC ( not compatible with hyoscine butylbromide high doses of Oxycodone) F further advice please contact the Palliative Care Team Pharmacy f advice. Renal anticipaty flow charts 5

6 Contact NNUH Palliative Care Team 7 days / week on Ext 3227 DECT 7181 F out of hours advice contact the Palliative Care Advice Line ANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL Doses must be proptional to current opiate/ benzodiazepine medication DYSPNOEA (Breathlessness) Is patient taking al opioids? Prescribe ALFENTANIL 125 micrograms SC PRN 2-4 hourly If Alfentanil is unavailable use: Yes Convert to Alfentanil using conversion chart contact palliative care team f advice. NB Do not remove fentanyl patch No Start syringe driver of Alfentanil 1mg + Midazolam 5mg/24 hrs If patient is breathless and anxious/agitated consider the use of MIDAZOLAM 2.5mg SC stat 5-10mg/24 hrs via syringe driver. Prescribe Midazolam 2.5mg PRN SC 2hrly OXYCODONE 1-2 milligrams SC PRN 2-4 hourly MORPHINE milligrams SC PRN 2-4 hourly 4) Prescribe Midazolam 2.5 mg PRN 2hrly SC Caution Many of the opioid analgesics and their metabolites may accumulate in renal failure causing toxicity and Alfentanil is therefe the opioid of choice at the end of life. F further advice please contact the Palliative Care Team Pharmacy f advice. Contact NNUH Palliative Care Team 7 days / week 9-5 on Ext 3227 DECT 7181 F out of hours advice contact the Palliative Care Advice Line Renal anticipaty flow charts 6