Algorithms for Symptom Management In End of Life Care The Use of Drugs Beyond Licence (off label) -The Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK regulates the activity of the pharmaceutical company when marketing a drug. -Authorised drugs can be used legally in clinical situations that fall outside the remit of the organisation e.g. for a different age group, a different indication, a different dose or route or method of administration. This is known as off-label. -Many drugs used in palliative care are used off-label -Few medications are licensed for subcutaneous use but there is extensive experience of this route in palliative care -The registered medical practitioner prescribing outside marketing authorisation should demonstrate that their practice accords with an appropriate body of professional opinion such as that provided in the Palliative Care Guidelines and where appropriate discussed with the patient. Palliative Adult Network Guidelines 5 th Edition 2014 (http://www.fowh.org.uk/media/1146/symptom-control-guidelines-5th-edition.pdf) The recommended diluent for drugs administered by continuous subcutaneous infusion via a syringe driver is water for injection (WFI) and this must be prescribed. Subcutaneous infusions for end of life care should be run over 24 hours. Administration of prn medications should start with the lowest dose prescribed. For information and advice please contact the Hospital Palliative Care Team (HPCT) Ext: 3807
Anticipatory Prescribing for Dyspnoea (Breathlessness) Is the patient breathless? Is the patient already taking oral Morphine? Prescribe regular Medication: Total previous 24 hour oral Morphine dose (regular and PRN) 2 = dose of Oral Morphine Capsules (Zomorph ) to be prescribed morning and evening (12 hours apart). Sulphate Oral Solution (Oramorph ) one sixth of regular 24 hour total dose as required 4 hourly Prescribe 2mg-5mg Morphine 10mg/5mls (Oramorph ) 4 hourly orally on as required section of drug chart If unable to swallow consider Morphine Sulphate s/c 1mg-2mg 4 hourly OR a syringe driver following discussion with HPCT If unable to swallow consider Morphine Sulphate s/c 1/2 of 4 hourly oral Morphine dose as required OR a syringe driver following discussion with HPCT If the patient is breathless and anxious consider sub lingual Lorazepam 500micrograms- 1mg as required 4 hourly (maximum dose: 4mg in 24 hours, 2mg in 24 hours for elderly patients) OR Midazolam 2mg-5mg s/c as required 4 hourly There are two strengths of Oramorph, 10mg/5mls and 100mg/5mls (concentrated). Please prescribe dosage in milligrams.
Anticipatory Prescribing for Nausea and Vomiting Is the patient nauseous / vomiting? Prescribe Levomepromazine 5mg- 10mg s/c as required 4 hourly; maximum total dose 25mg/24hours Review after 24 hours and if regular doses have been required consider a syringe driver and refer to HPCT Prescribe Cyclizine 50mg orally 8 hourly as required Prescribe Levomepromazine 5mg-10mg s/c as required 4 hourly; maximum total dose 25mg/24hours Commence syringe driver with Levomepromazine 10mg and continue 5mg-10mg s/c as required 4 hourly; maximum total dose 25mg/24hours, refer to HPCT In patients with Parkinson s Disease please consider prescribing oral Domperidone 10mg- 20mg three to four times daily (maximum dose 80mg/24 hours) and if unable to swallow Ondansetron 4mg-8mg s/c 8 hourly (maximum dose 24mg/24 hours) Alternative antiemetics according to local policy and procedure may be prescribed e.g. Haloperidol s/c 0.5mg-1.5mg as required 4 hourly (1.5mg-5mg via s/c syringe driver over 24 hours) mixed in water for injection NOT sodium chloride 0.9% (maximum total dose 5mg/24 hours). Cyclizine s/c 50mg as required 8 hourly (150mg via s/c syringe driver over 24 hours mixed in water for injection NOT sodium chloride 0.9%) Cyclizine is not recommended in patients with heart failure. Maximum dose 150mg/24 hours Levomepromazine as a single drug subcutaneous infusion dilute with normal saline (licensed diluent). For continuous subcutaneous infusion with other drugs via a syringe driver dilute with water for injection (unlicensed use). Maximum dose 50mg/24hours.
Anticipatory Prescribing for Respiratory Tract Secretions Does the patient have audible respiratory tract secretions they are unable to cough and clear independently? Prescribe Glycopyrronium Bromide 200 micrograms s/c as required 4 hourly. Maximum total dose 1200micrograms /24 hours Prescribe Glycopyrronium Bromide 200 micrograms s/c as required 4 hourly. Maximum total dose 1200micrograms/24 hours Review after 24 hours and if regular doses have been required consider a syringe driver with Glycopyrronium Bromide 1.2mg (1200 micrograms) and refer to HPCT. Hyoscine Hydrobromide 400 micrograms s/c as required 4 hourly if Glycopyrronium Bromide is ineffective, contact HPCT. Avoid suction unless secretions are pooling in the mouth which can be removed with a Yankauer suction catheter
Anticipatory Prescribing for Pain Does the patient have pain? Is the patient already taking oral Morphine? Is the patient already taking oral Morphine? Total previous 24 hour oral Morphine dose (regular and PRN) 2 = dose of Oral Morphine capsules (Zomorph ) to be prescribed morning and evening. (Oramorph ) one sixth of regular 24 hour total dose as required 4 hourly Sulphate s/c 50% of 4 hourly oral Morphine dose as required OR a syringe driver following discussion with HPCT (Oramorph ) 2mg- 5mg as required orally 4 hourly. Review after 24 hours then total 24 hour oral Morphine dose 2 = dose of oral Morphine (Zomorph ) to be prescribed morning and evening (12 hours apart). (Oramorph ) one sixth of regular 24 hour total dose as required 2-4 hourly Sulphate s/c 50% of 4 hourly oral Morphine dose as required OR a syringe driver following discussion with HPCT Total previous 24 hour oral Morphine dose (regular and PRN) 2 = dose of Oral Morphine (Zomorph ) to be prescribed morning and evening (12 hours apart). Sulphate Oral Solution (Oramorph ) one sixth of regular 24 hour total dose as required 4 hourly Sulphate s/c 50% of 4 hourly oral Morphine dose as required OR a syringe driver following discussion with HPCT (Oramorph ) 2mg- 5mg as required orally 4 hourly. Sulphate 2mg-5mg s/c as required 4 hourly If a patient is already on a Fentanyl Patch or a Buprenorphine Patch please continue with it. Consider Alfentanil 2 hourly subcutaneously as required if severe renal failure e.g. stages 4-5 chronic kidney disease or severe acute renal impairment (caution in liver disease).
Anticipatory Prescribing for Terminal Agitation and Restlessness MIDAZOLAM MUST NOT BE ADMINISTERED INTRAVENOUSLY Is the patient displaying signs of agitation and restlessness Prescribe Midazolam 2mg-5mg s/c as required 4 hourly (request Midazolam 10mg / 2ml ampoules from Pharmacy on a named patient basis) OR consider a syringe driver following discussion with HPCT, usual starting dose 10mg/24hours. Prescribe Midazolam 2mg-5mg s/c as required 4 hourly (request Midazolam 10mg / 2ml ampoules from Pharmacy on a named patient basis). If Midazolam unavailable on the ward consider prescribing: Levomepromazine 10mg-25mg 4 hourly s/c as required and / or Diazepam 5mg-10mg 4 hourly per rectum as required (Maximum dose 60mg / 24 hours) If a patient has been on anticonvulsants and is unable to take them commence a subcutaneous syringe driver with Midazolam 20-30mg in water for injection over 24 hours and titrate according to symptoms