PRIMARY CARE PALLIATIVE CARE FORMULARY This formulary has been developed between West Essex CCG and the palliative care team at St Clare Hospice. The aim of the formulary is to ensure that medicines use is both clinically appropriate and cost-effective. The pharmacy will only routinely supply medicines included in the formulary because they have been determined to be the most appropriate in terms of efficacy, safety, patient acceptability, convenience and economy. For medication by subcutaneous injection and continuous subcutaneous infusion in General Practice refer to Appendix 1, page 8. For St Clare Hospice guide to equivalent s for opioid medications use in cancer pain refer to Appendix 2, page 13. GP advice line: run 24/7 at St Clare Hospice providing advice on symptom management. Phone: 01279 773773. The drugs are classified as follows: GREEN Appropriate for prescribing by General Practice. AMBER Prescribing should only be undertaken in General Practice under the advice of the local hospice or specialist palliative care team. RED Should only be initiated by hospice doctors. Prescribing can be continued in General Practice with appropriate monitoring; advice to be sought from hospice when required. Monitoring will be carried out on a monthly basis: FP10s will be monitored via epact. Medicines supplied for in-patient use will be monitored via invoices submitted to West Essex CCG. Use of medicines outside the terms of the license (i.e. off-label ) may be judged by the prescriber to be in the best interest of the patient. DRUG INDICATION ANY OTHER INDICATION DOSE ANALGESICS Buprenorphine patches Moderate to Severe Pain Titrate through range COMMENT Butec (7d release patch) for moderate, non-malignant pain unresponsive to non-opioid analgesics. Transtec (96h release patch) or Hapoctasin (72h release patch) for moderate to severe chronic cancer pain and severe pain unresponsive to non-opioid analgesics. Max. 2 patches can be used at any one time. At low step 2 of WHO ladder and at higher, it would be 3rd step for WHO ladder. Buprenorphine is highly lipid-soluble making it suitable for TD delivery. Appears to act as full agonist in therapeutic range; other opioids can be used for breakthrough pain. 1
Co-codamol 30/500 Mild to Moderate pain 1 to 2 every 4hrs Max: 8 in 24hrs Codeine Phosphate Mild to Moderate pain Diarrhoea Cough Pain: 30 to 60 mg every 4hrs Max daily : 240 mg Diarrhoea: 30 mg qds Cough: 5 to 10 ml qds (linctus) Fentanyl patches Severe pain Transdermal systems Requires titration Morphine po Moderate to Severe Pain Breathlessness Cough Diarrhoea Titrate Usual starting : 5 to 10 mg every 4hrs Oxycodone po Moderate to Severe Pain Breathlessness Titrate Usual starting : 2.5 to 5 mg every 4hrs Paracetamol Mild to Moderate pain Fever PO or PR: 0.5 to 1 g every 4 to 6hrs Effervescent only in dysphagia. Approximately one tenth potency of morphine. Some Caucasians are poor metabolisers of codeine, other ethnic groups may be extensive or ultra-metabolisers. Combination product (Codeine + Paracetamol). Approximately one tenth potency of morphine. Some Caucasians are poor metabolisers of codeine, other ethnic groups may be extensive or ultra-metabolisers. Where transdermal fentanyl is necessary, prescribe a matrix patch. Durogesic, Matrifen, Mezolar, Osmanil and Vitanyl are interchangeable and the product with the lowest acquisition cost should be used. 72h release patch. Local recommendation: prescribe Matrifen. Brand prescribing recommended. Immediate release preparations Oramorph solution, Sevredol and for modified release preparations Zomorph capsules (except 5mg - only available as MST tablets). Reduce in the elderly and patients with renal impairment. Morphine intolerant only. Prescribe Longtec for the MR form and Shortec or Oxynorm liquid for immediate release. Reduce in the elderly and patients with renal impairment. Soluble only in dysphagia. Max 4 g in 24hrs Tramadol Moderate to Severe Pain 50 to 100 mg every 4 hrs Max 400 mg/d Fentanyl sublingual tablet Breakthrough cancer pain Trans-mucosal systems Requires titration Prescribe Marol for the MR form. At low step 2 of WHO ladder and at higher, it would be 3rd step for WHO ladder. Abstral only when oral morphine not suitable (if more than 4 episodes of breakthrough pain each day, background pain control should be adjusted). Trans-mucosal opioids are licensed for breakthrough cancer pain in patients on background opioid maintenance therapy. It is not possible to ensure interchangeability of the different formulations hence if switching re-titration is recommended. Nefopam Moderate pain 30mg to 90 mg tds Relief of persistent pain unresponsive to other non-opioid analgesics. 2
Methadone Severe pain Linctus available for cough Titrated Consider prescribing a laxative with the above medications (excluding Paracetamol) due to constipating effect ANALGESICS - Neuropathic pain Amitriptyline Neuropathic pain Depression Bladder spasm Depression: 75 mg to 100mg/d Neuropathic pain: start 10 to 25 mg/d titrate to 75 mg/d Exceptional complex patients unresponsive to other opioids. Long half-life. Can be used in renal failure. Caution if switching from another opioid as conversion factor highly variable and often dependant. Switching is best done with specialist support and if possible as an inpatient. Blocks the presynaptic re-uptake of serotonin and noradrenaline. Adjuvant analgesic for neuropathic pain. Analgesic effect usually seen at lower s and more quickly than antidepressant effect; anticholinergic adverse effects may be troublesome. Capsaicin cream Neuropathic pain 0.025% (Zacin ) or 0.075% (Axsain ) cream Apply sparingly up to tds/qds (not more often than every 4 h) Pregabalin Neuropathic pain Partial seizures Anxiety Initial range 25 mg od to 75 mg bd Lidocaine patches Neuropathic pain 5% w/w lidocaine (700 mg) 1 to 3 patches for 12 h a day ANALGESICS - NSAIDs Ibuprofen Mild to Moderate pain Inflammation Initial 300 to 400mg tds/qds Naproxen Mild to Moderate pain Inflammation PO: 0.5 to 1 g/d in 1 or 2 divided s Affects the synthesis, storage, transport and release of substance P in pain fibres. Start with lowest strength and wear gloves to administer. NB/ A self-adhesive patch containing capsaicin 8% (Qutenza ) is licensed for the treatment of peripheral neuropathic pain in nondiabetic patients restricted use. Pregabalin should only be prescribed for the treatment of neuropathic pain under the brand name Lyrica. Dose optimisation using the most appropriate strength. In normal renal function: 75 mg bd on day 1, 150 mg bd daily on days 3 7, then 300 mg bd days 10 14, then increased according to response > Max 600 mg/d OR 25 mg on on day 1, 25 mg bd on day 2, 75 mg bd on days 6 7, then increase by 25 mg bd every 2 days as needed to a maximum of 600 mg/d. Versatis - only for use in localised pain in patients unable to take oral medication due to a medical condition/disability. Post-herpetic neuralgia: apply plaster to intact, dry, non-hairy, nonirritated skin od for up to 12 h, followed by a 12-h plaster-free period; discontinue if no response after 4 weeks. Up to 3 plasters may be used to cover large areas; plasters may be cut. Has the lowest risk of serious GI side effects. Can be increased if necessary to max. 2.4 g/d; maintenance of 0.6 1.2 g/d may be adequate. Modified release preparation available (Brufen Retard 800 mg). Use IR unless clinical rationale for SR formulation. Intermediate risk of serious GI side effects prescribe with PPI. 3
Diclofenac Mild to Moderate pain Inflammation PO or PR: 75 to 150mg/d in divided s Celecoxib Mild to Moderate pain Inflammation Initial 100 mg bd and increase to 200 mg bd if required CV risk. Consider PPI if risk of peptic ulceration. Use IR unless clinical rationale for SR formulation. Associated with increased risk of thrombotic events thus not common practice to be initiated in the community. Discontinue after two weeks if no response. ANTIEMETICS Cyclizine po Nausea & vomiting 50 mg tds Useful for vomiting due to GI causes, or raised intracranial pressure. Domperidone po Nausea & vomiting 10 mg tds Prokinetic Not recommended for patients with underlying cardiac disease, risk of prolonged cardiac conduction intervals, congestive heart failure or already taking medications known to cause prolonged QT intervals. Also avoid in bowel obstruction. Haloperidol po Nausea & vomiting Psychosis Hiccup Restlessness Agitation Delirium Anti-emetic: initial 1.5 mg/d Anti-emetic: initial 1.5 mg/d stat & typical maintenance 1.5 to 3 mg/d; if necessary, increase progressively to 5 to 10 mg/d. Levomepromazine po Nausea, vomiting and sedative effect Psychosis Terminal agitation PO: 3 mg od/bd Nozinan / Restricted: Levinan (unlicensed & expensive; order for named patient only). First-line anti-emetic, start with 3 mg od/bd and if necessary, increase to 6 mg od/bd. Second line anti-emetic starting with 6 to 12.5 mg stat, and if necessary, increasing to 25 to 50 mg/24h. Metoclopramide po Nausea & vomiting Dyspepsia Reflex Hiccups PO: 10 mg tds Prokinetic Gastric irritation: 10 mg tds; prescribe appropriate gastro-protective drug. Delayed gastric emptying: 10mg tds Nausea and vomiting: 10 mg tds Increases gastric motility and gastric emptying. Use cautiously in GI obstruction. Ondansetron po pr Chemotherapy-induced nausea & vomiting Pruritus PO: 8 mg bd/tds PR: 16 mg/d If a 5-HT3-receptor antagonist is not clearly effective within 3 d, it should be discontinued. If clearly of benefit, continue indefinitely unless the cause is selflimiting. 4
ANXIETY Diazepam all presentations Anxiety Insomnia Muscle spasm Myoclonus Seizures Initial 2mg and titrate depending on effect for each indication Benzodiazepine with GABA-potentiating actions in the CNS. Long plasma half-life and several active metabolites. Anxiety: 2 to 10 mg PO, usual range 2 to 20 mg PO. Muscle spasm: 2 to 5 mg PO, usual range 2 to 20 mg PO. Anticonvulsant: 10 mg PR/IV, usual range 10 to 30 mg. Rectal solutions available. Short-term use only. Buspirone Anxiety Initial 5 mg tds Non-sedating anxiolytic. Response to treatment may take up to 2 weeks, discontinue if not effective. CONSTIPATION Bisacodyl po pr Stimulant laxative PO: 5 to 20 mg od PR: 10 mg prn Oral formulation works within 12hrs, rectal formulation within 1h. Avoid in bowel obstruction. Should be given in combination with Glycerol suppositories. Glycerol suppositories Lubricant laxative, also 4-g mould prn Should be given in combination with Bisacodyl suppositories. Stimulant laxative Macrogols Bowel cleansing Chronic constipation: 1 to 3 sachets/d Faecal impaction: 8 sachets/d Prescribe Laxido Inert polymers of ethylene glycol which sequester fluid in the bowel. Chronic constipation, 1 to 3 sachets daily in divided s usually for up to 2 w; contents of each sachet dissolved in half a glass (approx. 125 ml) of water; maintenance, 1 to 2 sachets/d Faecal impaction: 8 sachets/d dissolved in 1 l of water and drunk within 6 h, usually for max. 3 d. Phosphate enema Osmotic laxative 1 od Draws additional water from the bloodstream into the colon to increase the effectiveness of the enema, but can be rather irritating to the colon, causing intense cramping or "griping." 2nd line. Sodium citrate Osmotic laxative 1 od Micralax micro-enema - 2nd line. Docusate sodium Stimulant laxative PO: 100 mg bd and titrated to maximum 500 mg/d in divided s Soften stools and is weak stimulant. Acts in 1 to 2 days. Do not give with liquid paraffin. Rectal preparations not indicated if haemorrhoids or anal fissure. Liquid paraffin Faecal softener 10 to 30 ml od Named patient basis. Enhanced absorption with Docusate. Naloxegol Opioid-induced constipation 25 mg od Recommended by NICE TA 345 for Opioid Induced Constipation following a failure of a four week trial of conventional laxatives. This medicinal product is subject to additional monitoring. Patients should be advised that if they develop any sudden severe abdominal pain they should stop taking naloxegol and let the doctor know. They should also be warned of the potential of opioid withdrawal symptoms which should also be reported to their doctor immediately. 5
Senna liquid 7.5mg/5ml Stimulant laxative PO: 10 to 20 ml on 2nd line - only if Bisacodyl is unsuitable. Higher s frequently used by patients on opioids. Max 30 mg on but up to 60 mg reported. Often used on combination with a stool softener. Stimulant laxatives increase intestinal motility and often cause abdominal cramp; they should be avoided in intestinal obstruction. Arachis oil enema Faecal softener 1 PRN max od For faecal impaction. Acts by lubricating and softening the faeces, and promoting bowel movement. Avoid in peanut allergy or Inflammatory bowel disease. Methylnaltrexone Opioid-induced constipation Initial 8 mg (patients weighing 38 to 61 kg) or 12 mg (patients weighing 62 to 114 kg) DRY MOUTH Biotène oral balance Relief of dry mouth Apply up to 6 times a day Saliveze oral spray Relief of dry mouth Apply up to 6 times a day Saliva Orthana oral spray Relief of dry mouth Apply up to 6 times a day Initially give a single on alternate days. If there is no response, a second can be given after 24 h, but not more often. Alternatively the interval can be extended. About 50% patients defaecate within 4 h of a without impairment of analgesia or the development of withdrawal symptoms. Common undesirable effects include abdominal pain, diarrhoea, flatulence, and nausea. In severe renal impairment (creatinine clearance <30ml/min), the should be reduced. It is contra-indicated in the presence of known or suspected GI obstruction. GPs should seek advice on PRN basis if continuing treatment. Triple enzyme product Used for dry mouth caused by medications, diabetes, drug or radiation therapies, stress and depression. Aqueous solution of electrolytes present in concentrations similar to those found in human saliva. Used for dry mouth including dry mouth secondary to radiotherapy. Saliva Orthana is natural mucin-based saliva substitute. Formulated from naturally occurring mucin. ph neutral. Lasts for longer period than water based substitutes. GASTRO-INESTINAL TRACT Lansoprazole Anti-ulcer agent 15 to 30 mg od Orodispersible tablets should only be used when the patient has swallowing difficulties. Loperamide Acute diarrhoea Chronic diarrhoea Faecal incontinence 2 to 4 mg stat Acute diarrhoea, 4 mg initially followed by 2 mg after each loose stool for up to 5 days; usual 6 to 8 mg/d; max. 16 mg/d. Chronic diarrhoea: initially, 4 to 8 mg/d in divided s, subsequently adjusted according to response and given in 2 divided s for maintenance; max. 16 mg/d. Faecal incontinence [unlicensed indication], initially 500 mcg/d, adjusted according to response; max. 16 mg/d in divided s. Adverse effects include abdominal cramps, dizziness, drowsiness, and skin reactions. 6
Mebeverine Antispasmodic 135 mg tds Musculotropic antispasmodic drug without anticholinergic sideeffects. Should be taken 20 minutes before meals. Pancreatin Steatorrhoea Treatment of exocrine pancreatic insufficiency 1 to 2 capsules with meals Creon 10,000 Creon 25,000 Creon 40,000 Initiated at the lowest recommended and gradually increased. The dosage of Creon should be individualized based on clinical symptoms, the degree of steatorrhoea present, and the fat content of the diet. MISCELLANEOUS Aspirin Anticoagulation 75 to 150 mg od Dexamethasone po inj Nausea & vomiting, neuropathic pain, raised intracranial pressure due to cerebral oedema, anorexia, dyspnoea, SCC, SVCO Used for symptoms associated with pressure from tumour mass effect Daily ranges from 2mg to 16mg depending on indication Alendronic acid Bone pain & hypercalcaemia Osteoporosis 10 mg od 70 mg weekly Appetite and fatigue: 2 to 4 mg Nerve compression, vomiting, breathlessness: 8 to 12 mg. SCC, SCVO, raised intracranial pressure: 16 mg (sometimes higher). Metabolism accelerated by carbamazepine and phenytoin (reduced effect). Doses best given in the morning. Can be delivered by CSCI. Consider PPI if risk of peptic ulceration. Remember to give patient a steroid card. Tablets should be swallowed whole with plenty of water while standing or sitting. To be taken on an empty stomach 30 minutes before breakfast or other oral medications. Continue to sit up for 30 minutes after oral intake (breakfast or oral medication) as well. Enoxaparin Anticoagulation DVT: 1.5 mg/kg/24 hours Increased risk of bleeding in renal impairment and those who are underweight or overweight. Dose and duration in Palliative care to be carefully supervised. Ibandronic acid po Zoledronic acid inj Bone pain & hypercalcaemia Bone pain & hypercalcaemia SEDATIVES Lorazepam po inj Anxiety & insomnia Seizures Insomnia Anxiety Agitation 50 mg od Renal failure only. Prescribe generically. Tablets should be swallowed whole with plenty of water while standing or sitting. To be taken on an empty stomach 30 minutes before breakfast or other oral medications. Continue to sit up for 30 minutes after oral intake (breakfast or oral medication) as well. Beware of Osteonecrosis of Jaw. 4 mg every 3 to 4 w Inhibitor of osteoclastic bone resorption. Max response for hypercalcaemia seen after 4 days. Relief for bone pain can take up to 14 days. Osteonecrosis of the jaw a potential complication. 1 to 4 mg daily in divided s Insomnia: 2 to 4mg PO. Anxiety: 1 mg SL/PO stat and bd, if necessary, increase to 2 to 6 mg/24h. Acute psychotic agitation: 2 mg PO every 30 min until the patient is settled; often used with haloperidol or risperidone to control psychotic agitation. Zopiclone Insomnia 3.75 to 7.5 mg on Non-benzodiazepine hypnotic agent used in the treatment of insomnia. Side effects of taste disturbances including bitter metallic taste not uncommon. 7
PAIN RECOMMENDED STARTING DOSES OF MEDICATION BY SUBCUTANEOUS INJECTION AND CONTINUOUS SUBCUTANEOUS INFUSION FOR USE IN GENERAL PRACTICE Appendix 1 The medicines and s included here are intended only as a guide for prescribing. Other medicines or s may be used acco rding to individual need, local guidance and medicine availability. Always check medicine compatibilities if prescribing more than one medicine to be mixed in a syringe driver: http://www.palliativedrugs.com/index.html OR http://book.pallcare.info/index.php The following drugs should NOT be given by the subcutaneous route: antibiotics, NSAIDS (except ketorolac/diclofenac), diazepam, chlorpromazine Seek advice from your local hospice or specialist palliative care team: St Clare Hospice Tel: 01279 773773 INDICATION MEDICINE Initial / range for Bolus PRN injection Frequency Initial and range for continuous SC infusion over 24 hours Maximum total in 24 hours COMMENTS STRENGTH 1 st Line Morphine If opioid naïve, start with 2.5mg to 5mg Every 2 to 4 hours If opioid naïve, start with 5 to 10mg. If on oral morphine - calculate total morphine in last 24 hours including breakthrough s and divided by 2 Dose increases are not usually more than by 30 to 50% of previous No maximum but unusual to need more than 200mg Prescribe diluent (Water for Injections) to reconstitute If on opioid patch leave in place and continue to change as normal Poorer solubility of morphine may necessitate that when higher s are reached (>180mg), switch to Diamorphine to reduce syringe volume 5mg/ml 10mg/ml 15mg/ml 20mg/ml 30mg/ml 1ml and 2ml amps 1 st Line Diamorphine If opioid naïve, start with 2.5mg Every 2 to 4 hours If opioid naïve, start with 2.5mg to 5mg If on oral morphine, calculate total morphine-equivalent (including breakthrough s) and divide by 3 (Round down to whole number not up) Dose increases are not usually more than by 30 to 50% of previous No maximum but unusual to need more than 100mg May be incompatible with higher concentrations of haloperidol or midazolam. Prescribe diluent (water for injection) to reconstitute If on opioid patch leave in place and continue to change as normal Concentration-dependent incompatibility occurs with cyclizine or haloperidol at higher concentrations. Powder amps requiring reconstitution 10mg 30mg 100mg 500mg 8
ANXIETY / AGITATION / DELIRIUM PAIN MEDICINE 2 nd Line Oxycodone Initial / range for Bolus PRN injection If opioid naïve, start with 1.25mg to 2.5mg Frequency Every 2 to 4 hours Initial and range for continuous SC infusion over 24 hours If opioid naïve, start with 7.5mg Maximum total in 24 hours No maximum but unusual to need more than 100mg COMMENTS Contra-indicated in renal failure (creatinine clearance <10mL/min). Concentration-dependent incompatibility may occur when oxycodone is mixed with cyclizine - check compatibility charts STRENGTH 10mg in 1ml 20mg in 2ml 50mg in 1ml PAIN If on opioid patch leave in place and continue to change as normal 3 rd Line Alfentanil For use in stages 4 and 5 CKD - SPECIALIST ADVICE AND SUPERVISION REQUIRED 1 st Line Midazolam 2.5mg to 5mg Every 2 hours 2.5mg to 10mg 60mg Schedule 3 CD For s higher than 60mg, seek specialist advice Concentration-dependent incompatibility with cyclizine check compatibility tables Incompatible with dexamethasone 2mg in 2ml 5mg in 5ml 10mg in 2ml 10mg in 5ml 50mg in 10ml Avoid antipsychotics in dementia where possible. If unavoidable use lowest effective 25mg in 1ml Levomepromazine 25mg (12.5mg in elderly) Every 4 hours 25mg to 50mg 150mg Use with caution in Parkinson s Disease Concentration-dependent incompatibility may occur when mixed with dexamethasone check compatibility charts. 9
RESPIRATORY SECRETIONS ANXIETY/AGITATION/DELIRIUM MEDICINE Initial / range for Bolus PRN injection Frequency Initial and range for continuous SC infusion over 24 hours Maximum total in 24 hours COMMENTS STRENGTH Haloperidol Patient distress mild moderate and not an immediate danger to self or others: start with 500 microgram. If necessary, increase the progressively (e.g. 1mg 1.5mg etc Patient distress severe and/or an immediate danger to self or others: start with 1.5 3mg stat, possibly combined with a benzodiazepine (e.g midazolam),. If necessary, increase the further, e.g. 5mg. 2 hourly 2 hourly 2.5mg to 5mg 15mg AVOID IN PARKINSON S DISEASE Avoid antipsychotics in dementia where possible. If unavoidable use lowest effective Can cause potentially fatal prolongation of the QT interval and torsade de pointes. Avoid in patients with predisposing conditions (see BNF) The maintenance is based on the initial cumulative needed to settle the patient; usual maximum 5mg/24h. (terminal agitation Maintenance CSCI 10-15mg/24 hours) Concentration-dependent incompatibility occurs with dexamethasone, diamorphine, hydromorphone and morphine sulfate 5mg in 1ml 1 st Line Hyoscine Hydrobromide 400micrograms Every 4 hours 800microgrammes to 1200micrograms 2000 micrograms Can cause anticholinergic syndrome i.e.agitated delirium, drowsiness, ataxia Contraindicated in narrowangle glaucoma, prostatic hyperplasia, pyloric obstruction, paralytic ileus Blocks prokinetic effect of metoclopromide 400micrograms in 1ml 600micrograms in 1ml 10
NAUSEA / VOMITING RESPIRATORY SECRETIONS MEDICINE Initial / range for Bolus PRN injection Frequency Initial and range for continuous SC infusion over 24 hours Maximum total in 24 hours COMMENTS STRENGTH Glycopyrronium 200micrograms to 400micrograms Every 6 hours 600micrograms to 800micrograms 1200micrograms Use if no response to hyoscine hydrobromide Use with caution in conditions predisposing to tachycardia (e.g. thyrotoxicosis, heart failure, concurrent β2 agonists), and prostatism For s > 1200 micrograms seek specialist advice Inflammation at site of injection is common (>10%) Incompatible with Dexamethasone 200micrograms in 1ml 600micrograms in 3ml 1 st Line Haloperidol 1mg to 2.5mg Once or twice a day 2.5mg to 5mg 5mg AVOID IN PARKINSON S DISEASE See also under agitation/anxiety/delirium 5mg in 1ml Long half life, can be given as a single at night if sedation a problem Levomepromazine 6.25mg Once or twice a day 6.25mg to 12.5mg 25mg Concentration-dependent incompatibility may occur when mixed with dexamethasone check compatibility charts. 25mg in 1ml 10mg in 2ml Metoclopramide 10mg Every 4 hours 30mg to 40mg 100mg Do not use in intestinal obstruction prokinetic effect of metoclopramide blocked by antimuscarinics 11
MEDICINE Initial / range for Bolus PRN injection Frequency Initial and range for continuous subcutaneous infusion over 24 hours Maximum total in 24 hours COMMENTS STRENGTH Cyclizine 50mg Every 8 hours 100mg to 150mg 150mg Dilute in water for injection for CSCI. Incompatible with 0.9% saline. Avoid in heart failure Incompatibility may occur with cyclizine may precipitate 50mg in 1ml ANTI- SPASMODIC / INTESTINAL COLIC Hyoscine butylbromide 20mg Every 4 hours 60mg to 80mg 120mg Incompatibility may occur with cyclizine may precipitate 20mg in 1ml Morphine If opioid naïve, start with 2.5mg to 5mg Every 2 to 4 hours If opioid naïve, start with 5mg As for pain As for pain as for pain BREATHLESS- NESS Midazolam 2.5mg to 5mg Every 4 hours 5mg to 10mg 60mg Concentration-dependent incompatibility with cyclizine check compatibility tables Incompatible with dexamethasone As for anxiety / agitation / delirium DYSPEPSIA Ranitidine Every 24 hours 150mg to 300mg 300mg 25mg in 1ml GASTRIC SECRETIONS / BOWEL OBSTRUCTION PULMONARY OEDEMA Octreotide Every 24 hours 300mcg to 900mcg 1200mcg Furosemide 40mg to 80mg Once a day 80mg Commence after discussion with Specialist Palliative Care Team. Commence after discussion with Specialist Palliative Care Team. 50mcg in 1ml 100mcg in 1ml 200mcg in 1ml 500mcg in 1ml 10mg in 1ml Recommended starting s of medication by subcutaneous route; L Crowley; Dr. J Zeppetella March 2015 Version 1. Updated by L Wright; Dr. Q Abbas September 2016 Version 2. 12
Appendix 2 ST CLARE HOSPICE GUIDE TO EQUIVALENT DOSES FOR OPIOID MEDICATIONS USE IN CANCER PAIN N.B. This is to be used as a guide rather than a set of definitive equivalences. Some of these s have by necessity been rounded. If pain remains uncontrolled, please contact the St Clare Hospice Advice Line on 01279 773773. Oral Codeine 6 hourly Oral Tramadol 6 hourly 12 hourly 4-hr Oral Morphine 12-hr SR 24-hr total Subcutaneous Morphine 4-hr 24-hr total Subcutaneous Diamorphine 4-hr 24-hr total 4-hr Oral Oxycodone 12-hr SR 24-hr total Subcutaneous Oxycodone 4-hr 24-hr total Fentanyl Patch Patch strength (mcg per Hour) Buprenorphine Patch Subcutaneous Alfentanil 1.5 5 10 0.75 5 0.5 3 1 5 10 0.5 4-5 - - 30 2 5 10 1 6 1 5 10 0.5 5 50 100 3 10 20 1.5 10 1 5 2 5 10 1.5 8-10 60 4 10 20 2 12 3 10 20 1.5 10 stclarehospice.org.uk 5 15 30 2.5 15 1.5 10 3 10 20 2.5 15-0.05 1 100 200 6 20 40 3 20 4 15 25 2.5 15 12 15 8.5 25 50 4 25 2.5 15 5 15 30 2.5 20 20 0.1 1.5 10 30 60 5 30 3 20 7 20 40 5 25-0.1 2 15 40 80 7 40 4 25 8 25 50 5 35 25 35 0.25 2.5 20 60 120 10 60 6 40 15 40 80 10 50 37 52.5 0.25 4 30 90 180 15 90 10 60 20 60 120 15 80 50 70 0.5 6 40 120 240 20 120 15 80 25 80 160 15 100 75 105 0.5 8 60 180 360 30 180 20 120 40 120 240 25 160 100-1 12 80 240 480 40 240 25 160 50 160 320 35 200 150-1.5 16 100 300 600 50 300 30 200 65 200 400 40 250 175-1.5 20 150 400 800 70 400 45 260 90 260 520 60 350 250-2 25 (mcg per hour) (mcg per hour) PRN 24-hr total 13
Please note that s of rapid-onset Fentanyl preparation (Abstral/Effentora) tablets are independent of of background analgesia. These are to be administered for patients with rapid-onset Breakthrough pain/incident pain. Patients should already be on background opioids equivalent of 60mg of Morphine in 24 hours. Methadone should only be started by specialists as an in-patient and its can be independent of previous opioids. Some institutions use the following conversions: Oral Morphine : Oxycodone ratio at 1:2 Oxycodone PO : Oxycodone SC at 2:1 References and Conversion ratio used: Codeine: Morphine PO = 1:10 (Palliative Care Formulary 4 printed by palliativedrugs.com PCF) Tramadol: Morphine PO = 10:1 - PCF Morphine PO: Morphine SC = 2:1 - PCF Morphine PO: Diamorphine SC = 3:1 - PCF Oxycodone PO: Morphine PO = 1:1.5 - PCF Oxycodone PO: Oxycodone SC = 1.5:1 - PCF Morphine PO: Fentanyl TD = 150:1 (Summary of Product Characteristics SPC) Morphine PO: Buprenorphine TD = 100:1 (X10 then 24) - PCF Alfentanil SC: Diamorphine SC = 10:1 - PCF Alfentanil SC 24 hours: Alfentanil SC PRN (2 hourly) Common practice Prepared by Dr. Qamar Abbas, Deputy Medical Director, St Clare Hospice Reviewed by St Clare Hospice Clinical Governance Working Group, Chair: Dr. John Zeppetella, August 2014 stclarehospice.org.uk Registered Charity No. 1063631 14
Prepared by: Dr. Qamar Abbas, Deputy Medical Director, St Clare Hospice Lucy Wright, Prescribing Support Pharmacy Technician, WECCG Reviewed by: Dr. John Zeppetella, Medical Director, St Clare Hospice Anurita Rohilla, Chief Pharmacist, WECCG Approved by West Essex Clinical Commissioning Group Medicines Optimisation Programme Board on: 29 September 2016 Ref: Palliative care in Clinical Practice. By Zeppetella G. ISBN 978-1-4471-2842-7 ISBN 978-1-4471-2843-4 (ebook). Springer-Verlag London 2012 Produced: September 2016 Review: September 2018 15