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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 doses 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 COMMENT

ANALGESICS

Buprenorphine patches Moderate to Severe Pain Titrate through dose range

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 dose step 2 of WHO ladder and at higher dose, 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.

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Co-codamol 30/500 Mild to Moderate pain 1 to 2 every 4hrs Max: 8 in 24hrs

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).

Codeine Phosphate Mild to Moderate pain Diarrhoea Cough

Pain: 30 to 60 mg every 4hrs Max daily dose: 240 mg Diarrhoea: 30 mg qds Cough: 5 to 10 ml qds (linctus)

Approximately one tenth potency of morphine. Some Caucasians are poor metabolisers of codeine, other ethnic groups may be extensive or ultra-metabolisers.

Fentanyl patches Severe pain Transdermal systems Requires titration

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®.

Morphine po Moderate to Severe Pain Breathlessness Cough Diarrhoea

Titrate dose Usual starting dose: 5 to 10 mg every 4hrs

Brand prescribing recommended. Immediate release preparations Oramorph solution®, Sevredol® and for modified release preparations Zomorph® capsules (except 5mg - only available as MST® tablets). Reduce dose in the elderly and patients with renal impairment.

Oxycodone po Moderate to Severe Pain Breathlessness Titrate dose Usual starting dose: 2.5 to 5 mg every 4hrs

Morphine intolerant only. Prescribe Longtec® for the MR form and Shortec®or Oxynorm® liquid for immediate release. Reduce dose in the elderly and patients with renal impairment.

Paracetamol Mild to Moderate pain Fever PO or PR: 0.5 to 1 g every 4 to 6hrs Max dose 4 g in 24hrs

Soluble only in dysphagia.

Tramadol Moderate to Severe Pain 50 to 100 mg every 4 hrs Max dose 400 mg/d

Prescribe Marol® for the MR form. At low dose step 2 of WHO ladder and at higher dose, it would be 3rd step for WHO ladder.

Fentanyl sublingual tablet Breakthrough cancer pain Trans-mucosal systems Requires titration

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.

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Methadone Severe pain Linctus available for cough

Titrated 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 dose dependant. Switching is best done with specialist support and if possible as an inpatient.

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

Blocks the presynaptic re-uptake of serotonin and noradrenaline. Adjuvant analgesic for neuropathic pain. Analgesic effect usually seen at lower doses 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)

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 non-diabetic patients – restricted use.

Pregabalin Neuropathic pain Partial seizures Anxiety

Initial dose range 25 mg od to 75 mg bd

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 dose 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.

Lidocaine patches Neuropathic pain 5% w/w lidocaine (700 mg) 1 to 3 patches for 12 h a day

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, non-irritated 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.

ANALGESICS - NSAIDs

Ibuprofen Mild to Moderate pain Inflammation Initial dose 300 to 400mg tds/qds

Has the lowest risk of serious GI side effects. Can be increased if necessary to max. 2.4 g/d; maintenance dose 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.

Naproxen Mild to Moderate pain Inflammation PO: 0.5 to 1 g/d in 1 or 2 divided doses

Intermediate risk of serious GI side effects – prescribe with PPI.

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Diclofenac Mild to Moderate pain Inflammation PO or PR: 75 to 150mg/d in divided doses

CV risk. Consider PPI if risk of peptic ulceration. Use IR unless clinical rationale for SR formulation.

Celecoxib Mild to Moderate pain Inflammation Initial dose 100 mg bd and increase to 200 mg bd if required

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 dose 1.5 mg/d

Anti-emetic: initial dose 1.5 mg/d stat & typical maintenance dose 1.5 to 3 mg/d; if necessary, increase dose 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 self-limiting.

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ANXIETY

Diazepam all presentations Anxiety Insomnia Muscle spasm

Myoclonus Seizures

Initial dose 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 dose 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 Stimulant laxative

4-g mould prn Should be given in combination with Bisacodyl suppositories.

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 doses 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 dose 500 mg/d in divided doses

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.

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Senna liquid 7.5mg/5ml Stimulant laxative PO: 10 to 20 ml on 2nd line - only if Bisacodyl is unsuitable. Higher doses frequently used by patients on opioids. Max dose 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 dose 8 mg (patients weighing 38 to 61 kg) or 12 mg (patients weighing 62 to 114 kg)

Initially give a single dose on alternate days. If there is no response, a second dose 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 dose 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 dose 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.

DRY MOUTH

Biotène oral balance Relief of dry mouth Apply up to 6 times a day

Triple enzyme product Used for dry mouth caused by medications, diabetes, drug or radiation therapies, stress and depression.

Saliveze oral spray Relief of dry mouth Apply up to 6 times a day

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 oral spray Relief of dry mouth Apply up to 6 times a day

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 dose 6 to 8 mg/d; max. 16 mg/d. Chronic diarrhoea: initially, 4 to 8 mg/d in divided doses, subsequently adjusted according to response and given in 2 divided doses for maintenance; max. 16 mg/d. Faecal incontinence [unlicensed indication], initially 500 mcg/d, adjusted according to response; max. 16 mg/d in divided doses. Adverse effects include abdominal cramps, dizziness, drowsiness, and skin reactions.

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Mebeverine Antispasmodic

135 mg tds Musculotropic antispasmodic drug without anticholinergic side-effects. 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 dose 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 dose ranges from 2mg to 16mg depending on indication

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.

Alendronic acid Bone pain & hypercalcaemia

Osteoporosis 10 mg od 70 mg weekly

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 Bone pain & hypercalcaemia

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.

Zoledronic acid inj Bone pain & hypercalcaemia

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.

SEDATIVES

Lorazepam po inj Anxiety & insomnia Seizures Insomnia Anxiety Agitation

1 to 4 mg daily in divided doses

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.

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Appendix 1

RECOMMENDED STARTING DOSES OF MEDICATION BY SUBCUTANEOUS INJECTION AND CONTINUOUS SUBCUTANEOUS INFUSION FOR USE IN GENERAL PRACTICE

The medicines and doses included here are intended only as a guide for prescribing. Other medicines or doses 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 dose / range for Bolus PRN injection

Frequency Initial dose and range for continuous SC infusion over 24 hours

Maximum total dose in 24 hours

COMMENTS STRENGTH

PA

IN

1st 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 dose in last 24 hours including breakthrough doses and divided by 2

Dose increases are not usually more than by 30 to 50% of previous dose

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 doses are reached (>180mg), switch to Diamorphine to reduce syringe volume

May be incompatible with higher concentrations of haloperidol or midazolam.

5mg/ml 10mg/ml 15mg/ml 20mg/ml 30mg/ml 1ml and 2ml amps

1st 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 dose (including breakthrough doses) and divide by 3 (Round down to whole number not up)

Dose increases are not usually more than by 30 to 50% of previous dose

No maximum but unusual to need more than 100mg

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

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MEDICINE

Initial dose / range for Bolus PRN injection

Frequency Initial dose and range for continuous SC infusion over 24 hours

Maximum total dose in 24 hours

COMMENTS STRENGTH

2nd

Line Oxycodone If opioid naïve, start with

1.25mg to 2.5mg Every 2 to 4 hours

If opioid naïve, start with 7.5mg

No maximum but unusual to need more than 100mg

Contra-indicated in renal failure (creatinine clearance <10mL/min).

Concentration-dependent incompatibility may occur when oxycodone is mixed with cyclizine - check compatibility charts

If on opioid patch leave in place and continue to change as normal

10mg in 1ml 20mg in 2ml 50mg in 1ml

PAIN 3rd

Line

Alfentanil

For use in stages 4 and 5 CKD - SPECIALIST ADVICE AND SUPERVISION REQUIRED

AN

XIE

TY

/ A

GIT

AT

ION

/ D

EL

IRIU

M

1st

Line Midazolam 2.5mg to 5mg Every 2 hours 2.5mg to 10mg 60mg

Schedule 3 CD

For doses 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

Levomepromazine 25mg (12.5mg in elderly) Every 4 hours 25mg to 50mg 150mg

Avoid antipsychotics in dementia where possible. If unavoidable use lowest effective dose

Use with caution in Parkinson’s Disease

Concentration-dependent incompatibility may occur when mixed with dexamethasone – check compatibility charts.

25mg in 1ml

P

AIN

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MEDICINE Initial dose / range for Bolus PRN injection

Frequency Initial dose and range for continuous SC infusion over 24 hours

Maximum total dose 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 dose 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 dose 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 dose

Can cause potentially fatal prolongation of the QT interval and torsade de pointes. Avoid in patients with predisposing conditions (see BNF)

The maintenance dose is based on the initial cumulative dose needed to settle the patient; usual maximum ≤5mg/24h. (terminal agitation Maintenance dose CSCI 10-15mg/24 hours)

Concentration-dependent incompatibility occurs with dexamethasone, diamorphine, hydromorphone and morphine sulfate

5mg in 1ml

RE

SP

IRA

TO

RY

SE

CR

ET

ION

S

1st

Line

Hyoscine Hydrobromide

400micrograms

Every 4 hours

800microgrammes to

1200micrograms

2000 micrograms

Can cause anticholinergic syndrome i.e .agitated delirium, drowsiness, ataxia

Contraindicated in narrow-angle glaucoma, prostatic hyperplasia, pyloric obstruction, paralytic ileus

Blocks prokinetic effect of metoclopromide

400micrograms in 1ml

600micrograms in 1ml

AN

XIE

TY

/AG

ITA

TIO

N/D

EL

IRIU

M

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MEDICINE Initial dose /

range for Bolus PRN injection

Frequency Initial dose and range

for continuous SC infusion over 24 hours

Maximum total dose 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 doses > 1200 micrograms seek specialist advice

Inflammation at site of injection is common (>10%)

Incompatible with Dexamethasone

200micrograms in 1ml

600micrograms in 3ml

NA

US

EA

/ V

OM

ITIN

G

1st

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

Levomepromazine 6.25mg Once or twice a day 6.25mg to 12.5mg 25mg

Long half life, can be given as a single dose at night if

sedation a problem

Concentration-dependent incompatibility may occur when mixed with dexamethasone – check compatibility charts.

25mg in 1ml

Metoclopramide 10mg Every 4 hours 30mg to 40mg 100mg

Do not use in intestinal obstruction

prokinetic effect of metoclopramide blocked by antimuscarinics

10mg in 2ml

RE

SP

IRA

TO

RY

SE

CR

ET

ION

S

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MEDICINE

Initial dose / range for Bolus PRN injection

Frequency

Initial dose and range for continuous subcutaneous infusion over 24 hours

Maximum total dose 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

BREATHLESS- NESS

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

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

Octreotide Every 24 hours 300mcg to 900mcg 1200mcg Commence after discussion with Specialist Palliative Care Team.

50mcg in 1ml 100mcg in 1ml 200mcg in 1ml 500mcg in 1ml

PULMONARY OEDEMA

Furosemide 40mg to 80mg Once a day 80mg Commence after discussion with Specialist Palliative Care Team.

10mg in 1ml

Recommended starting doses 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.

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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 doses have by necessity been

rounded. If pain remains uncontrolled, please contact the St Clare Hospice Advice Line on 01279 773773.

Oral

Codeine

Oral

Tramadol

Oral

Morphine

Subcutaneous

Morphine

Subcutaneous

Diamorphine

Oral

Oxycodone

Subcutaneous

Oxycodone

Fentanyl

Patch

Buprenorphine

Patch

Subcutaneous

Alfentanil

6 hourly (mg)

6 hourly (mg)

12 hourly (mg)

4-hr dose (mg)

12-hr SR

dose (mg)

24-hr total dose (mg)

4-hr dose (mg)

24-hr total dose (mg)

4-hr dose (mg)

24-hr total dose (mg)

4-hr dose (mg)

12-hr SR

dose (mg)

24-hr total dose (mg)

4-hr dose (mg)

24-hr total dose (mg)

Patch strength (mcg per

Hour)

(mcg per

hour)

(mcg per

hour)

PRN dose (mg)

24-hr total dose (mg)

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

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

stclarehospice.org.uk

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Please note that doses of rapid-onset Fentanyl preparation (Abstral/Effentora) tablets are independent of dose 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 dose 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

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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