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Sheffield Palliative Care Formulary3rd Edition

Approved by Dr Kay Stewart, Lead Clinician for Palliative Care, Sheffield Teaching Hospitals NHS Foundation Trust (STHFT)Dr Vandana Vora, Director of Medicine and Clinical Governance, St Luke’s Hospice (SLH)Dr Richard Oliver, GP & Clinical Director, NHS SheffieldRatifying Bodies Sheffield Teaching Hospitals Medicines Management & Therapeutics Committee, Sheffield Area Prescribing Committee, St Luke’s Hospice Clinical GovernanceDate March 2012Review date March 2015Authors: Irene Lawrence, Palliative Care Pharmacist, STHFT, Liz Miller, Palliative Care Pharmacist, STHFT/SLH

Disclaimer: This formulary is intended to provide local advice in Sheffield to prescribers in hospital, community and primary care on medications for pain and symptom management in adults receiving palliative/ supportive care. Prescribers must check the BNF and data sheet of individual drugs for full prescribing information.

- Seek specialist advice* - Unlicensed use - Not included in Sheffield Formulary

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ContentsPage (click to view)

Introduction 4Specialist Palliative Care Services’ Contact Numbers 5How to Refer to Sheffield Palliative Care Services 6Abbreviations 7

Agitation/Confusion (Delirium) 8 Anorexia/Cachexia 11 Anxiety 13 Bleeding 15 Bowel Obstruction 17 Constipation 19 Cough 24 Depression 25 Diarrhoea 27 Dyspepsia 30 Dyspnoea 32 Fatigue 34 Hiccup 35 Insomnia 36 Lymphoedema 37 Nausea & Vomiting 39 Oral Care 42 Pain Relief 45 (Analgesic conversion tables 52-56 ) Palliative Care Emergencies 57 Pruritus/Itch 59 Respiratory Tract Secretions 61 Swallowing Difficulties 62 Sweating 64 Syringe Drivers 66

Prescribing in the Last Few Days of Life 69

Acknowledgements 71

Drug Index 73-77


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Sheffield Palliative Care Formulary:Introduction

This formulary is intended as a guide for hospital staff and for healthcare workers in the community in Sheffield. It should be used in association with Sheffield Teaching Hospitals NHS Foundation Trust formularies and the Sheffield Formulary. This guidance is intended for adult treatment only.

The vast majority of symptoms can be effectively managed within the formulary enhancing the quality and consistency of care for palliative care patients. Where the suggested treatment is not effective then specialist palliative care advice should be sought (see contact numbers).

Using the formulary The formulary is arranged under symptom headings. See

contents. An index is available (click here). It is intended that while some treatments may, and should, be

initiated without referral, input from specialists in palliative care is recommended.

First line treatment has not always been indicated since in many cases this will depend on the aetiology of the symptom concerned.

Drugs labelled as ◊ are not included in the Sheffield Formulary.

Drugs labelled with should be used only under the guidance of a palliative care specialist.

Drugs labelled as * are unlicensed (indication, route or dosage) but accepted practice in palliative care. The prescriber takes personal responsibility for prescribing these treatments. The information on unlicensed use is correct at time of printing.

Check the Summary of Product Characteristics (SPC) and BNF for full prescribing information for individual drugs.

Further information can be obtained from a palliative care specialist working in your area. See contact numbers.


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Specialist Palliative Care ServicesContact Numbers

Northern General HospitalTel: (0114) 2434343 (Switchboard)Referrals to the Palliative Care Hospital Support Team or for In-Patient admission

Tel: (0114) 2266770Fax: (0114) 2714289

Medicines Information - for Hospital Related queries

Tel: (0114) 2714371

Royal Hallamshire Hospital & Weston Park Hospital (Central Site)Tel: RHH (0114) 2711900 WPH (0114) 2265000 (Switchboards)Referrals to the Palliative Care Hospital Support Team

Tel : (0114) 2265602Fax: (0114) 2265745

Medicines Information - for Hospital Related queries

Tel: (0114) 2712346

St Luke’s HospiceReferrals for In-patient admission, Day Therapies & Rehabilitation and the Community Palliative Care Team

Tel: (0114) 2369911Fax: (0114) 2351321

The Cavendish CentreWilkinson Street, Sheffield S10Offers support, and certain complementary therapies, to patients with cancer, and their carers, free of charge. Patients need to refer themselves.Referrals Tel: (0114) 2784600

Medicines Information – for Non-Hospital/Primary Care Related queries (PCT Medicines Management Team)

Tel: (0114) 3051667

Cancer Support Centre Tel: (0114) 2265666


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Sheffield Palliative Care ServicesHow to Refer

To refer to Sheffield Specialist Palliative Care Services, FAX a referral form to the appropriate team. Referral forms and referral criteria are available on the Sheffield Palliative Care website:

http://www.sheffield.nhs.uk/palliativecare

Further information about Sheffield Specialist Palliative Care Services is available on the website or by contacting the appropriate team.

NGH Hospital Support Team or Clinic FAX: (0114) 2714289Tel: (0114) 2266770

Sheffield Macmillan Palliative Care Unit: Admission

FAX: (0114) 2714289Tel: (0114) 2266770

RHH/WPH Hospital Support Team or Clinic

FAX: (0114) 2265745Tel: (0114) 2265602

St Luke’s Hospice: Admission FAX: (0114) 2351321Tel: (0114) 2369911

St Luke’s Hospice: Day Therapies & Rehabilitation Centre

FAX: (0114) 2351321Tel: (0114) 2369911

St Luke’s: Community Palliative Care Team

FAX: (0114) 2351321Tel:(0114) 2369911

Intensive Home Nursing or VIP Service

FAX: (0114) 2716026Tel: (0114) 2716010


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http://www.sheffield.nhs.uk/palliativecare

Sheffield Palliative Care Formulary:Abbreviations

ACBS Advisory Committee on Borderline substances

BNF British National Formulary

CSCI Continuous subcutaneous infusion

EOLC End of Life Care

im intramuscular

iv/IV intravenous

LMWH Low molecular weight heparin

NSAID Non steroidal anti inflammatory drug

po orally

PPI Proton pump inhibitor

PR rectally

prn/PRN When required

sc/SC subcutaneous

SPC Summary of Product Characteristics

SSRI Selective serotonin reuptake inhibitor

stat immediately


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Sheffield Palliative Care FormularyAgitation/Confusion (Delirium)

Agitation may be present in the acutely confused or delirious patient. It may also be present in those with a previous psychiatric disorder.

Patients who have chronic anxiety/agitation as part of a mood disorder should be considered and treated, if appropriate, with anti-depressants (see the chapter on depression). For patients with anxiety, see anxiety chapter.

Even when prognosis is days rather than weeks, underlying causes should be considered, and treated appropriately (see local EOLC algorithms), e.g.

Relieve urinary retention and/or disimpact rectum If nicotine withdrawal suspected, encourage smoking or apply

nicotine patch If alcohol withdrawal suspected offer alcoholic beverage or

prescribe benzodiazepine according to local policy Review medication, reduce steroids or other medication if

thought to contribute Check for reversible biochemical causes and treat if

appropriate

Attempt to help patient by discussing their distress

Ask about hallucinations Ask about fears and anxieties. Explore their feelings Provide clear explanation and reassurance to patient and

family Provide specialist psychiatric, psychological or religious

support as appropriate


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Staff should:

Keep calm and avoid confrontation Respond to patients’ comments Clarify perceptions and validate those that are accurate Explain what is happening and why State what can be done to help Repeat important and helpful information Restraints should never be used Allow patients to walk about accompanied if safe to do so Allay fear and suspicion and reduce misinterpretations by

limiting number of different staff, not changing position of bed, presence of family member/close friend, keep room illuminated

Prescribe medication to help settle the patient if indicated

Indication Drug Comments

Acute confusional states

Titrate doses accordingly

Haloperidol 1.5mg po/sc at night +/- every four to six hours when required

Olanzapine 2.5mg po stat and at bedtime

Risperidone◊ 500micrograms po twice daily

Max 10mg/24hrs Care with side-effects

Terminal Restlessness

End of Life Care – see also Last Few Days of Life chapter p67

Haloperidol 1.5-5mg po or sc +/- Midazolam◊ 2.5 - 10mg sc stat

Levomepromazine◊ 6.25mg-25mg po or sc may be used if period of sedation required

More sedating than haloperidol


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On rare occasions when an agitated patient is a danger to themselves or others it is necessary to give an injection against their wishes. Forcing a patient to have an injection is an assault which must be justifiable on the grounds of necessity and clearly in the patient’s best interests. It is a treatment of last resort, a step taken only after discussion within the care team.


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Sheffield Palliative Care Formulary:Anorexia/Cachexia

Please also refer to the Fatigue chapter and the Oral Care chapter.

Primary anorexia is the absence or loss of appetite for food. Cachexia is a condition of profound weight loss and catabolic loss of muscle and adipose tissue.

Treatment

Drug Induced Complications

Drugs may cause problems with anorexia by

inducing nausea, e.g. antibiotics, opioids irritating the gastric mucosa, e.g. NSAIDs,

antibiotics delaying gastric emptying, e.g. opioids,

cyclizine, tricyclic antidepressants.

Reassessing the need for the drug and whether it can be given in a different form or by an alternative route can be beneficial.

Non-drug Related Treatment

Occasionally it is the poor presentation of food that can cause anorexia and nausea. Small portions attractively presented at a correct temperature can often tempt the unwilling. The environment in which people eat is also important. Eating is a social activity and for some people company is valuable. At the other extreme, it is important to provide privacy for people who feel embarrassed about their eating habits.


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Treatment

Drug Management

If reduced appetite is due to gastric stasis/early satiety, a prokinetic drug may be useful

Metoclopramide 10mg po three times daily half an hour before meals

If anorexia persists, an appetite stimulant may be useful.

Dexamethasone 4mg each morning will normally be effective within 1 week. However effectiveness is not sustained and it should not be continued long term due to side effects. (Short term use only). Consider co-prescribing a Proton Pump Inhibitor (PPI) to protect the stomach.

Medroxyprogesterone 400mg each morning is slower to act than steroids (>2 weeks) but has fewer side effects.

Megestrol acetate◊ 160mg each morning. If poor effect after 2 weeks can increase up to twice a day. Takes several weeks to achieve full effect, but results can last for several months.

Anorexia in Depression

Anorexia in association with other depressive symptoms should be treated with an anti-depressant (see the chapter on Depression)

Vitamin Deficiency Induced Anorexia

Some instances of anorexia can be attributed to taste alteration and studies have shown that zinc or Vitamin B deficiency may be to blame. Correcting these deficiencies may alleviate the problem.


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Sheffield Palliative Care Formulary: Anxiety

When treating severely ill patients, it may be difficult to distinguish between the diagnoses of anxiety or depression and the emotional reactions of fear and sadness. The decision to prescribe need not depend only on the diagnosis of a psychiatric disorder, but may be made on the basis of relief of distress/symptoms.

Chronic anxiety as part of a mood disorder should be considered and treated, if appropriate, with anti-depressants (see depression chapter).

Drug treatment of anxiety utilises anxiolytic benzodiazepine or sedative antipsychotic medication. Typical or atypical antipsychotics should be used when anxiety or agitation is a consequence of delirium or psychotic mental disorder. Drug treatment does not preclude other types of therapy. The effects of drugs and psychotherapy, such as Cognitive Behavioural Therapy, may be complementary.

It is important to remember correctable factors that may exacerbate anxiety, e.g.

medication - psychostimulants, corticosteroids or SSRIs drug withdrawal – alcohol, antidepressants, nicotine pain, insomnia and other uncontrolled symptoms


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Management of anxiety

Symptoms Drug

Mild to Moderate anxiety or Situational anxiety

Lorazepam◊ 0.5-1mg po or sublingually (Genus brand) as required up to 4mg/day

Diazepam 2-5mg po nocte prn or in divided doses up to 20mg/day

Generalised anxiety disorder, Panic attacks or Overwhelming fear and agitation

If recurrent or resistant, consider antidepressants

Lorazepam◊ 0.5-1mg po or sublingually (Genus brand) as required up to 4mg/day

Midazolam◊ 1.25-10mg sc prn every two to four hours or CSCI 2.5-60mg/24hrs

Diazepam 5-10mg po or PR every four to eight hours

e.g. Sertraline, Trazodone, Mirtazepine, Duloxetine

Anxiety or agitation with delirium or psychotic features

Haloperidol 2.5-10mg po/sc every four to six hours. Max 10mg/24hrs

Levomepromazine◊ 6.25-25mg po/sc every four to six hours or CSCI 6.25-50mg/24hrs. Max 50mg/24hrs

Olanzapine◊ 2.5mg po prn and 10mg at night. Max 20mg/24hrs


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Sheffield Palliative Care Formulary: Bleeding

In advanced cancer, bleeding occurs in about 20% cases. Consider thrombocytopenia, vitamin K deficiency, heparin-induced thrombocytopenia (HIT), hepatic impairment and renal impairment. Haemoptysis may occur with chest infection, tumour progression in lungs or pulmonary embolism.

Where appropriate, correct the correctable including reviewing current medication. Discontinue medication that would exacerbate bleeding, e.g. aspirin, NSAIDs, warfarin, LMWH.

Management Comments

Surface Bleeding

Gauze soaked in Adrenaline 1mg/ml (1 in 1000)* or Tranexamic acid 500mg/5ml injection*

Silver Nitrate sticks◊ applied to bleeding points

Haemostatic dressings i.e. alginate

Apply with pressure for 10 mins

Haemoptysis Cough suppressionCodeine linctus◊ 10ml 3-4 times a day when required.If not responding, low dose immediate release Morphine Sulphate* 1.25-2.5mg every four hours when required.For mainly nocturnal cough, Methadone linctus (2mg/5ml) 1-4mg po at night Bleeding control – see box below

Haematemesis and Melaena

Gastroprotective drug, i.e. PPI Bleeding Control – see box below

Haematuria, Rectal and Vaginal bleeding

Bleeding Control – see box below


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Bleeding Control (minor bleed)

Tranexamic acid 1g four times a day po. Increase to 2g four times daily if necessary

Etamsylate◊ * 500mg four times a day po

Useful for blood streaking; not effective for major bleeding

Avoid if renal in origin & risk of ureteric obstruction

Stop if no effect after one week or one week after bleeding stopped

Consider long term use at lower end of dose range if bleeding recurs

Major (terminal) bleeding

If patient at high risk of catastrophic bleed, consider availability of opioid and midazolam in the patient’s house/on ward

Major catastrophic bleeds are rare, but can occur when a major artery is eroded by tumour

In patients for whom active treatment of such an occurrence is inappropriate, the bleed usually leads to death within a matter of minutes

There is unlikely to be time to administer controlled drugs; most important is to stay with the patient

Provide explanation, support and reassurance to the family and other observers.

Consider giving:

Morphine or Diamorphine 10mg iv or sc, repeating if required

Midazolam 5-20mg iv or sc if still frightened

If the bleed is visible, dark coloured towels can make the appearance of blood less frightening.


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Sheffield Palliative Care Formulary:Bowel Obstruction

Management requires specialist input and once diagnosed in a patient, referral to a palliative care team should be made.

Patients at risk include those suffering from intra-abdominal pathology, e.g. Carcinoma of the ovary, colon, stomach, rectum or cervix.

Symptoms and signs (variable, not all always present) Nausea Vomiting (often intermittent, large volume and results in relief

of nausea) Pain (often colicky) Abdominal distension Constipation Borborygmi (loud bowel sounds) Tenderness.

Investigations CT if intervention likely

Management Surgery ) if appropriate to stage of Radiotherapy ) illness and patient’s Chemotherapy ) performance status

Drug therapy – see below Drugs which do not improve symptoms when given at

maximum dose, or which cause unacceptable side effects should be withdrawn

Steroids may be considered under specialist supervision

Not all drug combinations are suitable for mixing in one syringe driver. Please contact Medicines Information for advice on compatibility data (see contacts).


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Treatment of Bowel Obstruction


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Review within 24 hrs




Does the patient have colicky pain?

YES NO

Stop prokinetic agents (metoclopramide, domperidone). Start CSCI Hyoscine Butylbromidexe "Hyoscine:Hyoscine Butylbromide"◊ 60mg for colic + Haloperidolxe "Haloperidol" 3mg for nausea+/- opioid for pain over 24 hours

If still vomiting increase Octreotide*xe "Octreotide"◊ by increments of 300 micrograms every 24 hours to a maximum of CSCI 1200micrograms/24hrs

If nausea and large volume vomiting persistent consider naso-gastric tube for patient comfort

If still colicky pain increase Hyoscine Butylbromidexe "Hyoscine:Hyoscine butylbromide"◊ (up to 240mg/24hrs CSCI) and maximize haloperidol to 5mg/24hrsxe "Haloperidol" by CSCI

If still vomiting add in CSCI Octreotide*◊ 600 -1200 micrograms/24hrs (discontinue Hyoscine butylbromide if no benefit seen)

If patient develops colicky pain stop prokinetic and steroid and start treatment of colicky pain.xe "Hyoscine:Hyoscine Butylbromide"xe "Haloperidol"

Trial of prokinetic agent. Metoclopramidexe "Metoclopramide" CSCI 30-80mg/24hrs. If beneficial optimize dose to 100mg/24hrs. If constipation an issue consider a softener laxative (see constipation chapter p18)

Consider trial of steroid if obstruction thought not to be complete and no colicky pain. Continue as long as symptoms controlled.

Consider replacing Haloperidol with Levomepromazine◊ CSCI 12.5mg/24hrs if nausea not controlled

If ineffective contact Specialist Palliative Care Team

Sheffield Palliative Care Formulary: Constipation

Definition ‘Normal’ bowel activity is unique to the individual. Constipation occurs when bowel actions are less frequent

than normal for the individual, which may include persistent, difficult, infrequent or incomplete defecation, which may or may not be accompanied by dry hard stools.

Assessment & Management It is important to assess the patient's perception and make a

comparison of their current bowel habit and ease of passage with what they consider to be normal. This is a large determinant of whether or not patient is considered to be constipated.

Comprehensive assessment and review of patient's bowel habits and causative factors of constipation are essential. Use of assessment charts such as the Bristol Stool Chart may be appropriate.

Laxative therapy needs to be individualised to the patient. If the patients stools are predominantly hard then a softener should be tried first, if straining and incomplete evacuation are the main symptoms then a stimulant would be the first line. It may be that both stimulant and softener need to be used together.

It is important to try and diagnose and treat the underlying cause. As well as treating the cause it is also important to use symptom directed treatments. All treatments must be reviewed every few days for efficacy and side effects.

Endeavour to reverse the reversible.

Specific causes include: Reduced mobility - encourage exercise and activity if

appropriate. Inability to access private toilet facilities or suitable position.

Consider improving environment.


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http://nww.sth.nhs.uk/STHcontDocs/STH_CGP/Nursing/BristolStoolChart.doc

Low fibre diet - encourage foods rich in fibre if appropriate. High fibre/bulk laxatives are often not tolerated.

Dehydration – increase fluid intake if appropriate/possible. Renal failure. Hypercalcaemia – see Palliative Care Emergencies chapter. Drugs: including anticholinergics, 5HT3 antagonists, and

opioid therapy. It is good practise to prescribe prophylactic treatment.

Spinal cord compression – see Palliative Care Emergencies chapter.

Orally Administered Laxatives

Mode of Action Drug/Dose Comments

Softener laxatives Osmotic agents:

retain water in gut lumen

Surfactant agents: increase water penetration of stool

Macrogols: hydrate hardened stool, increase stool volume, decrease duration of colon passage and dilate bowel wall that then triggers defaecation reflex

Lactulose 10-30ml once or twice daily

Docusate sodium◊

100-300mg twice daily

Laxido®/Movicol®

(polyethylene glycol) 1-3 sachets a day. Up to 8 sachets/day for faecal impaction

Patient needs to be well hydrated. Onset of action 1-2 days. Can cause bloating, flatulence and abdominal cramping. Taste may be problem.

Onset of action 1-3 days. Liquid is bitter tasting

Sachets need to be dissolved in 125ml water or juice (N.B. large volume). Onset of action 1-2 days


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Stimulant laxativesDirect stimulation of myenteric nerves to induce peristalsis. Reduce absorption of water in the gut

Senna 7.5-15mg once to twice daily

Bisacodyl 5-10mg once daily

May cause colic. Do not use if colic/obstruction present

Combination Stimulant and Softening Agents

Co-danthramer 25/200 1-3 capsules or 5-15ml once to three times daily

Co-danthramer Strong 1-3 capsules once to twice daily or 2.5-10ml once or twice daily

Co-danthrusate 50/60 1-3 capsules or 5-15ml once to twice daily

Danthron containing products restricted to treating constipation in terminal illness. Urine may be stained red. Do not use in urinary or faecal incontinence as may ‘burn’ skin

Peripheral Opioid-receptor Antagonist


Peripheral opioid-receptor antagonistIndicated for opioid-induced constipation in palliative care patients when response to other laxatives inadequate

Methylnaltrexone◊ – subcutaneous injection, dose dependant on body weight (see BNF/SPC), on alternate days or less frequently depending on response.

May act within 30-60 minutes.Max duration of treatment 4 months


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Rectally Administered Drugs


Softener Glycerin 4g suppositories 1-2 once daily

Arachis oil◊ enema 1 to be given once daily for faecal impaction

Warm before administration. Do not give to patients with a peanut allergy.

Stimulant Bisacodyl suppositories 1-2 suppositories daily

Phosphate enema 1 enema once daily

Sodium Citrate Enemas (Micralax®, Microlette®, Relaxit®) 1 enema once daily

Not to be used for prolonged periods of time due to absorption of phosphate into the systemic circulation.

Spinal Injury – see next page


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Spinal Injury

Spinal cord injury, e.g. Spinal Cord Compression, Cauda Equina Syndrome can cause constipation. Different treatments are given depending on the level of damage/injury to the spinal cord.

Level of Injury Treatment

Upper Motor Neurone damage (Thoracic Level 12 and above) causes spastic, reflexic bowel. Reflex activity is maintained; the bowel will contract and empty when stimulated. Anal sphincter tone is maintained.

Treat reversible causes. Senna 15mg po or Bisacodyl

10mg po on alternate days Phosphate or Micralax® enema

on alternate days Bisacodyl 10mg or Glycerin 4g

suppositories alternate days Abdominal massage

Lower Motor Neurone damage (Lumbar level 1 and below) causes flaccid, areflexic bowel. Anal sphincter will be flaccid, which can lead to a build up of faecal material, which may be difficult to empty and may also cause overflow of faecal material.

Gravity assisted evacuation – perform over the toilet

Bear down – using strong abdominal muscles

Massage abdomen and get patient to lean forward if they can

If these measures fail, perform manual evacuation

Daily if tolerated

Cauda equina syndromeDamage to the nerves at the base of the spine. Sensory nerves often intact. Nerves for movement often impaired. Bowel then becomes flaccid.

2 Glycerin 4g suppositories alternate days

Daily digital rectal examination followed by manual evacuation.

Please refer to local guidelines or protocols for treatment.


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Sheffield Palliative Care Formulary: CoughTreat reversible causes, e.g. post nasal drip, asthma, respiratory infection, gastro-oesophageal reflux, heart failure, malignant airway obstruction or drug induced cough, etc.

Management Comments

Soothing agents

Simple linctus 5ml three to four times daily

To loosen thick mucus.

Mucolytics in COPD patients

Nebulised Sodium Chloride 0.9%◊ *5ml when required (limited evidence)

Carbocisteine 750mg three times daily. Caution in those with history of peptic ulcer

May need physiotherapy afterwards to expectorateStop after 4 weeks if no benefit

Opioids Codeine linctus◊ 10ml three to four times a day when required

If not responding, low dose immediate release Morphine Sulphate* 1.25- 2.5mg every four hours when required

For mainly nocturnal cough, consider Methadone linctus 2mg/5ml 1mg po at night increasing to 2mg twice daily as tolerated

Will need laxative combination (see).Monitor side effects especially in COPD patients

Corticosteroid Only if there is history of COPD/asthma exacerbation, pulmonary fibrosis


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Sheffield Palliative Care Formulary: Depression

When treating patients with advanced disease, it may be difficult to distinguish between the diagnoses of anxiety or depression and the emotional reactions of fear and sadness. The decision to prescribe in palliative care need not depend only on the diagnosis of a psychiatric disorder.

Drug choice may be made with regard to targeting particularly troublesome depressive symptoms, or the need to avoid side effects that augment the symptoms of physical disease. Drug treatment does not preclude other interventions and the effects of drugs and psychotherapy may be complementary.

All classes of antidepressants have contraindications, interactions and cautions that impact on the treatment of depressed patients with conditions such as: renal impairment, hepatic disease, heart disease, gastro-intestinal bleeding, epilepsy, nausea, glaucoma, delirium, sexual dysfunction, bladder neck obstruction and analgesic therapy. Nevertheless, evidence indicates that antidepressants are effective in depressed patients with physical illness and benefits accrue from 4-5 weeks and persist after 18 weeks.

In palliative care patients, the onset of response tends to be delayed and in a meta-analysis, significant benefits were first apparent after 4 weeks with tricyclics and after 16 weeks with SSRIs. Therefore, antidepressants require proper titration to achieve their desired effect and in the case of patients with a poor prognosis, this should be done as quickly as possible with steps at intervals equivalent to 5 half-lives of the chosen drug.


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Antidepressant Drug Choice

Indication Management Comments

First line for depression or where prognosis less than 16 weeks or with neuropathic pain.

Amitriptyline 10-200mg po at night

Nortriptyline◊ 25-150mg po at night Less sedating

For refractory depression or depression with diabetic or other neuropathy.

Duloxetine◊ 30mg po daily increasing to 60mg po twice a day

For patients with anorexia, insomnia, anxiety or agitation

Mirtazepine◊ 15-45mg po at night

May improve appetite

For patients with insomnia or a history of seizures

Trazodone 100-300mg at night to a maximum of 300mg twice a day

Less cardiotoxic

Alternative antidepressants when both sedation and stimulation need to be avoided.

Sertraline 50-200mg po once daily

Citalopram 20mg po once daily

Lofepramine 70-210mg po once daily

N.B. All antidepressants can cause withdrawal symptoms if stopped abruptly, so should be gradually withdrawn over 2-3 weeks.


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Sheffield Palliative Care Formulary: Diarrhoea

Assessment Presentation of diarrhoea demands a careful history and

examination. This includes the frequency and nature of defecation and the time course of the problem

Consider optimising prescription for previous underlying conditions, e.g. Crohns, Ulcerative Colitis

If the history and examination do not indicate a likely cause then faecal microscopy and culture are indicated

Review laxative usage

Treatment for non-specific cause

Antimotility Loperamide 4mg po initially followed by 2mg after each loose stool. Max. 16mg in 24 hours

Opioids Codeine Phosphate 30-60mg po 4-6 hourly. Max 240mg/24hrs

Anti-cholinergic Hyoscine Butylbromide◊ 80mg/day po or CSCI 80-160mg/24hrs (NB. Oral absorption POOR)

Somatostatin Analogues Octreotide◊* CSCI 300-1200 micrograms/24hrs to reduce secretions in possible case of ‘blind loop’ or fistula


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Treatment for disease specific cause

Cause Treatment

Overflow from severe constipation

Appropriate Laxative Treatment (see Constipation guidelines)

Malignancy Refer to oncologist for possible chemo- or radiotherapy

Infection Please refer to Local Infection Guidelines

Drug therapy, e.g. chemotherapy

Review therapy and reduce dose/discontinue as appropriate.

Non-specific treatment, e.g. Loperamide 2mg po after each loose stool up to 16mg/24hrs or 2-4mg regularly four times a day, if avoidance of drug cause not possible. Alternatively Codeine phosphate 30-60mg four times daily up to max 240mg/24hrs

Acute Radiation Enteritis

Steroid, e.g. Dexamethasone 4mg po once daily

Colestyramine◊ 4-12g po three times a day

‘Blind-loop’ Metronidazole 400mg po three times a day

Steatorrhoea Pancreatin◊ supplements, e.g. Creon® 10,000 units 1-2 capsules po with each meal and fatty snacks

Cholegenic Diarrhoea

Colestyramine◊ 4-12g po three times a day.

Carcinoid Syndrome

Octreotide◊ 100-1200micrograms/24hrs sc in divided doses or CSCI


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Ulcerative Colitis Mesalazine◊ 1.2-2.4g po daily in divided doses.

Sulfasalazine◊ 500mg - 2g po four times daily

Rectal preparations such as mesalazine enema/suppositories, sulfasalazine suppositories, prednisolone enema/suppositories

If problem remains persistent, please contact appropriate specialist.

Short Bowel Malabsorption due to loss of 2/3 of the small bowel. Can result from congenital disorders, surgical resection or bypass of intestine

Loperamide 4mg po four times daily increasing to 16mg four times a day

Codeine Phosphate 30-60mg po four times a day

Lansoprazole 30mg po twice a day

Omeprazole 40mg po twice a day

Octreotide◊ * commence 50 micrograms sc three times a day increasing to 100 micrograms sc three times daily

Hypertonic electrolyte solution, e.g. Double strength Dioralyte® 2 sachets in 200ml water increasing from once daily to five times daily po

Involve dietician and Nutritional Support Teams for control of dietary intake as appropriate


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Sheffield Palliative Care Formulary: Dyspepsia

Dyspepsia has many causes. In practice, management depends on evaluating and treating the principal component of the dyspepsia.1

Cause of Dyspepsia Management

Small stomach Small meals, often

Pro-kinetic agent (see in dysmotility below)

Antiflatulent Asilone®◊ 10ml po after meals

Dysmotility Prokinetic agent 15 minutes pre-meals, e.g. Domperidone 10mg po or 30mg PR three times a day or Metoclopramide 10-20mg po three times a day

Acidity (may be drug induced)

(may consider urea breath test or stool antigen test for H.pylori. These tests need to be done before starting PPI or antibiotics)

Discontinue offending drugs if possible, e.g. NSAIDs, steroids, aspirin

If NSAIDs to continue, add PPI cover, e.g. Lansoprazole, Omeprazole, Ranitidine2 or consider switch to COX2 inhibitor, e.g. Celecoxib◊ or Etoricoxib◊

Antacids or Alginates may be effective on a PRN basis, e.g. Maalox®◊ or Peptac®

Gassy Dyspepsia Anti-flatulent, e.g. Asilone®◊ suspension 10ml after meals


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Cause of Dyspepsia Management

Gastro-oesophageal reflux

Raise bed head, avoid caffeine and alcohol, stop smoking

Review drugs that decrease sphincter tone, e.g. Theophylline, nitrates, Ca-channel blockers, beta-blockers, alpha-blockers, benzodiazepines, tricyclics, anticholinergics

Lansoprazole 15-30mg po daily

Antacids, e.g. Maalox®◊ 10ml po after meals and before bed

Alginates, e.g. Peptac® 10ml po after meals and before bed

Prokinetic agent 15 minutes pre-meals, e.g. Metoclopramide 10-20mg po three times a day or Domperidone 10mg po or 30mg PR three times a day

1NICE guidelines – Dyspepsia: Managing Dyspepsia in Adults in Primary Care.2STHFT guidelines – Gastroprotection in Patients Taking Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)


31

Sheffield Palliative Care Formulary: Dyspnoea

Whenever possible, treat reversible causes, e.g. reversible airflow obstruction, heart failure, pneumonia. If appropriate consider treating pulmonary embolism, pleural effusion, anaemia, etc.

In addition to treatment for specific causes of dyspnoea, non-specific treatment may be helpful irrespective of cause.

Non-drug measures: Cool draught (open window, fan) Breathing exercises / relaxation therapy Modify way of life, e.g. bed downstairs, home-help

Opioids are usually first line treatment. If anxiety is a major component consider adding benzodiazepines. It may be necessary to use both treatments together.

Treatment Regime Comments

Opioids If not already on a strong opioid, start with immediate release Morphine Sulphate* po 2.5mg every 4 hours prn

If preferred by patient, consider converting to a slow release preparation

If already on strong opioid for pain control, consider increasing prn dose by 25-50%

Caution for patients with chronic respiratory disease

Must prescribe laxatives (see Constipation)

Consider anti-emetic for first few days (see Nausea and Vomiting)


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Treatment Regime Comments

Benzodiazepines Lorazepam◊ 0.5mg prn po or sublingually* increasing gradually to max 2mg/24hrs

Watch for sedation.

Sublingually use Genus brand of Lorazepam – other brands may not dissolve under tongue.

Avoid diazepam (long half-life).

In terminal stage, consider Midazolam◊ * 2.5mg sc PRN. If required regularly consider CSCI Midazolam◊ * - start at 5-10mg/24hrs, increase gradually if necessary

Ensure PRN dose prescribed for use in addition to CSCI

Oxygen If hypoxic (resting SaO2

<90) give oxygen 2 l/min as required

Caution if there is a history of hypercapnia; use low flow rates and preferably when required for exertion.

Nebulisers Consider trial of nebulised Salbutamol 2.5-5mg prn

Consider nebulised Sodium Chloride 0.9%◊ * to thin secretions

May be reversible bronchoconstriction even in absence of wheeze


33

Sheffield Palliative Care Formulary: FatigueFatigue is difficult to manage because of lack of understanding of causes and mechanisms. Where possible treat reversible causes, e.g. pain, emotional distress, anaemia, sleep disturbance, nutrition, activity level, co-morbidities, electrolyte imbalances/hypercalcaemia and medication side-effects.

First line management, after treating contributing factors are:

Exercise/activity enhancement – consider referral to OT/ Physiotherapy

Patient Education – providing information and support and allowing patients to talk about fatigue, its meaning and implications

Modifying patients’ activity and rest patterns - help patients to prioritise activities, limit naps to 20-30 minutes, taking frequent short breaks rather than one long rest period

Physical therapies, e.g. massage Psychosocial interventions, e.g. Cognitive Behavioural

Therapy, educational therapy to manage stress and increase support and energy conservation

Ensure adequate nutrition and hydration – consider dietician referral

Pharmacological interventions are not useful for first line management of fatigue. They are adjuvants in the following situations:

Indication Treatment Drug and Dose Comments

Fatigue/ Sleepiness/ Opioid induced sleepiness

Psycho-stimulants

Methylphenidate◊* initially 5mg po morning and lunchtime titrated according to response up to 15mg twice a day

Dose times 8am and no later than 2pm to allow time to wear off and allow nocturnal sleep

Caution cardiac disease


34

Sheffield Palliative Care Formulary: Hiccup

Hiccup has many possible causes but the most likely is gastric distension. In this case, meals that are ‘small and often’ may be beneficial.

Cause of Hiccups Management

Gastric distension Anti-flatulent agent, e.g. Asilone®◊ po 10ml after meals

Prokinetic agent 15 min pre meals, e.g. Domperidone 10mg po or 30mg PR three times a day OR Metoclopramide 10-20mg po three times a day

All other causes (anecdotal evidence only)

Haloperidol 1.5mg po three times daily

Baclofen* 5-10mg po twice a day up to 20mg three times a day (caution sedation increase slowly)

Midazolam◊ * 10-60mg/24hrs CSCI if patient in last days of life


35

Sheffield Palliative Care Formulary: Insomnia

Take detailed sleep history from patient AND family.

Sleep hygiene – optimise sleep environment, improve circadian rhythm (e.g. rise same time each day and increase activity), regular pre-sleep routine, hot bath/milky drink before bed.

Treat or remove precipitating factors including Drug treatment, e.g. steroids, xanthines, β-blockers, CNS

stimulants – methylphenidate, caffeine, avoid alcohol Modify timings of medication regime as appropriate, e.g.

diuretics, steroids Anxiety Depression Unrelieved symptoms, e.g. dyspnoea/cough; pain; cramps/

restless legs; pruritus Environmental factors

Non drug management, e.g. Cognitive Behavioural Techniques combined with sleep hygiene and reduced focus on sleep is effective in 70-80% of patients.

Treatment Drug and Dose Comments

Hypnotics Temazepam 10-20mg po at bedtime

Zopiclone 3.75 – 7.5mg po at bedtime

Short term use only. Choose according to duration of action, e.g. Zopiclone (Short acting), Temazepam (long acting)

Other medicines that aid sleep

Opioids, antidepressants, antipsychotics, sedative antihistamines, melatonin

Use if needed for treatment of other symptoms


36

Sheffield Palliative Care Formulary: Lymphoedema

Definition Lymphoedema is a chronic swelling resulting from a failure of

part of the lymphatic system

This may be as a result of an internal defect in the system (primary lymphoedema) or an external influence (secondary lymphoedema)

Secondary lymphoedema is most commonly associated with cancer and its treatments (secondary cancer related lymphoedema) but may also be due to trauma, surgery, venous problems, immobility and obesity (secondary lymphoedema)

Management Most of the underlying causes of lymphoedema are

irreversible so appropriate treatment should be implemented to reduce the swelling and keep it to a minimum

Specialist management of lymphoedema encompasses four areas – skin care, compression, lymphatic drainage and exercise.

Aim Management

Skin Care To keep skin/tissues in good condition and prevent/reduce infection

Keep area clean, dry well and apply a moisturiser, e.g. Aqueous cream daily.

Compression bandaging /garment

To prevent / reduce swelling building up

Refer to Lymphoedema specialist


37

Lymphatic Drainage

Gentle massage technique to move swelling from affected area

Can be taught to patients and carers by Lymphoedema specialist

Exercise To try and maximise drainage without over exertion

Encourage patient to be as active as possible whilst wearing compression hosiery

Avoid if possible injections into / taking blood from the affected limb

Furosemide has minimal effect on lymphoedema.

If a patient has “lymphorrhoea” or leaking of lymphatic fluid through the skin, lightweight compression bandaging must be applied appropriately and competently

If the patient has truncal oedema (breast, head and neck, genital) the patient should be referred on to the Specialist Macmillan Lymphoedema Team

Specialist Contact Numbers Community Specialist Macmillan Lymphoedema Team 0114

2320689

Hospital setting – Refer to the Clinical Nurse Specialists (Breast RHH 0114 2713311, WPH 0114 2265000 / Gynaecology RHH via switch 0114 2711900 /Skin RHH 0114 2713014)

St Luke’s Hospice – Refer to Palliative Care Physiotherapist (St Luke’s Hospice 0114 2369911).


38

Sheffield Palliative Care Formulary: Nausea and Vomiting

Identify any causes/exacerbating factors that can be treated, e.g. drug side-effects, constipation, severe pain, infection, cough, hypercalcaemia, raised intracranial pressure, bowel obstruction. Anxiety exacerbates nausea and vomiting and may need specific treatment.

Non-Drug Measures: Treat reversible causes Control odours from colostomy, wounds and fungating

tumours Minimise sight/smell of food Give small snacks not large meals Try acupressure wrist bands

Prescribing Notes:1) Avoid prescribing prokinetic drugs (Metoclopramide and Domperidone) with antimuscarinic drugs.2) Use Domperidone in Parkinson’s disease patients to avoid extrapyramidal side-effects caused by other anti-emetics.

Cause Management Comments

Gastric Stasis /Irritation

Ascites

GI Tract infiltration

Metoclopramide 10-20mg po/sc three times daily or CSCI 40-80mg/24hrs

Domperidone 10mg po or 30mg PR three to four times daily

Consider PPI )) Abdominal cramps ) may occur) Take half an hour ) before food


39


Biochemical/drug, e.g. uraemia, hypercalcaemia, digoxin, opioids

Haloperidol 0.5-5mg po/sc at night or CSCI 1.5-10mg/24hrs


Levomepromazine◊ 6.25mg po/sc at night or CSCI 6.25-12.5mg/24hrs. (6mg tablets - ‘named patient’ order)

More sedating than Haloperidol and Metoclopramide.

Chemotherapy or Radiotherapy

Domperidone 10mg po / 30mg PR three times daily


Ondansetron◊ 8mg twice daily for three days starting on Day 1 of chemotherapy

)) Abdominal cramps ) may occur.))May reduce analgesic effect of tramadol. May cause constipation

Raised intracranial pressure

Dexamethasone 4-16mg po/sc once a day or in two divided doses, morning and lunchtime

Cyclizine◊ 25-50mg po three times a day or CSCI 50-150mg/24hrs

Caution with diabetes

Potential incompatibility problems in syringe driver


40


Vestibular Disorders

Cyclizine◊ 25-50mg po three times a day or CSCI 50-150mg/24hrs

Prochlorperazine 5-10mg po/12.5mg im three times a day or 3mg buccal tabs three times daily

Hyoscine Hydrobromide◊

CSCI 0.8-1.2mg/24hrs or 1mg/72hrs transdermal patch

Potential incompatibility problems in syringe driver

Fear and Anxiety Haloperidol 0.5-5mg po/sc at night or CSCI 1.5-10mg/24hrs

Lorazepam◊ 0.5-1mg po/sublingual* prn

For anticipatory vomiting

Sublingually use Genus brand (see)

Refractory nausea/vomiting

Seek specialist advice


41

Sheffield Palliative Care Formulary:Oral Care

Assessment is essential to exclude/treat any precipitating factors. Attention should be paid to ensure:

Good oral hygiene

Adequate hydration

Regular dental checks


Xerostomia (Dry Mouth)

Sugar-free Chewing gum

Artificial Saliva Spray choose neutral pH spray, e.g. Xerotin®, Saliva Orthana®◊ contains mucin (pork)

Biotene Oralbalance® gel◊, BioXtra® gel◊ neutral pH

Pilocarpine Tablets◊ 5-10mg three times a day

Saliva Orthana®, Biotene Oralbalance® gel and BioXtra® gel are all ACBS for primary care prescribing

Bleeding Mouths/Gums Mild/Moderate

Cases

Severe Cases

Tranexamic acid 500mg/5ml solution◊*

Use 5-10ml as gargle/mouthwash four times daily

Refer to specialist


42


Stomatitis/Mucositis

Mild Benzydamine 0.15% Mouthwash (Difflam®) 10ml four times a day or Spray 4-8 sprays every 1½ to 3hrs

Choline salicylate 8.7% gel (Bonjela®)◊ use every 3 hours up to 6 times daily

Moderate to Severe

Antacid and Oxetacaine◊ * 10ml four times daily post radiotherapy for painful swallowing

Lidocaine 0.2%◊ * mouthwash 10ml four times daily

Morphine Hydrochloride*◊ (alcohol free) 10mg/5ml solution (special license) 5ml as a mouthwash/gargle every 4 hours.

Not morphine sulphate due to high alcohol content

Infected lesions Broad Spectrum antibiotic Refer to antibiotic guidelines

Halitosis

If due to malodorous malignancy

Establish good oral hygiene including mouthwashes

Metronidazole 400mg po three times a day or 500mg rectally twice a day (to reduce odour).

Patients on longer term therapy may be maintained at a reduced dose


43


Candidiasis

Correct underlying causes, e.g. poor fitting denture/oral hygiene and dry mouth.

Nystatin suspension 1-2ml four times a day after meals given for duration and 48 hours after resolution of condition. (5ml four times daily if immunosuppressed)

Fluconazole 50mg po once daily for 7 days

Suggested soaking regimes for dentures (each night) Dilute Sodium

hypochlorite 1% (Milton) solution 1 part hypochlorite to 80 parts water for plastic dentures

Chlorhexidine gluconate 0.2% (Corsodyl®) solution for dentures with any metal parts.

Hold in the mouth for as long as possible before swallowing.

A longer course may be needed if dentures worn or patient immunocompromised

Check for drug interactions

Not compatible with nystatin – rinse thoroughly after use

Symptomatic management of pain in mouth (alongside disease specific treatments)

Gelclair® concentrated oral gel◊. Dilute contents of sachet with 3 tablespoons (~40ml) water and stir. Rinse around the mouth for at least one minute to coat oral cavity. Expel any remaining rinse. Use one hour before food and drink, three times daily or as needed.


44

Sheffield Palliative Care Formulary: Pain relief

A framework for the logical manipulation of an analgesic regime is based on the World Health Organisation 3-step analgesic ladder.The WHO analgesic ladder suggests a structured but flexible approach is used in the management of pain and is summarised in 5 phrases:

By mouth – oral route is preferred By the clock – in persistent pain give analgesics regularly not

PRN By the ladder – to maximise effect For the individual Attention to detail

Step 3Strong Opioide.g. Morphine 2.5-10mg every four hours or other strong opioid, see page 49

+ Nonopioid(s)Step 2 +/- Adjuvants

Weak Opioide.g. Codeine phosphate 30-60mg four times daily

Step 1 + Nonopioid(s)Nonopioid(s)e.g. Paracetamol 1g four times daily, NSAIDs (unless contra-indicated)

+/- Adjuvants

+/- Adjuvants

At all steps in the analgesic ladder consider:


45

Specific measures to moderate the cause of the pain, e.g. surgery, radiotherapy, physiotherapy, nerve blocks, TENs, stenting, chemotherapy, hormonal therapy, antibiotics, bisphosphonates etc.

Emotional, social and spiritual supportive care

Choice of Adjuvant Analgesics

The choice depends on the mechanism of the pain.

Nociceptive Pain Drug

Due to soft tissue bone or joint disease, pelvic disease or originating in the renal tract or retroperitoneal pain

Non-steroidal anti-inflammatory drugs (NSAIDs) such as Diclofenac or a COX 2 inhibitor, e.g. Celecoxib◊ with PPI cover

Metastatic bone pain NSAIDs or COX 2 + adjuvant – seek specialist advice

Due to muscle spasm Diazepam 2mg three times daily po or Baclofen◊ 5mg three times daily po

Due to intestinal colic Antispasmodics, e.g. Mebeverine◊ 135mg three times daily po or Hyoscine Butylbromide◊ 20mg four times daily sc (for CSCI – seek specialist advice)

Due to liver capsule pain NSAIDs or Dexamethasone 4mg once daily po for 5 day trial


46

Neuropathic Pain Drug

Due to infiltration by tumour, zoster, scar tissue or compression unrelieved by steroid or specific therapies

Amitriptyline 10-75mg/day (higher doses under pain/palliative team)Gabapentin 300-3600mg/day (divided doses)Pregabalin◊ 25-600mg/day (divided doses)Capsaicin 0.075% cream◊ apply sparingly three to four times daily (avoid contact with mouth and eyes) Clonazepam◊ * 125microgram – 4mg/day po/sc (Dilute before use

as subcutaneous bolus)

Due to compression by tumour

Dexamethasone 4mg po once daily

Due to diabetic neuropathy

Duloxetine◊ 30mg once daily po titrating to 60mg twice daily

Titrating morphineOpioid Naïve/ Initiating Morphine

Morphine Sulphate immediate release (Morphine Sulphate 10mg/5ml liquid or Sevredol® tablet) EITHER: PRN Prescription 1.25-2.5mg po/sc every four hours as requiredOR: Regular prescription 1.25-2.5mg po every four hours and PRN Prescription 1.25-2.5mg po/sc every four hours as required (FOR MORE CONSTANT PAIN). Assess pain control after 1-2 days and titrate 4

hourly dosage until adequate pain relief achieved. Once pain controlled on four hourly dosage convert

to m/r morphine every 12 hours by adding up the total morphine use in 24 hours, dividing by 2 and prescribing the nearest sensible dose of Zomorph®/MST®◊


47

Regular Morphine

Continue the regular Zomorph®/MST®◊ every 12 hours at the same dose

Prescribe PRN prescription of 1/6 of the total 24 hour dose of oral morphine every four hours as required

Assess pain control after 1-2 days and titrate regular 12hrly dose based on the total regular + PRN dosage over previous 24 hours, if necessary. (Guide – if more than 2 PRN doses are required in 24 hours, the regular dose should be increased to incorporate these doses. Leave 48 hours between dose increases)

Side effects of opioids 50% of patients prescribed opioids experience nausea or

vomiting. Warn patient and provide prn antiemetic. (See nausea and vomiting chapter)

Most patients prescribed opioids experience constipation. Prescribe prophylactic laxatives. (See constipation chapter)

Cognitive impairment, drowsiness, myoclonic jerks, dysphoria and respiratory depression are dose-related side effects indicating a need to reduce opioid dose, review adjuvants or substitute the opioid

Acute respiratory depression/bradypnoea. Give Naloxone 0.1-2.0 mg. by slow IV injection titrated against respiratory rate avoiding complete reversal of analgesia if possible. Continue with intravenous infusion or repeated injections as necessary. Consider reducing or omitting regular and PRN dose of opioid until patient recovers. Use lower PRN dose of opioid if pain returns.

Refractory painPatients with unresponsive pain or opioid toxicity may need to be referred to the Palliative Care Service, see contact numbers.


48

Opioid substitutionPain may be opioid resistant, consider other treatment options. Patients who experience poor analgesia or suffer from significant side-effects may benefit from a change in the opioid used. The choice of opioid may be influenced by

Individual patient factors Route of administration Drug profile Side-effect profile

Seek specialist advice – patients will require regular review after opioid switch. Conversion information can be found on pages 52-56.

Relevant considerations when substituting opioids include the following:

Drug Notes Preparations

Tramadol◊ Alternative for moderate pain - two analgesic actions - like an opioid and like a tricyclic

Caution lowers seizure threshold

Normal release capsules

Modified release tablets

Oxycodone◊ Orally 1.5-2 times more potent than morphine

Normal release capsules and liquid (Oxynorm)

Modified release tablets (Oxycontin)

10mg/ml injection (50mg/ml injection available only for patients on very high dose when no suitable alternative)


49

Diamorphine Given subcutaneously 3 times more potent

than oral morphine

Available in 5mg, 10mg, 30mg, 100mg and 500mg ampoules

Fentanyl Patch applied every 3 days

Pain needs to be stable, i.e. not fluctuating

Safe in renal failure Useful when poor oral

compliance Takes several days to

reach steady state

Patches For PRN use (all

forms specialist initiation ) fentanyl sublingual or buccal tablets, fentanyl lozenges and nasal spray

Morphine or oxycodone can be used for breakthrough pain

Buprenorphine Patch formulation Safe in renal failure Pain needs to be stable,

i.e. not fluctuating Takes several days to

reach steady state Not completely reversed

by naloxone

Butrans* (7 day patch) and Transtec (4 day patch)

PRN: Sublingual tablets

(N.B. Butrans is unlicensed for cancer pain)

Methadone Seek specialist advice Liquid 1mg/ml and 10mg/ml

Injection

Alfentanil◊ Short-lasting effect so usually used in CSCI

Safe in renal failure Seek specialist advice 10 times more potent

than diamorphine/30 times more potent than morphine

Injection comes in two strengths -500micrograms/ml (2ml and 10ml amps) or 5mg/ml amps


50

N.B. Patients who have seen a palliative care/pain management consultant may on occasion be prescribed two regular opioids in parallel. This is not something a non-specialist should initiate.

Switching to Subcutaneous Preparations of Opioids

Patient unable to swallow or poor gastrointestinal absorption:

Keep on the same opioid which they received orally, i.e. Morphine po to sc morphine/diamorphine; Oxycodone po to sc oxycodone

N.B. Diamorphine sc and Morphine sc are not interchangeable

Patient on fentanyl patch and in the last few days of life:

If patient needs extra opioid analgesia continue the fentanyl patch and add additional pain relief into syringe driver. For further information see page 56

Doses of opioids need to be altered when the route of administration changes as opioids have different potencies when given by different routes.

Please refer to the conversion charts on pages 52-56 for further information.


51

Equianalgesic tables These tables serve as a guide only. The prescriber must

assess each individual patient and clinical situation and take responsibility for his/her actions. The conversion ratios are for guidance only as there are large variations due to inter-patient variability, drug interactions and different brands of products. Initial dose conversions should be conservative; it is preferable to under dose and provide rescue medication for any shortfall. When switching from high doses of morphine, e.g. 1-2g/24 hours dose conversions become less accurate therefore it is best to give lower than the calculated equivalent dose and rely on ‘as required’ doses to make up any deficit while re-titrating the new opioid. Similarly, if there has been a recent rapid escalation of the first opioid, use the pre-escalation dose to calculate the initial dose of the second opioid. When switching opioids regular and frequent assessment of response should be made and doses amended as necessary. Prescribe all strong opioids by brand where applicable to ensure continuity of therapy

Continue with transdermal patches when the patient can no longer tolerate oral medication and use subcutaneous injections for prn doses.

Doses shown are approximated to the most practical, based on current formulations.

The tables have been generated using manufacturers recommendations:

o Oral morphine 2mg = oral oxycodone 1mg (manufacturer’s recommendation)

o Oral morphine 3mg = SC morphine 1.5mg = SC diamorphine 1mg

o Oral oxycodone 2mg = SC oxycodone 1mg (manufacturer’s recommendation)

o Oral morphine to transdermal fentanyl conversion ratio = 150:1 (manufacturer’s recommendation)


52

Opioid Conversion Chart – (doses have been rounded up or down to convenient dose volumes)

Morphine (mg) Diamorphine(mg)

Oxycodone (mg) Fentanyl patch(microgram)

Route Oral SC SC Oral SC TD24h total

q4hprn

CSCI24h

q4h prn

CSCI24h

q4h prn

24h total

q4h prn

CSCI24h

q4h prn

hourly dose (over 72 hrs)

Dose 30 5 15 2.5 10 2.5 15 2.5 7.5 1.25 -60 10 30 5 20 5 30 5 15 2.5 12 microgram*90 15 45 7.5 30 5 45 7.5 20 2.5 25 microgram120 20 60 10 40 5 60 10 30 5 37 microgram150 25 75 10 50 10 75 10 40 5 50 microgram180 30 90 15 60 10 90 15 45 7.5 50 microgram240 40 120 20 80 10 120 20 60 10 62 microgram270 45 135 25† 90 15 135 25 70 10 75 microgram360 60 180 30† 120 20 180 30 90 15 100 microgram480 80 240 40† 160 25 240 40 120 20 125 microgram600 100 300 50† 200 30 300 50 150 25# 175 microgram800 130 400 60† 260 40 400 60 200 30# 225 microgram

Note: This table does not indicate incremental steps. Increases are normally in 30-50% steps – more if indicated by need for prn doses.


53

SC volumes over 2ml are uncomfortable; consider using two separate injection sites per prn dose or switch to diamorphine († or #) * The 12mcg/hr strength of Fentanyl patch is not licensed as a starting dose. Manufacturer does not recommend going above 300microgram/hr dose. Fentanyl patch changed every 72 hours.


54

Conversion from BuTrans® patches to other opioidsWhen a patch is removed buprenorphine serum levels decrease gradually over time. As a general rule, the new opioid should not be administered until 24 hours after removal. The table below uses a ratio of 75-100:1 to determine a safe starting dose of morphine. Titrate with immediate release opioid to analgesic effect. Butrans® is unlicensed in cancer pain.

BuTrans® patch strength 5 microgram/hour 10 microgram/hour 20 microgram/hour

Oral morphine ~10mg/day ~20mg/day ~40mg/day

Conversion factorsoral codeine/dihydrocodeine

to

oral morphine divide by 10(tramadol)* oral morphine divide by 10oral morphine oral oxycodone divide by 2oral morphine SC diamorphine divide by 3oral morphine SC morphine divide by 2oral oxycodone SC oxycodone divide by 2SC diamorphine SC alfentanil divide by 10fentanyl patch SC diamorphine 4hly prn divide by 5

*Note conversion from tramadol to other opioids is not recommended in practice due to dependence on cytochrome CYP2D6 for analgesic activity and risk of withdrawal reactions.


55

Converting To/From Fentanyl PatchesConverting To Fentanyl PatchesWhen converting patients from an oral opioid onto fentanyl patches, the regular opioid needs to be continued for the first 12 hours after the patch is applied to allow plasma fentanyl to increase to a therapeutic level.

Fentanyl Patches and End of Life CareFor patients using fentanyl patches that are entering the terminal phase of their illness and are requiring further opioid analgesia and for those with rapidly escalating pain, it is best to continue transdermal fentanyl and give rescue doses of their usual subcutaneous opioid or add a continuous subcutaneous infusion of their usual opioid as set out below.

Rescue doses of opioid for breakthrough pain for patients using fentanyl patches:

Give rescue doses of opioid as per chart on page 53.

e.g. fentanyl 50mcg/hr patch = 10mg diamorphine sc PRN 5 = 10mg morphine sc PRN

= 5mg oxycodone sc PRN

(For subcutaneous diamorphine use ‘the rule of 5’ - divide the patch strength by 5 and give as mg of diamorphine).

Maintain the current patch strength Continue to change the patch every 72 hours

Rapidly escalating pain requiring the addition of a syringe driver:

Infuse the equivalent of 2 or 3 ‘when required’ doses of usual opioid over the next 24 hours

This represents a total increase in dose of 30-50%


55

Converting From Fentanyl PatchesShould it be decided to completely replace the transdermal fentanyl with an alternative opioid, it must be remembered that a reservoir of fentanyl within the subcutaneous tissue will continue to provide clinically significant levels of fentanyl for several hours after the patch has been removed.

Replacing fentanyl patches with oral sustained release morphine or oxycodone preparations:

Remove the patch

Calculate equivalent 24 hour opioid dose, give half this dose in first 24 hours increasing to full equivalent oral opioid dose after 24 hours

Administer as twice a day sustained release preparation with access to appropriate prn doses (i.e. 1/6th of full equivalent 24 hour dose)

For example replacing fentanyl 50mcg/hr patch with oxycodone SR – give oxycodone SR 20mg bd for first 24 hours increasing to 40mg bd thereafter.

* These guidelines are based on recommendations published in the PCF4 and Palliative Drugs Website.


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Sheffield Palliative Care Formulary:Palliative Care Emergencies

Emergency Signs and Symptoms Management and Comments

Metastatic spinal cord compression (MSCC)

Change in back pain; leg weakness or ‘funny’ feeling in legs

Ataxia without objective evidence of weakness

Sensory and motor changes; incontinence

Spinal cord compression may present without neurological signs

Give stat dose Dexamethasone 16mg po/sc

Consider spinal surgery or vertebroplasty

Contact MSCC co-ordinator/oncologist with a view to radiotherapy

Superior vena cava obstruction (SVCO)

Swelling of face, torso and arms

Prominent veins on chest and neck

Breathlessness Headache or feeling of

fullness in the head

Give stat dose Dexamethasone 16mg po/sc

Seek urgent oncological opinion; may respond to chemotherapy, radiotherapy or stenting.

HypercalcaemiaConsider treatment if corrected calcium is >2.8mmol/l & symptoms are present

Nausea Constipation Polyuria and polydypsia Lethargy and mental

dullness, leading to confusion and coma

Rehydrate with normal saline.

Depending on renal function treat with bisphosphonates e.g. Zoledronic acid◊ 4mg intravenously stat


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Major (terminal) bleeding

Major catastrophic bleeds are rare, but can occur when a major vessel is eroded by tumour

In patients for whom active treatment of such an occurrence is inappropriate, the bleed usually leads to death within a matter of minutes

Apply pressure to bleeding site if appropriate (surface lesion)

There is unlikely to be time to administer controlled drugs; most important is to stay with the patient

Provide explanation, support and reassurance to the family and other observers.

Sit the patient up if coming from chest/upper gut

Consider giving : Morphine or

Diamorphine 5-10mg im or sc, repeating if required

Midazolam 5-10mg sc if still frightened

If the bleed is visible, dark coloured towels can make the appearance of blood less frightening.


58

Sheffield Palliative Care Formulary: Pruritus/ItchTreat reversible causes if possible, e.g. medication side-effects, dry skin, scabies, allergic reaction, urticaria, uraemia, dermatitis, systemic disease. Sometimes the cause may be multifactorial.

Non-drug treatments include: Gentle rubbing not scratching Keeping finger nails short Avoiding prolonged hot baths. Add 500mg bicarbonate of

soda to evening bath to give prolonged nocturnal skin hydration

Drying skin by ‘patting’ Avoiding overheating and sweating Increasing bedroom air humidity to avoid skin drying

For pruritus of unknown cause or when other options exhausted or inappropriate, consider the following:

Treatment Comments

Routine skin care - pruritus often associated with dry skin

Emollient agents, e.g. aqueous cream (not in atopic eczema), Diprobase®/Zerobase®

E45® cream Urea containing

preparations, e.g. E45® Itch relief cream◊, Balneum® Plus◊

Also use as soap replacement

Consider emollient bath additive

Topical Antipruritic agents

Preparations containing phenol, menthol and camphor available OTC

Topical steroid e.g. Hydrocortisone cream 1%, Betamethasone cream 0.025%

For inflamed localized itching


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Antihistamines – only effective if due to histamine release

Chlorphenamine 4mg – 12mg po four times a day. Sedative

Hydroxyzine◊ 10-25mg po once to three times a day. Sedative

Cetirizine 10mg po daily. Non-sedating

A sedating anti-histamine may be used in combination with a non-sedating anti-histamine in resistant cases according to patient tolerance

Steroids – for severe, resistant drug induced itch

Dexamethasone 2-8mg po daily for 1 week

Other treatment options are dependent on the cause:

Cause Treatment Comments

For severe localized itch

Capsaicin cream◊ * 0.025-0.075% applied once to twice daily

Wash hands after application

Cholestasis Seek specialist advice

End Stage Lymphoma

Prednisolone 10mg – 20mg po three times daily

Cimetidine◊ * 400mg po twice daily

Paraneoplastic pruritus

Paroxetine◊ * 5-20mg po once daily


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Sheffield Palliative Care Formulary:Respiratory Tract Secretions

The secretions that cause noisy breathing (also known as ‘death rattle’) are not usually relieved by drug treatment once they are established. Treatment should therefore be started at the first sign of noisy breathing due to respiratory tract secretions.

While not causing distress to the patient, the noisy breathing can be upsetting for carers. Explanation and reassurance that the patient is not distressed or being choked by the secretions should always be provided. Changing the patient’s position may improve the situation.

If secretions are purulent or offensive consider the use of parenteral antibiotics for symptom management.

If the patient has heart failure, consider parenteral diuretics if pulmonary oedema is the cause of excessive secretions.

Three drugs are considered to be the mainstay of treatment for respiratory tract secretions:-

Drug Dose Comments

Hyoscine Butylbromide◊ (Buscopan®)

20mg sc prn hourly or CSCI 60-240mg/24hrs

Does not cause sedation.

Glycopyrrolate◊ 200micrograms sc prn hourly or CSCI 400-2400micrograms/24hrs

Does not cause sedation.

Hyoscine Hydrobromide◊

400micrograms sc prn hourly or CSCI 400-2400micrograms/24hrs

Useful sedative effects but can cause agitation in some patients.


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Sheffield Palliative Care Formulary:Swallowing DifficultiesIt is important to try to diagnose and treat the underlying cause. As well as treating the cause it is also important to use symptom directed treatments. All treatments must be reviewed every few days for efficacy and side effects.

Specific causes include:

painful mouth/pharynx/oesophagus – ulceration, infection (fungal, bacterial, viral), local tumour, radiotherapy or chemotherapy, iron or vitamin deficiency

painful swallowing (odynophagia) – see painful mouth dry mouth – poor hydration, medication, radiotherapy, neurological in-coordination – local tumour invasion, CNS

dysfunction

Other considerations:

Check dentures fit correctly (if appropriate) Consider thickening fluids Contact medicines information/pharmacy regarding

availability of liquid medication or possibility of opening capsule/crushing tablet

Refer to speech and language therapist and/or dietician where appropriate

Cause of Dysphagia Management

Viral ulceration due to herpes simplex

Contact Virology for advice

Local Bacterial infection Refer to local infection policy Consider sending swab to microbiology

and taking their advice

Oral Candidiasis Refer to Oral Care chapter


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Oesophageal candidiasis Fluconazole 50mg po daily for 7 days (beware of drug interactions)

Iron or vitamin deficiency Check serum levels

Iron, B12 or folate supplementation

Dry mouth Refer to Oral Care chapter

Tumour in mouth, pharynx or oesophagus

May respond to radiotherapy or chemotherapy – seek oncology opinion

Radiotherapy May result in temporary or permanent dry mouth. Mucilage liquid◊ * 10ml pre meals and prn may help

Neurological in-coordination

Prokinetic for dysmotility either Domperidone 10-20mg po three times daily or Metoclopramide 10-20mg po three times daily

Symptom directed management of dysphagia

Management

Symptomatic management of pain in mouth/stomatitis/mucositis

Refer to Oral Care chapter

Excessive secretions (which may be caused by dysphagia)

Hyoscine Butylbromide◊ 20mg sc three times daily or 60mg/24hrs CSCI

Hyoscine Hydrobromide◊ transdermal patch 1mg/72hrs


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Sheffield Palliative Care Formulary:Sweating (Hyperhidrosis)

Treatment of excessive sweating depends on the cause. Where possible treat/remove the cause. Drug management in isolation is often ineffective. In cancer patients there can be extreme sweating with no obvious cause.

Cause Treatment

High ambient temperature Reduce heating, increase ventilation, electric fans, cotton clothing and bed linen

Infection Treat referring to local guidelines

Alcohol Reduce intake where possible

Medication Tricyclic antidepressants

/SSRIs Opioids

Replace with alternative antidepressant, e.g. Mirtazepine◊

Change to different opioid

Limited evidence suggests the following may be useful for treatment of sweating of unknown or unavoidable cause

Cause Treatment

Antipyretics Paracetamol up 1g four times a day +/-

NSAIDs, e.g. Ibuprofen 200-400mg po three times a day, Naproxen 250mg-500mg po twice a day, Diclofenac 25-50mg po three times daily

Topical treatment for localised sweating

Aluminium chloride


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Cause Treatment

Antimuscarinics Propantheline*◊ 15-30mg po two to three times a day (max 120mg/24hrs)

Hyoscine Hydrobromide*◊ 1mg/72hrs transdermal patch

Amitriptyline* 25-50mg po at night

Sweating due to hormone-related malignancy

Refer to Oncology team


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Sheffield Palliative Care Formulary:Syringe DriversFor general advice on the use of syringe drivers please refer to the local policy.Local policies state that no more than THREE different medications may be mixed in a syringe Conversion Doses of opioids Information for conversion of opioids can be found in the Pain

section of this formulary (pages 52-56)

Further information can be obtained by contacting a Palliative Care specialist or a Medicines Information department – contact details

Recommended Diluents Water for Injection should be used to dilute the contents of a

syringe in most cases.

Sodium Chloride 0.9% should be used for the following medications:

Granisetron* ◊ Ketamine* ◊ Ketorolac* ◊ Octreotide◊ Ondansetron* ◊

Drug Compatibility Problems

Incompatibilities have been reported with many drug combinations administered via a syringe driver.

Drugs that are often used in palliative care and are known to cause problems in combination with others in particular include:

Cyclizine * ◊

Hyoscine Butylbromide* ◊


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The risk of incompatibility is increased with:o Increasing doseso Increasing number of drugs in combination in one

syringe

It is not recommended that the following drugs be used in a syringe driver:

Chlorpromazine* ◊

Dexamethasone*Diazepam* Prochlorperazine*

Compatibility charts and a compatibility search function are available at www.palliativedrugs.com (free login required). A compatibility search function is also available at www.pallcare.info

For further information on compatibility please contact a palliative care pharmacist or a Medicine Information department – contact details

Clonazepam * ◊ has been reported to bind to PVC tubing – consider using non-PVC tubing

Troubleshooting

The contents of the syringe should be checked regularly for signs of degradation, e.g. cloudiness, precipitation. Check local policy for frequency, i.e. STHFT every four hours; community at every patient contact

N.B. Physical appearance does not guarantee chemical stability. Any untoward reaction should be noted and if necessary, further information can be sought from a Palliative Care Pharmacist or a Medicines Information department – contact details

Levomepromazine◊ (Nozinan) is known to turn purple when exposed to strong light. This is from a highly coloured but inert degradation product. Covering the contents of the syringe or placing the syringe driver in a bag/holster can avoid the reaction.


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http://www.pallcare.info/

http://www.palliativedrugs.com/

Injection-site reactions Injection-site reactions have been most commonly reported

with the following drugs:Cyclizine* ◊

Levomepromazine◊

Methadone* Site reactions are possible with any drug and the risk is

increased with higher doses/concentrations contained within the infusion. If a reaction occurs the following can be tried to resolve/improve the problem:

o Review the need and appropriateness of therapy and adjust the regime accordingly

o Move to 12-hourly infusion to dilute the concentration further. N.B. The dosages and rate need to be adjusted accordingly – further information can be sought from a Palliative Care specialist or a Medicines Information department – contact details

o Consider changing site more frequently

An allergy to metal needles should be considered if all the above measures fail. Teflon coated cannulas are available. Please consult the local syringe driver policy.


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Sheffield Palliative Care Formulary:Prescribing in the Last Few Days of Life

Advice on prescribing for patients in the last few days of life can be found in the following: Sheffield Citywide End of Life Care Pathway (available via

NHS Sheffield website) Sheffield Teaching Hospitals NHSFT/St Luke’s End of Life

Care Pathway (EOLCP)

It is good practice that as a patient approaches the last few days of life that the following are considered with regard to medication: Current medication is assessed and non-essentials

discontinued. Consider alternative route/formulation for essential

medications if the patient is unable to swallow e.g. syringe driver to administer analgesia and antiemetics, sublingual/orodispersible preparations (lorazepam, lansoprazole), transdermal preparations (nitrates/nicotine patches), single daily injections (haloperidol or clonazepam (dilute before use as subcutaneous bolus)).

Prescribe subcutaneous ‘as required’ medication for the following symptoms (using the algorithms in the End of Life Care Pathway)

(1) Pain(2) Dyspnoea(3) Terminal Restlessness and Agitation(4) Nausea and vomiting(5) Respiratory tract secretions

N.B. Opioids can be used for pain and dyspnoea; Haloperidol can be used for agitation and nausea; Midazolam can be used for agitation and dyspnoea

It is important that these medications are available in the patient’s house/on ward should they be needed


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For Primary Care pre-emptive prescribing, below are listed the strengths and pack sizes of Medications used in the End of Life Care pathway algorithms

Symptom Medication No. vials in

box

Comments

Pain Morphine 10mg/ml injectionMorphine 15mg/ml injectionMorphine 30mg/ml injection

555

Controlled Drug

Diamorphine 5mg injectionDiamorphine 10mg injection

55

Controlled Drug

Oxycodone 10mg/ml injectionOxycodone 20mg/2ml injection

55

Controlled Drug

Dyspnoea Morphine as aboveMidazolam as below

Terminal Restlessness/ Agitation

Midazolam 10mg/2ml injection 10 Controlled Drug

Nausea & Vomiting

Haloperidol 5mg/ml injection 5

Metoclopramide 10mg/2ml injection 10

Cyclizine 50mg/ml injection 5

Levomepromazine 25mg/ml injection

10

Respiratory Tract Secretions

Hyoscine Butylbromide 20mg/ml injection

10


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Sheffield Palliative Care Formulary:AcknowledgementsMany thanks to everyone who has contributed to this and previous editions of the Sheffield Palliative Care Formulary. In particular the following: Dr Ashique Ahamed, SpR Palliative Medicine, Sheffield Professor Sam Ahmedzai, Professor of Palliative Medicine,

University of Sheffield & Consultant, Palliative Medicine STHFT

Lynne Ghasemi, Community Specialist Nurse in Palliative Care, St Luke’s Hospice

Jane Harding, Lymphoedema Physiotherapist, NHS Sheffield Alison Humphrey, CNS Palliative Care, STHFT Irene Lawrence, Palliative Care Pharmacist, STHFT Liz Miller, Palliative Care Pharmacist, STHFT/St Luke’s

Hospice Dr Bill Noble, Macmillan Senior Lecturer in Palliative Medicine

& Consultant, Palliative Medicine, STHFT Julia Newell, CNS Palliative Care, STHFT Elizabeth Newell, CNS Palliative Care, STHFT Dr Sam Kyeremateng, Consultant, Palliative Medicine,

STHFT/ St Luke’s Hospice Sian Richardson, CNS Palliative Care, STHFT Pete Saunders, CNS Palliative Care, STHFT Dr Ellie Smith, Consultant, Palliative Medicine, STHFT/St

Luke’s Hospice Vanessa Spawton, CNS Palliative Care, STHFT Dr Kay Stewart, Lead Clinician, Palliative Medicine, STHFT Dr Rachel Vedder, SpR Palliative Medicine, Sheffield Dr Vandana Vora, Consultant, Palliative Medicine, STH/St

Luke’s Hospice Lynne Wells, CNS Palliative Care, STHFT Andrea Underwood & Emma Harrison: Secretarial Support,

Pharmacy, STHFT


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Also the following staff now working outside Sheffield:

Dr Jason Boland, Dr Ruth Broadhurst, Dr Kathryn Brown, Dr Rebecca Hirst and Dr Sarah Mollart


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Sheffield Palliative Care FormularyDrug Index

Drug Page Number/sAdrenaline 14Alfentanil 48, 52Aluminium chloride 62Amitriptyline 25, 45, 63Antacid & Oxetacaine 41Antacids 29Aqueous Cream 36, 57Arachis Oil 21Artificial Saliva Spray 40Asilone® 29, 34Baclofen 34, 44Balneum® Plus 57Benzydamine 41Betamethasone Cream 57Biotene Oralbalance® Gel 40BioXtra® Gel 40Bisacodyl 20-22Bonjela® 41Buprenorphine 48, 52BuTrans® 52Capsaicin Cream 45, 58Carbocisteine 23Celecoxib 29, 44Cetirizine 58Chlorhexidine Gluconate 42Chlorphenamine 58Chlorpromazine 65Choline Salicylate 41Cimetidine 58Citalopram 25Clonazepam 45, 65Co-Danthramer 20


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Drug Page Number/sCo-Danthrusate 20Codeine Linctus 14, 23Codeine Phosphate 26-28, 43, 52Colestyramine 27COX 2 44Cyclizine 39, 64, 66, 68Dexamethasone 11, 27, 39, 44, 45, 55, 58, 65Diamorphine 15, 48, 49, 51, 53, 56, 68Diazepam 13, 44, 65Diclofenac 44, 62Dihydrocodeine 52Difflam® 41Dioralyte® 28Diprobase® 57Docusate Sodium 19Domperidone 29, 30, 34, 38, 39, 61Duloxetine 13, 25, 45E45® Itch Relief Cream 57Etamsylate 15Etoricoxib 29Fentanyl 48, 50-54Fluconazole 42, 61Gabapentin 45Gelclair® Concentrated Oral Gel 42Glycerin 21, 22Glycopyrrolate 59Granisetron 64Haloperidol 9, 13, 17, 34, 38, 39, 67, 68Hydrocortisone Cream 57Hydroxyzine 58Hyoscine Butylbromide 17, 26, 44, 59, 61, 64, 68Hyoscine Hydrobromide 39, 59, 61, 63Hypertonic Electrolyte Solution 28Ibuprofen 62


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Drug Page Number/sKetamine 64Ketorolac 64Lactulose 19Lansoprazole 28-30Laxido® 19Levomepromazine 9, 13, 17, 38, 65, 66, 68Lidocaine 41Lofepramine 25Loperamide 26-28Lorazepam 13, 32, 39Maalox® 29, 30Mebeverine 44Medroxyprogesterone 11Megestrol Acetate 11Mesalazine 28Methadone 48, 66Methadone Linctus 14, 23Methylphenidate 33Methylnaltrexone 20Metoclopramide 11, 17, 29, 30, 34, 38, 39, 61, 68Metronidazole 27, 41Micralax Micro-enema® 22Midazolam 9, 13, 15, 32, 34, 56, 67, 68Mirtazepine 13, 25, 62Morphine Sulphate 14, 15, 23, 31, 43, 45, 49-54, 56, 68Morphine Hydrochloride 41Movicol® 19MST® 45, 46Mucilage Liquid 61Naloxone 46Naproxen 62Nortriptyline 25NSAIDs 43, 44Nystatin 42


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Drug Page Number/sOctreotide 17, 26, 27, 28, 64Olanzapine 9, 13Omeprazole 28, 29Ondansetron 39, 64Oxetacaine 41Oxycodone 47, 50-54, 68Pancreatin 27Paracetamol 43, 62Paroxetine 58Peptac® 29, 30Phosphate enema 21, 22Pilocarpine Tablets 40Prednisolone 58Pregabalin 45Prochlorperazine 39, 65Propantheline 63Ranitidine 29Risperidone 9Salbutamol 32Saliva Orthana® 40Senna 20, 22Sertraline 13, 25Sevredol® 45Silver Nitrate sticks 14Simple Linctus 23Sodium Chloride 23, 32Sodium Citrate 21Sodium Hypochlorite solution 42Sulfasalazine 28Temazepam 35Tramadol 47, 52Tranexamic Acid 14, 15, 40Trazodone 13, 25Xerotin® 40


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Drug Page Number/sZerobase® 57Zoledronic Acid 55Zomorph® 45, 46Zopiclone 35


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