Pain/breathlessness/cough/pyrexia

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Pain/breathlessness/cough/pyrexia

Medicine

Route

Dose

Administration/ Comments

Paracetamol suppositories 500mg and 1g

Rectal

SHORT ACTING

500mg to 1g every 4-6 hours (max 4g/24hrs)
  • Use 500mg dose if: Weight <50kg, hepatic impairment, eGFR<30ml/min, history of alcohol excess.
  • Opioid patches (see https://www.palliativecareguidelines.scot.nhs.uk for conversions).
    • Opioid patches are recommended for stable pain.
    • Used patches still contain opioid; after removal, fold the patch with the adhesive side inwards and discard in a sharps container (hospital) or dustbin (home), and wash hands. Ultimately, any unused patches should be returned to a pharmacy.
    • It is important to bear in mind that fever will increase the rate of absorption of opioids from patches – it may be necessary to use a reduced dose and change the patch more frequently. It may also impact on how well patches adhere to skin, and tape (e.g. Micropore®) can be applied to the edges to improve this.
  • Buprenorphine is the drug of choice in opioid naïve patients. 5micrograms/hr buprenorphine patch is approximately equivalent to 12mg oral morphine/24 hr.
  • Matrix (not reservoir) 12micrograms/hr fentanyl patches (approximately equivalent to 30mg to 60mg oral morphine/24hr) can also be cut in half (diagonally) to provide a lower starting dose†.

Refer to:

Fentanyl patches

Buprenorphine patches

Buprenorphine Patch – 5 and 10micrograms/hr

Larger doses available for converting from other opioids 15, 20, 35, 52.5, 70micrograms/hr

Transdermal

LONG ACTING

 

Opioid naïve – 5micrograms/hr patch – equivalent to 12mg oral morphine/24hr

On regular opioid – 20micrograms/hr patch equivalent to 48mg oral morphine/24hr
  • Apply patch to dry, hairless skin.
  • Note: some brands are 7 day patches and some 3 or 4 day patches.

 

Fentanyl matrix patch

12, 25, 50, 75, or 100micrograms/hr

Transdermal
LONG ACTING

Convert from current regular opioid (12micrograms/hr patch equivalent to 30mg to 60mg of oral morphine in 24 hours)
  • Apply patch and change every 3 days.
  • 12micrograms/hr patch can be halved (diagonally) to give a 6micrograms/hr dose†.
  • Do not half reservoir patches.

Morphine sulphate MR Capsules:

Zomorph® 10mg, 30mg, 60mg, 100mg, 200mg

Please note: MST Continus suspension sachets have been discontinued

Enteral feeding tube
LONG ACTING

Convert from current opioid dose and give every 12 hours
  • Zomorph® capsules can be opened and the contents given via enteral tubes with a diameter of more than 16 FG. Rinse with 30mL to 50mL of water†.

MST Continus® tablets can be given rectally†.

Rectal

LONG ACTING

Convert from current oral opioid dose
  • MST tablets can be given rectally although the absorption is not as reliable as orally. Dose as per oral MST dose.

Diclofenac sodium suppositories 25mg, 50mg, 100mg

Rectal

LONG ACTING

75mg to 150mg daily in two divided doses

 

Rapid acting fentanyl: nasal sprays, such as Pecfent®, or buccal/sublingual tablets, such as Abstral® and Effentora®, may be used under specialist palliative care advice.

 

Nausea and vomiting

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Nausea and vomiting

Medicine

Route

Dose

Administration/ Comments

QT†Prochlorperazine 3mg buccal tablets (eg Buccastem®)

 

Buccal

SHORT ACTING

3mg to 6mg every 6 to 12 hours
  • Maximum 12mg per day

QT†Ondansetron 4mg oro-dispersible tablets

Oro-dispersible

SHORT ACTING

4mg every 6 to 8 hours, maximum 16mg/day

 
  • Place on tongue and allow to dissolve
  • Mouth must be moist

†Hyoscine hydrobromide 300microgram tablets

(eg Kwells®)

Sublingual or buccal

SHORT ACTING

300 micrograms every 6 hours
  • Watch for delirium
  • Maximum 1.2mg/24hr

 

QT†Levomepromazine injection 25mg/ml

Sublingual or buccal

LONG ACTING

2.5mg every 4 to 6 hours as required
  • The injection solution can be administered by the off label sublingual or buccal route

†Hyoscine hydrobromide 1.5mg patches (1mg in 72 hr) (e.g. Scopoderm®)

Transdermal patch

LONG ACTING

1 to 4 patches every 72 hours
  • Ideally placed on the skin behind the ear
  • Hyoscine hydrobromide may cause agitation/delirium – monitor for this and remove patches should this occur

QT†Olanzapine oro-dispersible tablets 5mg, 10mg

Sublingual

LONG ACTING

2.5mg stat dose and every 2 to 4 hours if required up to 10mg daily
  • Place on or under tongue and allow to dissolve
  • 5mg tablet can be halved and the other half discarded safely

 

Respiratory secretions

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Respiratory secretions

Medicine

Route

Dose

Administration/ Comments

†Hyoscine hydrobromide 1.5mg patches (1mg in 72 hr) (e.g. Scopoderm®)

Transdermal patch

LONG ACTING

1 to 4 patches every 72 hours
  • Ideally placed on the skin behind the ear
  • Hyoscine hydrobromide may cause agitation/delirium – monitor for this and remove patches should this occur

†Hyoscine hydrobromide 300microgram tablets (e.g. Kwells®)

Sublingual or buccal

SHORT ACTING

300micrograms every 6 hours
  • Watch for delirium
  • Maximum 1.2mg/24hr

†Atropine 1% eye drops

Sublingual

SHORT ACTING

2 to 4 drops every 4 hours
  • Watch for delirium
  • Caution in cardiac disease
  • Do not administer via eyes

†Glycopyrronium bromide injection 200micrograms/ml

Sublingual

SHORT ACTING

200microgram every hour as required
  • Maximum 1.2mg/24hr
  • Can use higher doses under specialist advice

†Ipratropium 2 puffs via inhaler and spacer or 250micrograms via nebuliser

Inhaled

SHORT ACTING

Every 4 to 6 hours

 

 

Anxiety and distress, for example associated with breathlessness

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Anxiety and distress, for example associated with breathlessness

Medicine

Route

Dose

Administration/ Comments

†Lorazepam 1mg tablets (blue, scored tablets – Genus, PVL or TEVA brands- can be halved and administered sublingually)

Sublingual

SHORT ACTING

500micrograms every 4 hours, as required
  • Put half a tablet under the tongue and leave to dissolve

†Midazolam

Buccal preparation or midazolam injection 10mg/2ml

Buccal

SHORT ACTING

2.5mg every hour as required
  • Note: Epistatus® is double the concentration of Buccolam®
  • Buccolam® (5mg/ml, 2.5mg; 5mg; 7.5mg and 10mg syringes available) or Epistatus® (10mg/ml)

Diazepam 2.5mg, 5mg or 10mg rectal tubes

Rectal

SHORT ACTING

 

2.5 to 5mg every 4 to 6 hours†.

 

Note: fans are not recommended for breathlessness in the context of COVID-19.

 

Delirium and agitation

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Delirium and agitation

Medicine

Route

Dose

Administration/ Comments

QT†Levomepromazine injection 25mg/ml

Sublingual or buccal

LONG ACTING

5mg every 2 to 4 hours as required
  • The injection solution can be administered by the off label sublingual or buccal route
  • May be advised to give higher doses or more frequently on specialist advice

QT†Olanzapine oro-dispersible tablets 5mg, 10mg

Sublingual

LONG ACTING

2.5mg at night and2.5mg every 4 hours as required, up to maximum 10mg in 24 hours
  • Place on or under tongue and allow to dissolve
  • 5mg tablet can be halved and the other half discarded safely

QT†Risperidone oro-dispersible tablets 500micrograms, 1mg, 2mg, 3mg, 4mg

Sublingual

LONG ACTING

Start with 500micrograms every 12 hours
  • Place on or under tongue and allow to dissolve

QTAripiprazole oro-dispersible tablets 10mg and 15mg

Sublingual

LONG ACTING

Start with 10mg every 24 hours
  • Place on or under tongue and allow to dissolve

If antipsychotics are contraindicated, midazolam can be given via the buccal route, however benzodiazepines can worsen delirium so are not used first line. Benzodiazepines can be used first line for agitation.

†Midazolam

Buccal preparation or midazolam injection 10mg/2ml

Buccal

SHORT ACTING

2.5mg every hour as required
  • Note: Epistatus® is double the concentration of Buccolam®
  • Buccolam® (5mg/ml, 2.5mg, 5mg, 7.5mg and 10mg syringes available) or Epistatus® (10mg/ml)

Note: withdrawal of oral drugs which cannot be directly replaced as patients are approaching end of life, such as gabapentin or antidepressants, may contribute to delirium and agitation, and may require higher doses of the above medications to be prescribed.

 

Seizures

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Seizures

Medicine

Route

Dose

Administration/ Comments

Midazolam

Buccal preparation or midazolam injection 10mg/2ml

Buccal

SHORT ACTING

10mg in event of seizure; can repeat after 15 minutes
  • Note: Epistatus® is double the concentration of Buccolam®
  • Buccolam® (5mg/ml, 2.5mg; 5mg; 7.5mg and 10mg syringes available) or Epistatus® (10mg/ml)

Diazepam 5mg or 10mg rectal tubes

Rectal

SHORT ACTING

10mg in event of seizure

 

Carbamazepine suppositories

125mg, 250mg

Rectal

LONG ACTING

Convert previous oral dose and give twice daily; not for use in new seizures
  • 125mg suppository equivalent to 100mg orally

If recurrent seizures seek palliative medicine advice.

 

Regular administration of bolus subcutaneous medication to replace regular long acting oral medication

Regular bolus SC administration of a single medication or a combination of medications is an effective way to manage symptoms when:

  • There is no syringe pump available
  • There are no/insufficient staff present who are trained to set up or maintain a syringe pump
  • Trained nursing staff are available to give regular medication or in some areas family carers can be trained to give regular medication

When giving SC opioid injections, the maximum volume is 2ml. If a patient needs a dose that is in an injection volume above 2ml – seek advice

As required medication can be given in addition to this regular dosing.

 

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Opioids

Note: If a patient is already on a regular opioid, use the as required subcutaneous dose of the same opioid regularly at intervals as below.

Drug

Dose

Frequency

Comments

Morphine sulfate

2mg

Every 4 hours
  • These doses are for opioid naïve patients. If the patient is already on an oral opioid, see www.palliativecareguidelines.scot.nhs.uk for appropriate dosing and conversions.
  • Lower dose or less frequent administration should be used when the patient has renal impairment

Oxycodone

1mg

Every 4 hours

Diamorphine

2mg

Every 4 hours

Anti-Emetics

Note: If a patient is already on a regular anti-emetic, use the as required subcutaneous dose of the same anti-emetic regularly at intervals as below

Cyclizine

50mg

Every 8 hours
  • If a patient is already on an oral anti-emetic, use the same medication subcutaneously where possible

QT†Haloperidol

500micrograms

Daily or every 12 hours

QT†Levomepromazine

2.5mg

Every 12 hours

QTMetoclopramide

10mg

Every 8 hours

Anticholinergics for chest secretions or bowel colic

†Hyoscine butylbromide

20mg

Every 4 to 6 hours

 

†Glycopyrronium

200micrograms

 

Every 6 to 8 hours

 

†Hyoscine hydrobromide

400micrograms

Every 6 hours

 

Non Steroidals (NSAIDS) Drugs for Pain

†Diclofenac

50mg

Every 8 hours

 

†Ketorolac

15mg

Every 8 hours

Drugs for Agitation

Midazolam

2mg

Every 4 to 6 hours
  • May be advised to give higher doses or more frequently on specialist advice

QT†Levomepromazine

 

 

5mg

Every 12 hours

Miscellaneous

Dexamethasone

3.3mg subcutaneously is equivalent to 4mg orally

Daily
  • Dose depending on indication; convert from oral dose

†Levetiracetam

500mg or the same dose as oral maintenance dose

Every 12 hours
  • Dilute in 100ml sodium chloride 0.9% and infuse subcutaneously over 30 minutes.
  • 1:1 conversion from oral to subcutaneous

†Octreotide

100micrograms

Every 12 hours

 

†Ranitidine

75mg

Every 12 hours