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Sheffield Palliative Care Formulary

3rd 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 Sheffield

Ratifying Bodies Sheffield Teaching Hospitals Medicines Management & Therapeutics Committee, Sheffield Area Prescribing Committee, St Luke’s Hospice Clinical Governance

Date March 2012

Review date March 2015

Authors: 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.

Contents

Page (click to view)

Introduction 4

Specialist Palliative Care Services’ Contact Numbers 5

How to Refer to Sheffield Palliative Care Services 6

Abbreviations 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

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.

Specialist Palliative Care Services

Contact Numbers

|Northern General Hospital |

|Tel: (0114) 2434343 (Switchboard) |

|Referrals to the Palliative Care Hospital Support Team or |Tel: (0114) 2266770 |

|for In-Patient admission |Fax: (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) 2265602 |

| |Fax: (0114) 2265745 |

|Medicines Information - for Hospital Related queries |Tel: (0114) 2712346 |

|St Luke’s Hospice |

|Referrals for In-patient admission, Day Therapies & |Tel: (0114) 2369911 |

|Rehabilitation and the Community Palliative Care Team |Fax: (0114) 2351321 |

|The Cavendish Centre |

|Wilkinson Street, Sheffield S10 |

|Offers 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 |Tel: (0114) 3051667 |

|Related queries (PCT Medicines Management Team) | |

|Cancer Support Centre |Tel: (0114) 2265666 |

Sheffield Palliative Care Services

How 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:



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) 2714289 |

| |Tel: (0114) 2266770 |

|Sheffield Macmillan Palliative Care Unit: Admission|FAX: (0114) 2714289 |

| |Tel: (0114) 2266770 |

|RHH/WPH Hospital Support Team or Clinic |FAX: (0114) 2265745 |

| |Tel: (0114) 2265602 |

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

| |Tel: (0114) 2369911 |

|St Luke’s Hospice: Day Therapies & Rehabilitation |FAX: (0114) 2351321 |

|Centre |Tel: (0114) 2369911 |

|St Luke’s: Community Palliative Care Team |FAX: (0114) 2351321 |

| |Tel:(0114) 2369911 |

|Intensive Home Nursing or VIP Service |FAX: (0114) 2716026 |

| |Tel: (0114) 2716010 |

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 |

Sheffield Palliative Care Formulary

Agitation/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

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|Haloperidol 1.5mg po/sc at night +/- every |Max 10mg/24hrs Care with |

|Titrate doses |four to six hours when required |side-effects |

|accordingly |Olanzapine 2.5mg po stat and at bedtime | |

| |Risperidone◊ 500micrograms po twice daily | |

|Terminal Restlessness |Haloperidol 1.5-5mg po or sc +/- Midazolam◊ | |

|End of Life Care – see |2.5 - 10mg sc stat | |

|also Last Few Days of |Levomepromazine◊ 6.25mg-25mg po or sc may be | |

|Life chapter p67 |used if period of sedation required |More sedating than |

| | |haloperidol |

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.

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. |

| |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 |Anorexia in association with other depressive symptoms should be treated |

|Depression |with an anti-depressant (see the chapter on Depression) |

|Vitamin Deficiency |Some instances of anorexia can be attributed to taste alteration and studies|

|Induced Anorexia |have shown that zinc or Vitamin B deficiency may be to blame. Correcting |

| |these deficiencies may alleviate the problem. |

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

Management of anxiety

| | |

|Symptoms |Drug |

|Mild to Moderate anxiety or Situational|Lorazepam◊ 0.5-1mg po or sublingually (Genus brand) |

|anxiety |as required up to 4mg/day |

| |Diazepam 2-5mg po nocte prn or in divided doses up to|

| |20mg/day |

| |Lorazepam◊ 0.5-1mg po or sublingually (Genus brand) |

|Generalised anxiety disorder, Panic |as required up to 4mg/day |

|attacks or Overwhelming fear and |Midazolam◊ 1.25-10mg sc prn every two to four hours |

|agitation |or CSCI 2.5-60mg/24hrs |

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

| |e.g. Sertraline, Trazodone, Mirtazepine, Duloxetine |

| | |

| | |

| | |

|If recurrent or resistant, consider | |

|antidepressants | |

| |Haloperidol 2.5-10mg po/sc every four to six hours. |

|Anxiety or agitation with delirium or |Max 10mg/24hrs |

|psychotic features |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 |

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 |Apply with pressure |

| |Tranexamic acid 500mg/5ml injection* |for 10 mins |

| |Silver Nitrate sticks◊ applied to bleeding points | |

| |Haemostatic dressings i.e. alginate | |

|Haemoptysis |Cough suppression | |

| |Codeine 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 |Gastroprotective drug, i.e. PPI | |

|Melaena |Bleeding Control – see box below | |

|Haematuria, Rectal and|Bleeding Control – see box below | |

|Vaginal bleeding | | |

|Bleeding Control |Tranexamic acid 1g four times a day |Useful for blood streaking; not effective|

|(minor bleed) |po. Increase to 2g four times daily |for major bleeding |

| |if necessary |Avoid if renal in origin & risk of |

| |Etamsylate◊ * 500mg four times a day |ureteric obstruction |

| |po |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) |Major catastrophic bleeds are rare, |Provide explanation, support and |

|bleeding |but can occur when a major artery is |reassurance to the family and other |

| |eroded by tumour |observers. |

|If patient at high |In patients for whom active treatment|Consider giving: |

|risk of catastrophic |of such an occurrence is |Morphine or Diamorphine 10mg iv or sc, |

|bleed, consider |inappropriate, the bleed usually |repeating if required |

|availability of opioid|leads to death within a matter of |Midazolam 5-20mg iv or sc if still |

|and midazolam in the |minutes |frightened |

|patient’s house/on |There is unlikely to be time to |If the bleed is visible, dark coloured |

|ward |administer controlled drugs; most |towels can make the appearance of blood |

| |important is to stay with the patient|less frightening. |

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).

Treatment of Bowel Obstruction

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.

• 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 |Lactulose 10-30ml once or twice |Patient needs to be well hydrated. |

|gut lumen |daily |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 |

|Surfactant agents: increase water | |bitter tasting |

|penetration of stool |Docusate sodium◊ 100-300mg twice | |

|Macrogols: hydrate hardened stool,|daily |Sachets need to be dissolved in 125ml|

|increase stool volume, decrease |Laxido®/Movicol® (polyethylene |water or juice (N.B. large volume). |

|duration of colon passage and |glycol) 1-3 sachets a day. Up to |Onset of action 1-2 days |

|dilate bowel wall that then |8 sachets/day for faecal impaction| |

|triggers defaecation reflex | | |

|Stimulant laxatives | | |

|Direct stimulation of myenteric |Senna 7.5-15mg once to twice daily|May cause colic. Do not use if |

|nerves to induce peristalsis. |Bisacodyl 5-10mg once daily |colic/obstruction present |

|Reduce absorption of water in the | | |

|gut | | |

|Combination Stimulant and | | |

|Softening Agents |Co-danthramer 25/200 1-3 capsules |Danthron containing products |

| |or 5-15ml once to three times |restricted to treating constipation |

| |daily |in terminal illness. Urine may be |

| |Co-danthramer Strong 1-3 capsules |stained red. Do not use in urinary |

| |once to twice daily or 2.5-10ml |or faecal incontinence as may ‘burn’ |

| |once or twice daily |skin |

| |Co-danthrusate 50/60 1-3 capsules | |

| |or 5-15ml once to twice daily | |

Peripheral Opioid-receptor Antagonist

| Mode of Action |Drug/Dose |Comments |

|Peripheral opioid-receptor |Methylnaltrexone(◊ – subcutaneous |May act within 30-60 minutes.|

|antagonist |injection, dose dependant on body weight |Max duration of treatment 4 |

|Indicated for opioid-induced |(see BNF/SPC), on alternate days or less |months |

|constipation in palliative care |frequently depending on response. | |

|patients when response to other | | |

|laxatives inadequate | | |

Rectally Administered Drugs

| Mode of Action |Drug/Dose |Comments |

|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 |Not to be used for prolonged periods |

| |once daily |of time due to absorption of |

| | |phosphate into the systemic |

| | |circulation. |

Spinal Injury – see next page

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 |Treat reversible causes. |

|above) causes spastic, reflexic bowel. Reflex |Senna 15mg po or Bisacodyl 10mg po on alternate days |

|activity is maintained; the bowel will contract and|Phosphate or Micralax® enema on alternate days |

|empty when stimulated. Anal sphincter tone is |Bisacodyl 10mg or Glycerin 4g suppositories alternate|

|maintained. |days |

| |Abdominal massage |

|Lower Motor Neurone damage (Lumbar level 1 and |Gravity assisted evacuation – perform over the toilet |

|below) causes flaccid, areflexic bowel. Anal |Bear down – using strong abdominal muscles |

|sphincter will be flaccid, which can lead to a |Massage abdomen and get patient to lean forward if |

|build up of faecal material, which may be difficult|they can |

|to empty and may also cause overflow of faecal |If these measures fail, perform manual evacuation |

|material. |Daily if tolerated |

|Cauda equina syndrome |2 Glycerin 4g suppositories alternate days |

|Damage to the nerves at the base of the spine. |Daily digital rectal examination followed by manual |

|Sensory nerves often intact. Nerves for movement |evacuation. |

|often impaired. Bowel then becomes flaccid. | |

Please refer to local guidelines or protocols for treatment.

Sheffield Palliative Care Formulary: Cough

Treat 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 |Nebulised Sodium Chloride 0.9%◊ *5ml when |May need physiotherapy |

|mucus. |required (limited evidence) |afterwards to expectorate|

| | |Stop after 4 weeks if no |

| |Carbocisteine 750mg three times daily. |benefit |

|Mucolytics in COPD |Caution in those with history of peptic | |

|patients |ulcer | |

|Opioids |Codeine linctus◊ 10ml three to four times a|Will need laxative |

| |day when required |combination (see). |

| |If not responding, low dose immediate |Monitor side effects |

| |release Morphine Sulphate* 1.25- 2.5mg |especially in COPD |

| |every four hours when required |patients |

| |For mainly nocturnal cough, consider | |

| |Methadone linctus 2mg/5ml ( 1mg po at night| |

| |increasing to 2mg twice daily as tolerated | |

|Corticosteroid |Only if there is history of COPD/asthma | |

| |exacerbation, pulmonary fibrosis | |

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.

Antidepressant Drug Choice

|Indication |Management |Comments |

|First line for depression or where |Amitriptyline 10-200mg po at night | |

|prognosis less than 16 weeks or with |Nortriptyline◊ 25-150mg po at night | |

|neuropathic pain. | |Less sedating |

|For refractory depression or |Duloxetine◊ 30mg po daily increasing | |

|depression with diabetic or other |to 60mg po twice a day | |

|neuropathy. | | |

|For patients with anorexia, insomnia,|Mirtazepine◊ 15-45mg po at night |May improve appetite |

|anxiety or agitation | | |

|For patients with insomnia or a |Trazodone 100-300mg at night to a |Less cardiotoxic |

|history of seizures |maximum of 300mg twice a day | |

|Alternative antidepressants when both|Sertraline 50-200mg po once daily | |

|sedation and stimulation need to be |Citalopram 20mg po once daily | |

|avoided. |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.

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 |

Treatment for disease specific cause

|Cause |Treatment |

|Overflow from severe |Appropriate Laxative Treatment (see Constipation guidelines) |

|constipation | |

|Malignancy |Refer to oncologist for possible chemo- or radiotherapy |

|Infection |Please refer to Local Infection Guidelines |

|Drug therapy, e.g. |Review therapy and reduce dose/discontinue as appropriate. |

|chemotherapy |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 |

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

|due to loss of 2/3 of the |Codeine Phosphate 30-60mg po four times a day |

|small bowel. Can result from|Lansoprazole 30mg po twice a day |

|congenital disorders, |Omeprazole 40mg po twice a day |

|surgical resection or bypass|Octreotide(◊ * commence 50 micrograms sc three times a day increasing to |

|of intestine |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 |

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) |Discontinue offending drugs if possible, e.g. NSAIDs, |

|(may consider urea breath test or |steroids, aspirin |

|stool antigen test for H.pylori. |If NSAIDs to continue, add PPI cover, e.g. Lansoprazole,|

|These tests need to be done before|Omeprazole, Ranitidine2 or consider switch to COX2 |

|starting PPI or antibiotics) |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 |

|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)

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, |Caution for patients with chronic |

| |start with immediate release Morphine |respiratory disease |

| |Sulphate* po 2.5mg every 4 hours prn |Must prescribe laxatives (see |

| |If preferred by patient, consider |Constipation) |

| |converting to a slow release |Consider anti-emetic for first few|

| |preparation |days (see Nausea and Vomiting) |

| |If already on strong opioid for pain | |

| |control, consider increasing prn dose | |

| |by 25-50% | |

|Treatment |Regime |Comments |

|Benzodiazepines |Lorazepam◊ 0.5mg prn po or |Watch for sedation. |

| |sublingually* increasing gradually to |Sublingually use Genus brand of |

| |max 2mg/24hrs |Lorazepam – other brands may not |

| | |dissolve under tongue. |

| | |Avoid diazepam (long half-life). |

| |In terminal stage, consider Midazolam◊ |Ensure PRN dose prescribed for use|

| |* 2.5mg sc PRN. If required regularly |in addition to CSCI |

| |consider CSCI Midazolam◊ * - start at | |

| |5-10mg/24hrs, increase gradually if | |

| |necessary | |

|Oxygen |If hypoxic (resting SaO2 2.8mmol/l & symptoms are |Lethargy and mental dullness, leading |acid◊ 4mg intravenously stat |

|present |to confusion and coma | |

|Major (terminal) bleeding |Major catastrophic bleeds are rare, but|Provide explanation, support and |

| |can occur when a major vessel is eroded|reassurance to the family and other |

| |by tumour |observers. |

| |In patients for whom active treatment |Sit the patient up if coming from |

| |of such an occurrence is inappropriate,|chest/upper gut |

| |the bleed usually leads to death within|Consider giving : |

| |a matter of minutes |Morphine or Diamorphine 5-10mg im or |

| |Apply pressure to bleeding site if |sc, repeating if required |

| |appropriate (surface lesion) |Midazolam 5-10mg sc if still |

| |There is unlikely to be time to |frightened |

| |administer controlled drugs; most |If the bleed is visible, dark |

| |important is to stay with the patient |coloured towels can make the |

| | |appearance of blood less frightening.|

Sheffield Palliative Care Formulary: Pruritus/Itch

Treat 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 - |Emollient agents, e.g. aqueous cream |Also use as soap replacement |

|pruritus often |(not in atopic eczema), |Consider emollient bath |

|associated with dry skin|Diprobase®/Zerobase® E45® cream |additive |

| |Urea containing preparations, e.g. E45®| |

| |Itch relief cream◊, Balneum® Plus◊ | |

|Topical Antipruritic |Preparations containing phenol, menthol| |

|agents |and camphor available OTC | |

| |Topical steroid e.g. Hydrocortisone | |

| |cream 1%, Betamethasone cream 0.025% | |

| | |For inflamed localized |

| | |itching |

|Antihistamines – only |Chlorphenamine 4mg – 12mg po four times|A sedating anti-histamine may|

|effective if due to |a day. Sedative |be used in combination with a|

|histamine release |Hydroxyzine◊ 10-25mg po once to three |non-sedating anti-histamine |

| |times a day. Sedative |in resistant cases according |

| |Cetirizine 10mg po daily. Non-sedating|to patient tolerance |

|Steroids – for severe, |Dexamethasone 2-8mg po daily for 1 week| |

|resistant drug induced | | |

|itch | | |

Other treatment options are dependent on the cause:

|Cause |Treatment |Comments |

|For severe localized |Capsaicin cream◊ * 0.025-0.075% applied|Wash hands after application|

|itch |once to twice daily | |

|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 | |

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◊ |20mg sc prn hourly or CSCI |Does not cause sedation. |

|(Buscopan®) |60-240mg/24hrs | |

|Glycopyrrolate◊ |200micrograms sc prn hourly or CSCI |Does not cause sedation. |

| |400-2400micrograms/24hrs | |

|Hyoscine Hydrobromide◊ |400micrograms sc prn hourly or CSCI |Useful sedative effects but can cause|

| |400-2400micrograms/24hrs |agitation in some patients. |

Sheffield Palliative Care Formulary:

Swallowing Difficulties

It 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 |Contact Virology for advice |

|simplex | |

|Local Bacterial infection |Refer to local infection policy |

| |Consider sending swab to microbiology and taking their |

| |advice |

|Oral Candidiasis |Refer to Oral Care chapter |

|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 |May respond to radiotherapy or chemotherapy – seek oncology |

|oesophagus |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 |Management |

|dysphagia | |

|Symptomatic management of pain in |Refer to Oral Care chapter |

|mouth/stomatitis/mucositis | |

|Excessive secretions (which may be |Hyoscine Butylbromide◊ 20mg sc three times daily or |

|caused by dysphagia) |60mg/24hrs CSCI |

| |Hyoscine Hydrobromide◊ transdermal patch 1mg/72hrs |

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 |Replace with alternative antidepressant, e.g. |

|Opioids |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 |

|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 |

Sheffield Palliative Care Formulary:

Syringe Drivers

For 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* ◊

• The risk of incompatibility is increased with:

o Increasing doses

o 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 (free login required). A compatibility search function is also available at

• 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.

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.

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

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|Comments |

| | |box | |

|Pain |Morphine 10mg/ml injection |5 |Controlled Drug |

| |Morphine 15mg/ml injection |5 | |

| |Morphine 30mg/ml injection |5 | |

| |Diamorphine 5mg injection |5 |Controlled Drug |

| |Diamorphine 10mg injection |5 | |

| |Oxycodone 10mg/ml injection |5 |Controlled Drug |

| |Oxycodone 20mg/2ml injection |5 | |

|Dyspnoea |Morphine as above | | |

| |Midazolam as below | | |

|Terminal Restlessness/|Midazolam 10mg/2ml injection |10 |Controlled Drug |

|Agitation | | | |

|Nausea & Vomiting |Haloperidol 5mg/ml injection |5 | |

| |Metoclopramide 10mg/2ml injection |10 | |

| |Cyclizine 50mg/ml injection |5 | |

| |Levomepromazine 25mg/ml injection |10 | |

|Respiratory Tract |Hyoscine Butylbromide 20mg/ml injection |10 | |

|Secretions | | | |

Sheffield Palliative Care Formulary:

Acknowledgements

Many 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

Also the following staff now working outside Sheffield:

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

Sheffield Palliative Care Formulary

Drug Index

|Drug |Page Number/s |

|Adrenaline |14 |

|Alfentanil |48, 52 |

|Aluminium chloride |62 |

|Amitriptyline |25, 45, 63 |

|Antacid & Oxetacaine |41 |

|Antacids |29 |

|Aqueous Cream |36, 57 |

|Arachis Oil |21 |

|Artificial Saliva Spray |40 |

|Asilone® |29, 34 |

|Baclofen |34, 44 |

|Balneum® Plus |57 |

|Benzydamine |41 |

|Betamethasone Cream |57 |

|Biotene Oralbalance® Gel |40 |

|BioXtra® Gel |40 |

|Bisacodyl |20-22 |

|Bonjela® |41 |

|Buprenorphine |48, 52 |

|BuTrans® |52 |

|Capsaicin Cream |45, 58 |

|Carbocisteine |23 |

|Celecoxib |29, 44 |

|Cetirizine |58 |

|Chlorhexidine Gluconate |42 |

|Chlorphenamine |58 |

|Chlorpromazine |65 |

|Choline Salicylate |41 |

|Cimetidine |58 |

|Citalopram |25 |

|Clonazepam |45, 65 |

|Co-Danthramer |20 |

|Drug |Page Number/s |

|Co-Danthrusate |20 |

|Codeine Linctus |14, 23 |

|Codeine Phosphate |26-28, 43, 52 |

|Colestyramine |27 |

|COX 2 |44 |

|Cyclizine |39, 64, 66, 68 |

|Dexamethasone |11, 27, 39, 44, 45, 55, 58, 65 |

|Diamorphine |15, 48, 49, 51, 53, 56, 68 |

|Diazepam |13, 44, 65 |

|Diclofenac |44, 62 |

|Dihydrocodeine |52 |

|Difflam® |41 |

|Dioralyte® |28 |

|Diprobase® |57 |

|Docusate Sodium |19 |

|Domperidone |29, 30, 34, 38, 39, 61 |

|Duloxetine |13, 25, 45 |

|E45® Itch Relief Cream |57 |

|Etamsylate |15 |

|Etoricoxib |29 |

|Fentanyl |48, 50-54 |

|Fluconazole |42, 61 |

|Gabapentin |45 |

|Gelclair® Concentrated Oral Gel |42 |

|Glycerin |21, 22 |

|Glycopyrrolate |59 |

|Granisetron |64 |

|Haloperidol |9, 13, 17, 34, 38, 39, 67, 68 |

|Hydrocortisone Cream |57 |

|Hydroxyzine |58 |

|Hyoscine Butylbromide |17, 26, 44, 59, 61, 64, 68 |

|Hyoscine Hydrobromide |39, 59, 61, 63 |

|Hypertonic Electrolyte Solution |28 |

|Ibuprofen |62 |

|Drug |Page Number/s |

|Ketamine |64 |

|Ketorolac |64 |

|Lactulose |19 |

|Lansoprazole |28-30 |

|Laxido® |19 |

|Levomepromazine |9, 13, 17, 38, 65, 66, 68 |

|Lidocaine |41 |

|Lofepramine |25 |

|Loperamide |26-28 |

|Lorazepam |13, 32, 39 |

|Maalox® |29, 30 |

|Mebeverine |44 |

|Medroxyprogesterone |11 |

|Megestrol Acetate |11 |

|Mesalazine |28 |

|Methadone | 48, 66 |

|Methadone Linctus | 14, 23 |

|Methylphenidate |33 |

|Methylnaltrexone |20 |

|Metoclopramide |11, 17, 29, 30, 34, 38, 39, 61, 68 |

|Metronidazole |27, 41 |

|Micralax Micro-enema® |22 |

|Midazolam |9, 13, 15, 32, 34, 56, 67, 68 |

|Mirtazepine |13, 25, 62 |

|Morphine Sulphate |14, 15, 23, 31, 43, 45, 49-54, 56, 68 |

|Morphine Hydrochloride |41 |

|Movicol® |19 |

|MST® |45, 46 |

|Mucilage Liquid |61 |

|Naloxone |46 |

|Naproxen |62 |

|Nortriptyline |25 |

|NSAIDs |43, 44 |

|Nystatin |42 |

|Drug |Page Number/s |

|Octreotide |17, 26, 27, 28, 64 |

|Olanzapine |9, 13 |

|Omeprazole |28, 29 |

|Ondansetron |39, 64 |

|Oxetacaine |41 |

|Oxycodone |47, 50-54, 68 |

|Pancreatin |27 |

|Paracetamol |43, 62 |

|Paroxetine |58 |

|Peptac® |29, 30 |

|Phosphate enema |21, 22 |

|Pilocarpine Tablets |40 |

|Prednisolone |58 |

|Pregabalin |45 |

|Prochlorperazine |39, 65 |

|Propantheline |63 |

|Ranitidine |29 |

|Risperidone |9 |

|Salbutamol |32 |

|Saliva Orthana® |40 |

|Senna |20, 22 |

|Sertraline |13, 25 |

|Sevredol® |45 |

|Silver Nitrate sticks |14 |

|Simple Linctus |23 |

|Sodium Chloride |23, 32 |

|Sodium Citrate |21 |

|Sodium Hypochlorite solution |42 |

|Sulfasalazine |28 |

|Temazepam |35 |

|Tramadol |47, 52 |

|Tranexamic Acid |14, 15, 40 |

|Trazodone |13, 25 |

|Xerotin® |40 |

|Drug |Page Number/s |

|Zerobase® |57 |

|Zoledronic Acid |55 |

|Zomorph® |45, 46 |

|Zopiclone |35 |

-----------------------

[pic]

Review within 24 hrs

Review within 24 hrs

Review within 24 hrs

Review within 24 hrs

Does the patient have colicky pain?

YES

NO

Stop prokinetic agents (metoclopramide, domperidone). Start CSCI Hyoscine ButylbromideÊ% 60mg for colic

+ Haloperidol 3mg for nausea

+/-◊ 60mg for colic

+ Haloperidol 3mg for nausea

+/- opioid for pain over 24 hours

If still vomiting increase 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 Butylbromide◊ (up to 240mg/24hrs CSCI) and maximize haloperidol to 5mg/24hrs 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.

Trial of prokinetic agent. 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

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