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HOSPICE MEDICATION UTILIZATION GUIDELINES Contact Information ProCare HospiceCare – Atlanta Pharmacy Help Desk 1267 Professional Parkway Gainesville, GA 30507 866-457-6337 Business Hours: 24/7/365 ProCare Pharmacy Care 3891 Commerce Parkway Miramar, FL 33025 800-662-0586 Business Hours: 8am - 8pm ET ProCare HospiceCare – Website www.ProCarePharmacyCare.com Website tools: • Lexi-Comp Connection • Lunch-n-Learn Schedule & Audio Library • Pain & Symptom Management Video (2 hr) • Adverse Drug Reaction Reporting Form • Current Drug Updates and Other Important Information Acknowledgements � Editors-in-Chief: Raeanna Lewarne, RPh, PharmD, BCPS Megan Saenz, PharmD, CPE Authors: Karen Bruestle-Wallace, PharmD Maria Castano, PharmD Brett Gillis, PharmD Ashley Provenzano, PharmD Megan Saenz, PharmD, CPE � Acknowledgements: Victoria Ferraresi, PharmD, FASHP, FCSHP, Pathways Hospice Mary Mihalyo, PharmD, CGP Lorin Yolch, PharmD, CGP Excellence in Pharmacy and Clinical Services . . . One Patient at a Time ProCare HospiceCare Vision Statement � ProCare HospiceCare will drive positive change in end-of-life care as the premier Hospice Pharmacy Benefit Manager and Hospice Clinical Pharmacy Consulting Service. ProCare HospiceCare Mission Statement ProCare HospiceCare will provide simply the best hospice patient focused medication-therapy-management and pharmacy benefit management services. Disclaimer The material in ProCare HospiceCare’s Hospice Medication Utilization Guide is for informational and educational purposes only. It is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. The editors and contributors of this Guide have made extensive efforts to ensure that the treatments, algorithms, drugs, and dosage regimens are accurate and conform to the standards accepted at the time of publication. Ongoing changes in information are made as a result of continuing research and clinical experience, differences of opinion among authorities, and the unique aspects of individual clinical situations. These ongoing changes require the reader to exercise judgment when making a clinical decision and, if necessary, consult and compare information from other sources. Accordingly, ProCare HospiceCare shall not be responsible for the choice of treatment or clinical decisions resulting from use of this Guide. This Guide is intended for readers throughout the United States; however, you must comply with the laws, regulations, and statutes of the state in which the hospice is located and the federal laws regulating the practice of medicine and the prescription and use of drugs. The reader is also advised to check the product information provided by the manufacturer of a drug product before prescribing or administering it. All information contained in this handbook is protected by copyright. All rights are reserved. Table of Contents ....................................................................................................................................................... Section One: General Information Benzodiazepine Medication Comparison .......................................................................................7 Child-Pugh Grading Scale ........................................................................................................................29 Do Not Use List ...........................................................................................................................................1 Drugs and Taste Disturbances................................................................................................................8 ECOG Scale.....................................................................................................................................................22 FDA Drug Safety Communication: Erythropoiesis-Stimulating Agents (ESAs) ........4-6 Functional Assessment Staging (FAST) Score ..............................................................................23 Karnofsky Scale...............................................................................................................................................20 Medication Administration with Continuous Enteral Nutrition..........................................10 Medications that May Cause Confusion and/or Agitation in the Elderly.......................27 Medicines Recommended for Disposal by Flushing..................................................................32-34 Opioid Conversion Table for Hospice Population......................................................................28 Opioids for Shortness of Breath .........................................................................................................3 Oral Dosage Forms that Should Not be Crushed....................................................................9 Pain Assessment in Advanced Dementia (PAINAD) Scale...................................................24-25 Palliative Performance Score v2............................................................................................................21 Proper Disposal of Prescription Drugs.............................................................................................31 Recommendations for Administering Medications with Continuous Enteral Nutrition......................................................................................................................................11-18 Renal Dosing Chart......................................................................................................................................30 Undesirable Effects of Antipsychotics................................................................................................19 Use of Anticholinergics in the Treatment of Terminal Illness.................................................2 WHO 3-Step Ladder..................................................................................................................................26 Wound Care Kit.............................................................................................................................................34-35 Section Two: Preferred Drug List DISEASE STATES: Alzheimer’s................................................................................................................................................37 Cancer.........................................................................................................................................................38 Cardiac........................................................................................................................................................39-49 Pulmonary Disease..............................................................................................................................49-51 Hepatic Disease.....................................................................................................................................51-53 Parkinson’s Disease..............................................................................................................................53-55 Renal Disease..........................................................................................................................................55 FORMULARY: SYMPTOM MANAGEMENT Anorexia.....................................................................................................................................................56 Anxiety/Agitation..................................................................................................................................56 Bladder Spasm........................................................................................................................................59 Congestion................................................................................................................................................59-60 Constipation.............................................................................................................................................60-62 Cough-Dry; Non-Productive..........................................................................................................62-63 Cough-Wet; Productive.....................................................................................................................63 Depression................................................................................................................................................63-66 Diarrhea/Gas...........................................................................................................................................66-67 Dysphagia..................................................................................................................................................67 Table of Contents ....................................................................................................................................................... Section Two: Preferred Drug List (continued) Dyspnea/Shortness of Breath...........................................................................................67-69 Edema ...........................................................................................................................................69-70 Extrapyrmidal Symptoms.....................................................................................................71 Fever................................................................................................................................................71-72 Gastrointestinal Irritation/Colic........................................................................................72-73 Gout................................................................................................................................................74 Hiccups...........................................................................................................................................74 Hyperglycemia...........................................................................................................................74 Insomnia........................................................................................................................................75 Mucositis/Dry Mouth.............................................................................................................76 Muscle Spasms...........................................................................................................................76-77 Nausea/Vomiting......................................................................................................................77-80 Pain - Nociceptive....................................................................................................................80-84 Pain - Nociceptive (Mild)...................................................................................................80-81 Pain - Nociceptive (Moderate)........................................................................................82 Pain - Nociceptive (Severe)...............................................................................................82-84 Pain - Neuropathic (shooting, stabbing, burning, tingling)......................................84-85 Pruritis............................................................................................................................................86-87 Seizure - Active..........................................................................................................................87 Seizure - Maintenance...........................................................................................................87-88 Terminal Secretions.................................................................................................................89 INFECTIONS / ANTIBIOTICS Antibiotics IV / IM...................................................................................................................89-93 Antifungals....................................................................................................................................93-94 Antivirals........................................................................................................................................94 Topical Agents............................................................................................................................94-96 Topical Agents - Anesthetics..............................................................................................94 Topical Agents - Ophthalmic............................................................................................94-95 Topical Agents - Wound Care...........................................................................................95 Topical Agents - Misc...........................................................................................................95-96 Section Three: Treatment Algorithms Anorexia/Cachexia ................................108 Anxiety .........................................................112 Bone Pain ....................................................117 Complete Bowel Obstruction ........123 Cough/Congestion ................................127 Constipation ..............................................132 Delirium .......................................................136 Depression .................................................141 Diarrhea ......................................................145 Dyspepsia ...................................................148 Dyspnea .......................................................151 Edema ...........................................................156 Fever ..............................................................159 Hiccups ........................................................161 Insomnia ......................................................165 Nausea/Vomiting ....................................169 Neuropathic Pain ...................................175 Nociceptive Pain .....................................181 Pruritus .........................................................186 Secretions ...................................................189 Seizures ........................................................192 Thrush ..........................................................195 Table of Contents ....................................................................................................................................................... Section Four: Methadone Information Methadone Equianalgesic Dosing Chart ............................................................................. 198 Methadone Safe Use Protocol ................................................................................................. 199 A Clinical Approach to Drug-Induced QT Prolongation .................................200-201 Drugs that Prolong the QT Interval to Induce Torsades De Pointes .......202-203 Section Five: Patient Information Leaflets (PILs) Alprazolam .................................................204 Atropine ......................................................205 Choline mag trisalicylate ....................206 Dexamethasone .....................................207 Diazepam ....................................................208 Fentanyl ........................................................209 Glycopyrrolate .........................................210 Haloperidol ................................................211 Hydromorphone ....................................212 Hyoscyamine .............................................213 Ibuprofen .....................................................214 Lorazepam .................................................215 Methadone .................................................216 Mirtazapine ................................................217 Morphine ....................................................218 Naproxen ...................................................219 Ondansetron ............................................220 Oxycodone ...............................................221 Prednisone .................................................222 Prochlorperazine ....................................223 Promethazine ...........................................224 Temazepam ...............................................225 Zolpidem ....................................................226 (For a complete list of PILs go to www.ProCareHospiceCare.com)
