Download Sheffield Palliative Care Formulary

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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
2
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)
Anorexia/Cachexia
Anxiety
Bleeding
Bowel Obstruction
Constipation
Cough
Depression
Diarrhoea
Dyspepsia
Dyspnoea
Fatigue
Hiccup
Insomnia
Lymphoedema
Nausea & Vomiting
Oral Care
Pain Relief
(Analgesic conversion tables
Palliative Care Emergencies
Pruritus/Itch
Respiratory Tract Secretions
Swallowing Difficulties
Sweating
Syringe Drivers
8
11
13
15
17
19
24
25
27
30
32
34
35
36
37
39
42
45
52-56)
57
59
61
62
64
66
Prescribing in the Last Few Days of Life
69
Acknowledgements
71
Drug Index
73-77
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
3
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
4
Specialist Palliative Care Services
Contact Numbers
Northern General Hospital
Tel: (0114) 2434343 (Switchboard)
Referrals to the Palliative Care Hospital
Support Team or for In-Patient
admission
Medicines Information - for Hospital
Related queries
Tel: (0114) 2266770
Fax: (0114) 2714289
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 Tel : (0114) 2265602
Support Team
Fax: (0114) 2265745
Medicines Information - for Hospital
Tel: (0114) 2712346
Related queries
St Luke’s Hospice
Referrals for In-patient admission, Day
Therapies & Rehabilitation and the
Community Palliative Care Team
Tel: (0114) 2369911
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 NonHospital/Primary Care Related queries
(PCT Medicines Management Team)
Tel: (0114) 3051667
Cancer Support Centre
Tel: (0114) 2265666
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
5
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:
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) 2714289
Tel: (0114) 2266770
Sheffield Macmillan Palliative Care
Unit: Admission
FAX: (0114) 2714289
RHH/WPH Hospital Support Team or
Clinic
FAX: (0114) 2265745
St Luke’s Hospice: Admission
FAX: (0114) 2351321
Tel: (0114) 2266770
Tel: (0114) 2265602
Tel: (0114) 2369911
St Luke’s Hospice: Day Therapies &
Rehabilitation Centre
FAX: (0114) 2351321
St Luke’s: Community Palliative Care
Team
FAX: (0114) 2351321
Intensive Home Nursing or VIP
Service
FAX: (0114) 2716026
Tel: (0114) 2369911
Tel:(0114) 2369911
Tel: (0114) 2716010
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
6
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
7
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
8
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 four to six
hours when required
Max 10mg/24hrs
Care with sideeffects
Titrate doses
accordingly

Olanzapine 2.5mg po stat
and at bedtime

Risperidone◊
500micrograms po twice
daily

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
Terminal
Restlessness
End of Life Care
– see also Last
Few Days of
Life chapter p67
More sedating
than haloperidol
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
9
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
10
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
11
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
12
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
13
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

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

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
Generalised anxiety
disorder, Panic attacks or
Overwhelming fear and
agitation
If recurrent or resistant,
consider antidepressants
Anxiety or agitation with
delirium or psychotic
features
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
14
Sheffield Palliative Care Formulary: Bleeding
In advanced cancer, bleeding occurs in about 20% cases.
Consider thrombocytopenia, vitamin K deficiency, heparininduced 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
Surface
Bleeding
Haemoptysis
Comments

Gauze soaked in Adrenaline 1mg/ml Apply with
pressure for 10
(1 in 1000)* or Tranexamic acid
mins
500mg/5ml injection*

Silver Nitrate sticks◊
applied to bleeding points

Haemostatic dressings i.e. alginate
 Cough suppression
Codeine linctus◊ 10ml 3-4 times a day
when required.
If not responding, low dose immediate
release Morphine Sulphate* 1.252.5mg 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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
15
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
Major
(terminal)
bleeding

Major catastrophic
bleeds are rare, but
can occur when a
major artery is eroded
by tumour
If patient at
high risk of
catastrophic
bleed,
consider
availability of
opioid and
midazolam in
the patient’s
house/on ward

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

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

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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
16
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
 Radiotherapy
 Chemotherapy

)
)
)
if appropriate to stage of
illness and patient’s
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).
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
17
Treatment of Bowel Obstruction
If nausea and large volume vomiting persistent consider
naso-gastric tube for patient comfort
Does the patient have colicky pain?
NO
YES
Stop prokinetic agents
(metoclopramide, domperidone).
Start CSCI Hyoscine
Butylbromide◊ 60mg for colic
+ Haloperidol 3mg for nausea
+/- opioid for pain over 24 hours
Trial of prokinetic agent.
Metoclopramide CSCI 3080mg/24hrs. If beneficial optimize
dose to 100mg/24hrs. If constipation
an issue consider a softener laxative
(see constipation chapter p18)
Review within 24 hrs
If still colicky pain increase
Hyoscine Butylbromide◊ (up to
240mg/24hrs CSCI) and maximize
haloperidol to 5mg/24hrs by CSCI
Consider trial of steroid if obstruction
thought not to be complete and no
colicky pain. Continue as long as
symptoms controlled.
Review within 24 hrs
Consider replacing Haloperidol
with Levomepromazine◊ CSCI
12.5mg/24hrs if nausea not
controlled
Review
If patient develops colicky pain stop
prokinetic and steroid and start
treatment of colicky pain.
within 24 hrs
If still vomiting add in CSCI Octreotide*◊ 600 -1200
micrograms/24hrs (discontinue Hyoscine butylbromide if
no benefit seen)
Review within 24 hrs
If still vomiting increase Octreotide*◊ by increments of
300 micrograms every 24 hours to a maximum of CSCI
1200micrograms/24hrs
If ineffective contact Specialist Palliative Care Team
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
18
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
19






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, 5HT 3 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
Softener laxatives
 Osmotic agents:
retain water in gut
lumen
Drug/Dose
Comments

Lactulose 10-30ml
once or twice daily
Patient needs to be well
hydrated. Onset of action
1-2 days. Can cause
bloating, flatulence and
abdominal cramping.
Taste may be problem.

Surfactant agents:
increase water
penetration of stool

Docusate sodium◊
100-300mg twice
daily
Onset of action 1-3 days.
Liquid is bitter tasting

Macrogols: hydrate
hardened stool,
increase stool
volume, decrease
duration of colon
passage and dilate
bowel wall that then
triggers defaecation
reflex

Laxido®/Movicol®
(polyethylene
glycol) 1-3 sachets
a day. Up to 8
sachets/day for
faecal impaction
Sachets need to be
dissolved in 125ml water
or juice (N.B. large
volume). Onset of action
1-2 days
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
20
Stimulant laxatives
Direct stimulation of
myenteric nerves to
induce peristalsis.
Reduce absorption
of water in the gut

Combination
Stimulant and
Softening Agents




Senna 7.5-15mg
once to twice daily
Bisacodyl 5-10mg
once daily
May cause colic. Do not
use if colic/obstruction
present
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 2.510ml 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
Mode of Action
Peripheral opioidreceptor antagonist
Indicated for opioidinduced constipation in
palliative care patients
when response to
other laxatives
inadequate
Drug/Dose
 Methylnaltrexone◊ –
subcutaneous injection,
dose dependant on body
weight (see BNF/SPC), on
alternate days or less
frequently depending on
response.
Comments
May act within 3060 minutes.
Max duration of
treatment 4 months
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
21
Rectally Administered Drugs
Mode of Action
Drug/Dose
Softener

Glycerin 4g
suppositories 1-2
once daily

Arachis oil◊ enema
1 to be given once
daily for faecal
impaction

Bisacodyl
suppositories 1-2
suppositories daily

Phosphate enema
1 enema once daily

Sodium Citrate
Enemas
(Micralax®,
Microlette®,
Relaxit®) 1 enema
once daily
Stimulant
Comments
Warm before
administration. Do not
give to patients with a
peanut allergy.
Not to be used for
prolonged periods of time
due to absorption of
phosphate into the
systemic circulation.
Spinal Injury – see next page
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
22
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.





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.





Cauda equina syndrome
Damage to the nerves at the base of
the spine. Sensory nerves often
intact. Nerves for movement often
impaired. Bowel then becomes
flaccid.


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
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
2 Glycerin 4g suppositories
alternate days
Daily digital rectal examination
followed by manual evacuation.
Please refer to local guidelines or protocols for treatment.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
23
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

Soothing
agents
To loosen thick 
mucus.
Mucolytics in

COPD patients
Opioids
Corticosteroid
Comments
Simple linctus 5ml three to
four times daily
May need
physiotherapy
afterwards to
expectorate
Carbocisteine 750mg three Stop after 4 weeks
if no benefit
times daily. Caution in
those with history of peptic
ulcer
Nebulised Sodium
Chloride 0.9%◊ *5ml when
required (limited evidence)

Codeine linctus◊ 10ml
three to four times a day
when required

If not responding, low dose
immediate release
Morphine Sulphate* 1.252.5mg 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

Only if there is history of
COPD/asthma
exacerbation, pulmonary
fibrosis
Will need laxative
combination (see).
Monitor side
effects especially
in COPD patients
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
24
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
25
Antidepressant Drug Choice
Indication
Management
Comments
First line for depression
or where prognosis less
than 16 weeks or with
neuropathic pain.

Amitriptyline 10200mg po at night

Nortriptyline◊ 25150mg po at night
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◊ 1545mg po at night
May improve
appetite
For patients with
insomnia or a history of
seizures

Trazodone 100300mg 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 70210mg po once daily
Less sedating
N.B. All antidepressants can cause withdrawal symptoms if
stopped abruptly, so should be gradually withdrawn over 2-3
weeks.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
26
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
27
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
28
Ulcerative Colitis
Short Bowel
Malabsorption due
to loss of 2/3 of the
small bowel. Can
result from
congenital
disorders, surgical
resection or
bypass of intestine

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.

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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
29
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 meals, often

Pro-kinetic agent (see in dysmotility
below)

Antiflatulent Asilone®◊ 10ml po after
meals
Dysmotility

Prokinetic agent 15 minutes premeals, 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, 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®

Anti-flatulent, e.g. Asilone®◊
suspension 10ml after meals
Small stomach
(may consider urea
breath test or stool
antigen test for
H.pylori. These tests
need to be done before
starting PPI or
antibiotics)
Gassy Dyspepsia
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
30
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, betablockers, 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 premeals, e.g. Metoclopramide 1020mg po three times a day or
Domperidone 10mg po or 30mg PR
three times a day
guidelines – Dyspepsia: Managing Dyspepsia in Adults in
Primary Care.
2STHFT guidelines – Gastroprotection in Patients Taking NonSteroidal Anti-Inflammatory Drugs (NSAIDs)
1NICE
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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, nonspecific 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
Caution for patients
with chronic respiratory
disease

If preferred by patient,
consider converting to
a slow release
preparation
Consider anti-emetic
for first few days (see
Nausea and Vomiting)

If already on strong
opioid for pain control,
consider increasing prn
dose by 25-50%
Must prescribe
laxatives (see
Constipation)
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
32
Treatment
Regime
Comments
Benzodiazepines

Watch for sedation.
Lorazepam◊ 0.5mg prn
po or sublingually*
increasing gradually to
max 2mg/24hrs
Sublingually use Genus
brand of Lorazepam –
other brands may not
dissolve under tongue.
Avoid diazepam (long
half-life).
Oxygen
Nebulisers

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

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.

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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
33
Sheffield Palliative Care Formulary: Fatigue
Fatigue 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
Psychostimulants

Dose times 8am
and no later than
2pm to allow time
to wear off and
allow nocturnal
sleep
Methylphenidate
◊* initially 5mg
po morning and
lunchtime titrated
according to
response up to
15mg twice a day
Caution cardiac
disease
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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

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
All other causes (anecdotal
evidence only)
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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).
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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
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
Comments
Consider PPI
)
)
)
)
)
Abdominal cramps
may occur
Take half an hour
before food
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
39
Cause
Management
Biochemical/drug,
e.g. uraemia,
hypercalcaemia,
digoxin, opioids

Haloperidol 0.5-5mg po/sc
at night or CSCI 1.510mg/24hrs

Metoclopramide 10-20mg
po/sc three times daily or
CSCI 40-80mg/24hrs

Levomepromazine◊ 6.25mg
po/sc at night or CSCI 6.2512.5mg/24hrs. (6mg tablets ‘named patient’ order)

Domperidone 10mg po /
30mg PR three times daily
Chemotherapy
or Radiotherapy

Raised
intracranial
pressure
Metoclopramide 10-20mg
po/sc three times daily or
CSCI 40-80mg/24hrs
Comments
More sedating than
Haloperidol and
Metoclopramide.
)
) Abdominal cramps
) may occur.
)
)

Ondansetron◊ 8mg twice
daily for three days
starting on Day 1 of
chemotherapy

Dexamethasone 4-16mg
po/sc once a day or in two
divided doses, morning
and lunchtime
Caution with
diabetes

Cyclizine◊ 25-50mg po
three times a day or CSCI
50-150mg/24hrs
Potential
incompatibility
problems in syringe
driver
May reduce
analgesic effect of
tramadol. May cause
constipation
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
40
Cause
Management
Comments
Vestibular
Disorders

Cyclizine◊ 25-50mg po three
times a day or CSCI 50150mg/24hrs

Prochlorperazine 5-10mg
po/12.5mg im three times a
day or 3mg buccal tabs three
times daily
Potential
incompatibility
problems in syringe
driver

Hyoscine Hydrobromide◊
CSCI 0.8-1.2mg/24hrs or
1mg/72hrs transdermal patch

Haloperidol 0.5-5mg po/sc at
night or CSCI 1.510mg/24hrs

Lorazepam◊ 0.5-1mg
po/sublingual* prn

Seek specialist advice
Fear and Anxiety
Refractory
nausea/vomiting
For anticipatory
vomiting
Sublingually use
Genus brand (see)
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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
Cause
Management
Comments
Xerostomia (Dry
Mouth)

Saliva Orthana®,
Biotene
Oralbalance® gel
and BioXtra® gel are
all ACBS for primary
care prescribing



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
Bleeding
Mouths/Gums
 Mild/Moderate
Cases

Tranexamic acid
500mg/5ml solution◊*
Use 5-10ml as
gargle/mouthwash four
times daily


Refer to specialist
Severe Cases
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
42
Cause
Management
Comments
Stomatitis/Mucositis


Mild
Moderate to
Severe

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

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.



Infected lesions
Halitosis

Broad Spectrum antibiotic

Establish good oral
hygiene including
mouthwashes
Metronidazole 400mg po
three times a day or
500mg rectally twice a
day (to reduce odour).

If due to malodorous
malignancy
Not morphine
sulphate due to high
alcohol content
Refer to antibiotic
guidelines
Patients on longer
term therapy may be
maintained at a
reduced dose
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
43
Cause
Management
Candidiasis

Correct underlying
causes, e.g. poor
fitting denture/oral
hygiene and dry
mouth.
Nystatin suspension 12ml 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)
Symptomatic
management of pain
in mouth (alongside
disease specific
treatments)

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.

Comments
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
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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 3
Strong Opioid
e.g. Morphine
2.5-10mg every
four hours or other
strong opioid, see
page 49
+ Nonopioid(s)
Step 2
+/- Adjuvants
Weak Opioid
e.g. Codeine
phosphate 30-60mg
four times daily
Step 1
Nonopioid(s)
e.g. Paracetamol 1g
four times daily,
NSAIDs (unless
contra-indicated)
+ Nonopioid(s)
+/- Adjuvants
+/- Adjuvants
At all steps in the analgesic ladder consider:
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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 morphine
Opioid
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 required
OR: 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®◊
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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 pain
Patients with unresponsive pain or opioid toxicity may need to be
referred to the Palliative Care Service, see contact numbers.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
48
Opioid substitution
Pain 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 5256.
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

Orally 1.5-2 times more
potent than morphine


Oxycodone◊




Normal release
capsules
Modified release
tablets
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)
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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
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

Seek specialist advice





Buprenorphine





Methadone


Butrans* (7 day
patch) and
Transtec (4 day
patch)
 PRN: Sublingual
tablets
(N.B. Butrans is
unlicensed for cancer
pain)

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

Liquid 1mg/ml and
10mg/ml
Injection
Injection comes in
two strengths 500micrograms/ml
(2ml and 10ml
amps) or 5mg/ml
amps
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
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)
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
52
Opioid Conversion Chart – (doses have been rounded up or down to convenient dose volumes)
Morphine (mg)
24h
total
Oral
q4h
prn
30
60
90
120
150
180
240
270
360
480
600
800
5
10
15
20
25
30
40
45
60
80
100
130
Route
Dose
Oxycodone (mg)
SC
CSCI q4h
24h
prn
Diamorphine
(mg)
SC
CSCI q4h
24h
prn
15
30
45
60
75
90
120
135
180
240
300
400
10
20
30
40
50
60
80
90
120
160
200
260
15
30
45
60
75
90
120
135
180
240
300
400
2.5
5
7.5
10
10
15
20
25†
30†
40†
50†
60†
2.5
5
5
5
10
10
10
15
20
25
30
40
24h
total
Oral
q4h
prn
2.5
5
7.5
10
10
15
20
25
30
40
50
60
CSCI
24h
7.5
15
20
30
40
45
60
70
90
120
150
200
SC
q4h
prn
1.25
2.5
2.5
5
5
7.5
10
10
15
20
25#
30#
Fentanyl patch
(microgram)
TD
hourly dose
(over 72 hrs)
12 microgram*
25 microgram
37 microgram
50 microgram
50 microgram
62 microgram
75 microgram
100 microgram
125 microgram
175 microgram
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.
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
53
Conversion from BuTrans® patches to other opioids
When 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
Oral morphine
5 microgram/hour
10 microgram/hour
20 microgram/hour
~10mg/day
~20mg/day
~40mg/day
Conversion factors
oral codeine/dihydrocodeine
(tramadol)*
oral morphine
oral morphine
oral morphine
oral oxycodone
SC diamorphine
fentanyl patch
to
oral morphine
oral morphine
oral oxycodone
SC diamorphine
SC morphine
SC oxycodone
SC alfentanil
SC diamorphine 4hly prn
divide by 10
divide by 10
divide by 2
divide by 3
divide by 2
divide by 2
divide by 10
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
54
Converting To/From Fentanyl Patches
Converting To Fentanyl Patches
When 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 Care
For 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%
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
55
Converting From Fentanyl Patches
Should 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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
56
Sheffield Palliative Care Formulary:
Palliative Care Emergencies 
Signs and Symptoms
Emergency

Metastatic
spinal cord
compression
(MSCC)




Superior vena
cava
obstruction
(SVCO)



Hypercalcaemia
Consider
treatment if
corrected calcium
is >2.8mmol/l &
symptoms are
present




Management and
Comments
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

Swelling of face, torso
and arms
Prominent veins on
chest and neck
Breathlessness
Headache or feeling of
fullness in the head

Nausea
Constipation
Polyuria and polydypsia
Lethargy and mental
dullness, leading to
confusion and coma





Give stat dose
Dexamethasone
16mg po/sc
Consider spinal
surgery or
vertebroplasty
Contact MSCC coordinator/oncologist
with a view to
radiotherapy
Give stat dose
Dexamethasone
16mg po/sc
Seek urgent
oncological opinion;
may respond to
chemotherapy,
radiotherapy or
stenting.
Rehydrate with
normal saline.
Depending on renal
function treat with
bisphosphonates e.g.
Zoledronic acid◊
4mg intravenously
stat
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
57
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 510mg 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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
58
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:
Routine skin
care - pruritus
often associated
with dry skin
Topical
Antipruritic
agents
Treatment
Comments


Also use as
soap
replacement

Consider
emollient bath
additive

For inflamed
localized itching
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◊

Preparations containing
phenol, menthol and
camphor available OTC

Topical steroid e.g.
Hydrocortisone
cream 1%,
Betamethasone
cream 0.025%
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
59
Antihistamines –
only effective if
due to histamine
release
Steroids – for
severe, resistant
drug induced
itch

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

Dexamethasone 28mg po daily for 1 week

A sedating antihistamine may
be used in
combination
with a nonsedating antihistamine in
resistant cases
according to
patient
tolerance
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

Cholestasis

Seek specialist advice
End Stage
Lymphoma

Prednisolone 10mg –
20mg po three times
daily

Cimetidine◊ * 400mg
po twice daily

Paroxetine◊ * 5-20mg
po once daily
Paraneoplastic
pruritus
Wash hands
after
application
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
60
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 4002400micrograms/24hrs
Does not cause sedation.
Hyoscine
Hydrobromide◊
400micrograms sc prn
hourly or CSCI 4002400micrograms/24hrs
Useful sedative effects
but can cause agitation in
some patients.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
61
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
Viral ulceration due to
herpes simplex
Local Bacterial infection
Oral Candidiasis
Management

Contact Virology for advice

Refer to local infection policy

Consider sending swab to microbiology
and taking their advice

Refer to Oral Care chapter
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
62

Fluconazole 50mg po daily for 7 days
(beware of drug interactions)

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

May result in temporary or permanent
dry mouth. Mucilage liquid◊ * 10ml pre
meals and prn may help
Neurological incoordination

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
Oesophageal candidiasis
Iron or vitamin deficiency
Radiotherapy
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
63
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. Mirtazepine◊

Opioids

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 200400mg po three times a day,
Naproxen 250mg-500mg po twice
a day, Diclofenac 25-50mg po
three times daily

Aluminium chloride
Topical treatment for localised
sweating
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
64
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
65
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* ◊
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
66

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 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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
67
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.
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
68
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
69
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 injection
Morphine 15mg/ml injection
Morphine 30mg/ml injection
5
5
5
Controlled
Drug
Diamorphine 5mg injection
Diamorphine 10mg injection
5
5
Controlled
Drug
Oxycodone 10mg/ml injection
Oxycodone 20mg/2ml injection
5
5
Controlled
Drug
Controlled
Drug
Dyspnoea
Morphine as above
Midazolam as below
Terminal
Restlessness/
Agitation
Midazolam 10mg/2ml injection
10
Nausea &
Vomiting
Haloperidol 5mg/ml injection
5
Metoclopramide 10mg/2ml injection
10
Cyclizine 50mg/ml injection
5
Levomepromazine 25mg/ml
injection
10
Hyoscine Butylbromide 20mg/ml
injection
10
Respiratory
Tract
Secretions
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
70
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
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
71
Also the following staff now working outside Sheffield:
Dr Jason Boland, Dr Ruth Broadhurst, Dr Kathryn Brown, Dr
Rebecca Hirst and Dr Sarah Mollart
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
72
Sheffield Palliative Care Formulary
Drug Index
Drug
Adrenaline
Alfentanil
Aluminium chloride
Amitriptyline
Antacid & Oxetacaine
Antacids
Aqueous Cream
Arachis Oil
Artificial Saliva Spray
Asilone®
Baclofen
Balneum® Plus
Benzydamine
Betamethasone Cream
Biotene Oralbalance® Gel
BioXtra® Gel
Bisacodyl
Bonjela®
Buprenorphine
BuTrans®
Capsaicin Cream
Carbocisteine
Celecoxib
Cetirizine
Chlorhexidine Gluconate
Chlorphenamine
Chlorpromazine
Choline Salicylate
Cimetidine
Citalopram
Clonazepam
Co-Danthramer
Page Number/s
14
48, 52
62
25, 45, 63
41
29
36, 57
21
40
29, 34
34, 44
57
41
57
40
40
20-22
41
48, 52
52
45, 58
23
29, 44
58
42
58
65
41
58
25
45, 65
20
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
73
Drug
Co-Danthrusate
Codeine Linctus
Codeine Phosphate
Colestyramine
COX 2
Cyclizine
Dexamethasone
Diamorphine
Diazepam
Diclofenac
Dihydrocodeine
Difflam®
Dioralyte®
Diprobase®
Docusate Sodium
Domperidone
Duloxetine
E45® Itch Relief Cream
Etamsylate
Etoricoxib
Fentanyl
Fluconazole
Gabapentin
Gelclair® Concentrated Oral Gel
Glycerin
Glycopyrrolate
Granisetron
Haloperidol
Hydrocortisone Cream
Hydroxyzine
Hyoscine Butylbromide
Hyoscine Hydrobromide
Hypertonic Electrolyte Solution
Ibuprofen
Page Number/s
20
14, 23
26-28, 43, 52
27
44
39, 64, 66, 68
11, 27, 39, 44, 45, 55, 58, 65
15, 48, 49, 51, 53, 56, 68
13, 44, 65
44, 62
52
41
28
57
19
29, 30, 34, 38, 39, 61
13, 25, 45
57
15
29
48, 50-54
42, 61
45
42
21, 22
59
64
9, 13, 17, 34, 38, 39, 67, 68
57
58
17, 26, 44, 59, 61, 64, 68
39, 59, 61, 63
28
62
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
74
Drug
Ketamine
Ketorolac
Lactulose
Lansoprazole
Laxido®
Levomepromazine
Lidocaine
Lofepramine
Loperamide
Lorazepam
Maalox®
Mebeverine
Medroxyprogesterone
Megestrol Acetate
Mesalazine
Methadone
Methadone Linctus
Methylphenidate
Methylnaltrexone
Metoclopramide
Metronidazole
Micralax Micro-enema®
Midazolam
Mirtazepine
Morphine Sulphate
Morphine Hydrochloride
Movicol®
MST®
Mucilage Liquid
Naloxone
Naproxen
Nortriptyline
NSAIDs
Nystatin
Page Number/s
64
64
19
28-30
19
9, 13, 17, 38, 65, 66, 68
41
25
26-28
13, 32, 39
29, 30
44
11
11
28
48, 66
14, 23
33
20
11, 17, 29, 30, 34, 38, 39, 61, 68
27, 41
22
9, 13, 15, 32, 34, 56, 67, 68
13, 25, 62
14, 15, 23, 31, 43, 45, 49-54, 56, 68
41
19
45, 46
61
46
62
25
43, 44
42
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
75
Drug
Octreotide
Olanzapine
Omeprazole
Ondansetron
Oxetacaine
Oxycodone
Pancreatin
Paracetamol
Paroxetine
Peptac®
Phosphate enema
Pilocarpine Tablets
Prednisolone
Pregabalin
Prochlorperazine
Propantheline
Ranitidine
Risperidone
Salbutamol
Saliva Orthana®
Senna
Sertraline
Sevredol®
Silver Nitrate sticks
Simple Linctus
Sodium Chloride
Sodium Citrate
Sodium Hypochlorite solution
Sulfasalazine
Temazepam
Tramadol
Tranexamic Acid
Trazodone
Xerotin®
Page Number/s
17, 26, 27, 28, 64
9, 13
28, 29
39, 64
41
47, 50-54, 68
27
43, 62
58
29, 30
21, 22
40
58
45
39, 65
63
29
9
32
40
20, 22
13, 25
45
14
23
23, 32
21
42
28
35
47, 52
14, 15, 40
13, 25
40
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
76
Drug
Zerobase®
Zoledronic Acid
Zomorph®
Zopiclone
Page Number/s
57
55
45, 46
35
 - Seek specialist advice
* - Unlicensed use
 - Not included in Sheffield Formulary
77