| Formulary Chapter 21: Palliative Care Formulary - Full Chapter
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| Notes: |
This chapter of the formulary is under continual development, please let the team know if you have any comments about the contents: mlcsu.lscformulary@nhs.net.
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| Chapter Links... |
 LSCMMG: Palliative Care Clinical Practice Summary |
| Details... |
| 21 |
Palliative Care Formulary Drugs |
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Alfentanil injection
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Formulary
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Palliative care
500micrograms/ml injection
Moderate to severe pain in palliative care patients with severe renal impairment or intolerance to other opioids.
Use on specialist advice only.
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Amitriptyline
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Formulary
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Palliative care
Neuropathic pain
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Bisacodyl
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Formulary
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Palliative care
Constipation
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Buprenorphine
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Formulary
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Palliative care
Pain.
Only for use in patients who are unable to take or tolerate oral medicine (including soluble tablets and liquids) OR where use of the low-dose buprenorphine patches may prevent administration problems for frail, elderly patients in the community.
Do not confuse the formulations of transdermal patches which are available in various strengths as 7-day, 4-day and 3-day patches; 3 day patches are not recommended to avoid confusion in dosing.
Always prescribe by brand name.
7 day transdermal patches: 5 microgram / hour, 10 microgram / hour, 15 microgram/hour, 20 microgram / hour (In primary care please prescribe as Sevodyne®, Butec® or Bunov®)
4 day transdermal patches are much stronger: 35 microgram/hour, 52.5 microgram/hour, 70 microgram/hour (In primary care please prescribe as Bupeaze®, Relevtec® or Carlosafine®)
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Celecoxib
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Formulary
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Palliative care
Pain: Anti-inflammatory
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Co-danthramer
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Formulary
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Palliative care
Constipation
Opiod-induced constipation
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Cyclizine
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Formulary
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Palliative care
Nausea and vomiting
Nausea and vomiting in the last days of life
Opioid-induced nausea and vomiting
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Dexamethasone
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Formulary
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Palliative care
Bowel obstruction - reduction of tumour oedema associated with bowel obstruction
Breathlessness
Corticosteroids in palliative care - Anorexia, Adjuvant analgesic, Nausea and vomiting associated with chemotherapy, Obstructive syndromes, Raised intracranial pressure, Spinal cord compression
Nausea and vomiting - raised Intracranial Pressure
Palliative care emergencies - SVC obstruction AND Metastatic spinal cord compression
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Diazepam
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Formulary
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Palliative care
Seizures
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Docusate
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Formulary
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Palliative care
Constipation
Opioid-induced constipation
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Domperidone
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Formulary
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Palliative care
Nausea and vomiting
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Duloxetine
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Formulary
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Palliative care
Neuropathic pain
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Esomeprazole injection
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Formulary
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Palliative care
(powder for reconstitution) - 40mg vial
Patients for whom parenteral administration of PPI is indicated for symptom control but for whom iv access is not possible.
May not be available from community pharmacies - check supply.
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Fentanyl
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Formulary
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Palliative care
Pain
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MHRA: Fentanyl skin patches: How to use and dispose of them safely
 MHRA: Serious and fatal overdose of fentanyl patches
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Fentanyl buccal tablets (Effentora®)
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Formulary
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Palliative care
Buccal tablets 100mcg, 200mcg, 400mcg, 600mcg, 800mcg
Pain.
For other preparations, see section 04.07.02. Sublingual tablets are for use in palliative care only.
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Gabapentin
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Formulary
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Palliative care
Neuropathic pain
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Glycopyrronium
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Formulary
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Palliative care
Bowel obstruction - colic associated with bowel obstruction AND GI secretions associated with bowel obstruction
Respiratory tract secretions in the last days of life
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Haloperidol
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Formulary
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Palliative care
Care in the last weeks or days of life - Nausea and vomiting in the last days of life AND Agitation/terminal restlessness in the last days of life
Nausea and vomiting
Opioid-induced nausea and vomiting
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Hydromorphone
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Formulary
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Palliative care
Immediate release capsules 1.3mg, 2.6mg
Modified release capsules 2mg, 4mg, 8mg, 16mg, 24mg
Solution for injection for infusion 2mg/ml, 10mg/ml
Opioid rotation in patients with intolerable side effects or inadequate response to other opioids.
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Hyoscine butylbromide
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Formulary
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Palliative care
Bowel obstruction - colic associated with bowel obstruction AND GI secretions associated with bowel obstruction
Respiratory tract secretions in the last days of life
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Hyoscine hydrobromide
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Formulary
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Palliative care
Respiratory tract secretions in the last days of life
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Ibuprofen
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Formulary
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Palltiave care
Pain: Anti-inflammatory
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Ketamine
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Formulary
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Palliative care
Oral solution 50mg/5ml
Pain.
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Lactulose
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Formulary
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Palliative care
Constipation
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Levetiracetam
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Formulary
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Palliative care
Concentrate for solution for infusion 500mg/5ml
Management for prolonged seizures or status epilepticus in palliative and end of life care.
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Levomepromazine
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Formulary
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Palliative care
Care in the last weeks or days of life - Nausea and vomiting in the last days of life AND Agitation/terminal restlessness in the last days of life
Nausea and vomiting
Opioid-induced nausea and vomiting
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Lidocaine 5% medicated plasters
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Formulary
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Palliative care
5% medicated plasters
Complex neuropathic pain.
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Lorazepam
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Formulary
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Palliative care
Breathlessness
Breathlessness in the last days of life
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Methadone
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Formulary
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Palliative care
Tablets 5mg,
Injection 10mg/1mL, liquid 1mg/ml
Pain or cough.
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Metoclopramide
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Formulary
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Palliative care
Nausea and vomiting
Opioid-induced nausea and vomiting
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Midazolam
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Formulary
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Palliative care
Breathlessness
Care in the last weeks or days of life - Breathlessness in the last days of life AND Agitation/terminal restlessness in the last days of life
Palliative care emergencies - Seizures AND Anixolytic following major blood loss
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Morphine
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Formulary
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Palliative care
Breathlessness
Pain in the last weeks or days of life
Breathlessness in the last days of life
Pain
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Morphine sulfate orodispersible tablets (Actimorph®)
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Formulary
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Palliative care
Orodispersible tablets (Actimorph) 1mg, 2.5mg, 5mg, 10mg, 20mg, 30mg
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Naloxegol
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Formulary
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Palliative care
Opioid-induced constipation
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Naproxen
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Formulary
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Palliative care
Pain: Anti-inflammatory
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Nefopam tablets
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Formulary
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Palliative care
30mg tablets
Pain.
Useful in patients with liver failure.
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Octreotide
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Formulary
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Palliative care
Bowel obstruction - GI secretions associated with bowel obstruction.
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Olanzapine
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Formulary
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Palliative care
Tablets, orodispersible tablets, powder for solution for injection
Nausea and vomiting, appetite stimulant.
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Ondansetron
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Formulary
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Palliative care
Bowel obstruction - nausea and vomiting associated with bowel obstruction
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Oxycodone
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Formulary
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Palliative care
Breathlessness in the last days of life (on the advice of a specialist)
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Oxygen
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Formulary
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Palliative care
Breathlessness
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Parecoxib
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Formulary
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Palliative care
40mg powder for solution for injection
Pain.
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Phenobarbital injection
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Formulary
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Palliative care
Injection 200mg / ml
Third line for patients who fail to respond to combined use of midazolam and anti psychotic (usually levomepromazine) for refractory agitation at the end of life.
Use on specialist advice only.
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Pregabalin
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Formulary
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Palliative care
Neuropathic pain
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Prochlorperazine (buccal)
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Formulary
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Palliative care
Nausea and vomiting in the last days of life
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Salbutamol 2.5mg nebules
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Formulary
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Palliative care
Breathlessness
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Senna
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Formulary
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Palliative care
Constipation
Opioid-induced constipation
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Sodium chloride 0.9% nebules
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Formulary
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Palliative care
Breathlessness
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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Traffic Light Status Information
| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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