Contents:
Management
The following information outlines common doses of drugs used to treat the most experienced symptoms and is for use in all settings. They have been designed to be used in conjunction with any local prescribing guidance and authorisation forms.
For further information, or if symptoms not managed, please consult your local palliative care team or your pharmacist. For the purposes of this guideline the dying phase is a prognosis of less than six weeks, or if ‘phase of illness’ ranking is used then when patient considered to be ‘deteriorating’ or ‘dying’ (for further guidance see section Recognising dying phase).
For community medicines administration please complete the local authorisation form.
There is no exact equivalence between opioids, starting low and titrating upwards is recommended safe practice.
Approximately equivalent opioid doses for PRN use
Oral Morphine
5mg
10mg
Morphine injection
2.5mg
5mg
Fentanyl injection (eGFR <30ml/min)
25 micrograms
50 micrograms
Approximately equivalent opioid doses for starting doses in subcutaneous infusion
Oral Morphine in 24hours
30mg
60mg
Morphine injection via CSI
15mg
30mg
Fentanyl injection via CSCI (eGFR <30ml/min)
150 micrograms
300 micrograms
Alfentanil injection via CSI (eGFR <30ml/min)
1mg
2mg
DO NOT use these equivalent doses for larger doses without specialist palliative advice, as the small numbers entailed have been rounded up.
For further information see Relative doses of opioids.
Opioid choice in Renal Impairment
Morphine is NOT routinely used as a continuous infusion in a patient with known renal impairment (eGFR <30ml/min) because of the high risk of accumulation and adverse effects.
However it is not necessary to routinely check the renal function of all dying patients who are comfortable on their regular opioid – even if they develop undetected renal impairment, it may not be necessary to convert to an alternative unless they develop side effects or signs of opioid toxicity such as myoclonic jerks; please note drowsiness and reduced consciousness can be part of the dying process and doesn’t necessarily mean the person is opioid toxic.
If eGFR <30ml/min either Fentanyl or Alfentanil are used as an alternative to morphine as they are less likely to accumulate, the choice of drug will be locality specific.
Seek specialist palliative care advice:
- If converting from alternative strong opioids
- If analgesia requirements are escalating
- If distressing opioid side effects
- If clinician is unclear about appropriate choice of opioid
- If an alternative opioid is prescribed
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.