Contents:
These are the common doses of drugs prescribed in anticipation of the commonly experienced symptoms by patients entering the terminal phase given by the subcutaneous (SC) route if needed when unable to take by oral route.
Drug: Morphine Sulfate
If eGFR <30 consider either opioid switch below, or dose reduction
Dose: 2.5mg – 5mg PRN
Route: Subcutaneous injection
Notes: Maximum dose 30mg/24hrs however if patient already taking regular morphine the PRN dose is usually 1/6th of the 24 hour opioid dose. For patients receiving alternative opioids please contact the palliative care team or pharmacist for advice.
See Pain section in Guidelines for more information
Drug: Fentanyl
Dose: 25 micrograms PRN
Route: Subcutaneous injection
Notes: Maximum 150 micrograms in 24hrs
or
Drug: Morphine sulfate
Dose: 1.25mg-2.5mg 2 hourly PRN
Route: Subcutaneous injection
Notes: Maximum 10mg in 24hrs
Notes
- Seek specialist palliative care advice: if existing strong opioids, if analgesia requirements are escalating, distressing opioid side effects, if clinician is unclear about appropriate choice of opioid or an alternative opioid is prescribed.
- The use of fentanyl for ‘as required’ doses is limited by the volume of solution required at higher doses – do not give more than 100 micrograms at once. An alternative is to use low dose alternative subcutaneous opioid e.g. morphine or oxycodone.
- Alfentanil is not generally appropriate for ‘as required’ doses as has a rapid onset of action (within 10 minutes) but short duration of action (30 minutes or less) but it may be helpful for anticipated breakthrough pain where rapid onset is required e.g. wound dressings, positioning and daily care.
- Starting dose of fentanyl or alfentanil CSCI will be based on prior opioid requirements (see Anticipatory medication management) and titrated upwards according to the amount of subsequent PRN doses required in addition to the continuous infusion – there is no upper limit provided the pain is responding well to the opioid and there are no symptoms or signs of adverse effects or toxicity.
N.B. Alfentanil and fentanyl are different drugs. The choice of which one is used is generally based on availability in local formulary or volume considerations.
For more information see algorithms for fentanyl and alfentanil and section Relative doses of opioids.
Drug: Midazolam
Dose: 2.5mg – 5mg PRN
Route: Subcutaneous injection
Notes: Maximum 60mg in 24hrs
Drug: Midazolam
Dose: 1.25mg-2.5mg PRN
Route: Subcutaneous injection
Notes: Maximum 30mg in 24hrs
Drug: Levomepromazine
Dose: 2.5mg – 5mg 4 hourly PRN
Route: Subcutaneous injection
Notes: Maximum dose 25mg in 24 hours
Drug: Hyoscine butylbromide
Dose: 20mg 2 hourly PRN
Route: Subcutaneous injection
Notes: Maximum 120mg in 24 hours
Drug: Morphine Sulfate
Dose: 2.5mg – 5mg PRN
Route: Subcutaneous injection
Notes: Maximum 30mg in 24hrs
Drug: Morphine Sulfate
Dose: 1.25mg-2.5mg PRN
Route: Subcutaneous injection
Notes: Maximum 10mg in 24hrs
Or
Drug: Fentanyl
Dose: 25 micrograms PRN
Route: Subcutaneous injection
Notes: Maximum 150 micrograms/24hrs
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.