netFormulary NHS
NHS Bath and North East Somerset, Swindon and Wiltshire CCG
Royal United Hospitals Bath NHS Foundation Trust
Great Western Hospitals NHS Foundation Trust
Salisbury NHS Foundation Trust
 Search
 Formulary Chapter 21: Palliative Care Formulary - Full Chapter
Notes:

APRIL 2020 BSW End of life COVID palliative care guidance EOL COVID prescription support v5 Note this contains options that may be suitable to use in EoL patients with swallowing difficulties and where syringe drivers may be unavailable.

NICE NG163 - COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community

The Wessex Palliative Care handbook contains guidance to help GPs, community nurses and hospital staff as well as specialist palliative care teams. It aims to provide a checklist for the management of common problems in palliative care, with some information on drug treatment. It is not a comprehensive textbook. The Palliative Care Handbook: A Good Practice Guide Wessex Palliative Physicians Ninth Edition 2019 

RUH - Palliative Care Guidance for GPs

For contact details of hospices and emergency drug lists and participating pharmacies across BSW, scroll to end of chapter or click here Community Pharmacy Emergency Drugs List & Contact Details

 Details...
21.01  Expand sub section  Symptom Control
21.01.01  Expand sub section  Analgesics
21.01.01.01  Expand sub section  Non-opioid analgesics
Paracetamol
(Oral)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • Tablet 500mg    
  • Dispersible tablet 500mg
  • Oral SuspensionSF 120mg/5ml, 250mg/5ml     
  • Suppository 60mg, 120mg, 240mg, 500mg, 1g
 
Ibuprofen
(Oral)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • 200mg, 400mg and 600mg tablets
  • Oral suspension
 
Ibuprofen
(Topical)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • 100g gel containing 5% ibuprofen
  • Fenbid brand is most cost effective    
 
Naproxen
(Tablets)
View adult BNF View SPC online
Second Choice
traffic lightGreen
  • 250mg and 500mg tablets
  • Oral suspension and effervescent tablets available 
  • No evidence for GI benefit of EC preparation - use standard tablets.
 
 
21.01.01.02  Expand sub section  Opioid analgesics
Controlled Drug Morphine Sulphate M/R
(Zomorph®)
View adult BNF View SPC online
First Choice
traffic lightGreen
  • m/r capsule 10mg, 30mg, 60mg, 100mg, 200mg
  • 12 hourly dosing
  • Zomorph can be opened & contents administered in semi-solid food for patients with swallowing difficulties.
  • Zomorph also licensed for use via gastric or gastronomy tubes (diameter >16F.G.).
  • There is no evidence of superior clinical analgesic effect of other opioids over morphine.
 
Controlled Drug Morphine Sulphate solution
(Oramorph®)
View adult BNF View SPC online
First Choice
traffic lightGreen
  • 10mg/5ml   Schedule 5 (CD Inv)
  • 100mg/5ml Schedule 2 (CD)
  • 4 hourly dosing PRN

 

 
Controlled Drug Morphine Sulphate
(Sevredol®)
View adult BNF View SPC online
First Choice
traffic lightGreen
  • 10mg,20mg,50mg immediate release tablets
  • Sevredol® tablet - 4 hourly dosing
 
Controlled Drug Oxycodone (Longtec®)
(Modified Release tablets)
View adult BNF View SPC online
Second Choice
traffic lightGreen
  • M/R Tablets 5mg, 10mg, 20mg, 40mg, 60mg, 80mg Longtec®. Prescribe by brand.
  • For the treatment of moderate to severe pain in patients with cancer pain.
  • Oxycodone may be initiated in preference to morphine for the management of pain by a GP with experience in palliative care or on the advice of the palliative care team or pain team when: Dose escalation with morphine is not possible due to opioid toxicity eg. hallucinations, myoclonic jerks and confusion.
 
 
Controlled Drug Oxycodone (Shortec®)
(Oral)
View adult BNF View SPC online
Second Choice
traffic lightGreen
  • Tablets 5mg, 10mg, 20mg, Shortec®.
  • Oral solution 5mg/5ml, or concentrate 10mg/ml
  • Prescribe by brand.
  • Oxycodone may be initiated in preference to morphine for the management of pain by a GP with experience in palliative care or on the advice of the palliative care team or pain team. 

 

 
 
Controlled Drug Buprenorphine
(7 day patch)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • LOW STRENGTH PATCH
  • 7 day patch of choice for consistency and safety
  • Patch 5 microgram/hour for 7 days 
  • Patch 10 microgram/hour for 7 days
  • Patch 15 micrograms/hour for 7 days
  • Patch 20 microgram/hour for 7 days
  • Only to be used in patients with cognitive deficit or swallowing difficulties, after a trial of soluble/liquid medication. Zomorph capsules can be opened up for ease of swallowing.
  • Buprenorphine patches are NOT suitable, or licensed, for management of acute / intermittent pain.
  • Patients and/or their carers neeed to be aware that these patches need to be applied at appropriate seven-day intervals. Remember to remove the old patch before application of new patch. Avoid use of multiple patches.
 
 
Codeine Phosphate
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablet 15mg, 30mg, 60mg
  • Useful for the relief of mild to moderate pain but is too constipating for long-term use
 
 
Controlled Drug Buprenorphine
(4 day patch)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • HIGH STRENGTH PATCH
  • Patch 35 microgram/ hour, for 4 days
  • Patch 52.5 microgram/ hour, for 4 days
  • Patch 70 microgram/ hour, for 4 days
  • Only to be used in patients with cognitive deficit or swallowing difficulties, after a trial of soluble/liquid medication. Zomorph capsules can be opened for ease of swallowing.
  • Buprenorphine patches are not suitable for management of acute / intermittent pain.
  • Patients and/or their carers need to be aware that these patches need to be applied at appropriate 96 hour intervals (or 4 days). Remember to remove the old patch before application of new patch. Avoid use of multiple patches.
 
 
Controlled Drug Tramadol
(Oral)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • Capsules 50mg
  • Soluble tablets 50mg
  • Modified release MR capsules (limited use)
  • Schedule 3 CD with exemption from safe custody requirements
 
 
Controlled Drug Fentanyl
(3 day Patch)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 12microgram/hour, for 3 days
  • 25microgram/hour, for 3 days
  • 50microgram/hour, for 3 days
  • 75microgram/hour, for 3 days
  • 100microgram/hour, for 3 day
  • Fentanyl patches are only licensed for chronic intractable pain. For palliative care use.
  • Fentanyl patches are not suitable for use in the management of acute / intermittent pain.
  • Only to be used in patients who require equivalent dose of at least 60mg morphine daily
  • Fentanyl is available both as a reservoir patch and a matrix patch (do not cut either)
  • Patients and/or their carers need to be aware that fentanyl patches need to be applied at appropriate 72-hour (three-day) intervals. Remember to remove the old patch before application of new patch
  • For dose conversion see BNF link below
 
Link  •MHRA Drug Safety Update Oct 2018 | Transdermal fentanyl “patches”: reminder of potential for life-threatening harm from accidental exposure, particularly in children
Link  BNF opiate conversion information
 
Controlled Drug Fentanyl
(buccal tablets)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • 100micrograms, 200micrograms, 400micrograms, 600micrograms, 800micrograms
  • Breakthrough cancer pain for patients in whom oral morphine sulphate solution is inappropriate.  Under the recommendation of a palliative care specialist only.
  • NOT approved for non cancer pain
  • Patients must be assessed by the palliative care or pain team before commencing treatment. They should be used in the minority of patients with breakthrough pain that fail immediate release morphine or oxycodone. Review weekly.  
  • Prescribe by brand name to ensure that the correct product is dispensed.
 
 
Controlled Drug Fentanyl
(sublingual tablets)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • 100micrograms, 200micrograms, 300micrograms, 400micrograms, 600micrograms, 800micrograms
  • Palliative care or pain specialist initiation only
  • Patients must be assessed by the palliative care or pain team before commencing treatment. They should be used in the minority of patients with breakthrough pain that fail immediate release morphine or oxycodone. Review weekly.

 

 
 
Controlled Drug Methadone
(Oral)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • Tablets 5mg 
  • Oral Solution 1mg/ml
  • Only on recommendation of palliative care specialist
 
 
21.01.01.03  Expand sub section  Neuropathic Pain to top
Amitriptyline
(Tablet)
View adult BNF View SPC online
First Choice
traffic lightGreen
  •  Tablet 10mg, 25mg, 50mg
  • 'Off label' use for  neuropathic pain

 

 

 
Duloxetine
(Capsule)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Capsules 30mg, 60mg
  • For the treatment of neuropathic pain

 

 
 
Pregabalin
(Capsule)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 225mg, 200mg, 300mg
  • Note pregabalin tablets are not included on the BSWformulary
  • For neuropathic pain

 

 
Controlled Drug Schedule 3 CD
Link  Controlled drugs use regulations
 
Gabapentin
(Capsule)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Capsules 100mg, 300mg, 400mg 
 
Controlled Drug Schedule 3 CD
Link  Controlled drugs use regulations
 
Nortriptyline
(Tablets)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • Tablets 10mg, 25mg
  • 'Off label' use for neuropathic pain
  • Should only be used if amitriptyline isn't tolerated or is contra indicated
 
 
21.01.01.04  Expand sub section  Bone pain / Other Pain
Ibuprofen
(Oral)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • 200mg, 400mg and 600mg tablets
  • Oral suspension

 

 
Ibuprofen
(Topical)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • 100g gel containing 5% ibuprofen
  • Fenbid brand is most cost effective    
 
Paracetamol
(Oral)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • Tablet 500mg    
  • Dispersible tablet 500mg
  • Oral SuspensionSF 120mg/5ml, 250mg/5ml     
  • Suppository 60mg, 120mg, 240mg, 500mg, 1g
 
Naproxen
(Tablets)
View adult BNF View SPC online
Second Choice
traffic lightGreen
  • 250mg and 500mg tablets
  • Oral suspension and effervescent tablets available 
  • No evidence for GI benefit of EC preparation - use standard tablets.
 
 
Dexamethasone
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • For specific indications
  • Tablets 500 microgram, 2mg

 

 
 
Diazepam
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablets 2mg, 5mg, 10mg
  • Oral Solution 2mg in 5ml,
 
Controlled Drug CD Benz POM
 
Lidocaine
(plaster 5%)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • Can be used as per Palliative Care specialist recommendation (off-label)  on a case by case basis between specialist and GP. Locally agreed indication (August 2019).
  • For all other indications see entry under neuropathic pain 04.07.03
  • Medicated plasters lidocaine 5%. Prescribe by the brand name: Ralvo®
 
Link  BSW Lidocaine Plaster guidance
Link  Items which should not routinely be prescribed in primary care guidance for CCGs
 
Zoledronic Acid
(IV infusion)
View adult BNF View SPC online
Formulary
traffic lightRed
  • 800 micrograms/ml, 5ml (4mg) vial
  • Prevention of skeletal related events (pathological fractures, spinal compression, radiation or surgery to bone, or tumour-induced hypercalcaemia) in adult patients with advanced malignancies involving bone. 
  • Treatment of adult patients with tumour-induced hypercalcaemia (TIH).
 
 
21.01.02  Expand sub section  Antiemetics
Cyclizine
(Tablet)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablet 50mg
 
 
Domperidone
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablet 10mg
  • Suspension 5mg in 5ml
  • Domperidone should be used at the lowest effective dose for the shortest possible duration
  • Recommended adult dose for GI pain in palliative care is 10mg TDS. Higher doses should only be considered under specialist palliative care services.
 
Link  BSW Domperidone Guidance
Link  MHRA Drug Safety Update (Dec 2019): Domperidone for nausea and vomiting: lack of efficacy in children; reminder of contraindications in adults and adolescents
Link  MHRA Drug Safety Update Dec 2014: Domperidone: risks of cardiac side effects
 
Haloperidol
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablets 500 micrograms, 1.5mg, 5mg, 10mg
  • Oral liquidSF 1mg in 1ml
 
 
Levomepromazine
(Tablet)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 25mg Tablets 
  • For palliative care for the management of pain, associated restlessness, distress or vomiting
 
 
Metoclopramide
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablet 10mg
  • Syrup 5mg in 5ml
  • Metoclopramide and prochlorperazine are associated with a high risk of dystonias and oculogyric crises particularly in children, young adults and elderly. 
  • Severe reactions to metoclopramide should be treated with procyclidine injection
 
Link  MHRA DSU Dec 2014 Metoclopramide: risk of neurological adverse effects
 
Ondansetron
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablet 4mg, 8mg
  • SyrupSF 4mg in 5ml
 
 
Prochlorperazine
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablet 5mg
  • Syrup 5mg in 5ml
  • Buccal tablet 3mg (as an alternative to injection in Primary Care)
  • Notes: Severe reactions to prochlorperazine should be treated with procyclidine injection, Prochlorperazine should not be prescribed for patients with Parkinson's & should be used with caution in the elderly.
 
 
Olanzapine
(oral)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • Orodispersible tablet (Velotab®) 5mg
  • For Nausea and Vomiting
 
 
21.01.03  Expand sub section  Antisecretory drugs
Hyoscine Butylbromide (Tablet )
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 10mg tablets. 
 
Link  MHRA Drug Safety Update (Feb 2017): Hyoscine butylbromide injection & risk of serious adverse effects in patients with underlying cardiac disease
 
Hyoscine Hydrobromide
(Tablets, patches, sublingual tablets)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 150mcg tablet
  • 300mcg sublingual tablets
  • Scopoderm® TTS Patch 1mg/ 72hrs
 
 
21.01.04  Expand sub section  Anticonvulsants / Anxiolytics
Diazepam
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablets 2mg, 5mg, 10mg
  • Oral Solution 2mg in 5ml,
 
Controlled Drug CD Benz POM
 
Lorazepam
(Tablets)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablets 1mg
  • Can be given subligually (off label) 
  • Not all brands of lorazepam can be absorbed sublingually. Please use Genus, Metwest and Genesis brands

 

 
Controlled Drug CD Benz POM
 
Controlled Drug Midazolam Maleate
(Epistatus®)
(Buccal)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Epistatus® Oromucosal solution prefilled single syringe 10mg/1ml 
  • Epistatus® Oromucosal solution 10mg/ml prefilled syringes: 2.5mg/0.25ml, 5mg/0.5ml, 7.5mg/0.75ml, (unlicensed).  Individually wrapped in a pack of 4.
  • Prescribe by BRAND (NB Buccolam brand is a different salt, STRENGTH and volume) 
  • In the palliative care setting PRN use only

 

 
 
21.01.05  Expand sub section  Laxatives to top
Naloxegol
(Tablet)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 12.5mg & 25mg tablets.
  • Please note: This may be considered as an option for treatment of opioid- induced constipation in adults, whose constipation has failed to adequately respond to laxatives appropriately escalated in accordance with our BSW Guidance on the Management of Constipation in Adults (2018), and in whom stopping opiates would be clinically inappropriate.
 
Link  BSW Guidance on the Management of Constipation in Adults (2018)
Link  NICE TA345: Naloxegol for treating opioid‑induced constipation
 
Methylnaltrexone
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
  • 12 mg/0.6 mL
  • Opioid induced constipation in terminal illness when response to other laxatives inadequate.
  • Formulary status under review
 
 
21.01.06  Expand sub section  Miscellaneous or Other
Antacid and Oxetacaine
(Suspension)
View adult BNF View SPC online
Unlicensed Drug Unlicensed
traffic lightRed
  • Oxetacaine 10mg/5ml with aluminium and magnesium hydroxides Suspension
  • For palliative care use
 
 
 ....
 Non Formulary Items
Controlled Drug  Fentanyl
(Nasal Spray)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Fentanyl
(lozenges)

View adult BNF View SPC online
Non Formulary
 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG
Blueteq
High Cost Drug Approval System

Traffic Light Status Information

Status Description

Traffic LightRed

RED - Hospital only – to be prescribed by a specialist and supplied from secondary care ONLY throughout treatment.  

Traffic LightAmber

Amber medicines are considered suitable for GP prescribing following specialist initiation or recommendation.  

Traffic LightAmber with Shared Care

Shared Care - these medicines require specialist initiation and stabilisation. Ongoing division of responsibility for drug and disease monitoring between specialist and GP by a Shared Care Guideline (SCG). If no SCG in place status reverts to red.  

Traffic LightGreen

These medicines are appropriate for initiation in both primary and secondary care. Prescribing is appropriate within licensed or local recommendations.  

Traffic LightSelf

Suitable for patient to be directed to buy themselves  

Traffic LightGrey

Not currently used. We intend to include this TLS in future to highlight where a decision to use this medicine is under review.   

Traffic LightBlack

(In use from Oct 2020) Used where a decision has been made by the BSW APC not to routinely commission this preparation for its licensed indications. Do not prescribe.   

Traffic LightRed Specialist Centre

Not currently used. We intend to include this TLS in future to highlight where this medicine and indication is ONLY available through a Specialist Centre according to a NICE Highly Specialised Technology or NHSE Specialised Commission Circular / Policy.  

netFormulary