| Formulary Chapter 21: Palliative Care Formulary - Full Chapter
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| 21.01 |
Symptom Control |
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| 21.01.01 |
Analgesics |
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| 21.01.01.01 |
Non-opioid analgesics |
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Paracetamol
(Oral)
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First Choice
 
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- Tablet 500mg
- Dispersible tablet 500mg
- Oral SuspensionSF 120mg/5ml, 250mg/5ml
- Suppository 60mg, 120mg, 240mg, 500mg, 1g
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Ibuprofen
(Oral)
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First Choice
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- 200mg, 400mg and 600mg tablets
- Oral suspension
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Ibuprofen
(Topical)
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First Choice
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- 100g gel containing 5% ibuprofen
- Fenbid brand is most cost effective
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Naproxen
(Tablets)
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Second Choice
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- 250mg and 500mg tablets
- Oral suspension and effervescent tablets available
- No evidence for GI benefit of EC preparation - use standard tablets.
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| 21.01.01.02 |
Opioid analgesics |
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Morphine Sulphate M/R
(Zomorph®)
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First Choice
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- 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.
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Morphine Sulphate solution
(Oramorph®)
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First Choice
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- 10mg/5ml Schedule 5 (CD Inv)
- 100mg/5ml Schedule 2 (CD)
- 4 hourly dosing PRN
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Morphine Sulphate
(Sevredol®)
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First Choice
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- 10mg,20mg,50mg immediate release tablets
- Sevredol® tablet - 4 hourly dosing
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Oxycodone
(Longtec®)
(Modified Release tablets)
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Second Choice
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- 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.
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Oxycodone
(Shortec®)
(Oral)
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Second Choice
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- 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.
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Buprenorphine
(7 day patch)
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Formulary
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- 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.
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Codeine Phosphate
(Oral)
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Formulary
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- Tablet 15mg, 30mg, 60mg
- Useful for the relief of mild to moderate pain but is too constipating for long-term use
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Buprenorphine
(4 day patch)
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Formulary
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- 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.
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Tramadol
(Oral)
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Formulary
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- Capsules 50mg
- Soluble tablets 50mg
- Modified release MR capsules (limited use)
- Schedule 3 CD with exemption from safe custody requirements
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Fentanyl
(3 day Patch)
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Formulary
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- 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
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 •MHRA Drug Safety Update Oct 2018 | Transdermal fentanyl “patches”: reminder of potential for life-threatening harm from accidental exposure, particularly in children
BNF opiate conversion information
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Fentanyl
(buccal tablets)
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Formulary
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- 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.
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Fentanyl
(sublingual tablets)
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Formulary
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- 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.
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Methadone
(Oral)
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Formulary
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- Tablets 5mg
- Oral Solution 1mg/ml
- Only on recommendation of palliative care specialist
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| 21.01.01.03 |
Neuropathic Pain |
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Amitriptyline
(Tablet)
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First Choice
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- Tablet 10mg, 25mg, 50mg
- 'Off label' use for neuropathic pain
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Duloxetine
(Capsule)
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Formulary
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- Capsules 30mg, 60mg
- For the treatment of neuropathic pain
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Pregabalin
(Capsule)
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Formulary
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- Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 225mg, 200mg, 300mg
- Note pregabalin tablets are not included on the BSWformulary
- For neuropathic pain
Schedule 3 CD
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Controlled drugs use regulations
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Gabapentin
(Capsule)
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Formulary
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- Capsules 100mg, 300mg, 400mg
Schedule 3 CD
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Controlled drugs use regulations
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Nortriptyline
(Tablets)
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Formulary
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- Tablets 10mg, 25mg
- 'Off label' use for neuropathic pain
- Should only be used if amitriptyline isn't tolerated or is contra indicated
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| 21.01.01.04 |
Bone pain / Other Pain |
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Ibuprofen
(Oral)
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First Choice
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- 200mg, 400mg and 600mg tablets
- Oral suspension
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Ibuprofen
(Topical)
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First Choice
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- 100g gel containing 5% ibuprofen
- Fenbid brand is most cost effective
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Paracetamol
(Oral)
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First Choice
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- Tablet 500mg
- Dispersible tablet 500mg
- Oral SuspensionSF 120mg/5ml, 250mg/5ml
- Suppository 60mg, 120mg, 240mg, 500mg, 1g
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Naproxen
(Tablets)
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Second Choice
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- 250mg and 500mg tablets
- Oral suspension and effervescent tablets available
- No evidence for GI benefit of EC preparation - use standard tablets.
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Dexamethasone
(Oral)
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Formulary
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- For specific indications
- Tablets 500 microgram, 2mg
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Diazepam
(Oral)
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Formulary
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- Tablets 2mg, 5mg, 10mg
- Oral Solution 2mg in 5ml,
CD Benz POM
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Lidocaine
(plaster 5%)
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Formulary
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- 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®
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BSW Lidocaine Plaster guidance
Items which should not routinely be prescribed in primary care guidance for CCGs
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Zoledronic Acid
(IV infusion)
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Formulary
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- 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).
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| 21.01.02 |
Antiemetics |
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Cyclizine
(Tablet)
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Formulary
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Domperidone
(Oral)
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Formulary
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- 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.
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BSW Domperidone Guidance
MHRA Drug Safety Update (Dec 2019): Domperidone for nausea and vomiting: lack of efficacy in children; reminder of contraindications in adults and adolescents
MHRA Drug Safety Update Dec 2014: Domperidone: risks of cardiac side effects
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Haloperidol
(Oral)
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Formulary
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- Tablets 500 micrograms, 1.5mg, 5mg, 10mg
- Oral liquidSF 1mg in 1ml
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Levomepromazine
(Tablet)
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Formulary
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- 25mg Tablets
- For palliative care for the management of pain, associated restlessness, distress or vomiting
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Metoclopramide
(Oral)
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Formulary
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- 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
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MHRA DSU Dec 2014 Metoclopramide: risk of neurological adverse effects
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Ondansetron
(Oral)
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Formulary
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- Tablet 4mg, 8mg
- SyrupSF 4mg in 5ml
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Prochlorperazine
(Oral)
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Formulary
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- 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.
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Olanzapine
(oral)
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Formulary
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- Orodispersible tablet (Velotab®) 5mg
- For Nausea and Vomiting
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| 21.01.03 |
Antisecretory drugs |
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Hyoscine Butylbromide
(Tablet )
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Formulary
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 MHRA Drug Safety Update (Feb 2017): Hyoscine butylbromide injection & risk of serious adverse effects in patients with underlying cardiac disease
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Hyoscine Hydrobromide
(Tablets, patches, sublingual tablets)
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Formulary
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- 150mcg tablet
- 300mcg sublingual tablets
- Scopoderm® TTS Patch 1mg/ 72hrs
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| 21.01.04 |
Anticonvulsants / Anxiolytics |
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Diazepam
(Oral)
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Formulary
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- Tablets 2mg, 5mg, 10mg
- Oral Solution 2mg in 5ml,
CD Benz POM
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Lorazepam
(Tablets)
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Formulary
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- Tablets 1mg
- Can be given subligually (off label)
- Not all brands of lorazepam can be absorbed sublingually. Please use Genus, Metwest and Genesis brands
CD Benz POM
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Midazolam Maleate
(Epistatus®)
(Buccal)
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Formulary
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- 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
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| 21.01.05 |
Laxatives |
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Naloxegol
(Tablet)
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Formulary
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- 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.
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BSW Guidance on the Management of Constipation in Adults (2018)
NICE TA345: Naloxegol for treating opioid‑induced constipation
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Methylnaltrexone
(Injection)
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Formulary
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- 12 mg/0.6 mL
- Opioid induced constipation in terminal illness when response to other laxatives inadequate.
- Formulary status under review
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| 21.01.06 |
Miscellaneous or Other |
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Antacid and Oxetacaine
(Suspension)
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 Unlicensed
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- Oxetacaine 10mg/5ml with aluminium and magnesium hydroxides Suspension
- For palliative care use
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| Non Formulary Items |
Fentanyl
(Nasal Spray)
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Non Formulary
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Fentanyl
(lozenges)
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Non Formulary
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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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High Cost Drug Approval System |
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Traffic Light Status Information
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