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Royal United Hospitals Bath NHS Foundation Trust
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 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 

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

 Details...
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
Self
  • 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
Self
  • 200mg, 400mg and 600mg tablets
  • Oral suspension
 
Ibuprofen 
(Topical)
View adult BNF View SPC online
First Choice
Self
  • 100g gel containing 5% ibuprofen
  • Fenbid brand is most cost effective    
 
Naproxen 
(Tablets)
View adult BNF View SPC online
Second Choice
Green
  • 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
Green
  • 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
Green
  • 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
Green
  • 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
  • Green  for cancer patients (rest of Wiltshire and Swindon)
  • Amber Amber for cancer patients BaNES
  • 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

Green  for cancer patients (rest of Wiltshire and Swindon)

Amber Amber for cancer patients BaNES

  • 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. 

 

 
   
Codeine Phosphate 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • 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
Green
  • 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 Buprenorphine 
(7 day patch)
View adult BNF View SPC online
Formulary
Green
  • 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.
 
   
Controlled Drug Tramadol 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • 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
Green
  • Patch 12 microgram/hour, for 3 days
  • Patch 25 microgram/hour, for 3 days
  • Patch 50 microgram/hour, for 3 days
  • Patch 75 microgram/hour, for 3 days
  • Patch 100 microgram/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.
  • Oral morphine 90mg over 24 hours is equivalent to one ’25 micrograms/hour’ patch.  
  • 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
 
Link  •MHRA Drug Safety Update Oct 2018 | Transdermal fentanyl “patches”: reminder of potential for life-threatening harm from accidental exposure, particularly in children
   
Controlled Drug Fentanyl (Effentora)
(buccal tablets)
View adult BNF View SPC online
Formulary
Amber
  • Buccal tablets 100 micrograms, 200 micrograms, 400 micrograms, 600 micrograms, 800 micrograms
  • 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  (PecFent®)
(Nasal Spray)
View adult BNF View SPC online
Formulary
Amber
  • 100micrograms/dose, 400micrograms/dose
  • 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 

 

 
   
Controlled Drug Methadone 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 5mg 
  • Oral Solution 1mg/ml
  • Only on recommendation of palliative care specialist
 
   
Controlled Drug Fentanyl  (Abstral®)
(sublingual tablets)
View adult BNF View SPC online
Formulary
Amber
  • 100mcg, 200mcg, 300mcg, 400mcg, 600mcg, 800mcg sublingual tablet
  • 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.

 

 
   
21.01.01.03  Expand sub section  Neuropathic Pain
Amitriptyline 
(Tablet)
View adult BNF View SPC online
First Choice
Green
  •  Tablet 10mg, 25mg, 50mg
  • 'Off label' use for  neuropathic pain

 

 

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

 

 
   
Pregabalin 
(Capsule)
View adult BNF View SPC online
Formulary
Green
  • 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
Green
  • Capsules 100mg, 300mg, 400mg 
 
Controlled Drug Schedule 3 CD
Link  Controlled drugs use regulations
   
Nortriptyline 
(Tablets)
View adult BNF View SPC online
Formulary
Amber
  • 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 to top
Ibuprofen 
(Topical)
View adult BNF View SPC online
First Choice
Self
  • 100g gel containing 5% ibuprofen
  • Fenbid brand is most cost effective    
 
Ibuprofen 
(Oral)
View adult BNF View SPC online
First Choice
Self
  • 200mg, 400mg and 600mg tablets
  • Oral suspension

 

 
Paracetamol  
(Oral)
View adult BNF View SPC online
First Choice
Self
  • 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
Green
  • 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
Green
  • For specific indications
  • Tablets 500 microgram, 2mg

 

 
   
Diazepam 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 2mg, 5mg, 10mg
  • Oral Solution 2mg in 5ml,
 
Controlled Drug CD Benz POM
   
Lidocaine  
(plaster 5%)
View adult BNF View SPC online
Formulary
Amber
  • 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
Red
  • 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).
 
   
 ....
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

Red

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

Amber

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

Amber 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.  

Green

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

Self

Suitable for patient to be directed to buy themselves  

Grey

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

Black

Not currently used. We intend to include this TLS in future to highlight where a decision has been made by either or both the local or national NHS not to routinely commission this preparation for its licensed indications. Do not prescribe.  

Red 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.  

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