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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 

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...
21.01.01  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)
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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)
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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
(sublingual tablets)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • 100, 200, 300, 400, 600, and 800micrograms sublingual tablets.
  • S/L tablets are first line immediate release fentanyl formulation for BSW.
  • 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 Fentanyl (PecFent)
(Nasal Spray)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • 100micrograms/dose and 400micrograms/dose nasal spray
  • Second line immediate release fentanyl preparation
 
 
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
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
Link  MHRA DSU: reports of severe respiratory depression
 
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 to top
Ibuprofen
(Topical)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • 100g gel containing 5% ibuprofen
  • Fenbid brand is most cost effective    
 
Ibuprofen
(Oral)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • 200mg, 400mg and 600mg tablets
  • Oral suspension

 

 
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).
 
 
 ....
 Non Formulary Items
Controlled Drug  Fentanyl
(buccal tablets)

View adult BNF View SPC online
Non Formulary

Buccal fentanyl tablets (Effentora®) removed from BSW formulary (Mar 2021) once existing stocks exhausted.  
Sublingual tablets aligned as first line immediate release fentanyl formulation for BSW

 
Controlled Drug  Fentanyl
(lozenges)

View adult BNF View SPC online
Non Formulary

Fentanyl lozenges (Actiq®) removed from BSW formulary.
Sublingual tablets aligned as first line immediate release fentanyl formulation for BSW

 
  
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.  

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