| Formulary Chapter 21: Palliative Care Formulary - Full Chapter
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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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| 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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