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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
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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...
21.02  Expand sub section  Injectable Drugs including those which may be given by CSI via a Syringe Drivers
21.02.01  Expand sub section  Analgesic Injectable Drugs
Controlled Drug Morphine
(Injection)
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First Choice
traffic lightGreen
  • For pain
  • 5mg/5ml, 10mg/ml, 15mg/ml, 20mg/ml, 30mg/ml
  • Can be used in syringe drivers
  • If eGFR known to be less than 30 mL/min please liaise with specialist palliative care
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
Controlled Drug Oxycodone
(Injection)
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Second Choice
traffic lightAmber
  • For palliative care use, specialist initiation
  •  10mg/ml,  20mg/2ml, (ONLY on specialist advice prescribe 50mg/1ml)

 

 
 
Controlled Drug Diamorphine
(Injection)
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Formulary
traffic lightGreen
  • Currently unavailable (March 2020)
  • Use Morphine first line in syringe drivers
  • For pain
  • 5mg, 10mg, 30mg
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
Controlled Drug Diamorphine
(Injection)
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Formulary
traffic lightAmber
  • Currently unavailable (March 2020)
  • Use Morphine first line in syringe drivers
  • For pain relief
  • 100mg and more in a syringe driver (where low volume required) on advice of palliative care specialist 
 
 
Diclofenac
(Injection)
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Formulary
traffic lightAmber
  • 75mg in 3ml injection
  • As recommended by palliative care specialists
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)

 

 
 
Controlled Drug Fentanyl
(Injection)
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Formulary
traffic lightAmber

FOR BaNES Patients ONLY on specialist recommendation

  • 100 micrograms in 2ml amp
  • Can be used in syringe drivers for in patients with renal impairment and an eGFR <30ml/min/1.73m2 or declining renal function on the advice of specialist palliative care service.

  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)

 
 
Controlled Drug Alfentanil
(injection)
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Formulary
traffic lightAmber

Alfentanil is only included on the BSWformulary for palliative care use in primary care when prescribed in SWINDON under specialist recommendation (AMBER TLS).

SAFETY NOTE - Alfentanil is a potent opioid anaesthetic agent that has a lower analgesic potency than fentanyl, but a much more rapid onset of action. Peak analgesic and respiratory depressant effects occur within 90 seconds. Use care when prescribing to ensure the dose is correct as severe harm and death has occurred from dose errors.

Preparations available: 

  • 500micrograms in 1mL (available as 1mg/2ml and  5mg/10ml ampoules)
  • 5mg in 1ml (THIS IS TEN TIMES THE STRENGTH OF PREPARATION ABOVE. This higher strength preparation will not be widely stocked in clinical settings)

All alfentanil preparations are RED TLS drugs in Wiltshire ans BaNES.

 
 
Ketorolac
(injection)
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Formulary
traffic lightRed

GWH Only

  • 30mg in 1ml amp
  • GWH: ONLY for specialist initiation and ongoing prescription by the Palliatve Care team, for the treatment of neuropathic cancer pain and bone pain in palliative care patients by sc injection / sc infusion (off-label use).
 
 
21.02.02  Expand sub section  Antiemetic Injectable Drugs
Metoclopramide
(Injection)
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Formulary
  • 100mg/20ml, 10mg in 2ml
  • Metoclopramide and prochlorperazine are associated with a high risk of dystonias and oculogyric crises particularly in children, young adults and the elderly. Severe reactions to metoclopramide should be treated with procyclidine injection
 
Link  MHRA DSU Dec 2014 Metoclopramide: risk of neurological adverse effects
 
Cyclizine
(Injection)
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Formulary
traffic lightGreen
  • For nausea and vomiting
  • 50mg/ml
  • Can be used in syringe drivers check compatibility
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
Dexamethasone
(Injection)
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Formulary
traffic lightAmber
  • 3.32 mg of dexamethasone (dexamethasone base) in 1 ml solution for injection which is equivalent to 4 mg dexamethasone phosphate (or 4.3 mg dexamethasone sodium phosphate)
  • For use in syringe pumps following advice from palliative care specialists
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
Haloperidol
(Injection)
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Formulary
traffic lightGreen
  • 5mg/ml
  • For hallucinations and agitation and opioid induced nausea 
 
 
Levomepromazine
(Injection)
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Formulary
traffic lightGreen
  • For nausea and vomiting
  • 25mg/ml
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
Prochlorperazine
(Injection)
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Formulary
traffic lightGreen
  • 12.5mg/1ml
  • 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.
 
 
Ondansetron
(Injection)
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Formulary
traffic lightAmber
  • 4mg/2ml, 8mg/4ml
 
 
21.02.03  Expand sub section  Antisecretory Injectable Drugs
Glycopyrronium Bromide (injection)
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Formulary
traffic lightGreen
  • 200 micrograms in 1ml amp
  • 600 micrograms in 3ml amp
  • As an alternative to hyoscine butyl bromide for respiratory tract secretions
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
Hyoscine Butlybromide
(Injection)
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Formulary
traffic lightGreen
  • For respiratory tract secretions
  • 20mg/ml
  • For colic/reduce secretions in inoperable bowel obstruction
  • See SPS website for Stock shortages 
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
Hyoscine Hydrobromide
(Injection)
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Formulary
traffic lightGreen
  • Injection 400mcg/ml
  • For respiratory tract secretions
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
Octreotide
(Short acting Injection)
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Formulary
traffic lightAmber
High Cost Medicine
  • 50microgram/1ml, 100microgram/1ml
  • For the short term management of high output stomas and fistulas and bowel obstructions
  • Octreotide is best administered in a separate syringe driver.  Please phone palliative care advice lines before mixing in a syringe driver.
 
 
Ranitidine
(Injection)
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Formulary
traffic lightAmber
  • 50mg/2ml
  • For use following advice of palliative care teams
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
21.02.04  Expand sub section  Anticonvulsant / Anxiolytic Injectable Drugs to top
Midazolam
(Injection)
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Formulary
traffic lightGreen
  • 10mg/2ml
  • For restlessness, anxiety and agitation
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
Controlled Drug Schedule 3
 
Haloperidol
(Injection)
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Formulary
traffic lightGreen
  • 5mg/ml
  • For hallucinations and agitation
 
 
Levomepromazine
(Injection)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • For nausea and vomiting
  • 25mg/ml
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
Levetiracetam
(Intravenous infusion)
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Formulary
traffic lightAmber
  • 100mg/ml 5ml vial
  • For use in syringe pumps following advice of palliative care specialists
  • To be used an alternative to midazolam for the treatment of seizures where sedation is not desirable.
  • Can be used in syringe drivers if patient on longterm oral levetiracetam.
  • Can be used in syringe drivers
  • See page 89/90 Wessex Palliative Care Handbook (link at start of chapter)
 
 
 ....
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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