Prescribing Notes for Palliative Care

N.B. If the patient's pain remains unresolved despite using the treatment guidance below, or local guidelines, refer to the appropriate team for further advice.

Step 1 - Mild pain

Use oral paracetamol (not IV) or NSAID (if not contraindicated) +/- other adjuvant (see below).

Paracetamol oral: 1g four times daily (max dose). Consider dose reduction in patients with low body weight (<50kg), renal impairment or glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15mg/kg/dose up to four times daily (max 60mg/kg/day). An example is: paracetamol oral 500mg four times daily.

In patients with hepatocellular insufficiency, a dose reduction of the oral preparation should be determined on a case by case basis with senior medical input. N.B. Patients with chronic liver failure may require a further dose adjustment (7.5mg/kg/dose, max 30mg/kg/day).

Step 2 - Moderate pain

Weak opioid + paracetamol (dose as above) or NSAID +/- other adjuvant

Co-codamol* oral 30/500mg 1 - 2 tablets four times daily (max 8 tablets in 24 hours) or

Codeine oral 30 - 60mg four times daily (max 240mg/day) or

Dihydrocodeine oral 30mg four times daily (max 120mg/day).

Note: dihydrocodeine 60mg will provide little additional analgesia but more pronounced side effects.

General Notes

• *Co-codamol contains paracetamol. Reduce dose as appropriate, see paracetamol dosing guidance above.
• Older patients are more likely to experience side effects e.g. confusion, constipation. Carry out early review of response to analgesia. Co-prescribe a laxative (refer to the Scottish Palliative Care Guidelines - Constipation).
• If step 2 analgesics are not tolerated, reassess pain and consider moving to step 3.

Step 3 - Severe pain

Opioid (morphine first-line) + paracetamol (dose as above) or NSAID +/- other adjuvant. N.B. If renal impairment (eGFR <60ml/minute/1.73m²) seek palliative care advice or refer to Choosing and Changing Opioids guidance.

General Notes

• Stop any Step 2 opioid (conversion: codeine / dihydrocodeine 240mg/24 hours ≈ morphine oral 24mg/24 hours). Avoid co-prescribing multiple opioids.
• If commencing with immediate release oral morphine give 5mg every 4 hours and as required for breakthrough pain. Use lower doses and increase slowly if patient is frail, elderly or has renal impairment. Convert to modified release morphine when stable by dividing total daily dose of immediate release morphine by 2 and prescribe the dose as oral morphine modified release 12 hourly.
• If starting patient with modified release oral morphine give 10 - 15mg twice a day and immediate release morphine 5mg as required for breakthrough pain. Use lower doses and increase slowly if patient is frail, elderly or has renal impairment.
• Dose titration: increase regular oral morphine dose by around 30% (or according to the breakthrough doses used) until pain is controlled or side effects develop. Also increase laxative dose as needed (refer to the Scottish Palliative Care Guidelines - Constipation for choice).
• Breakthrough pain - prescribe immediate release morphine at 1/6th of the regular 24 hour oral morphine dose, as required. Assess 30 - 60 minutes after a breakthrough dose and if pain persists then give a second breakthrough dose.
• If switching opioids see either flowchart (link below) or more detailed information, including opioid choice is available at www.palliativecareguidelines.scot.nhs.uk.

• Flowchart Opioid Conversion Chart

Renal and Hepatic Impairment

Morphine and oxycodone must be used with caution in patients with eGFR <60ml/minute/1.73m² due to the increased risk of toxicity. See Choosing and Changing Opioids guidance for further information. Contact local Palliative Care team for advice on alternative opioids (i.e. alfentanil). Avoid NSAIDs if possible in renal impairment. For further cautions / contraindications with NSAIDs see Prescribing Notes for Acute Pain.

N.B. Consider calculating CrCl in patients who are elderly or extremes of body weight.

Breakthrough pain (as required PRN)

• For same opioid and route: divide 24 hour opioid dose by 1/6th to 1/10th. Prescribe as required hourly (maximum of 6 doses in 24 hours). If 3 or more doses required within a 4 hour period with little or no benefit, seek urgent advice/review.
• For guidance on conversion to or from fentanyl patch see www.palliativecareguidelines.scot.nhs.uk. Seek specialist advice for prescribing breakthrough doses for patients on fentanyl patches.
• Consider increasing the breakthrough opioid dose as the background opioid dose increases.

Opioid toxicity (seek advice)

Signs include:

• Increased drowsiness / sedation
• Vivid dreams / hallucinations / delirium
• Muscle twitching / myoclonus / jerking
• Abnormal skin sensitivity to touch
• Respiratory depression

Treat by reducing opioid dose by 1/3, ensure patient is well hydrated, review and re-titrate the analgesia. Consider adjuvant therapies and/or alternative opioids. For naloxone dosing guidance in other circumstances, see Reversal of Opioid-induced Respiratory Depression. If patient is in renal or hepatic impairment seek dosing advice from your clinical pharmacist, senior member of medical staff or local palliative care team.

Adjuvants

NSAIDs

Consider NSAIDs for bone pain, liver pain, soft tissue infiltration or inflammatory conditions. If topical NSAID is required then consider ibuprofen 5% gel applied 3 - 4 times daily or ketoprofen 2.5% gel applied 2 - 4 times daily. For systemic NSAID options, see Prescribing Notes for Acute Pain. Consider gastroprotection if treating with systemic NSAIDs.

Note: diclofenac may be used subcutaneously in palliative care patients. Please contact Palliative Care team for advice on dosing and administration.

Other adjuvant therapies

Dexamethasone - Consider for intracranial, nerve or liver pain, but dose varies:

• Intracranial pressure - dexamethasone oral 8 to 16mg each morning (doses above 8mg given in divided doses before 4pm)
• Nerve pain - dexamethasone oral 4 to 8mg each morning
• Liver pain - dexamethasone oral 4mg to 8mg each morning 

For further information refer to dexamethasone medicine information sheet at www.palliativecareguidelines.scot.nhs.uk. Consider gastroprotection and monitor blood glucose.

For neuropathic pain signs and symptoms include burning, shooting, stabbing, throbbing, electric shocks / spasms, numbness, pain not relieved by rest, consider low dose anticonvulsants, e.g.:

• Gabapentin oral: 
  • Initial starting dose is 100mg once daily, can be increased by 100mg daily (as tolerated) to a maximum of 300mg three times a day.

• Pregabalin oral: 
  • Initial starting dose is 25mg once daily, can be increased by 25mg every 3 days (as tolerated) to a maximum of 150mg daily in 2 - 3 divided doses.
    

Specialists may recommend higher doses of gabapentin/pregabalin. Reduce dose in patients with renal impairment and seek specialist advice. For further information refer to neuropathic pain section at www.palliativecareguidelines.scot.nhs.uk.

Note: Neuropathic pain may not fully respond to opioids.

It may take several weeks to see full benefit. For all adjuvants reduce to the lowest effective dose.

Special circumstances

Swallowing difficulties:

If patients struggle to swallow analgesics in tablet form, consider switching to liquid preparations or parenteral alternatives. Seek advice from a pharmacist. Do not crush tablets before discussing with a pharmacist.

If patients are nil by mouth, consider switching to parenteral alternatives. 

PEG tubes:

Consider switching to liquid preparations or parenteral alternatives. Seek advice from a pharmacist. Some medications should not be given via PEG tubes even if crushed or in liquid form.