Drugs used in the dying phase

Glycopyrronium

Indication: Upper respiratory tract secretions.

Metabolism: Excreted via the kidneys.

Dose adjustments: Use at 50% dose.

Comments: Does not cross blood-brain barrier.

Hyoscine Butylbromide

Indication: Upper respiratory tract secretions.

Metabolism: Excreted via the liver.

Dose adjustments: No dose reductions necessary.

Comments: Does not cross blood-brain barrier.

Hyoscine Hydrobromide

Avoid

Dose adjustments: Avoid.

Comments: Crosses blood-brain barrier and can cause agitation.

Midazolam

Indication: Agitation.

Metabolism: Predominantly metabolised by the liver.

Dose adjustments: Start with small doses e.g. 1.25 – 2.5mg SC p.r.n. and 5mg/24hr via a syringe driver/pump.

Comments: Increased cerebral sensitivity can occur.

Alfentanil

Indication: Pain.

Metabolism: Extensively metabolised in the liver.

Dose adjustments: No change in dose required.
See conversions in Pain chapter.

Comments: Can be given via s.c. syringe driver/pump. Short duration of action limits its use for breakthrough analgesia.

Fentanyl

Indication: Pain.

Metabolism: Extensively metabolised in the liver.

Dose adjustments: No change in dose required.
See conversions in Pain chapter.

Comments: Can be given via s.c. syringe driver/pump. Volume limits its use for breakthrough analgesia.

DISCLAIMER

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.