Common Medicines

The use of common medicines in syringe driver/pumps

Start at lowest dose in the range especially in frail elderly patients; review dose every 24 hours and adjust  if necessary and seek Specialist Palliative Care Team advice if needed.
For further guidance on prescribing in organ failure see chapters Symptom Control in Patients with: Cardiac Failure, Liver Failure, & Renal Disease.

Analgesics

Diamorphine

Indication: Pain

Subcutaneous starting dose over 24 hrs
1/3 total daily dose of oral morphine

Ampoules available
5mg, 10mg, 30mg, 100mg, 500mg

Morphine

Indication: Pain

Subcutaneous starting dose over 24 hrs
1/2 total daily dose of oral morphine

Ampoules available
10mg/ml, 15mg/ml, 20mg/ml, 30m/ml as 1ml and 2ml ampoules

Fentanyl

Indication: Pain and chronic renal failure eGFR < 30

Dose: Seek Specialist palliative care advice

Oxycodone

Indication: Pain

Subcutaneous starting dose over 24 hrs
1/4 total daily dose of oral morphine or 1/2 total daily dose of oral oxycodone

Ampoules available
10mg/ml as 1ml and 2ml ampoules
50mg/ml as 1ml ampoules

Diamorphine

Indication: Pain

Subcutaneous starting dose over 24 hrs
1/3 total daily dose of oral morphine

Ampoules available
5mg, 10mg, 30mg, 100mg, 500mg

Morphine

Indication: Pain

Subcutaneous starting dose over 24 hrs
1/2 total daily dose of oral morphine.

Ampoules available
10mg/ml, 15mg/ml, 20mg/ml, 30m/ml as 1ml and 2ml ampoules

Oxycodone

Indication: Pain

Subcutaneous starting dose over 24 hrs
1/4 total daily dose of oral morphine or 1/2 total daily dose of oral oxycodone

Ampoules available
10mg/ml as 1ml and 2ml ampoules.
50mg/ml as 1ml ampoules.

Diamorphine or morphine should be the opioid of first choice for injection.

Antiemetics

Metoclopramide

Indication: Delayed gastric emptying

Subcutaneous starting dose over 24 hrs
30–40mg (range 30–100mg)

Ampoules available
10mg/2ml

Haloperidol

Indication: Drug induced or metabolic cause of nausea

Subcutaneous starting dose over 24 hrs
2.5mg (range 2.5–10mg)

Ampoules available
5mg/1ml and 20mg/2ml

Cyclizine

Indication: Bowel obstruction

Subcutaneous starting dose over 24 hrs
150mg

Ampoules available
50mg/1 ml

Antiemetic and sedative

Levomepromazine

Indication: Nausea / Sedation / Confusion / Agitation

Subcutaneous starting dose over 24 hrs
6.25mg–25mg (Nausea)
12.5mg–75mg (Sedation)

Start at lowest dose in the range especially in frail elderly patients.

Ampoules available
25mg/1 ml

Sedative

Midazolam

Start at lowest dose in the range especially in frail elderly patients

Indication: Terminal restlessness

Subcutaneous starting dose over 24 hrs
5mg–30mg


Indication: seizure prevention (no recent seizures)

Subcutaneous starting dose over 24 hrs
10mg–30mg


Indication: Ongoing seizure activity

Subcutaneous starting dose over 24 hrs
30mg–60mg


Ampoules available
10mg/5ml, 5mg/5ml, 10mg/2ml

Anticholinergic

Hyoscine Butylbromide

Indication: Terminal respiratory secretions with colic / Intestinal obstruction

Subcutaneous starting dose over 24 hrs
60mg–120mg (SC as required dose is 20mg)

Ampoules available
20mg/1ml

Glycopyrronium

Indication: Terminal respiratory secretions with colic / intestinal obstruction.

Subcutaneous starting dose over 24 hrs
0.6mg–1.2mg (SC as required dose is 200 micrograms)

Ampoules available
0.2mg/1ml and 0.6mg in 3ml

Hyoscine hydrobromide (also anti-emetic)

Indication: Terminal respiratory secretions with colic / intestinal obstruction.

Subcutaneous starting dose over 24 hrs
0.6mg–1.2mg (SC as required dose is 400 micrograms)

Ampoules available
0.4mg/1 ml and 0.6mg/1ml

Steroid

Dexamethasone

Indication: See Chapter: Corticosteroids

Subcutaneous starting dose over 24 hrs
2–16mg

Ampoules available
Dexamethasone as dexamethasone sodium phosphate 4mg/ml, 3.3mg/ml, 3.8mg/ml

Anti-secretory

Octreotide

Indication: Intestinal obstruction to reduce secretions if hyoscine butylbromide ineffective (with Specialist Palliative Cares advice)

Subcutaneous starting dose over 24 hrs
500 micrograms/24hr initially
– Can be increased to 800 micrograms/24hrs if necessary
– If ineffective stop after 48 hours
– If octreotide effective titrate to lowest effective dose
See Chapter Nausea and Vomiting – Syringe Driver Use

Ampoules available
50mcg/1ml
100mcg/1ml
500mcg/1ml
1000mcg/5ml

Contraindicated:

DIAZEPAM, PROCHLORPERAZINE AND CHLORPROMAZINE are too irritant to be used subcutaneously.

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.