Palliation prescribing

Buprenorphine and Alfentanil are safe to use in patients with renal impairment. No dose adjustments in Transdermal preparations. Morphine, Diamorphine and codeine derivatives which produce toxic metabolites accumulate in renal failure

About: Always check the BNF link here

Nausea and vomiting

• Nausea is common due to uraemia and co morbidity or side effect of other drugs.

Dose range:You must check with BNF or drug datasheet

Opioid for pain and/or breathlessness (for opioid naive patient)

Dose range: titrate to symptoms

Anti-secretory for respiratory secretions

• Consider repositioning. Try to avoid suction in case this stimulates distress or more secretions.
• Hyoscine butylbromide injection (Buscopan) (20mg/ml ampoules). Dose: 20mg SC, repeated at hourly intervals as needed for respiratory secretions. Maximum of 120mg in 24 hours. Supply 10 ampoules*.
• Second line: glycopyrronium bromide SC 100micrograms, 6 to 8 hourly as required.

Anxiolytic sedative for anxiety or agitation or breathlessness

• Midazolam SC 2mg as required hourly or 5mg to 10mg over 24 hours via syringe pump.
• Lorazepam sublingual 500micrograms 8 hourly as required.
• If agitation worsening despite midazolam, consider haloperidol 500micrograms to 1mg 8 hourly or levomepromazine 10mg to 25mg SC 12 hourly, use lower dose if not used before or in frail elderly.

Myoclonus or muscle stiffness or spasm or seizure

• Midazolam SC infusion, 5mg to 10mg over 24 hours (could be titrated to 20mg if necessary).
• Clonazepam 500micrograms orally or SC at night may be useful. Refer to clonazepam information sheet.
• Consider opioid toxicity and rotation to alfentanil if not already implemented.

Terminal agitation

• Seek specialist advice if delirium or agitation worsening.
• First step: Midazolam SC 10mg to 20mg over 24 hours in a syringe pump + midazolam SC 5mg hourly, as required.
• Second step: Titrate Midazolam with advice, starting at 10mg over 24 hours in a syringe pump. Doses can be gradually titrated up to 60mg over 24 hours under specialist advice.
• Levomepromazine may need to be used in addition to midazolam under specialist advice. Use lower doses if not used previously and in frail elderly, for example, 2.5mg to 5mg SC as required 2 hourly. Higher doses may be needed for persistent distress or delirium, for example, 10mg to 25mg SC as required 2 hourly. May need to be given more frequently initially, for example, hourly to control symptom

References

• Scottish Palliative Care Guidelines