Palliative Care

Palliative Care Specialist formulary list

**Other indications for particular drugs may be included on completion of further specialist lists**

For information on use of unlicensed medicines or medicines used 'off-label' - click here

The following medicines are approved for prescribing by or on the recommendation of a prescribing palliative care specialist:

MEDICINE	SUMMARY OF RESTRICTED INDICATION	CATEGORY	PROTOCOL
Alfentanil injection 1mg/2mL (used by subcutaneous injection, continuous subcutaneous infusion or sublingually) (unlicensed use ‘off-label’)	Pain management. Third line opioid. Used with specialist supervision.		Palliative care guidelines-Alfentanil in palliative care
Fentanyl injection (used by subcutaneous injection)	Pain management. Renal palliative care. Used with specialist supervision.		Palliative care guidelines-Renal palliative care - last days of life
Fentanyl sublingual tablets (Abstral^®▼)	Pain management. Restricted to patients unsuitable for other immediate release oral opioids. Used with specialist supervision.		Palliative care guidelines – Fentanyl sublingual tablet (Abstral)
Fentanyl nasal spray (PecFent^®▼)	Pain management. Restricted to patients unsuitable for Abstral^®. Used with specialist supervision.		Palliative care guidelines – Fentanyl nasal spray (PecFent)
Hydromorphone injection (unlicensed)	Pain management. Second line opioid. Used with specialist supervision.		Contact the local palliative care services* for further advice
Ketamine injection (used by subcutaneous injection or continuous subcutaneous infusion) (unlicensed use ‘off-label’)	Pain management. Third line analgesic. Used with specialist supervision.		Palliative care guidelines-Ketamine in palliative care
Ketamine oral solution 50mg/5mL (unlicensed)	Pain management. Third line analgesic. Used with specialist supervision.		Palliative care guidelines-Ketamine in palliative care
Ketorolac injection (unlicensed use ‘off-label’)	Pain management. Short term use. Used with specialist supervision.		Contact the local palliative care services* for further advice
Lidocaine 5% medicated plaster (Versatis^®) (unlicensed use ‘off-label’)	Pain management. For use in localised neuropathic pain and locally painful bone metastases when standard treatments are unresponsive, inappropriate, poorly tolerated or contraindicated, or for short term treatment of localised, severe uncontrolled bone or neuropathic pain, while adjuvant analgesics are being titrated.		Palliative care guidelines-Lidocaine plaster in palliative care
Methadone injection	Pain management. Fourth line opioid. Used with specialist supervision		Contact the local palliative care services* for further advice
Methadone oral	Pain management. Fourth line opioid. Used with specialist supervision.		Palliative care guidelines-Choosing and changing opioids in palliative care
Methylnaltrexone injection (Relistor^®▼)	Constipation. Opioid induced constipation unresponsive to usual laxative therapy. Use is restricted to physicians with expertise in palliative care.		Contact the local palliative care services* for further advice
Octreotide injection (used by continuous subcutaneous infusion) (unlicensed use ‘off-label’)	Vomiting in bowel obstruction.		Palliative care guidelines- Bowel Obstruction in Palliative Care
Oxycodone for injection or infusion 50mg/mL Note: this is a high strength injection. Oxycodone injection 50mg is equivalent to morphine injection 100mg.	Pain management. Second line opioid. Used with specialist supervision. Restricted to patients who have difficulty in tolerating morphine or diamorphine therapy and who require a high dose of oxycodone delivered via a syringe pump which necessitates the daily preparation of an additional syringe pump if oxycodone 10mg/mL is used.		Palliative care guidelines-Oxycodone
Phenobarbital injection	Seizure management. Persistent seizure management. Used with specialist supervision.		Palliative care guidelines-Seizures in palliative care

*Local palliative care services:

Angus & Dundee - Doctor of the Day, Roxburghe House, Dundee, Pager 2703 via Ninewells switchboard.
Perth & Kinross - Doctor of the Day, Cornhill Macmillan Centre, Perth Royal Infirmary, Pager 4757 via Ninewells switchboard.
Out of Hours (Tayside wide) - On call Consultant in Palliative Medicine via Ninewells switchboard.

The following medicines often prescribed by palliative care specialists may initiated by GPs or non-specialists. These medicines are included here for information. Further information on medicines not included can be obtained from the NHS Scotland Palliative Care Guidelines.

MEDICINE	SUMMARY OF INDICATION	PROTOCOL
Hyoscine butylbromide injection (Buscopan^®) (used by subcutaneous injection or continuous subcutaneous infusion)	First line choice for excess respiratory tract secretions in the last days of life (unlicensed use ‘off-label’). Colic in bowel obstruction.	Palliative care guidelines- Last days of life Palliative care guidelines- Bowel Obstruction in Palliative Care
Levomepromazine oral tablets 6mg (unlicensed)	Nausea & vomiting. Second line broad spectrum anti-emetic for intractable nausea & vomiting.	Palliative care guidelines-Levomepromazine in palliative care
Levomepromazine injection 25mg/mL (used by subcutaneous injection or continuous subcutaneous infusion)	Nausea & vomiting. Second line broad spectrum anti-emetic for intractable nausea & vomiting. Second line for severe delirium/agitation in a dying patient where sedation is desirable.
Lorazepam 0.5mg (scored 1mg tablet) (used sublingually)	Third line for anxiety/panic associated with severe breathlessness (patients with symptoms unresponsive to non-pharmacological methods and opioids).	Palliative care guidelines- Breathlessness in palliative care See Tayside Prescriber No 99 – Sublingual lorazepam
Midazolam buccal (unlicensed)	Seizure management. Acute seizure management.	Palliative care guidelines-Seizures in palliative care
Morphine oral (unlicensed use ‘off-label’)	Breathlessness. Second line (patients with symptoms unresponsive to non-pharmacological methods).	Palliative care guidelines- Breathlessness in palliative care
Morphine injection (used by subcutaneous injection or continuous subcutaneous infusion) (unlicensed use ‘off-label’)	Breathlessness, particularly in the last days of life.

Click here for contact details of pharmacies in the Tayside Palliative Care Network. For a stock list of medicines held by these pharmacies please click here. (NHS Tayside Staffnet intranet links only).

In palliative care many medicines are prescribed that are licensed drugs given for unlicensed indications, and/or via an unlicensed route. In the above list, where medicines are given for unlicensed indications this is stated next to the medicine. However if the route or usual dose for use in palliative care is different from those in the manufacturer’s Summary of Product Characteristics, this is not explicitly stated, particularly where this is recognised standard practice within palliative care.

Please refer to the NHS Scotland Palliative Care Guidelines for further information on:

Pain management
Symptom control
Subcutaneous infusion of medication and compatibility of drugs that can be given subcutaneously via a syringe driver or syringe pump

and other important issues including information for patients.

For local guidance on pain management in palliative care please refer to ‘Analgesic Prescribing Guidelines for the Management of Cancer Pain’ within the Pain guidance notes section of the formulary.

Refer to the NHS Tayside Liverpool Care Pathway (LCP) for the Dying Patient for information on care of patients in the last hours or days of life. See appendix in this document for medication guidance for patients with an eGFR <30mL/min. For the NHS Tayside policy for the use of ‘Just in Case’ boxes in primary care – click here (NHS Tayside Staffnet intranet links only).

Traffic light status information
	To be prescribed by Hospital Specialists Only.
	Can be prescribed in General Practice under the direction of a Specialist.