page41
be given 30 minutes before an activity that causes pain
(e.g.
wound dressing).
Morphine,
as oral
solution or
standard formulation tablets,
should be prescribed for
breakthrough pain. The standard dose of a strong opioid
for breakthrough pain is usually one-tenth to one-sixth
of the regular 24 hour total daily dose, repeated every 4
hours if necessary (review pain management if analgesic
required more
frequently).
Each patient
should be
assessed on an individual
basis.
Fentanyl
lozenges are
also licensed for breakthrough pain.
Oxycodone (p.
269) can be used in patients who require
an opioid but cannot tolerate morphine. If the patient is
already
receiving
an opioid,
oxycodone
should be
started at
a dose equivalent
to the current
analgesic
(see Equivalent Single Doses of Opioid Analgesics table,
p.
20).
Levomepromazine (p.
220) is licensed to treat pain in
palliative care, and may be of benefit in some patients. It
should be reserved for use in conjunction with strong
opioid analgesics in distressed patients with severe pain
unresponsive to other measures.
Parenteral
route
If
the patient
becomes unable to
swallow, the equivalent intramuscular dose of morphine
is half the oral solution dose; in the case of the modified-
release tablets it is half the total 24-hour dose (which is
then divided into 6 portions to be given every 4 hours).
Diamorphine
(p.
264)
is
preferred
for
injection
because, being more soluble, it can be given in a smaller
volume.
The
equivalent
intramuscular
(or
subcuta-
neous)
dose is approximately a third of
the oral
dose
of morphine.
Subcutaneous infusion
of diamorphine via
continuous infusion device can be useful (for details, see
p.
23).
If
the patient can resume taking medicines by mouth,
then oral
morphine may be substituted for
subcuta-
neous infusion of diamorphine. See table of approximate
equivalent doses of morphine and diamorphine,
p.
24.
Rectal route
Morphine (p.
269) is also available for
rectal
administration
as
suppositories;
alternatively
oxycodone (p.
269)
suppositories can be obtained on
special order.
Transdermal
route
Transdermal
preparations
of
fentanyl
and
buprenorphine
are
available
(section
4.7.2); they are not suitable for acute pain or in patients
whose
analgesic
requirements
are
changing rapidly
because the long time to steady state prevents rapid
titration of the dose. Prescribers should ensure that they
are familiar with the correct use of transdermal prepara-
tions (see under Fentanyl, p.
265) because inappropriate
use has caused fatalities.
The following 24-hour doses of morphine by mouth are
considered
to
be
approximately
equivalent
to
the
fentanyl patches shown:
Morphine salt 45 mg daily : fentanyl ‘12’
patch
Morphine salt 90 mg daily : fentanyl ‘25’
patch
Morphine salt 180 mg daily : fentanyl ‘50’
patch
Morphine salt 270 mg daily : fentanyl ‘75’
patch
Morphine salt 360 mg daily : fentanyl ‘100’
patch
Morphine (as
oral
solution or
standard formulation
tablets) is given for breakthrough pain.
Gastro-intestinal pain
The pain of
bowel colic
may
be reduced by loperamide 2–4 mg 4 times daily.
Hyo-
scine hydrobromide (section 4.6)
may also be helpful,
given sublingually at a dose of 300 micrograms 3 times
daily as
Kwells
c
tablets.
For the dose by subcutaneous
infusion,
see p.
23).
Gastric distension pain due to pressure on the stomach
may be helped by a preparation incorporating an anta-
cid with an antiflatulent (section 1.1.1) and a prokinetic
such as domperidone 10 mg 3 times daily before meals.
Muscle spasm
The pain of
muscle spasm can be
helped by a muscle relaxant such as diazepam 5–10 mg
daily or baclofen 5–10 mg 3 times daily.
Neuropathic pain
Patients
with neuropathic pain
(section 4.7.3)
may benefit
from a trial
of
a tricyclic
antidepressant
for
several
weeks.
An anticonvulsant
may be added or substituted if pain persists; gabapentin
and pregabalin (both section 4.8.1)
are licensed for
neuropathic pain.
Ketamine is sometimes used under
specialist
supervision
for
neuropathic
pain
that
responds poorly to opioid analgesics.
Pain due to nerve compression may be reduced by a
corticosteroid such as dexamethasone 8 mg daily, which
reduces
oedema around the tumour,
thus
reducing
compression.
Nerve blocks can be considered when pain is localised
to a specific area.
Transcutaneous electrical
nerve
stimulation (TENS) may also help.
Miscellaneous conditions
Unlicensed indications or routes
Several
recommendations
in this
section involve
unlicensed indications or routes.
Anorexia
Anorexia may be helped by prednisolone
15–30 mg daily or dexamethasone 2–4 mg daily.
Bowel colic and excessive respiratory secretions
Bowel colic and excessive respiratory secretions may be
reduced by a subcutaneous injection of hyoscine hydro-
bromide
400 micrograms,
hyoscine
butylbromide
20 mg,
or glycopyrronium 200 micrograms.
These anti-
muscarinics are generally given every 4 hours when
required,
but hourly use is occasionally necessary,
par-
ticularly in excessive respiratory secretions.
If
symp-
toms persist,
they can be given regularly via a contin-
uous infusion device, see p.
23. Care is required to avoid
the discomfort of dry mouth.
Capillary bleeding
Capillary bleeding can be treated
with tranexamic acid (section 2.11) by mouth; treatment
is usually discontinued one week after the bleeding has
stopped,
or,
if
necessary,
it
can be continued at
a
reduced dose. Alternatively, gauze soaked in tranexamic
acid 100 mg/mL or
adrenaline (epinephrine)
solution
1 mg/mL (1 in 1000) can be applied to the affected area.
Vitamin K may be useful for the treatment and preven-
tion of
bleeding associated with prolonged clotting in
liver disease.
In severe chronic cholestasis,
absorption
of
vitamin K may be impaired;
either
parenteral
or
water-soluble oral vitamin K should be considered (sec-
tion 9.6.6).
BNF 61
Prescribing in palliative care
21
Prescribing in palliative care