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Anticipatory meds in palliative care

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Anticipatory Prescribing

Introduction

NICE state with respect to anticipatory prescribing (1):

  • use an individualised approach to prescribing anticipatory medicines for people who are likely to need symptom control in the last days of life. Specify the indications for use and the dosage of any medicines prescribed
  • assess what medicines the person might need to manage symptoms likely to occur during their last days of life (such as agitation, anxiety, breathlessness, nausea and vomiting, noisy respiratory secretions and pain). Discuss any prescribing needs with the dying person, those important to them and the multiprofessional team
  • ensure that suitable anticipatory medicines and routes are prescribed as early as possible. Review these medicines as the dying person's needs change
  • when deciding which anticipatory medicines to offer take into account:
    • the likelihood of specific symptoms occurring the benefits and harms of prescribing or administering medicines
    • the benefits and harms of not prescribing or administering medicines
    • the possible risk of the person suddenly deteriorating (for example, catastrophic haemorrhage or seizures) for which urgent symptom control may be needed
    • the place of care and the time it would take to obtain medicines
  • before anticipatory medicines are administered, review the dying person's individual symptoms and adjust the individualised care plan and prescriptions as necessary.
  • if anticipatory medicines are administered: Monitor for benefits and any side effects at least daily, and give feedback to the lead healthcare professional. Adjust the individualised care plan and prescription as necessary

Anticipatory prescribing is undertaken in the last few weeks or days of life and may be termed "just in case" (JIC) medication:

  • JIC prescribing includes the most important medicines which might be required to manage predictable and distressing symptoms, or in the event that the patient cannot manage necessary oral medications.

Practicalities in community settings

  • prescriber must complete a community medication administration chart before nurses in the community can administer medicines
    • should include the dose, route, frequency, indication(s), limits, and when to seek advice
  • decision to prescribe medication for use in the future should always be based on a risk/benefit analysis
    • reasons for not providing anticipatory medicines include risk of drug diversion or misuse (2)
  • good practice to issue separate prescriptions for urgently required medicines so they can be dispensed at different pharmacies if needed

Management

Anticipatory medication

  • if a patient is currently receiving subcutaneous (SC) analgesics, anxiolytic/sedatives, anti-emetics, or anti-psychotics, an additional anticipatory medication supply may not be needed
    • check what medicines are already available in the patient's home before prescribing new anticipatory medication
  • if a patient is already prescribed an oral medication for symptom control and this is effective, the same medication may be suitable for prescribing by the subcutaneous route for the JIC box
  • morphine is, in general, the first-line opioid of choice - dose stated below is for an opioid naive patient
    • if the patient is taking a regular oral opioid, an SC breakthrough dose of the same opioid should be prescribed for the JIC box
      • SC dose would usually be half of oral dose e.g. the SC equivalent of morphine 10mg is SC morphine 5mg
        • breakthrough dose should be calculated as 1/6th to 1/10th of the 24 hour opioid dose (1) e.g. if a patient was taking oral morphine dose of 60mg per day then the total estimated daily SC morphine dose would be 30mg - thus the breakthrough dose would be morphine 3-5mg SC
      • see table below for conversion from oral to SC advice
    • attention should be paid to renal function. If the patient has stage 4/5 chronic kidney disease - use alfentanil SC

Suggested anticipatory/JIC medication for opioid naive patient (2):

Anticipatory prescription

The prescription should include the four medications that might be required for end of life symptom control, plus diluent

Note: It is important that prescription wording for controlled drugs meets the legal requirements to reduce delays in dispensing

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

Morphine sulfate injection (10mg/ml ampoules)

Dose: 2mg SC, repeated at hourly intervals as needed for pain or breathlessness

If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review

If more than 6 doses are required in 24 hours seek advice or review Supply ten (10) 1ml ampoules

Anxiolytic sedative for anxiety or agitation or breathlessness

Midazolam injection (10mg in 2ml ampoules)

Dose: 2mg SC, repeated at hourly intervals as needed for anxiety/distress

If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review

If more than 6 doses are required in 24 hours seek advice or review

Supply ten (10) ampoules of 2ml

Midazolam can be used in massive terminal haemorrhage

Note: if the patient is already on large background doses of benzodiazepines, a larger dose may be needed (if they are frail, a smaller dose may be sufficient)

Levomepromazine can be used in terminal agitation or agitated delirium under specialist advice at a different dose

Anti-secretory for respiratory secretions

Hyoscine butylbromide injection (Buscopan (R) (20mg/ml ampoules)

Dose: 20mg SC, repeated at hourly intervals as needed for respiratory secretions

Maximum of 120mg in 24 hours.

Supply 10 ampoules

Anti-emetic for nausea and vomiting

levomepromazine injection (25mg/ml ampoules)

Dose: 2.5 to 5mg SC, 12 hourly as needed for nausea.

Supply 10 ampoules.

Levomepromazine can be used in terminal agitation or agitated delirium under specialist advice at a different dose

Note that levomepromazine is associated with risk of prolongation of QT interval

 

Review (2)

  • essential to review the effect of any 'as required' medicine prescribed in an anticipatory fashion, after it has been administered. This will help to direct a review of the overall treatment plan
  • should be a review of the treatment plan within one hour to assess if the administered medication has:
    • had the desired effect
    • had no effect on the symptom
    • a partial, but inadequate, effect on the symptom
  • in each of these situations, a comprehensive review of symptoms, drug doses and alternative therapeutic options must be undertaken
  • should be a review of the treatment plan within 24 hours when the administered medication:
    • is effective for an appropriate and expected time
    • has had a limited duration of effectiveness that has necessitated three or more repeated doses
  • as part of the review, the doses of regular medication, such as modified release tablets, transdermal patches or those given by syringe pump, should be considered. If there are signs of toxicity, a dose reduction, or drug switch, may be required. Advice from specialist palliative care should be sought if needed.

Notes:

These conversions are a guide only - seek expert advice and consult local guidelines

  • at high doses, conversion from one opiate to another must always be reviewed cautiously to avoid sudden opiate toxicity.Take particular care if converting high doses of oral opiates to subcutaneous (s.c.) infusions

Analgesic

Potency ratio to oral morphine

approximate equivalence to 10mg oral morphine on repeat dosing for oral dose

approximate equivalence to 10mg oral morphine on repeated dosing for subcutaneous dose/IM dose

Duration of action (hours)

Morphine

1

PR (rectal route) 1

10mg

5mg

3-6

Buprenorphinesublingual

- see manufacturer's SPC

60

0.2 mg = 200 micrograms

-

6-8

codeine*

1/10

100mg

-

3-5

Diamorphine

1

10mg

3mg

3-4

Dihydrocodeine

1/10

100mg

-

4-6

Dextropropoxyphene (1) **

1/10

100mg

-

4-6

Tramadol (3)

1/10

100mg

-

4-5

Fentanyl

see linked item below

phenazocine (1)

5

2mg

-

6-8

Alfentanil

0.3mg = 300 micrograms

Seek specialist palliative care advice

 

30 minutes IM

60 minutes SC

Hydromorphone

1.3mg

0.6 mg = 600 microgram

3-4 hours

Oxycodone

5mg***

2.5

4 -6 hours

* determined for parenteral but also appears to apply to oral route

** methadone and dextropropoxyphene have prolonged half lives leading to accumulation when given repeatedly (3)

*** manufacturers guidelines of 2:1 ratio of oxycodone : morphine (note other conversions use a 1.5:1 ratio for oxycodone : morphine) (5)

Reference:


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