HUGs Book

HOSPICE MEDICATION UTILIZATION GUIDELINES

Contact Information

ProCare HospiceCare – Atlanta Pharmacy Help Desk
1267 Professional Parkway
Gainesville, GA 30507
866-457-6337

Business Hours:
24/7/365

ProCare Pharmacy Care
3891 Commerce Parkway
Miramar, FL 33025
800-662-0586
Business Hours:
8am - 8pm ET

ProCare HospiceCare – Website
www.ProCarePharmacyCare.com

Website tools:
• Lexi-Comp Connection
• Lunch-n-Learn Schedule & Audio Library
• Pain & Symptom Management Video (2 hr)
• Adverse Drug Reaction Reporting Form
• Current Drug Updates and Other Important Information

Acknowledgements

Editors-in-Chief:
Raeanna Lewarne, RPh, PharmD, BCPS

Megan Saenz, PharmD, CPE

�

Authors:
Karen Bruestle-Wallace, PharmD

Maria Castano, PharmD
Brett Gillis, PharmD

Ashley Provenzano, PharmD
Megan Saenz, PharmD, CPE

�

Acknowledgements:
Victoria Ferraresi, PharmD, FASHP, FCSHP, Pathways Hospice

Mary Mihalyo, PharmD, CGP
Lorin Yolch, PharmD, CGP

Excellence in Pharmacy and Clinical Services . . . One Patient at a Time

ProCare HospiceCare Vision Statement
ProCare HospiceCare will drive positive change in end-of-life
care as the premier Hospice Pharmacy Benefit Manager and

Hospice Clinical Pharmacy Consulting Service.

�

ProCare HospiceCare Mission Statement
ProCare HospiceCare will provide simply the best hospice

patient focused medication-therapy-management and
pharmacy benefit management services.

Disclaimer

The material in ProCare HospiceCare’s Hospice Medication Utilization Guide
is for informational and educational purposes only. It is not a substitute for
medical advice, diagnosis, or treatment provided by a qualified health care
provider. The editors and contributors of this Guide have made extensive
efforts to ensure that the treatments, algorithms, drugs, and dosage
regimens are accurate and conform to the standards accepted at the time
of publication. Ongoing changes in information are made as a result of
continuing research and clinical experience, differences of opinion among
authorities, and the unique aspects of individual clinical situations. These
ongoing changes require the reader to exercise judgment when making a
clinical decision and, if necessary, consult and compare information from other
sources. Accordingly, ProCare HospiceCare shall not be responsible for the
choice of treatment or clinical decisions resulting from use of this Guide.

This Guide is intended for readers throughout the United States; however, you
must comply with the laws, regulations, and statutes of the state in which the
hospice is located and the federal laws regulating the practice of medicine
and the prescription and use of drugs.The reader is also advised to check the
product information provided by the manufacturer of a drug product before
prescribing or administering it.

All information contained in this handbook is protected by copyright. All rights
are reserved.

Table of Contents

.......................................................................................................................................................

Section One: General Information

Benzodiazepine Medication Comparison ....................................................................................... 7
Child-Pugh Grading Scale ........................................................................................................................ 29
Do Not Use List ........................................................................................................................................... 1
Drugs and Taste Disturbances................................................................................................................ 8
ECOG Scale..................................................................................................................................................... 22
FDA Drug Safety Communication: Erythropoiesis-Stimulating Agents (ESAs) ........ 4-6
Functional Assessment Staging (FAST) Score .............................................................................. 23
Karnofsky Scale............................................................................................................................................... 20
Medication Administration with Continuous Enteral Nutrition.......................................... 10
Medications that May Cause Confusion and/or Agitation in the Elderly....................... 27
Medicines Recommended for Disposal by Flushing..................................................................3 2-34
Opioid Conversion Table for Hospice Population...................................................................... 28
Opioids for Shortness of Breath ......................................................................................................... 3
Oral Dosage Forms that Should Not be Crushed.................................................................... 9
Pain Assessment in Advanced Dementia (PAINAD) Scale...................................................2 4-25
Palliative Performance Score v2............................................................................................................ 21
Proper Disposal of Prescription Drugs............................................................................................. 31
Recommendations for Administering Medications with Continuous

Enteral Nutrition...................................................................................................................................... 11-18
Renal Dosing Chart...................................................................................................................................... 30
Undesirable Effects of Antipsychotics................................................................................................ 19
Use of Anticholinergics in the Treatment of Terminal Illness................................................. 2
WHO 3-Step Ladder.................................................................................................................................. 26
Wound Care Kit............................................................................................................................................. 34-35

Section Two: Preferred Drug List

DISEASE STATES:
Alzheimer’s................................................................................................................................................ 37
Cancer......................................................................................................................................................... 38
Cardiac........................................................................................................................................................ 39-49
Pulmonary Disease.............................................................................................................................. 49-51
Hepatic Disease..................................................................................................................................... 51-53
Parkinson’s Disease.............................................................................................................................. 53-55
Renal Disease.......................................................................................................................................... 55
FORMULARY:
SYMPTOM MANAGEMENT
Anorexia..................................................................................................................................................... 56
Anxiety/Agitation.................................................................................................................................. 56
Bladder Spasm........................................................................................................................................ 59
Congestion................................................................................................................................................ 59-60
Constipation............................................................................................................................................. 60-62
Cough-Dry; Non-Productive.......................................................................................................... 62-63
Cough-Wet; Productive..................................................................................................................... 63
Depression................................................................................................................................................ 63-66
Diarrhea/Gas........................................................................................................................................... 66-67
Dysphagia.................................................................................................................................................. 67

Table of Contents

.......................................................................................................................................................

Section Two: Preferred Drug List (continued)

Dyspnea/Shortness of Breath...........................................................................................67-69
Edema ...........................................................................................................................................69-70
Extrapyrmidal Symptoms..................................................................................................... 71
Fever................................................................................................................................................71-72
Gastrointestinal Irritation/Colic........................................................................................72-73
Gout................................................................................................................................................ 74
Hiccups........................................................................................................................................... 74
Hyperglycemia........................................................................................................................... 74
Insomnia........................................................................................................................................ 75
Mucositis/Dry Mouth............................................................................................................. 76
Muscle Spasms...........................................................................................................................76-77
Nausea/Vomiting......................................................................................................................77-80
Pain - Nociceptive....................................................................................................................80-84
Pain - Nociceptive (Mild)...................................................................................................80-81
Pain - Nociceptive (Moderate)........................................................................................ 82
Pain - Nociceptive (Severe)...............................................................................................82-84
Pain - Neuropathic (shooting, stabbing, burning, tingling)......................................84-85
Pruritis............................................................................................................................................86-87
Seizure - Active.......................................................................................................................... 87
Seizure - Maintenance...........................................................................................................87-88
Terminal Secretions................................................................................................................. 89
INFECTIONS / ANTIBIOTICS
Antibiotics IV / IM...................................................................................................................89-93
Antifungals....................................................................................................................................93-94
Antivirals........................................................................................................................................ 94
Topical Agents............................................................................................................................94-96
Topical Agents - Anesthetics.............................................................................................. 94
Topical Agents - Ophthalmic............................................................................................94-95
Topical Agents - Wound Care........................................................................................... 95
Topical Agents - Misc...........................................................................................................95-96

Section Three: Treatment Algorithms

Anorexia/Cachexia ................................1 08 Edema ...........................................................1 56
Anxiety .........................................................1 12 Fever ..............................................................1 59
Bone Pain ....................................................1 17 Hiccups ........................................................ 161
Complete Bowel Obstruction ........ 123 Insomnia ......................................................1 65
Cough/Congestion ................................1 27 Nausea/Vomiting .................................... 169
Constipation ..............................................1 32 Neuropathic Pain ...................................1 75
Delirium .......................................................1 36 Nociceptive Pain .....................................1 81
Depression ................................................. 141 Pruritus .........................................................1 86
Diarrhea ...................................................... 145 Secretions ................................................... 189
Dyspepsia ...................................................1 48 Seizures ........................................................1 92
Dyspnea ....................................................... 151 Thrush .......................................................... 195

Table of Contents

.......................................................................................................................................................

Section Four: Methadone Information

Methadone Equianalgesic Dosing Chart ............................................................................. 198
Methadone Safe Use Protocol ................................................................................................. 199
A Clinical Approach to Drug-Induced QT Prolongation .................................200-201
Drugs that Prolong the QT Interval to Induce Torsades De Pointes .......202-203

Section Five: Patient Information Leaflets (PILs)

Alprazolam ................................................. 204 Methadone ................................................. 216
Atropine ......................................................2 05 Mirtazapine ................................................2 17
Choline mag trisalicylate ....................2 06 Morphine ....................................................2 18
Dexamethasone .....................................2 07 Naproxen ...................................................2 19
Diazepam ....................................................2 08 Ondansetron ............................................2 20
Fentanyl ........................................................2 09 Oxycodone ............................................... 221
Glycopyrrolate ......................................... 210 Prednisone .................................................2 22
Haloperidol ................................................2 11 Prochlorperazine .................................... 223
Hydromorphone .................................... 212 Promethazine ...........................................2 24
Hyoscyamine .............................................2 13 Temazepam ...............................................2 25
Ibuprofen ..................................................... 214 Zolpidem .................................................... 226
Lorazepam .................................................2 15

(For a complete list of PILs go to www.ProCareHospiceCare.com)

General Info

oneGGEENNEERRAALL IINNFFOORRMMAATTIIOONN

The General Information section provides a wealth of
information including reference charts for Equilanalagesic
Dosing of Opioids and Benzodiazepines, Renal Dosing, and
Recommendations for Administering Medications with Continuous
Enteral Nutrition. We’ve included articles regarding conditions
common to the hospice environment and several patient
assessment scales, all in one condensed publication.

Do Not Use List

Official “Do Not Use” List1

Do Not Use Potential Problems Use Instead

U (unit) Mistaken for “0” (zero), the Write “unit”
number “4” (four) or “cc”

IU (International Unit) Mistaken for IV Write “International
(intravenous) or the Unit”

number 10 (ten)

Q.D., QD, q.d. (daily) Mistaken for each other Write “daily”
Q.O.D., QOD, q.o.d., qod Period after the Q Write “every other day”

(every other day) mistaken for “I” and the
“O” mistaken for “I”

Trailing zero (X.O mg)* Decimal point is missed Write X mg
Lack of leading zero Write 0.X mg
(.X mg)

MS Can mean morphine sulfate Write “morphine sulfate”
or magnesium sulfate

MSO4 and MgSO4 Confused for one another Write “magnesium

sulfate”

1Applies to all orders and all medication-related documentation that is handwritten (including free-
text computer entry) or on pre-printed forms.

*Exception: A “trailing zero” may be used only where required to demonstrate the level
of precision of the value being reported, such as for laboratory results, imaging studies
that report size of lesions, or catheter/tube sizes. It may not be used in medication

orders or other medication-related documentation.

Additional Abbreviations,Acronyms and Symbols

(For possible future inclusion in the Official “Do Not Use” List)

Do Not Use Potential Problems Use Instead

>(greater than) Misinterpreted as the number Write “greater than”
< (less than) “7” (seven) Write “less than”

or the letter “L”
Confused for one another

Abbreviations for Misinterpreted due to similar Write drug names in full
drug names abbreviations for multiple drugs

Apothecary units Unfamiliar to many practitioners Use metric units
Confused with metric units

@ Mistaken for the number Write “at”

“2” (two)

cc Mistaken for U (units) when Write “mL”

poorly written or “ml” or “milliliters”

(“mL” is preferred)

μg Mistaken for mg (milligrams) Write “mcg” or

resulting in one thousand-fold “micrograms”

overdose

Reference:
http://www.jointcommission.org/NR/rdonlyres/2329F8F5-6EC5-4E21-B932-54B2B7D53F00/0/dnu_list.pdf

© The Joint Commission, 2010. Reprinted with permission.

No changes in, additions to, or deletions from the text should be used without prior written approval of

The Joint Commission. Permission applies only to the material specified in this correspondence. New

applications should be made for subsequent use or for other uses of this material. 1

The Use of Anticholinergics in the Treatment of
Terminal Secretions

Terminal congestion, also known as the “death rattle”, is characterized by noisy moist
breathing and is a common sign of patients nearing death. Is it is collection or oscillating
mucous secretion in the oropharynx and trachea that cannot be removed during
inspiration or expiration by the patient. The symptom can often be palliated through
positioning, judicious use of anticholinergic medication and occasional aspiration of the
secretion. It is best to start an anti-secretory drug sooner rather than later because
it does not affect existing pharyngeal secretions. It is important to remember that
the moist respiration of the “death rattle” differs from pulmonary edema-related
congestion, on which anticholinergics offer little to no effect in reducing congestions.

A variety of anticholinergic agents exist that are effective in the treatment of
terminal secretions. These include hyoscine hydrobromide, hyoscine butylbromide,
glycopyrrolate, hyoscyamine sulfate, atropine sulfate, and scopolamine and are available
in oral, subcutaneous, and transdermal forms. When looking at the agents, hyoscine
hydrobromide crosses the blood-brain barrier and possesses antiemetic and sedative
properties. Scopolamine can also be used either intravenously or intramuscularly
every 4 hours, however it is very sedating.

An alternative agent that can be used is atropine 1% ophthalmic solution. The
ophthalmic solution is less expensive and more potent than alternative agents. The
antisecretory dose of atropine is 0.001mg, or 2 drops of the 1% solution, compared
to the effective dose of hyoscyamine (Levsin), which is 0.125mg/mL, or approximately
16 drops. The smaller amount of medication required allows for better tolerance by
the patient.

There may be some concern as to the use of an ophthalmic preparation given by
oral administration; however, it is not necessary to be concerned. The purity of the
preparation exceeds the requirements for that of an oral or sublingual preparation.
The solution is simply a concentrated sterile solution that contains preservatives to
ensure safe administration to the eye. The product literature may read, “avoid oral
administration”, which is due to the potential for systemic anticholinergic effect which
will result in drying of oral secretions. It would take nine to eleven grams of orally
administered atropine to cause any systemic toxicity, which is ultimately impossible
when using the ophthalmic drops.

A pilot study conducted by the Movement Disorder Program in Ontario, Canada looked
at reducing secretions in patients with Parkinson’s disease. The study used sublingual
atropine drops in 7 patients. The patients demonstrated statistically significant declines
in saliva production. The study concluded that the use of atropine drops sublingually
was a simple and inexpensive treatment. Another study published in the Journal of
Psychiatry and Neuroscience used atropine ophthalmic solution sublingually for the
treatment of clozapine-induced sialorrhea. This study also established that there was a
beneficial effect to the use of atropine of decreasing saliva production.

References:
Doyle D, et al. Oxford Textbook of Palliative Medicine. Second Edition. 985-986. New York. Oxford
Medical Publications.

Hyson HC, Johnson AM, Jog MS. “Sublingual atropine for sialorrhea secondary to Parkinsonism: a pilot
study.” Movement Disorders. 2002 November. 1318-1320.

Kay P. Symptom Control in Hospice & Palliative Care. Maine. Hospice Education Institute. 2003.

Kinzbrnner B, et al. 20 Common Problems in End-of-Life Care. New York. McGraw-Hill.

Tressier P,Wilcock A. Symptom Management in Advanced Cancer. United Kingdom: Radcliffe Medical
Press. 2001.

Twycross R,Wilcock A. Hospice & Palliative Care Formulary-USA, second edition. PalliativeDrugs.com LTD

Reprinted with permission.

2

Opioids for Shortness of Breath

Breathlessness is a significant source of distress for a large percentage of patients
requiring palliative care. A complex physiological and psychological phenomenon,
dyspnea is prominent in this patient population due to the underlying disease states,
cachexia, and deconditioning. While dyspnea can contribute to depression, panic,
anxiety, and insomnia, these symptoms also exacerbate breathlessness creating a
vicious cycle. Although non-pharmacological methods such as relaxation techniques
and breathing can be useful, most patients require the additional use of pharmacological
agents. When no treatable etiology can be identified or when patients are refractory
to therapy, opioids are the first-choice agents for treating dyspnea.

A meta-analysis by Jennings et al. showed a statistically significant positive effect of
opioids on the sensation of breathlessness. 1 In patients with COPD, opioids decrease
breathlessness and increase exercise tolerance with decreased ventilation. 2 In CHF,
low-dose opioids increase aerobic exercise capacity and tidal volume, as well as relieve
dyspnea. 3 Possible mechanisms of action for relieving dyspnea include reduction in
the central perception of dyspnea, reduction in sensitivity to hypercapnia, reduction in
oxygen consumption, and improved cardiovascular function. Current evidence suggests
that oral or parenteral opioids have a greater effect than using nebulized opioids.1

No evidence indicates that the use of opioids in dyspnea is associated with a deleterious
effect on arterial blood gases or oxygen saturation in the patient populations studied.1
Morphine is usually well-tolerated, even for opioid-naïve patients, when dosed
appropriately. Dosage of 5-10mg q 2 hours PRN is recommended. Morphine tends
to be the opioid-of-choice in hospice patients, but oxycodone will also help relieve
shortness of breath. Oxycodone is recommended in patients who have significant
renal impairment. The therapeutic value of opioids extends beyond its pain relieving
capability and provides practitioners an effective alternative for treating shortness of
breath.

References:
1 Jennings AL, Davies AN, Higgins JPT, Gibbs JSR, Broadley KE. A systematic review of the use of

opioids in the management of dyspnoea. Thorax 2002:57;939-944.

2 Abernathy AP, Currow DC, Frith P, Fazekas BS, McHugh A, Bui C. Randomised, double blind,
placebo controlled crossover trial of sustained release morphine for the management of
refractory dyspnoea. BMJ 2003:327;523-526.

3 Williams SG,Wright DJ, Marshall P, Reese A,Tzeng BH, Coats AJS,Tan LB. Safety and potential
benefits of low dose diamorphine during exercise in patients with chronic heart failure. Heart
2003:89;1085-1086.

Reprinted with permission.

3

Drug Safety Communication: Erythropoiesis-
Stimulating Agents (ESAs): Procrit®, Epogen® & Aranesp®

FDA Safety Announcement

The FDA is requiring all drugs called Erythropoiesis-Stimulating Agents (ESAs) to be
prescribed and used under a risk management program, known as a risk evaluation and
mitigation strategy (REMS), to ensure the safe use of these drugs. The ESAs that are
part of the REMS are marketed under the names Epogen®, Procrit®, and Aranesp®. FDA
required Amgen, the manufacturer of these products, to develop a risk management
program because studies show that ESAs can increase the risk of tumor growth and
shorten survival in patients with cancer who use these products. Studies also show that
ESAs can increase the risk of heart attack, heart failure, stroke or blood clots in patients
who use these drugs for other conditions.

ESAs work by stimulating the bone marrow to produce red blood cells. ESAs are
approved for the treatment of anemia (low red blood cells) resulting from chronic
kidney failure, chemotherapy, certain treatments for Human Immunodeficiency Virus
(HIV), and also to reduce the number of blood transfusions during and after certain
major surgeries.

As part of the REMS, a Medication Guide explaining the risks and benefits of ESAs must
be provided to all patients receiving ESAs. In addition to the Medication Guide, Amgen
was required to develop the ESA APPRISE (Assisting Providers and Cancer Patients
with Risk Information for the Safe use of ESAs) Oncology program for healthcare
professionals who prescribe ESAs to patients with cancer.

Under the ESA APPRISE Oncology program, Amgen will ensure that only those
hospitals and healthcare professionals who have enrolled and completed training in
the program will prescribe and dispense ESAs to patients with cancer. Amgen is also
required to oversee and monitor the program to ensure that hospitals and healthcare
professionals are fully compliant with all aspects of the program.

The goals of the REMS for the ESAs are:

• To support informed decisions between patients and their healthcare
professionals who are considering treatment with an ESA by educating them
on the risks of ESAs.

• To mitigate the risk of decreased survival and/or poorer tumor outcomes in
patients with cancer by implementing the part of the REMS called the ESA
APPRISE Oncology Program.

Additional Information for Patients:

Patients with cancer
Patients using ESAs should:

• Understand the risks associated with use of ESAs. These risks include:

• ESAs may cause tumors to grow faster.

• ESAs may cause some patients to die sooner.

• ESAs may cause some patients to develop blood clots, and serious heart
problems such as a heart attack, heart failure or stroke.

• Be aware that their healthcare professional has received special training
about the use of ESAs in patients with cancer.

• Read the Medication Guide to understand the benefits and risks of using
an ESA.

• Talk with their healthcare professional about any questions they may have
about using ESAs.

4

• Be aware that they will be asked to sign an acknowledgment form that says
they have talked with their healthcare professional about the risks of ESAs.
This form must be signed before patients begin a course of treatment with an
ESA.

Patients with chronic kidney failure (includes patients on dialysis and those not
on dialysis)
Patients using ESAs should:

• Know that the use of ESAs can increase the risk for stroke, heart attack,
heart failure, blood clots, and death.

• Read the Medication Guide to understand the benefits and risks of using
an ESA.

• Get blood tests while using ESAs.The test results may help guide the course
of therapy and lower the risks of using these drugs. Patients’ healthcare
professionals should make them aware of how often to have blood tests.

• Talk with their healthcare professional about any questions they have about the
risks and benefits of using ESAs.

Additional Information for Healthcare Professionals and Hospitals: ESA
use in cancer Healthcare Professionals

The ESA APPRISE Oncology program requires that all healthcare professionals who
prescribe ESAs for patients with cancer do the following:

• Complete a training module that covers the use of ESAs. Completion of
the training module is required for enrollment in the ESA APPRISE
Oncology program.

• Sign the patient/healthcare professional acknowledgement form prior to the
patient receiving an ESA.The acknowledgement form attests that the
healthcare professional and patient have discussed the risks of using an ESA.

• Re-enroll in the ESA APPRISE Oncology program every three years.

Healthcare professionals not enrolled in the ESA APPRISE Oncology program will not
be able to prescribe ESAs for use in patients with cancer.

As part of the enrollment in the ESA APPRISE Oncology program, healthcare
professionals must attest to their understanding of the following:

• That ESAs shortened overall survival and/or increased the risk of tumor
progression or recurrence in clinical studies in patients with breast, non-small
cell lung, head and neck, lymphoid, and cervical cancer.

• To decrease the risks of ESAs, the lowest dose needed should be used to avoid
red blood cell transfusion.

• ESAs should be discontinued following completion of a chemotherapy course
of treatment.

• Aranesp® is indicated for the treatment of anemia due to the effect of

concomitantly administered chemotherapy, based on studies that have shown

a reduction in the need for red blood cell transfusions in patients with

metastatic, non-myeloid malignancies.

• Epogen®/Procrit® is indicated for the treatment of anemia due to the effect
of concomitantly administered chemotherapy, based on studies that have
shown a reduction in the need for red blood cell transfusions in patients
with metastatic, non-myeloid malignancies receiving chemotherapy for a
minimum of 2 months.

• ESAs are not indicated for use in patients receiving hormonal agents,
therapeutic biologic products, or radiotherapy unless receiving concomitant
myelosuppressive chemotherapy.

• ESAs are not indicated for patients receiving myelosuppressive therapy when
the anticipated outcome is cure.

5

• ESA use has not been demonstrated in controlled clinical trials to improve
symptoms of anemia, quality of life, fatigue, or patient well-being.

Hospitals
Hospitals must do the following:

• Be enrolled in the ESA APPRISE Oncology program in order to dispense
ESAs to patients with cancer, even if the prescribing healthcare professional is
certified under the program.

• Have a system in place that ensures that all healthcare providers
who prescribe ESAs in the hospital are enrolled and comply with the ESA
APPRISE Oncology program.

Additional Information for Healthcare Professionals: non-cancer use of ESAs
• Healthcare professionals who prescribe ESAs for anemia not caused by cancer
chemotherapy are required to provide a copy of the Medication Guide to
each patient or their representative when an ESA is dispensed.
• Healthcare professionals who use ESAs only for non-cancer uses are
not required to enroll in the ESA APPRISE Oncology program.

Evaluation and Monitoring of the APPRISE Oncology Program
Amgen will be responsible for ensuring compliance with the program:

• Amgen will conduct real-time monitoring of prescribing and purchases in
private-practice settings and clinic audits.

• Hospitals in the program will be audited to ensure compliance with the ESA
APPRISE Oncology Program.

• Failure to comply will result in a suspension of access to ESAs.

Reference:
www.FDA.gov. Accessed 8 March 2010.
Reprinted with permission.

6

Medication Hospice care indications2 Relative Potency Usual Initial Adult Oral Onset1 Terminal
(mg)1 Dose1 Dosage Range/ Rapid Half Life
Day1 (Hours)1
2-10mg BID-TID
2-10mg BID-QID 20-100
Diazepam (Valium) Benzodiazepine Medication ComparisonAnxiety/panic, muscle relaxant,5
antiepileptic 15mg QHS 15-60mg Rapid 40-114
Flurazepam (Dalmane)7 5 15-60mg Rapid 50-100
Clorazepate (Tranxene) Short term night sedation 7.5 7.5-15mg BID-
QID 0.75-4mg Intermediate 12-15
Alprazolam (Xanax) Short term night sedation 0.5
Anxiety/Panic 0.25-0.5mg TID
Chlordiazepoxide 10
(Librium) Short term night sedation 5-25mg TID -QID 15-100mg Intermediate 24-96
Clonazepam (Klonapin) Anxiety/Panic 0.25-0.5
0.5mg TID 1.5-20mg Intermediate 18-50
Lorazepam (Ativan) Short term night sedation 1
Anxiety/Panic 0.5-2mg TID-QID 2-4mg Intermediate 10-20
Oxazepam (Serax) 15-30
Temazepam (Restoril) Anxiety/panic, antiepileptic, neuropathic 5 10-30mg TID-QID 30-120mg Slow 5-20
pain Slow 40-10
15-30mg QHS 15-30mg
Anxiety/panic, agitation, antiepileptic,
nausea/vomiting

Short term night sedation, anxiety/panic

Short term night sedation

References:
1. Lacy CF, Armstrong LL, Goldman MP, Lance LL. Drug Information Handbook. 18th ed. Hudson, OH: Lexi-Comp, Inc.: 2009.

2. Tywcross R,Wilcock A. Hospice and Palliative Care Formulary USA. 2nd ed. Ashland, OH. BookMasters Inc.;116.

Drugs and Taste Disturbances

Background

An estimated two million Americans may have altered taste sensations. Unfortunately,
altered taste sensations can adversely affect a patient’s food choices and nutritional
intake. In some cases, this can lead to weight loss, malnutrition, or the inappropriate
use of food additives such as salt and sugar. It is important to distinguish altered taste
sensations from altered flavor perceptions. Flavor is influenced by many things such as the
taste, smell, touch or feel, and temperature of food.

The primary taste organ is composed of taste buds. Approximately 10,000 taste buds
are located on the tongue and in the throat. Within the taste buds are receptors that
detect sweet, bitter, salty, and sour tastes. Information obtained from these receptors
is transmitted to the brain via cranial nerves VII (facial), IX (glossopharyngeal), and X
(vagus). Interestingly, there is some overlap between cranial nervesVII and IX; therefore, if
one of these nerves is damaged, total loss of taste does not occur. Saliva is also necessary
for normal taste sensations; therefore, patients with xerostomia or dry mouth, can have
altered taste sensations.

Taste disturbances can typically be classified into one of the following categories:
decreased taste (hypogeusia), altered taste (dysgeusia), or no taste (ageusia).2 Causes of
taste disturbances include drugs, increased age, oral medical conditions, Bell’s palsy, head
trauma, hypothyroidism, mass lesions of the taste pathway, dental or surgical procedures,
gastric reflux disease, renal failure, diabetes mellitus, gingivitis, colds, nerve damage,
Sjogren’s syndrome, radiation, pernicious anemia, Crohn’s disease, metal exposure
including lead poisoning, smoking, and pesticide exposure. Zinc deficiency can also lead
to altered taste sensations because zinc is needed for the formation of gustin, a protein
that is believed to be a taste receptor growth factor.

Most drug effects on taste are dose and duration related, meaning that larger drug doses
and longer therapy durations increase the risk of developing a taste disturbance. However,
taste disturbances can occur after only one drug dose. In most cases of drug induced
taste disturbances, taste will return to normal following either a decrease in drug dose
or discontinuation of the drug. However, in some cases, it may take weeks or months for
normal taste sensations to return. Some evidence suggests that zinc supplementation or
administration of alpha-lipoic acid (mechanism unknown) may be beneficial in patients
with taste disturbances. 2, 3

If you suspect your patient is experiencing taste disturbances due to medications, please
contact your ProCare Clinical Pharmacist.

References:
1. Comeau TB, Epstein JB, Migas C.Taste and smell dysfunction in patients receiving chemotherapy: a review of

current knowledge. Support Care Cancer 2001;9:575-80.
2. Scully C, Bagan JV. Adverse drug reactions in the orofacial region. Crit Rev Oral Biol Med 2004;15:221-39.
3. Ackerman BH, Kasbekar N. Disturbances of taste and smell induced by drugs Pharmacotherapy

1997;17:482-96.
4. Doty RL, Philip S, Reddy K, Kerr KL. Influences of antihypertensive and antihyperlipidemic drugs on the

senses of taste and smell: a review. J Hypertens 2003;21:1805-13.
5. Lacy CF, Armstrong LL, Goldman MP, Lance LL. Drug Information Handbook.13th ed. Hudson: Lexi-Comp 2005.
6. Henkin RI. Drug-induced taste and smell disorders. Incidence, mechanisms and management related primarily

to treatment of sensory receptor dysfunction. Drug Saf 1994;11:318-77.

82

Oral Dosage Forms That Should Not Be Crushed

Many medications have a special release mechanism designed to slowly release a
certain amount of medication over a given extended time. If the medication is altered
or destroyed (such as cut or crushed) in any way, the medication can be released
too fast and cause an adverse effect. Another example of a medication that cannot
be crushed is if the medication is Enteric Coated. This is a special coating to protect
the stomach or delay absorption until the drug gets into the intestines. If these tablets
were crushed or cut, it could make the medication ineffective or irritate the stomach.

There are multiple terms that are used to designate special release mechanisms.
While “Slow release” is the generic term used for any drug with a special release
mechanism, other terms used commonly on drug packaging may include: “delayed
release,” “extended release,”“sustained release,” or “controlled release.”

TIP: Often medications with special release mechanisms have letter abbreviations
associated with the name of the drug such as CD (controlled dose), CR,(con
trolled release), SR (sustained release), LA (long acting), SA (sustained action),
TD (time delayed),TR (time released), XL (extended release), XR (extended
release), EC (enteric coated).

TIP: Other prefixes and suffixes may help to indicate if a drug has a slow release
mechanism and may include: -DUR (duration – TheoDur), -BID (twice a day
dosing – HumaBID), -kote (coated product – Depakote), -exten (extended
action – Micro K Extencaps), -contin (continuous release – Oxycontin,
MSContin), -24 (acts for 24 hours – Theo24), Slo- (slow release – Slow-K)

Any medication that includes one of these terms may be a dosage form that cannot
be chewed, cut or crushed. Furthermore, any “enteric coated’ medication, as well as
lozenges, and some sublingual tablets may also not be crushed/chewed.

Please refer to The Institute for Safe Medication Practices website which provides a
free, downloadable list of oral dosage forms that should not be crushed.
https://www.ismp.org/tools/DoNotCrush.pdf

While these terms, abbreviations and tips may indicate a special release mechanism,
it is recommended that you double check with your Procare Pharmacist before
crushing, cutting or opening any medication.

References:

1. https://www.ismp.org/tools/DoNotCrush.pdf - accessed 11/21/13
2. http://www.pacificpointconsultants.com/sign/admin/NCSeditor/UserFiles/DO%20NOT%20
CRUSH%20LIST%20pdf(1).pdf- accessed 11/21/13

99

Medication Administration with
Continuous Enteral Nutrition

When medications are given via enteral feeding tubes, a variety of issues must be
considered. These include the physical properties and formulation of the drug, its
potential for drug-nutrient interactions, and possible changes in the drug’s absorption
and/or activity in the body due to its being administered via an enteral tube or with a
continuous enteral feeding.

In some cases, the formulation or physical properties of the drug may prevent it from
being successfully given via a feeding tube. For example, crushing extended-release
tablets can cause high doses of the medication to be released all at once, or a drug may
have properties that cause it to adhere to the plastic tubing and clog the tube. Some
medications exhibit drug-nutrient interactions that can decrease the drug’s absorption
or change the way it acts on the body, which could lead to decreased therapeutic
benefit or increased effects and potential toxicity. Even the location of the tip of the
feeding tube in the gut can have an impact, as some drugs have specific pH requirements
that are necessary for their absorption or activation.

In general, feeding tubes should be flushed with 30mL of water both before and after
medication administration. In addition, each medication should be given separately, and
the tube flushed with 5-30mLs of water between each. Medications should never be
mixed directly with enteral feeding formulas, due to the potential for interactions and
incompatibilities and the difficulty in knowing whether (and when precisely) the entire
dose of medication was successfully received by the patient. Liquid dosage forms are
typically preferred for tube administration, especially elixirs and suspensions; however,
even these should be diluted with at least 30mLs of water before giving. For tube
administration, immediate-release tablets can usually be crushed into a fine powder
and mixed with 30mLs of water to form a slurry, and immediate-release capsules can
typically be opened and the contents mixed with 30mLs of water to form a slurry. For
soft gelatin capsules, the contents can be aspirated with a needle and syringe and diluted
in 30mLs of water, or the contents can be dissolved in warm water and the entire
volume given after the undissolved gelatin portion has been removed. If medications
are being given via a nasogastric tube, it is preferred to clamp the tube for at least 30
minutes after dose administration, if tolerable for the patient, in order to prevent the
medication from being suctioned out before it can be adequately absorbed.

The chart on the following pages summarizes the findings of a recent literature review
on the subject of administering medications with continuous enteral nutrition. It includes
comments about drug-food interactions, where available.

10

Recommendations For Administering Medications
With Continuous Enteral Nutrition

Name of Drug: Recommendations: Comments:
acyclovir
(Zovirax) No medication administra-
aminophylline tion changes are needed.

amiodarone No medication Drug-Food Interactions:
(Cordarone, administration changes are Avoid extremes in dietary
Pacerone) needed. protein and carbohydrate
intake. Changes in diet may
amoxicillin/ affect elimination of the drug.
clavulanate Charbroiled foods may increase
(Augmentin) drug elimination and reduce
atovaquone drug’s half-life.
(Mepron)
No medication Drug-Food Interactions:
azithromycin administration changes Food may increase the rate and
(Zithromax) are needed. However, extent of absorption of oral
carbamazepine amiodarone should be amiodarone.
(Carbatrol, administered consistently
Tegretol) with regard to meals.

cimetidine No medication With Food: Optimal
(Tagamet) administration changes are adminstration time is at the
needed. beginning of a standardized
meal.

Administer with enteral Drug-Enteral Nutrition
nutrition for maximal Interactions: Drug’s serum
absorption. concentration was significantly
greater when given with enteral
nutrition (vs. in fasting state).
Drug-Food Interactions: Food
significantly increases the drug’s
bioavailability, and therapeutic
plasma concentrations may
not be achieved if drug is given
during fasting.

No medication
administration changes are
needed.

The same total daily dose Drug-Enteral Nutrition
can be administered but in 4 Interactions: The oral
equally divided doses of the suspension adheres to the
suspension or tablets.The polyvinyl chloride walls
suspension should be diluted of feeding tubes, causing
with an equal amount of inadequate drug delivery.
diluent (e.g. sterile water, Absorption of suspension is
0.9% sodium chloride generally slower and slightly
injection, or 5% dextrose diminished during nasogastric
injection) to prevent loss of tube feeding, however this
drug, and the dosage should may lessen unwanted adverse
be adjusted based on serum effects of drug.
carbamazepine levels. Drug-Food Interactions:
Coadministration with food
results in increased drug
bioavailability.

No medication administration
changes are needed.

11

Name of Drug: Recommendations: Comments:
ciprofloxacin
(Cipro) For severe infections: Drug-Enteral Nutrition
Administer the drug Interactions: The calcium,
clindamycin intravenously initially and aluminum, magnesium, and
(Cleocin) consider changing to zinc ions found in enteral
cyclosporin 750mg enterally BID when nutrition formulas cause
(Gengraf, the patient improves. For decreased absorption of
Neoral, mild-moderate infections: drug. Drug absorption may
Sandimmune) Administer 750mg enterally also be decreased if given via
diazepam BID (approx. equivalent jejunostomy tube.
(Valium) to 400mg IV BID). Enteral Drug-Food Interactions:
nutrition may be held for Coadministration with food
diltiazem 1 hour before and 2 hours caused decreased bioavailability.
(Cardizem, after dose administration.
Tiazac) Because maximum
serum drug levels may
not be obtained when
the drug is administered
via a jejunostomy tube,
ciprofloxacin should be
administered IV if no other
enteral route is available.
Ciprofloxacin suspension
should not be administered
via feeding tubes due to
its physical characteristics;
use tablets for tube
administration.

No medication
administration changes are
needed.

No medication Drug-Food Interactions:
administration changes are High-fat meals given 30 minutes
needed. However, monitor before drug or concurrent
serum cyclosporine levels. administration of drug with
low-fat meals both result in
decreased bioavailability.

Use diazepam tablets instead Drug-Enteral Nutrition
of diazepam solution. Interactions: Solution
binds to plastic tubing, and
administration of solution
via enteral tube is not
recommended.
Drug-Food Interactions:
Coadministration of tablet
with moderate-fat meals
causes delayed and decreased
absorption, although food has
minimal effect on bioavailability.

Administer same total daily Do not crush or chew
dose with continuous enteral extended-release formulations.
nutrition, but use immediate- Tablets may be administered
release tablets given every without regard to food.
6-8 hours.

12

Name of Drug: Recommendations: Comments:
esomeprazole Hold enteral nutrition
(Nexium) at least 1 hour before Note: Delayed-release
and 1 hour after dose capsules may be opened and
famotidine administration. intact granules emptied into
(Pepcid) a syringe for administration
fluconazole No medication administra- via nasogastric tube. Delayed-
(Diflucan) tion changes are needed. release suspension may be
No medication added to 15mL of water in an
hydralazine administration changes are oral syringe, shaken, allowed
(Apresoline) needed. to sit for 2-3 minutes, and
then given via a nasogastric or
itraconazole No medication gastric tube.
(Sporanox) administration changes are Drug-Food Interactions:
needed. However, monitor Take drug at least 1 hour
blood pressure levels for before meals, because
changes. coadministration with food can
No medication decrease bioavailability.
administration changes are
needed. However, patients Drug-Enteral Nutrition
concomitantly receiving a Interactions: Drug
proton-pump inhibitor (PPI) concentrations when given
or histamine H2-receptor with enteral nutrition were
antagonist should receive lower than those achieved with
the liquid formulation of IV administration, but were still
itraconazole, while patients adequate to treat most cases
not receiving a PPI or of deep mycoses.
H2-receptor antagonist
should receive the capsule Drug-Enteral
formulation (not the liquid Nutrition Interactions:
form) of itraconazole. Coadministration results in
decreased drug absorption and
lower serum concentrations.

Drug-Food Interactions:
Capsule formulation maximally
absorbed when administered
with a “full meal,” while
oral solution formulation is
maximally absorbed when
administered in a fasting state.

13

Name of Drug: Recommendations: Comments:
lansoprazole
(Prevacid) Hold enteral nutrition at Note: Crushing contents
least 1 hour before and 1 of delayed-release capsules
lanthanum hour after dose administra- or using granule packets can
(Fosrenol) tion. Intact granules of the clog tubes. Dissolving enteric-
delayed-release capsule can coated granules in water
levetiracetam be mixed with an acidic before administration via
(Keppra) juice (e.g. apple or orange), nasogastric tube can diminish
levofloxacin then flush with the acidic the efficacy of the drug before
(Levaquin) juice after administration it reaches its site of absorption
via gastric feeding tubes. If in the small intestine.
levothyroxine a small-bore feeding tube is Drug-Food Interactions:
(Synthroid, used, a compounded oral Bioavailability and activity of
Levoxyl) alkaline suspension made drug is not changed if given
with sodium bicarbonate before ingestion of food,
linezolid should be used. Use of the but can be reduced if given
(Zyvox) granule packet and the orally afterwards.
lorazepam disintegrating tablet may also
(Ativan) be tried. Drug-Enteral Nutrition
metoprolol Interactions: No interactions,
(Lopressor) Use with enteral nutrition however drug is not water
metronidazole is not recommended, as it soluble and would be difficult
(Flagyl) will likely result in a clogged to administer via a feeding
moxifloxacin feeding tube. Alternatively, tube.
(Avelox) calcium carbonate Drug-Food Interactions:
14 suspension can be used. Drug should be given with
food to reach maximal
No medication administra- therapeutic effect.
tion changes are needed.
Drug-Food Interactions:
Hold enteral nutrition for Tablets can be administered
1 hour before and 2 hours without regard to food; oral
after drug administration. If solution should be taken 1
infection is considered hour before or 2 hours after
severe, administer eating.
levofloxacin IV.
Drug-Enteral Nutrition
For use less than 7 days: No Interactions: Drug may
medication administration bind to enteral feeding tubes,
changes are needed. For use decreasing drug efficacy.
for 7 days or longer: Tube Drug-Food Interactions:
feedings should be held 1 Coadministration with food
hour before and 1 hour after may decrease absorption and
dose administration; monitor increase fecal elimination.
thyroid function weekly.
Drug-Food Interactions:
No medication administra- Drug should be taken with
tion changes are needed. food or directly after a meal.

No medication administra-
tion changes are needed.

No medication administra-
tion changes are needed.

No medication administra-
tion changes are needed.

No medication administra-
tion changes are needed.

Name of Drug: Recommendations: Comments:
mycophenolate No medication administra-
mofetil tion changes are needed. Drug-Enteral Nutrition
(CellCept) Hold enteral nutrition Interactions: Do not crush
omeprazole at least 1 hour before tablets or capsule granules,
(Prilosec) and 1 hour after dose as this destroys their enteric
administration. coating and allows gastric acid
Oxymorphone to inactivate the medication.
IR (Opana IR Hold enteral nutrition at Manufacturer recommends
and Opana SR) least 1 hour before and 1 using the powder for oral
hor after dose administration suspension in nasogastric or
pantoprazole of immediate release orogastric tubes.
(Protonix) oxymorphone. Drug-Food Interactions:
Food delays drug absorption
No medication and reduces bioavailability.
administration changes Take before meals; immediate-
are needed when using a release capsules and powder
compounded pantoprazole for oral suspension should be
suspension (made with taken 1 hour before meals.
sodium bicarbonate). For
the commercially available Drug-Enteral Nutrition
delayed-release oral Interactions: Do Not crush
suspension, hold enteral Oxymorphone sustained
nutrition 30 minutes before release tablets (Opana SR).
drug administration. Do not Use Oxymorphone immediate
crush pantoprazole delayed- release product (Opana IR),
release enteric-coated tablets which may be crushed and
for administration via feeding diluted with water for enteral
tubes. administration in patients with
a CrCl > 50 ml/min.
Drug-Food Interactions:
Food increases the
oral bioavailability of
Oxymorphone by up to
30%. Recommendation is
to maintain consistency in
administration eiher with or
without food in order to
avoid changes in oxymorphone
serum concentrattion from
one dose to the next.

Drug-Enteral Nutrition
Interactions: Crushing the
delayed-release tablet can clog
tubes; dissolve delayed-release
oral suspension in apple
juice before nasogastric tube
administration.
Drug-Food Interactions:
Neither food nor antacids
change the bioavailability
of the drug; manufacturer
recommends administering
delayed-release oral suspension
30 minutes before a meal.

15

Name of Drug: Recommendations: Comments:
penicillin V Hold enteral nutrition for
1 hour before and 2 hours Drug-Enteral Nutrition
phenytoin after drug administration. Interactions: Drug
(Dilantin) Higher doses may be absorption becomes
administered, or substitute unpredictable when combined
posaconazole with amoxicillin. with continuous enteral
(Noxafil) nutrition; bioavailability may
Hold enteral nutrition vary from 30-80%.
ranitidine at least 1 hour before Drug-Food Interactions:
(Zantac) and 1 hour after dose Coadministration with food
sevelamer administration. Alternatively, reduces and prolongs peak
(Renagel, the phenytoin dose can serum levels, although the
Renvela) be increased to overcome extent of absorption remains
the interaction with enteral unchanged.
feedings. IV phenytoin or
fosphenytoin can also be Drug-Enteral Nutrition
continued.The total daily Interactions: Both enteral
dose should preferably be nutrition formulas and feeding
divided into 2 daily doses tubes may decrease absorption
to minimize the time that of drug by up to 80% due to
enteral nutrition is held. protein binding, poor solubility,
or drug binding to feeding
Administer drug with enteral tubes.
nutrition for adequate Drug-Food Interactions:
absorption. Food has no effect on the
absorption of brand-name
No medication extended-release capsule
administration changes are formulations; however, food
needed. decreases the absorption of
Drug should not be given generic extended-release
with enteral nutrition. A capsule formulations.
compounded suspension
of the drug may be given Drug-Enteral Nutrition
via a gastrostomy tube in Interactions: Nutritional
certain situations, or calcium supplements increase drug
carbonate suspension may bioavailability significantly.
be tried as a substitution. Drug-Food Interactions:
Both high-fat and nonfat
meals increased bioavailability
significantly.

Drug-Enteral Nutrition
Interactions: Drug
can clog tubes, therefore
not recommended for
administration via feeding
tubes.
Drug-Food Interactions:
The phosphate-binding effect
of the drug requires that it be
given with food.

16

Name of Drug: Recommendations: Comments:
sirolimus
(Rapamune) No medication Drug-Food Interactions:
administration changes are High-fat meals can change
sucralfate needed for enteral feedings; the bioavailability of both the
(Carafate) however, serum sirolimus tablets and the oral solution.
levels should be monitored. To minimize variability, the oral
tacrolimus solution and tablets should
(Prograf) be taken consistently with or
without food.
theophylline
(Theo-24, Do not administer drug with Drug-Enteral Nutrition
Uniphyl) enteral feedings. Alternatives Interactions: Drug binds
include proton-pump to the protein in tube feeding
valganciclovir inhibitors or H2-receptor formulas and forms insoluble
(Valcyte) antagonists. complexes that can clog
feeding tubes. In addition,
valproic acid the alkaline pH of tube
(Depakene) feeding formulas do not allow
sucralfate to become activated.
vancomycin Drug-Food Interactions:
(Vancocin) For the above reasons,
administer sucralfate 1 hour
before or 2 hours after meals.

No medication Drug-Food Interactions:
administration changes are High-fat or high-carbohydrate
needed for enteral feedings; foods can change drug
however, tacrolimus levels bioavailability and kinetics.
should be monitored.

Hold enteral nutrition Drug-Enteral Nutrition
at least 1 hour before Interactions: Decreased
and 1 hour after dose drug levels have been reported
administration. Use rapid- when given with enteral
release theophylline products nutrition.
or solutions, if possible, and
monitor theophylline levels
closely.

No medication Drug-Food Interactions:
administration changes are Food enhances drug
needed for enteral feeding. bioavailability, therefore drug
should be administered with
food.

No medication Drug-Food Interactions:
administration changes are Coadministration with food
needed; however, valproate may delay rate of absorption
levels should be monitored. but does not change total
systemic exposure; this
difference is likely of minor
clinical significance under
steady-state conditions.

No medication
administration changes are
needed.

17

Name of Drug: Recommendations: Comments:

voriconazole No medication Drug-Food Interactions:
(VFEND) administration changes are Bioavailability of multiple doses
needed for enteral feeding; is reduced when given with
however, for treatments food (vs. in fasting state).
given longer than 7 days,
voriconazole levels should be
monitored.

Reference:
Wohlt PD, et al. Recommendations for the use of medications with continuous enteral nutrition.
Am J Health-Syst Pharm; Vol 66(16), Aug 15 2009. 1458-1467.

Reprinted with permission.

18

Undesirable Effects of Antipsychotics

Haloperidol is the preferred antipsychotic in end-of-life care. Haloperidol is the
medication of choice for the treatment of nausea and vomiting,agitation and restlessness
in the geriatric patient. Haloperidol is preferred over the use of benzodiazepines such
as lorazepam (Ativan®) because it does not cause the paradoxical agitation which
may occur with the benzodiazepine class of medications.

Low dose haloperidol used for short term treatment RARELY causes extrapyramidal
side effects or QT prolongation. The typical daily dose of haloperidol in the geriatric
patient is less than 5 mg!

Extrapyramidal syndroms
Parkinsonism, akathisia, dystonia, tardive dyskinesia.

Metabolic effects
More common with typical antipsychotics, and risperidone
Hyperprolactinemia resulting in amenorrhea, galactorrhea, gynecomastia, sexual
dysfunction, osteoporosis.

More common with atpicals, particularly olanzapine and clozapine

Weight gain
Dyslipidemia, possibly associated with weight gain.
Type 2 diabetes mellitus, both new onset and worsening of pre-existing disease; risk
independent of weight gain.

Cardiovascular effects
QT prolongation; dose-related, affected by presence of other risk factors, highest risk
with thioridazine and ziprasidone.

Venous thrombo-embolism; risk possibly highest with atypicals.

Stroke and increased risk of death in elderly patients.

Postural hypotension (α-adrenergic antagonism), particularly phenothiazines and
clozapine; also seen with quetiapine and risperidone.

Miscellaneous
Reduced seizure threshold.

Antimuscarinic effects; more with phenothiazines and clozapine.

Neuroleptic (antipsycotic) malignant syndrome.

Agranulocytosis is seen in about 1% of patients taking clozapine, generally after 3-6
months.

Reference:
Tywcross R,Wilcock A. Hospice and Palliative Care Formulary USA. 2nd ed. Ashland, OH. Book-
Masters Inc.;116.
Reprinted with permission.

19

Karnofsky Scale

Activity Score Ambulation
100%
Able to carry on normal Normal no complaints; no evidence of
activity and to work; no 90% disease.
special care needed.
Able to carry on normal activity; minor
Unable to work; able to live signs or symptoms of disease.
at home and care for most
personal needs; varying 80% Normal activity with effort; some signs
amount of assistance or symptoms of disease.
needed.
70% Cares for self; unable to carry on
Unable to care for self; normal activity or to do active work.
requires equivalent of
institutional or hospital care; 60% Requires occasional assistance, but is
disease may be progressing able to care for most of his personal
rapidly. needs.

50% Requires considerable assistance and
frequent medical care.

40% Disabled; requires special care and
assistance.

30% Severely disabled; hospital admission is
indicated although death not imminent.

20% Very sick; hospital admission necessary;
active supportive treatment necessary.

10% Moribund; fatal processes progressing
rapidly.

0% Death

Reprinted with permission.

20

Palliative Performance Score v2

PPS Ambulation Activity & Self Care Intake Conscious
Level Evidence Level
of Disease

100% Full Normal activity & Full Normal Full

work

No evidence of

disease

90% Full Normal activity & Full Normal Full

work

Some evidence of

disease

80% Full Normal activity Full Normal or Full

with Effort reduced

Some evidence of

disease

70% Reduced Unable normal Full Normal or Full

Job/Work reduced

Significant disease

60% Reduced Unable hobby/ Occasional Normal or Full or

house work assistance reduced Confusion

Significant disease necessary

50% Mainly Sit/Lie Unable to do any Considerable Normal or Full or

work assistance reduced Confusion

Extensive disease required

40% Mainly in Bed Unable to do Mainly Normal or Full or

most activity assistance reduced Drowsy +/-

Extensive disease Confusion

30% Totally Bed Unable to do any Total care Normal or Full or

Bound activity reduced Drowsy +/-

Extensive disease Confusion

20% Totally Bed Unable to do any Total care Minimal to Full or

Bound activity sips Drowsy +/-

Extensive disease Confusion

10% Totally Bed Unable to do any Total care Mouth Drowsy or
care Coma +/-
Bound activity only Confusion

Extensive disease

0% Death

PPS scores are determined by reading horizontally at each level to find a ‘best fit’ for the
patient who is then assigned as the PPS% score.

PPS may be used for several purposes. First, it is an excellent communication tool
for quickly describing a patient’s current functional level. Second, it may have value in
criteria for workload assessment or other measurements and comparisons. Finally, it
appears to have prognostic value.

PPS Score Average Survival in Hospice
• 50% = 13.9 days
• 40% = 10.3 days
• 30% = 6.7 days
• 20% = 2.6 days
• 10% = 1.9 days

Reference:

© 2010,Victoria Palliative Research Network. All Rights Reserved.

21

ECOG Scale

Grade ECOG PERFORMANCE STATUS*
0
1 ECOG

2 Fully active, able to carry on all pre-disease performance without
3 restriction
4
5 Restricted in physically strenuous activity but ambulatory and able to
carry out work of a light or sedentary nature, e.g., light house work,
office work

Ambulatory and capable of all selfcare but unable to carry out any
work activities. Up and about more than 50% of waking hours

Capable of only limited selfcare, confined to bed or chair more than
50% of waking hours

Completely disabled. Cannot carry on any selfcare.Totally confined to
bed or chair

Dead

* As published in Am. J. Clin. Oncol. Oken MM, Creech RH,Tormey DC, Horton J,
Davie TE, McFadden ET, Carbone PP:Toxicity and REsponse Criteria of the Eastern
Cooperative Oncology Group. Am J Clin Oncol, 5: 649-655, 1982.The Eastern
Cooperative Oncology Group (ECOG) is one of the largest clinical cancer research
organizations in the United States and conducts clinical trials in all types of adult
cancers. For more information: ecog.dfci.harvard.edu.

References:
Oken, M.M., Creech, R.H.,Tormey, D.C., Horton, J., Davis,T.E., McFadden, E.T., Carbone, P.P.:Toxicity
And Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655,
1982.

The ECOG Performance Status is in the public domain therefore available for public use. To
duplicate the scale, please cite the reference above and credit the Eastern Cooperative Oncology
Group, Robert Comis M.D., Group Chair.

22

Functional Assessment Staging (FAST) Score

Functional Assessment Staging (FAST):
Check highest consecutive level of disability
Stage
0 1 No difficulty, either subjectively or objectively.
0 2 Complains of forgetting location of objects. Subjective work difficulties.
0 3 Decreased job functioning evident to co-workers. Difficulty in traveling to new
locations. Decreased organizational capacity.
0 4 Decreased ability to perform complex tasks, e.g. planning dinner for guests,
handling personal finances (such as forgetting to pay bills), difficulty marketing, etc.*
0 5 Requires assistance in choosing proper clothing to wear for the day, season,
or occasion, e.g., patient may wear the same clothing repeatedly, unless supervised.*
0 6a Improperly putting on clothes without assistance or cuing (e.g., may put street
clothes on over night clothes , or put shoes on wrong feet, or have difficulty
buttoning clothing) occasionally or more frequently over the past weeks.*
6b Unable to bathe (shower) properly (e.g., difficulty adjusting bath water (shower)
temperature) occasionally or more frequently over the past weeks.*
6c Inability to handle mechanics of toileting (e.g., forgets to flush the toilet, does
not wipe properly or properly dispose of toilet tissue) occasionally or more
frequently over the past weeks.*
6d Urinary incontinence (occasionally or more frequently over the past weeks).*
6e Fecal incontinence (occasionally or more frequently over the past weeks).*
0 7a Ability to speak limited to approximately a half a dozen intelligible different
words or fewer, in the course of an average day or in the course of an intensive
interview.
7b Speech ability limited to the use of a single intelligible word in an average day or
in the course of an interview (the person may repeat the word over and over).

7c Ambulatory ability lost (cannot walk without personal assistance).
7d Cannot sit up without assistance (e.g., the individual will fall over if there are no
lateral rests [arms] on the chair).
7e Loss of ability to smile.
7f Loss of ability to hold up head independently.

*Scored primarily on the basis of information obtained from a knowledgeable informant
and/or caregiver.
FAST scoring instructions:
The FAST Stage is the highest consecutive level of disability. For clinical purposes,
in addition to staging the level of disability, additional, non-ordinal (nonconsecutive)
deficits should be noted, since these additional deficits are of clear clinical relevance.

References:
Copyright© 1984 by Barry Reisberg, M.D. Reproduced with permission.
Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin, 1988; 24:653-659.
Posted: July 31, 2008 Contact:Todd Semla, MS, Pharm.D., BCPS

23

Pain Assessment in Advanced Dementia
(PAINAD) Scale

Items* 0 1 2 Score

Breathing Normal Occasional Noisy labored
labored breathing. breathing. Long
independent Short period of period of
hyperventilation. hyperventilation.
of vocalization Cheyne-Stokes
respirations.

Negative None Occasional Repeated troubled
vocalization moan or groan. calling out. Loud
Low-level speech moaning or groaning.
with a negative Crying.
or disapproving
quality.

Facial Smiling or Sad. Frightened. Facial grimacing.
expression inexpressive Frown.

Body language Relaxed Tense. Distressed Rigid. Fists clenched.
pacing. Fidgeting. Knees pulled up.
Pulling or pushing
away. Striking out.

Consolability No need to Distracted or Unable to console,
console
reassured by voice distract or reassure.

or touch.

Total**

*Five-item observational tool (see the description of each item below).

**Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a
higher score indicating more severe pain (0=”no pain” to 1 0=”severe pain”).

Breathing

1. Normal breathing is characterized by effortless, quiet, rhythmic (smooth)
respirations.

2. Occasional labored breathing is characterized by episodic bursts of harsh, difficult
or wearing respirations.

3. Short period of hyperventilation is characterized by intervals of rapid, deep breaths
lasting a short period of time.

4. Noisy labored breathing is characterized by negative sounding respirations on
inspiration or expiration. They may be loud, gurgling, or wheezing. They appear
strenuous or wearing.

5. Long period of hyperventilation is characterized by an excessive rate and depth of
respirations lasting a considerable time.

6. Cheyne-Stokes respirations are characterized by rhythmic waxing and waning of
breathing from very deep to shallow respirations with periods of apnea (cessation
of breathing).

Negative vocalization

1. None is characterized by speech or vocalization that has a neutral or pleasant
quality.

2. Occasional moan or groan is characterized by mournful or murmuring sounds,
wails or laments. Groaning is characterized by louder than usual inarticulate
involuntary sounds, often abruptly beginning and ending.

3. Low level speech with a negative or disapproving quality is characterized
by muttering, mumbling, whining, grumbling, or swearing in a low volume with a
complaining, sarcastic or caustic tone.

24

4. Repeated troubled calling out is characterized by phrases or words being used over
and over in a tone that suggests anxiety, uneasiness, or distress.

5. Loud moaning or groaning is characterized by mournful or murmuring sounds, wails
or laments much louder than usual volume. Loud groaning is characterized by
louder than usual inarticulate involuntary sounds, often abruptly beginning and
ending.

6. Crying is characterized by an utterance of emotion accompanied by tears. There
may be sobbing or quiet weeping

Facial expression

1. Smiling is characterized by upturned corners of the mouth, brightening of the
eyes and a look of pleasure or contentment. Inexpressive refers to a neutral, at
ease, relaxed, or blank look.

2. Sad is characterized by an unhappy, lonesome, sorrowful, or dejected look. There
may be tears in the eyes.

3. Frightened is characterized by a look of fear, alarm or heightened anxiety. Eyes ap
pear wide open.

4. Frown is characterized by a downward turn of the corners of the mouth.
Increased facial wrinkling in the forehead and around the mouth may appear.

5. Facial grimacing is characterized by a distorted, distressed look. The brow is more
wrinkled as is the area around the mouth. Eyes may be squeezed shut.

Body language

1. Relaxed is characterized by a calm, restful, mellow appearance. The person seems
to be taking it easy.

2. Tense is characterized by a strained, apprehensive or worried appearance. The jaw
may be clenched (exclude any contractures).

3. Distressed pacing is characterized by activity that seems unsettled. There may be a
fearful, worried, or disturbed element present. The rate may be faster or slower.

4. Fidgeting is characterized by restless movement. Squirming about or wiggling
in the chair may occur.The person might be hitching a chair across the room.
Repetitive touching, tugging or rubbing body parts can also be observed.

5. Rigid is characterized by stiffening of the body. The arms and/or legs are tight and
inflexible. The trunk may appear straight and unyielding (exclude any contractures).

6. Fists clenched is characterized by tightly closed hands. They may be opened and
closed repeatedly or held tightly shut.

7. Knees pulled up is characterized by flexing the legs and drawing the knees up
toward the chest. An overall troubled appearance (exclude any contractures).

8. Pulling or pushing away is characterized by resistiveness upon approach or to
care.The person is trying to escape by yanking or wrenching him or herself free or
shoving you away.

9. Striking out is characterized by hitting, kicking, grabbing, punching, biting, or other
form of personal assault.

Consolability

1. No need to console is characterized by a sense of well being. The person appears
content.

2. Distracted or reassured by voice or touch is characterized by a disruption in the
behavior when the person is spoken to or touched. The behavior stops during the
period of interaction with no indication that the person is at all distressed.

3. Unable to console, distract or reassure is characterized by the inability to sooth the
person or stop a behavior with words or actions. No amount of comforting, verbal
or physical, will alleviate the behavior.

References:
Warden V, Hurley AC,Volicer L. Development and psychometric evaluation of the pain assessment in advanced
dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4:9-15.

Excerpted from Frampton K.“Vital Sign #5”. Caring for the Ages 2004; 5(5):26-35. & copy; 2004 Lippincott
Williams &amp;Wilkins.

All rights reserved. Reprinted with permission 25

Pharmacologic Approaches to Pain Management
WHO 3-Step Ladder

Step 3. Severe Pain

Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
±Nonopiod analgesics
±Adjuvants

Step 2. Moderate Pain

Acet or ASA +
Codeine
Hydrocodone
Oxycodone
Dihydrocodeine
Tramadol (not available with ASA or Acet)
±Adjuvants

Step 1. Mild Pain

Aspirin (ASA)
Acetaminophen (Acet)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
±Adjuvants

“Adjuvants” refers either to medications that are coadministered to manage
an adverse effect of an opiod, or to so-called adjuvant analgesics that are
added to enhance analgesia.

In 1986, the World Health Organization (WHO) developed a 3-step
conceptual model to guide the management of cancer pain. It provides a
simple, well-tested approach for the rational selection, administration, and
titration of a myriad of analgesics. Today, there is worldwide concensus
favoring its use for the medical management of all pain associated with
serious illness.

Reference:

Reprinted with permission

26

Medications that May Cause Confusion
and/or Agitation in the Elderly

Mary G. Mihalyo, B. S., PharmD

Anticholinergics

Atropine (SALTROPINE®)
Didyclomine (BENTYL®)
Glycopyrrolate (ROBINUL®)
Hyoscymine (LEVSIN®)
Scopolamine (SCOPACE®)

Anticonvulsants

Gabapentin (NEURONTIN®)
Phenytoin (DILANTIN®)
Topiramate (TOPAMAX®)

Antihistamines

Diphenhydramine (BENADRYL®)
Promethazine (PHENERGAN®)

H-2 Antagonists

Cimetidine (TAGAMET®)
Famotidine (PEPCID®)
Nizatadine (AXID®)
Ranitidine (ZANTAC®)

Benzodiazepines

Alprazolam (XANAX®)
Chlordiazepoxide (LIBRIUM®)
Clonazepam (KLONOPIN®)
Diazepam (VALIUM®)
Lorazepam (ATIVAN®)
Oxazepam (SERAX®)

Opioids (Pain Medications)

Codeine/apap (TYLENOL #2,3,4®)
Fentanyl (DURAGESIC®,TRANSDERMAL FENTANYL®)
Hydrocodone/Apap (VICODIN®, LORTAB®)
Hydromorphone (DILAUDID®)
Meperidine (DEMEROL®)
Methadone(DOLOPHINE®)
Morphine(ROXANOL®, MSIR®, MSCONTIN®, ORAMORPH®,

AVINZA®, KADIAN®)
Oxymorphone (OPANA IR®, SR®)
Oxycodone (ROXICODONE®, OXYIR®, OXYCONTIN®)
Tramadol (ULTRAM®, ULTRACET®)

TriCyclic Antidepresssants

Amitriptyline (ELAVIL®)
Desipramine (NORPRAMINE®)
Doxepin (SINEQUAN®)
Nortriptyline (PAMELOR®)

27

ProCare HospiceCare
Opioid Conversion Table for Hospice Population

Generic Name Trade Names SC, IV/24 hr ORAL/24
hr
Morphine Sulfate
Roxanol, MS Contin, MSIR 10 mg1 30 mg
Oxycodone - 20-30 mg
OxyContin, Roxicodone, 1.5
Hydromorphone Oxyfast, in Percocet, Roxicet, 7.5 mg

Hydrocodone Tylox

Levorphanol Dilaudid
Oxymorphone
In combinations Vicodin, 30 mg
Codeine Norco, Lortabs, Lorcet
Meperidine
Tramadol Levo-Dromoran 2 mg 4 mg
Tapentadol2
Buprenorphine Inj Opana 1 mg 10 mg
Buprenorphine
130 mg 200 mg
Patch3
Fentanyl Injection Demerol 75 mg 300 mg
Fentanyl Buccal
Ultram 150 mg
Lozenge
Fentanyl Buccal Nucynta 100 mg

Tablet Buprenex 0.4 mg
Fentanyl
Transdermal Butrans See below
Pentazocine
Butorphanol Sublimaze 300 mcg
Nalbuphine
Actiq 1000 mcg

Fentora see chart 250 mcg
below
Duragesic 60 mg see chart
Talwin below
Stadol 2 mg 180 mg
Nubain
10 mg

1SC/IV Morphine 100mg/24 hr = 10 mg/24 hr Epidural MS = 1 mg Intrathecal MS =
0.1 mg Intraventricular MS/24 hr

2Tapentadol - Dose ratio of 5:1 for Nucynta® ER to Oxycodone ER

3Buprenorphine Patch 5 mcg Patch = 12 mg Morphine/24 hr

Fentanyl to Morphine

Age/Body Composition Fentanyl patch (mcg/hr) Morphine (mg)
Adult, normal wt, non-cachectic 100 180-200*
100 120
Elderly & thin, non-cachectic 100 90
Cachectic patient

*Rationale: conservative dosing, easier to increase BT opioid dosing and LA opioid
than to decrease opioid due to over sedation.

28

Child-Pugh Grading Scale

The Child-Pugh grading scale utilizes five criteria to estimate the severity of liver disease.
These include serum bilirubin, serum albumin, prothrombin time (or International
Normalized Ratio –INR), degree of encephalopathy, and the presence of ascites (see
Table). The scoring scale allows for classifying the disease as mild (Class A: 5-6 points),
moderate (Class B: 7-9 points), or severe (Class C: 10-15 points). Class A patients are
considered low surgical risks while Child-Pugh Class C patients have severe disease
and generally should not undergo surgery except for liver transplantation.This scoring
system is also included in the product labeling of a number of drugs that require dose
modification in patients with significant liver disease.

Child-Pugh Scoring System Severity Score

Clinical marker 12 3
>3.1
Bilirubin (mg/dL) 1-2 2.1-3 <2.7
>6.1
Albumin (g/dL) >3.5 2.8-2.5 >2.3
Moderate
Prothrombin Time Or INR 1-4 4.1-6 3 or 4
<1.7 1.7-2.3

Ascites None Mild

Encephalopathy None 1 or 2

References:

Child CG,Turcotte JG. Surgery and portal hypertension. In:The liver and portal hypertension.
Edited by CG Child. Philadelphia: Saunders 1964:50-64.

Pugh RNH, Murray-Lyon IM, Dawson JL, Pietroni MC,Williams R.Transection of the esophagus i
bleeding oesophageal varices. Br J Surg 1973;60:648-52.

29

Renal Dosing Chart

Pain Management Is All About...

ü Age of the patient
ü Renal function
ü Hepatic function
ü Etiology of pain
ü Environment of care
ü Ambulation status

Renal Function Preferred Agents
CrCl > 40
Oxymorphone
CrCl = 30-40 Morphine
Oxycodone
CrCl = 10-30 Hydromorphone
CrCl < 10 Methadone
Fentanyl
Buprenorphine

Oxycodone
Hydromorphone
Methadone
Fentanyl

Oxycodone
Methadone
Fentanyl

Oxycodone
Methadone
Fentanyl

Cockroft Gault Equation

Estimated creatinine clearance (CrCl) (ml/min)=
Male = (140-age) (IBW) / 72 (Scr)
Female = CrCl male * 0.85

Common Medication Requiring Renal Dosing
Zovirax® (Acyclovir)
Antibiotics - All, except Rocephin® (Ceftriaxone)
Axid® (Nizatidine)
Cipro® (Ciprofloxacin)
Diflucan® (Fluconazole)
Levaquin® (Levofloxacin)
Lovenox® (Enoxaparin)
Pepcid® (Famotidine)
Reglan® (Metoclopramide)
Tagamet® (Cimetadine)
Theo-24® (Theophyllin)
Zantac® (Ranitidine)

30

PROPER DISPOSAL OF PRESCRIPTION DRUGS
Office of National Drug Control Policy 2009

Federal Guidelines

• Do not flush prescription drugs down the toilet or drain unless the label or
accompanying patient information specifically instructs you to do so. For
information on drugs that should be flushed, visit the FDA’s website.

• To dispose of prescription drugs not labeled to be flushed, you may be able
to take advantage of community drug take-back programs or other programs,
such as household hazardous waste collection events, that collect drugs at a
central location for proper disposal. Call your city or county government’s
household trash and recycling service and ask if a drug take-back program is
available in your community.

• If a drug take-back or collection program is not available:

1. Take your prescription drugs out of their original containers.

2. Mix drugs with an undersirable substance, such as cat litter or used coffee
grounds.

3. Put this mixture into a disposable container with a lid, such as an empty
margarine tub, or into a sealable bag.

4. Conceal or remove any personal information, including Rx number, on the
empty containers by covering it with black permanent marker or duct tape,
or by scratching it off.

5. Place the sealed container with the mixture, and the empty drug containers,
in the trash.

www.WhiteHouseDrugPolicy.gov

31

Medicines Recommended for Disposal by Flushing

Listed by Medicine and Active Ingredient

There is a small number of medicines that may be especially harmful and, in some cases,
fatal with just one dose if they are used by someone other than the person for whom
the medicine was prescribed. This list from FDA tells you what expired, unwanted, or
unused medicines you should flush down the sink or toilet to help prevent danger to
people and pets in the home.

Medicine Active Ingredient
Abstral, tablets (sublingual) Fentanyl
Actiq, oral transmucosal lozenge * Fentanyl Citrate
Avinza, capsules (extended release) Morphine Sulfate
Daytrana, transdermal patch system Methylphenidate
Demerol, tablets * Meperidine Hydrochloride
Demerol, oral solution * Meperidine Hydrochloride
Diastat/Diastat AcuDial, rectal gel Diazepam
Dilaudid, tablets * Hydromorphone Hydrochloride
Dilaudid, oral liquid * Hydromorphone Hydrochloride
Dolophine Hydrochloride, tablets * Methadone Hydrochloride
Duragesic, patch (extended release) * Fentanyl
Embeda, capsules (exteded release) Morphine Sulfate; Naltrexone
Hydrochloride
Exalgo, tablets (extended release) Hydromorphone Hydrochloride
Fentora, tablets (buccal) Fentanyl Citrate
Kadian, capsules (extended release) Morphine Sulfate
Methadone Hydrochloride, oral solution Methadone Hydrochloride
*
Methadose, tablets * Methadone Hydrochloride
Morphine Sulfate, tablets (immediate Morphine Sulfate
release) *
Morphine Sulfate, oral solution * Morphine Sulfate
MS Contin, tablets (extended release) * Morphine Sulfate
Nucynta ER, tablets (extended release) Tapentadol
Onsolis, soluble film (buccal) Fentanyl Citrate
Opana, tablets (immediate release) Oxymorphone Hydrochloride
Opana ER, tablets (extended release) Oxymorphone Hydrochloride
Oxecta, tablets (immediate release) Oxycodone Hydrochloride
Oxycodone Hydrochloride, capsules Oxycodone Hydrochloride
Oxycodone Hydrochloride, oral solution Oxycodone Hydrochloride
Oxycontin, tablets (extended release) * Oxycodone Hydrochloride
Percocet, tablets * Acetaminophen; Oxycodone
Hydrochloride
Percodan, tablets * Aspirin; Oxycodone Hydrochloride
Xyrem, oral solution Sodium Oxybate

February 2013

32

Medicines Recommended for Disposal by Flushing

Listed by Medicine and Active Ingredient (continued)

Medicine Active Ingredient

Acetaminophen; Oxycodone Percocet, tablets *
Hydrochloride

Aspirin; Oxycodone Hydrochloride Percodan, tablets *

Diazepam Diastat/Diastat AcuDial, rectal gel

Fentanyl Abstral, tablets (sublingual)
Meperidine Hydrochloride

Fentanyl Citrate Actiq, oral transmucosal lozenge *
Fentora, tablets (buccal)
Onsolis, soluble film (buccal)

Hydromorphone Hydrochloride Dilaudid, tablets *
Dilaudid, oral liquid *
Exalgo, tablets (extended release)

Meperidine Hydrochloride Demerol, tablets *
Demerol, oral solution *

Methadone Hydrochloride Dolophine Hydrochloride, tablets *
Methadone Hydrochloride, oral solution *
Methadose, tablets *

Methylphenidate Daytrana, transdermal patch system

Morphine Sulfate Avinza, capsules (extended release)
Kadian, capsules (extended release)
Morphine Sulfate, tablets (immediate)
Morphine Sulfate, oral solution *
MS Contin, tablets (extended releas)*

Morphine Sulfate; Naltrexone Embeda, capsules (extended release)
Hydrochloride

Oxycodone Hydrochloride Oxecta, tablets (immediate release)
Oxycodone Hydrochloride, capsules
Oxycodone Hydrochloride, oral solution
Oxycontin, tablets (extended release) *

Oxymorphone Hydrochloride Opana, tablets (immediate release)
Opana ER, tablets (extended release)

Sodium Oxybate Xyrem, oral solution

Tapentadol Nucynta ER, tablets (extended release)

February 2013
*These medicines have generic versions available or are only available in generic formulations.

FDA continually evaluates medicines for safety risks and will update the list as needed. Please visit
the Disposal of Unused Medicines:What You Should Know page at www.fda.gov for

more information.

33

Wound Care Kit

Available from ProCare PharmacyCare

A revolutionary, patented, expert designed Wound-Healing kit, created to transform
your patient’s wounds. Demonstrated healing “in-the-field” for all types of wounds:

• Pressure ulcers
• Tumor
• Terminal
• Vascular
• Neuropathic
• Skin Tears
Developed by ProCare HospiceCare and our expert clinicians. Useful for all wound
types and locations.
• Sacrum
• Foot
• Pelvis
• Heel
• Leg
• Other
Only contains physician-recommended products; safe, effective and economical.
Contents & Instructions
1. Contents
• Colloidal Antibiotic Solution (100mL)
• 4 x 4 Gauze (15)
• Zinc Oxide Ointment (4oz)
• Wintergreen oil, odor-controlling solution
a) You may need:
• Occlusive wrap (such as plastic wrap) - not included
• For BEST RESULTS, always use in conjunction with a static air-flow
device such as Waffle overlays from EHOB® - not included
b) Avoid:
• Avoid using tape on skin as much as possible.
2. Instructions for Use:
• Follow your facility’s standard wound care protocol for assessment and
potential debridement. Ensure exudate minimization.
• Apply a liberal amount of zinc oxide ointment to the area surrounding the
wound. Change dressing and reapply every 24 hours.
• Apply sufficient quantity of Colloidial Solution to moisten gauze pad as
desired. Place gauze moistened with Colloidial Solution over wound area (fit
in the wound). Change dressing and reapply every 24 hours.
• If Odor is present, apply 6-8 drops of wintergreen oil to the colloidal
solution. Alternatively, 1-2 drops may be placed directly on the pre-
moistened gauze PRN odor.
• Cover the entire wound area with occlusive wrap (e.g. plastic wrap - not
supplied), ONLY using the zinc oxide as adherent.

34

Wound Care Kit

Available from ProCare PharmacyCare

• Change dressing once every 24 hours or as needed for 14 days, then re-evaluate.
Clinical Evidence
Approximately 1 in 3 end-of-life care patients will experience a wound. 3,5
Elements of wound care therapy:
1. Remove all necrotic tissue & minimize exudate.
2. Flotation in bed & chair ­– Best used in conjunction with static air device
such as waffle overlays from EHOB.

3. Aggressive skin lubrication.
4. Appropriate wound treatment.
Results of Therapy:
1. Reduced risk of infection
2. Wound healing - 50% with good palliative care 3,4
3. Pain reduction
4. Maintenance of patient dignity
5. Improved function

For questions or to order Wound Care Kits, contact your ProCare HospiceCare
Account Manager or ProCare PharmacyCare at 800-662-0586.

References:

1. Tippett A. (2007). [Facility-wide application of novel dressing: Nursing Home Wound Healing
Rates.] Unpublished raw data.
2. Tippett A.Wounds at the End of Life.Wounds. 2005; 17 (4): 91-8.
3. Alvarez OM, Kalinski C, Sheehan P,Tippett A & Ennis W. Palliative Wound Care. Symposium
on Advanced Wound Care, 2007.
4. Alvarez OM. Palliative Wound Care: Guidelines for Success. http://www.jewishhome.org/
PDFs/Palliative_Wound_Care1.pdf.
5. Baranoski S and Ayello EA. Skin care needs of the palliative care patient. In:Wound Care
Essentials: Practice Principles. 2nd ed. Ambler: Lippincott Williams & Wilkins; 2008. p. 449

35

General Info

twoPPRREEFFEERRRREEDD DDRRUUGG LLIISSTT PDL

The ProCare HospiceCare Preferred Drug List is a proprietary
formulary, is symptom and diagnosis specific, and includes
dosing, side effects, and cost detail.

ProCare HospiceCare Preferred Drug List

ProCare HospiceCare

Disease Base Formulary Table of Contents

DISEASE STATES:
Alzheimer’s ............................................................................................................................... 37
Cancer........................................................................................................................................ 38
Cardiac............................................................................................................................... 39-49
Pulmonary Disease..................................................................................................... 39-51
Hepatic Disease............................................................................................................ 51-53
Parkinson’s Disease..................................................................................................... 53-55
Renal Disease.......................................................................................................................... 55

FORMULARY:

SYMPTOM MANAGEMENT
Anorexia ..........................................................................................................................56
Anxiety/Agitation................................................................................................ 56-59
Bladder Spasm..............................................................................................................59
Congestion............................................................................................................. 59-60
Constipation.......................................................................................................... 60-62
Cough-Dry; Non-Productive ....................................................................... 62-63
Cough-Wet; Productive..........................................................................................63
Depression............................................................................................................. 63-66
Diarrhea/Gas......................................................................................................... 66-67
Dysphagia........................................................................................................................67
Dyspnea/Shortness of Breath ..................................................................... 67-69
Edema ....................................................................................................................... 69-70
Extrapyrmidal Symptoms.......................................................................................71
Fever .......................................................................................................................... 71-72
Gastrointestinal Irritation/Colic .................................................................. 72-73
Gout...................................................................................................................................74
Hiccups.............................................................................................................................74
Hyperglycemia..............................................................................................................74
Insomnia...........................................................................................................................75
Mucositis/Dry Mouth ...............................................................................................76
Muscle Spasms ..................................................................................................... 76-77
Nausea/Vomiting................................................................................................. 77-80
Pain-Nociceptive................................................................................................. 80-84
Pain - Nociceptive (Mild)........................................................................... 80-81
Pain - Nociceptive (Moderate) .......................................................................82
Pain - Nociceptive (Severe) ...................................................................... 82-84
Pain - Neuropathic (shooting, stabbing, burning, tingling) ........................84
Pruritis....................................................................................................................... 86-87
Seizure - Active............................................................................................................87
Seizure - Mainenance....................................................................................... 87-88
Terminal Secretions...................................................................................................89

INFECTIONS / ANTIBIOTICS

Antiobiotics IV / IM ........................................................................................... 89-93
Antifungals .............................................................................................................. 93-94
Antivirals ..........................................................................................................................94
Topical Agents ...................................................................................................... 94-96

Topical Agents - Anesthetics ...........................................................................94
Topical Agents -Ophthalmic.................................................................... 94-95
Topical Agents - Wound Care ........................................................................95
Topical Agents - Misc................................................................................. 95-96

Copyright Protected Document 36

KEY:
ProCare HospiceCare Preferred Drug List
Oral forms of drugs indicated Drugs indicated as a “Tier 2” Drugs indicated as a “Tier 3” Tier 1D, 2D and 3D = Disease
37as a “Tier 1” are considered “First are considered “Second Line” aka are considered “Limited Use” and Directed Use Only.
Line” aka Basic Formulary Medications Basic Tier 2 Formulary Medications
require a Prior Authorization ODT: Orally Disintegrating Tab

Generic Brand/Available Form* (Available Dose Max/Day Comments Cost/ Tier
Day
form indicates commercial availability Tier 3D
$8 Tier 3D
only, not coverage of specific form.) Tier 3D
Tier 3D
DISEASE STATES
Alzheimers

Donepezil Aricept 5mg daily 23mg Limited, if any efficacy in hospice patients due to
Galantamine Tablet: 5, 10mg, 23mg (BRAND) end-stage severity of the disease.
OD: 5, 10mg
Memantine 16-24mg daily 24mg Limited, if any efficacy in hospice patients. $6
Rivastigmine Razadyne, Razadyne ER
Tablets: 4, 8, 12mg 16mg Give w/food.
Capsule, ER: 8, 16, 24mg
Solution, oral: 4mg/mL (renal/hepatic) Creatinine Clearance (CrCl) <9mL/min: avoid use.

Namenda 10mg BID 20mg Limited, if any efficacy in hospice patients. $7
Tablet: 5, 10mg CrCl 5-29: max 5mg PO BID. $7
Solution, oral: 2mg/mL 1.5mg BID 12mg CrCl <5: not defined.

Exelon Incr. 1.5mg/dose Q2wk as tolerated.
Capsule: 1.5, 3, 4.5, 6mg Give w/food; retitrate from 1.5mg BID if tx
Solution, oral (BRAND): 2mg/mL interrrupted more than several days.

ProCare HospiceCare Preferred Drug ListGenericBrand/Available FormDoseMax/DayCommentsCost/Day Tier
1-3 caps with meals Cancer $5 - $15 Tier 1D
38 Subcategory: Pancreatic cancer
Pancreatic Pancreaze, Creon, Helps w/steatorrhea.
Enzymes Pancrelipase Do not cut/crush/chew; may open caps and
sprinkle on soft food w/ pH 4.5 or less
Various
Subcategory: Cancer with PD/DVT (not
Warfarin Coumadin Individualized Based upon pre-existing). Requires monitoring by INR. $1 Tier 1D
Tablet: 1, 2, 2.5, 3, 4, 5, 6, 7.5,10mg INR level Discontinue when oral intake declines.

Calcitonin Miacalcin 1 spray each nostril 2 sprays Subcategory: Bone cancer/metastases $4 Tier 2D
Finasteride Nasal spray 200 units/ACT daily 5mg For bone pain ¢ Tier 2D

Proscar 5mg daily Subcategory: Cancer with PE/DVT (not
Tablet: 5mg pre-existing)
Dosage based upon INR
Phytonadione Mephyton 2.5-25mg daily PRN, 25mg/dose ¢ Tier 2D
(Tablet only) Tablet: 5mg PO only Subcategory: Cancer with PE/DVT (not
pre-existing)
Tamsulosin Flomax 0.4 mg daily 0.8mg Dosage based upon INR $5 Tier 2D
Enoxaparin Capsule: 0.4mg $5 - $7 Tier 3D
Prophylaxis: Subcategory: Prostate cancer
Lovenox 30 mg subcut Q12hr Take 30 mins after meal; Swallow whole
Syringe: 30, 40, 60, 100, 150, 300mg Treatment:1 mg/kg
Q12hr Subcategory: Cancer with PE/DVT (not pre-
existing)
Does not Require Monitoring INR Monitor
CBC & Platelets

Generic Brand/Available Form Dose Max/Day Comments Cost/Day Tier
20mg
5-10 mg 1600mg Cardiac
daily
200-1600mg 10mg Give with food.
Renal impairment/Cr >1.5: contraindicated
5-10mg daily 10mg /
80mg Very long half-life. Discontinue once diagnosis less
1 capsule than 1 month. Use in caution in patients on
daily methadone. Give with meals.

Subcategory: Abdominal Aortic Aneursym (AAA),
Ischemic Heart Disease
Therapeutic Class: Calcium channel blocker
May cause constipation

Not for initial treatment. May increase dose Qweek.
Amiloride ProCare HospiceCare Preferred Drug ListMidamor$1 - $3Tier 1D
Amiodarone Tablet: 5mg $1 Tier 1D
39
Cordarone
Tablet: 200, 400mg

Amlodipine Norvasc $1 - $3 Tier 1D
Tablet: 2.5, 5, 10mg

Amlodipine/ Lotrel 325-650mg 4000mg Monitor for antiplatelet effects. $3 Tier 1D
Benazepril Capsule: 2.5/10, 5/10, 5/20, Q4hr PRN ¢ Tier 1
Aspirin 5/40, 10/20,10mg/40mg $1 Tier 1D
50-100mg 100mg Subcategory: Congestive Heart Failure, Ischemic
Atenolol Bayer, Ecotrin daily Heart Disease, Abdominal Aortic Aneurysm (AAA), Severe
Tablet: 81, 325, 500, 650mg Aortic Stenosis w/Angina
Supp: 300, 600mg Therapeutic Class: Beta Blocker
May mask symptoms of hypoglycemia
Tenormin
Tablet: 25, 50, 100mg

ProCare HospiceCare Preferred Drug ListGeneric Brand/Available FormDoseMax/DayCommentsCost/Day Tier
$1 Tier 1D
40 Cardiac (continued)

Benazepril Lotensin 5-20mg daily 80mg Subcategory: Congestive Heart Failure, Abdominal Aortic
Tablet: 5, 10, 20, 40mg Aneurysm (AAA), Severe Aortic Stenosis
Therapeutic Class: Angiotensin-Converting Enzyme (ACE)
Inhibitors
Requires renal dosing. Use lower dose if also on diuretics.

Bisoprolol Zebeta 5-20mg daily 20mg Subcategory: Ischemic Heart Disease, Abdominal $1 - $2 Tier 1D
Tablet: 5, 10mg
Aortic Aneurysm (AAA), Severe Aortics Stenosis w/Angina
Therapeutic Class: Beta Blocker

May mask symptoms of hypoglycemia

Bumetanide Bumex 0.5-10mg/day 10mg Subcategory: Congestive Heart Failure , Abdominal ¢ Tier 1D
Tablet: 0.5, 1, 2mg daily BID
Aortic Aneurysm (AAA), Severe Aortic Stenosis w/CHF
Therapeutic Class: Diuretics (loop)

Monitor for hypokalemia; administer last dose before 4pm

Candesartan Atacand 4-32mg daily 32mg Subcategory: Congestive Heart Failure, Abdominal $4 Tier 1D
Tablet: 4, 8, 16, 32mg Aortic Aneurysm (AAA), Severe Aortic Stenosis
Therapeutic Class: Angiotensin II Receptor
Blockers (ARBs) – If intolerant to ACE Inhibitors
Dizziness/headache, monitor signs/symptoms of hypotension.

Captopril Capoten 50mg TID 450mg Subcategory: Congestive Heart Failure, Abdominal ¢ Tier 1D
Aortic Aneurysm (AAA), Severe Aortic Stenosis
Tablet: 12.5, 25, 50, 100mg Therapeutic Class: Angiotensin-Converting Enzyme (ACE)
Inhibitors
Short acting ACE Inhibitor. Must be titrated slowly.