HUGs Book

Generic ProCare HospiceCare Preferred Drug ListBrand/Available FormDoseMax/DayCommentsCost/DayTier
Doxycycline $3 Tier 1
Erythromycin91 Infections / Antibiotics (continued) $4 - $8 Tier 1

Metronidazole Vibramycin 100mg 200mg Useful in pulmonary infections. $2 Tier 1
Penicillin Hyclate, capsule: 50, 100mg capsule BID Give with or without food. $2 Tier 1
Phenazopyridine Hyclate, tablet: 100mg x10d $2 - $3 Tier 1
Tetracycline Suspension (BRAND): 25, 50mg/5mL $2 Tier 1

Ery-tab, E.E.S, EryPed 250-500mg 4000mg Useful in pulmonary infections; causes GI
Suspension (BRAND): 200, 400mg/5mL BID 4x daily upset and diarrhea
Tablet, DR: 250, 333 (BRAND), 500mg (BRAND) Give IR on empty stomach
Tablet, as base/stearate: 250, 500mg
Capsule, as base/stearate: 250mg
Tablet, as ethylsuccinate: 400mg

Flagyl 500mg Q8h 1 g/dose, GI upset; NO ALCOHOL within 24
Tablet: 250, 500mg x 7-14 days 4000mg hours; useful in C. diff and anaerobic
Capsule: 375mg infections; may crush and apply
Tablet, ER (BRAND): 750mg topically for odiferous wounds

Pen VK 250-500mg Give 1h before or 2h after meals
Tablet: 250, 500mg Q6-8h
Suspension: 125, 250mg/5mL

Pyridium 100mg TID x 3 600mg CrCl 50-80: give Q12-16h
Tablet: 100, 200mg days CrCl <50: contraindicated
Max: 3 day course

Sumycin 1-2g/day div CrCl 50-80: give Q8-12h;
Capsule: 250, 500mg BID-4x daily CrCl 10-50: give Q12-24h;
CrCl<10: give Q24h
Give at least 1h before or 2h after meals

Generic ProCare HospiceCare Preferred Drug ListBrand/Available FormDoseMax/DayCommentsCost/DayTier
Trimethoprim $1 Tier 1
Trimethoprim/92 Infections / Antibiotics (continued) $3 Tier 1
Sulfamethoxazole $1 - $3
Primsol 100mg BID x 10 Useful in sulfa allergy Tier 2
Amoxicillin/ Solution (BRAND): 50mg/5mL days CrCl 15-30: decr. dose 50%; CrCl <15: $4
Clavulanate Tablet: 100, 200mg avoid use $7 - $14 Tier 2

Clindamycin Bactrim, Septra 1 DS tablet BID 6 DS Useful in pulmonary and urinary tract Tier 2
Suspension, oral:TMP 40mg/SMX x 10-14 days tablets infections (Formerly
Levofloxacin 200mg/5mL CrCl 15-30: decr. Dose 50% Tier 3)
Tablet, SS:TMP 80mg/SMX 400mg CrCl <15: avoid use
Tablet, DS:TMP 160mg/SMX 800mg

Augmentin 500-875mg 4000mg Useful for pulmonary infection
Tablet: 250/125mg, 500/125mg, 875/125mg Q12h 1500mg Must be taken WITH FOOD to avoid
Tablet, chewable: 400/57mg (renal) severe diarrhea;
Solution, oral: 125/31.25/5mL (BRAND), CrCl <30: contraindicated
200/28.5/5mL, 250/62.5/5mL, 400/57/5mL,
600/42.9mg/mL (BRAND)
Tablet, ER: 1000/62.5mg

Cleocin 300mg 4x daily 4800mg Side effect of pseudomembranous colitis;
Capsule: 150, 300mg daily yogurt intake may decrease
Capsule (BRAND): 75mg diarrhea
Suspension: 75mg/5mL

Levaquin 250–750mg Useful in lung and urinary tract infections
Tablet: 250, 500, 750mg PO daily x 5–7 Give oral solution 1h before or 2h after
Solution, oral: 25mg/mL days meals.
RENALLY DOSE.

Generic ProCare HospiceCare Preferred Drug ListBrand/Available FormDoseMax/DayCommentsCost/DayTier
Nitrofurantoin $4 Tier 2
Rifampin93 Macrobid, Macrodantin Infections / Antibiotics (continued) $3 Tier 2
Ceftriaxone Capsule, macrocrystal monohydrate $3 Tier 3
ER:100mg 100mg BID 400mg Useful in urinary tract infections
Linezolid Rifadin x 10-14 days Give w/ food $150 Tier 3
Vancomycin Capsule: 150, 300mg CrCl <60: contraindicated; Ineffective at CrCl <40 Tier 3

Clotrimazole Rocephin 300mg BID 600mg Discolors urine and tears orange Tier 1
Fluconazole Injection: 1, 2g Give on empty stomach Tier 1
CrCl <50: decr. dose 0-50%
Zyvox
Tablet: 600mg 1-2g IM daily 4g Painful IM Injection, add lidocaine 2% to injection
Suspension: 100mg/5mL soln.
Vancocin Hepatic impairment w/ significant renal dz:
Capsule (BRAND): 125, 250mg Max 2g/day

Lotrimin 600mg 1200mg MAOI; serotonergic drug interactions
Cream: 1% Q12hr
Solution, topical: 1%
Diflucan 125-500mg May also mix IV powder in 30mL water and give PO $140
Tablet: 50, 100, 150, 200mg q6h x 10-14
Suspension: 10, 40mg/mL days Antifungals $15
Apply BID BID Use for 2-4 weeks (15 grams)

100mg daily 400m CrCl <50: give usual loading dose x1, $5
then decr. dose 50%

Generic ProCare HospiceCare Preferred Drug ListBrand/Available FormDoseMax/DayCommentsCost/Day Tier
Nystatin Not systemically absorbed Tier 1
94 Mycostatin Antifungals (continued) Info: use x48h after sx resolve $21 - 15g (Formerly
Acyclovir Tablet: 500,000 units POWDER Tier 2)
Suspension: 100,000 units/mL 500,000- 2.4 million Requires renal dosing, CrCl <25 $3.50 SUSP
Famciclovir Topical (crm/oint/pwdr): 100,000 units/g 1,000,000 units units Tier 1
4x daily x 10-14 Most effective when started $4.50 - $8
Lidocaine Zovirax days swish +/-swallow within 72h of rash onset Tier 2
Ointment Tablet: 400, 800mg Wash hands after use $10 - $11
Phenol Spray Capsule: 200mg Antivirals Spray: Keep in place for 15 secs, Tier 1
Suspension: 200mg/5mL then expectorate $11 (30 grams) Tier 1
Artificial Tears/ Famvir 200-800mg 5x daily x 5-10 Spray:
Lubricating Tablet: 125, 250, 500mg days Useful for dry eyes $6/bottle Tier 1
Gel Lozenge: $4 box
Xylocaine 500mg daily TID x 7 days,
depending on renal function $10 (3.5 grams)
Chloraseptic
Throat spray: 1.4% Topical Agents - Anesthetics
Lozenge: regular or extra strength
Apply PRN
Tears Naturale
1-2 sp onto throat Q2H 5 sp Q2H
PRN 2 lozenges
1-2 lozenges Q2H PRN Q2H

Topical Agents - Ophthalmic

Apply TID 4x daily

ProCare HospiceCare Preferred Drug ListGenericBrand/Available FormDoseMax/DayCommentsCost/DayTier
$25 (2.5mL) Tier 1
95 Topical Agents - Ophthalmic (continued)

Ciprofloxacin Ciloxan Opth Instill 1-2 drops into affected eye Adminster in conjuctival sac
Ophthalmic Soln 0.3% Q2H for 2 days and 1-2 drops
Q4H for the next 5 days

Erythromycin Ilotycin 1/2 “ ribbon 2x daily to affected 6x daily Ophthalmic ointment $12 (12grams) Tier 1
Ophthalmic eye
Ointment

Tobramycin Tobrex Opth Instill 1-2 drops Q2-4H 2 drops Q1H Ophthalmic solution $32 (3.5grams) Tier 1
Ophthalmic Soln 0.3% for severe inf $10 (3.5grams) Tier 1

Vaseline Ophthalmic Lacrilube Opth Ointment Apply PRN No limit Sterile petroleum

Topical Agents - Wound Care

Balsam Peru/Castor Granulex Spray,Vasolex Apply BID No limit For Ulcers; debridement $20 (113mg spray); Spray:Tier1
$25-70 (30mg oint) Oint:Tier 3
Oil/Trypsin Oint, Xenaderm Oint

Collagenase Oint Santyl Apply once daily Daily and Enzymatic debridement; may $90 (30 grams) Tier 3
Wound Care Kit Per package instructions PRN apply PRN if dsg soiled Tier 2
Ingredients: Colloidal Antibiotic
Clotrimazole Soln, Gauze, Zinc Oxide and Daily Available from ProCare $65 Tier 1
Wintergreen Oil
PharmacyCare Mail Order
Lotrimin
Apply BID Topical Agents - Misc. Use for 2-4 weeks $15 (15 grams)
BID

Colloidal Oatmeal/ Aveeno Apply PRN Very good for dry skin; some $8 (8 package) Tier 1
Mineral Oil formulations contain menthol

ProCare HospiceCare Preferred Drug ListGenericBrand/Available FormDoseMax/DayCommentsCost/DayTier
Desenex Desenex $8 (4 ounces)
96 Topical Agents - Misc. (continued) Tier 1
Tier 1
Apply TID-4x daily
Tier 1
Dual Antibiotic Polysporin Apply PRN $10 (28 grams) Tier 1
Ointment Tier 1
Eucerin 1-2% applied topically BID $15 (16 ounces)
Emollient Cream Lidex $11 (15 grams) Tier 1
Apply 2x daily 4x daily For itching/inflammation Tier 1
Fluocinonide Cream
Tier 1
Hydrocortisone Cortaid, Cortisone Apply PRN Useful if rash is present. Do not use $5 (28 grams) Tier 1
on open areas.
Tier 1
Menthol/Camphor Lotion Sarna Lotion Apply BID TID Effective for pruritis $11 (222mL)
Neomycin/ Triple Antibiotic Apply daily TID Tier 1
Polymyxin/Bacitracin Ointment, Neosporin TID $4 (14.2 grams)
Nystatin Powder Nystop Apply 4x daily
Silver Sulfadiazine (SSD) Silvadene Apply daily BID 4x daily Useful as an anti-fungal for moist areas $21 (15 grams)
Cream
Triamcinolone Cream Aristocort, Kenalog Apply 4x daily Useful for burns and wounds $12 (50 grams)
Cream: 0.025%, 0.1%, 0.5%
Vitamin A+D Ointment Vitamin A+D Ointment Apply PRN 4x daily $4-$10 (15
grams)
None Also contains zinc
$8 (4 oz)

Mupirocin Bactroban 2% Apply topically TID Reserve for patients with MRSA only. $54 (22 grams) Tier 3
Ointment: 2% TID x 10 days Limit to area <100 cm^2 or length
Cream: 2% <10 cm; may cover w/ gauze

97 PDL Index Key
Bold = Generic Italic = Brand

Drug Names PDL Page #s Drug Names PDL Page #s Drug Names PDL Page #s
Accupril p. 47 Ambien,Ambien CR p. 75 Artificial Tears/Lubricating Gel p. 94
Acetaminophen p. 71, 80 Amicar p. 53 Aspirin p. 39, 71, 80
Acetaminophen/Codeine (CIII) p. 82 Amiloride p. 39 Atacand p. 40
Actiq p. 83 Aminocaproic acid p. 53 Atarax p. 57, 86
Acyclovir p. 94 Amiodarone p. 39 Atenolol p. 39
Adalat p. 45 Amitriptyline p. 65, 85 Ativan p. 58, 68, 78, 87, 88
Advair Diskus,Advair HFA p. 51 Amlodipine p. 39 Atropine 1% p. 89
Advil p. 71, 80 Amlodipine/Benazepril p. 39 Atrovent p. 50, 68
Afrin p. 60 Amoxicillin p. 89 Augmentin p. 92
Albuterol p. 49, 67 Amoxicillin/clavulanate p. 92 Avapro p. 43
Aldactone p. 47, 52, 70 Amoxil p. 89 Aveeno p. 86, 96
Allopurinol p. 74 Antivert p. 78 Avinza p. 84
Alprazolam (CIV) p. 56, 67 Apresoline p. 43 Axid p. 73
Altace p. 47 Arformoterol p. 50 Azithromycin p. 90
Aluminum/Magnesium p. 72 Aricept p. 37 Baciguent p. 90
Aluminum/Magnesium/Simethicone P. 72 Aristocort p. 96 Bacitracin p. 90
Amantadine p. 53 Artificial Saliva p. 76 Baclofen p. 74, 76

PDL Index

98 Drug Names PDL Page #s Drug Names PDL Page #s Drug Names PDL Page #s
Bactrim p. 92 Brovana p. 50 Cardizem, Cardizem CD p. 41
Bactroban p. 96 Budeprion SR/XL p. 65 Cardura p. 42
Balsam Peru/Castor Oil/Trypsin p. 95 Bumetanide p. 40, 51, 69 Carisoprodol p. 77
Bayer, Aspirin p. 39, 71, 80 Bumex p. 40, 51, 69 Cartia XT p. 41
Beclomethasone p. 50 Bupropion HCl p. 65 Carvedilol p. 41
Benadryl p. 59, 71, 75, 86 Buspar p. 58 Catapres p. 41
Benazepril p. 40 Buspirone p. 58 Ceclor p. 90
Benicar p. 48 Calan p. 48 Cefaclor p. 90
Bentyl p. 72 Calcitonin p. 38 Ceftin p. 90
Benzonatate p. 62 Calcium Carbonate p. 72 Ceftriaxone p. 93
Benztropine p. 53, 71 Candesartan p. 40 Cefuroxime p. 90
Biotene p. 76 Capoten p. 40 Celebrex p. 81
Bisacodyl p. 60 Captopril p. 40 Celecoxib p. 81
Bismuth Subsalicylate p. 66 Carafate p. 73, 76 Celexa p. 63
Bisoprolol p. 40 Carbamazepine p. 84, 87 Cephalexin p. 90
Bonine p. 78 Carbidopa/Levodopa p. 53 Cheratussin AC p. 63
Bromocriptine p. 53 Carbidopa/Levodopa/Entacapone p. 54 Chloraseptic p. 94
Bronchosaline p. 50, 60, 68 Cardene p. 45 Chlorhexidine Rinse p. 76

99 PDL Index

Drug Names PDL Page #s Drug Names PDL Page #s Drug Names PDL Page #s
Chlorpheniramine p. 86 Colchicine p. 74 Decadron p. 55, 64, 68, 80
Chlorpromazine p. 57, 74 Colcrys p. 74 Delsym (ER) p. 62
Chlor-Trimeton p. 86 Collagenase Oint p. 95 Deltasone p. 56, 65, 69, 81
Cholestyramine p. 52, 55, 66, 86 Colloidal Oatmeal/Mineral Oil p. 86, 95 Demadex p. 47, 52
Choline Magnesium Trisalicylate p. 81 Combivent p. 50, 68 Depakene p. 58, 85, 88
Ciloxan Ophthalmic p. 95 Compazine p. 79 Depakote,Depakote Sprinkles p. 57, 84, 88
Cipro p. 90 Comtan p. 54 Desenex p. 96
Ciprofloxacin p. 90 Constulose p. 52, 62 Desipramine p. 63, 84
Ciprofloxacin Ophthalmic p. 95 Cordarone p. 39 Desyrel p. 65, 75
Citalopram p. 63 Coreg, Coreg CR p. 41 Detrol p. 59
Cleocin p. 92 Corgard p. 45 Dexamethasone p. 56, 64, 68, 80
Clindamycin p. 92 Cortaid/Cortisone p. 86, 96 Dextromethorphan p. 62
Clonazepam (CIV) p. 57, 75, 76, 87 Coumadin p. 38, 48 Diazepam (CIV) p. 57, 77, 87
Clonidine p. 41 Cozaar p. 44 Dicyclomine p. 72
Clopidogrel p. 49 Creon p. 38 Diflucan p. 93
Clotrimazole p. 93, 95 Cyclobenzaprine p. 77 Digoxin p. 41
Cogentin p. 53, 71 Cymbalta p. 66, 85 Dilantin p. 88
Colace p. 61 Cyproheptadine p. 56 Dilaudid p. 83

100 Drug Names PDL Page #s PDL Index PDL Page #s Drug Names PDL Page #s
Dilt-CD, Diltia XT p. 41 p. 60 Erythromycin p. 77, 91
Diltiazem p. 41 Drug Names p. 66, 85 Erythromycin Ophthalmic p. 95
Diovan p. 48 Dulcolax p. 50, 68 Eucerin p. 96
Diphenhydramine p. 59, 71, 75, 86 Duloxetine p. 83 Exelon p. 37
Diphenoxylate/Atropine (CV) p. 66 DuoNeb p. 44 Famciclovir p. 94
Dipyridamole p. 42 Duragesic p. 49 Famotidine p. 73
Ditropan, Ditropan XL p. 59 Dynacirc p. 39, 71, 80 Famvir p. 94
Divalproex sodium p. 57, 84, 88 Dyrenium p. 66 Felodipine p. 42
Docusate p. 61 Ecotrin p. 65, 85 Fentanyl (CII) p. 83
Dolophine p. 55, 82, 85 Effexor p. 53 Fentora p. 83
Donepezil p. 37 Elavil p. 96 Finasteride p. 38
Doxazosin p. 42 Eldepryl p. 42 Flagyl p. 91
Doxepin p. 64, 86 Emollient Cream p. 38 Fleet Enema p. 62
Doxycycline p. 91 Enalapril p. 54 Flexeril p. 77
Dramamine p. 78 Enoxaparin p. 52, 62 Flomax p. 38
Dronabinol p. 79 Entacapone p. 55 Flovent p. 50
Dry Mouth rinse p. 76 Enulose p. 55 Fluconazole p. 93
Dual Antibiotic Ointment p. 96 Epoetin p. 77, 91 Fluocinonide cream p. 96
Epogen
Ery-Tab, E.E.S, EryPed

101 PDL Index

Drug Names PDL Page #s Drug Names PDL Page #s Drug Names PDL Page #s
Fluoxetine p. 64 Guaifenesin/Codeine p. 63 Ibuprofen p. 71, 80
Fluticasone p. 50 Guaifenesin/Dextromethorphan p. 63 Ilotycin p. 95
Fluticasone/salmeterol p. 51 Halcion p.75 Imdur p. 43
Foradil p. 51 Haldol p. 57, 78 Imodium p. 66
Formoterol p. 51 Haloperidol p. 57, 78 Inderal p. 46
Fosinopril p. 42 Humulin 70/30, Humulin R p. 74 Indocin p. 81
Furosemide p. 42, 52, 69 Hydralazine p. 43 Indomethacin p. 81
Gabapentin p. 84 Hydrochlorothiazide p. 43, 69 Insulin (short/intermediate/
Galantamine p. 37 Hydrocodone/Acetaminophen long-acting) p. 74
Gaviscon p. 72 (CIII) p. 82 Invega
Generlac p. 52, 62 Hydrocodone/Homatropine (CIII) Iophen C-NR p. 59
Glycerin Suppository p. 61 Hydrocortisone p. 63 Ipratropium p. 63
Glycopyrrolate p. 79, 89 Hydrodiuril p. 86, 96 Ipratropium/Albuterol p. 50, 68
Gold Bond Medicated Lotion p. 86 Hydromet p. 43, 69 Irbesartan p. 50, 68
Granisetron p. 79 Hydromorphone (CII) p. 63 Isopto Atropine p. 43
Granulex Spray p. 95 Hydroxyzine p. 83 Isordil p. 89
Guaiatussin AC p. 63 Hyoscyamine p. 57, 86 Isosorbide Dinitrate p. 43
Guaifenesin, Guaifenesin LA p. 60 Hytrin p. 78, 89 Isosorbide Mononitrate p. 43
p. 47 p. 43

102 Drug Names PDL Page #s PDL Index PDL Page #s Drug Names PDL Page #s
Isradipine p. 44 p. 51 Losartan p. 44
Kaopectate p. 66 Drug Names p. 92 Lotensin p. 40
K-Dur p. 46, 70 Levalbuterol p. 78, 89 Lotrel p. 39
Keflex p. 90 Levaquin p. 92 Lotrimin p. 93, 95
Kenalog p. 96 Levbid p. 78, 89 Lovenox p. 38
Ketalar p. 85 Levofloxacin p. 96 Luminal p. 58, 88
Ketamine p. 85 Levsin p. 94 Maalox p. 72
Klonopin p. 57, 75, 76, 87 Lidex p. 85 Macrobid, Macrodantin p. 93
Klor-Con p. 46, 70 Lidocaine Ointment p. 76 Magnesium Citrate p. 61
Kristalose p. 52, 62 Lidocaine Patch p. 85 Magnesium Hydroxide p. 61
Kytril p. 79 Lidocaine (Viscous) p. 93 Marinol p. 79
Labetalol p. 44 Lidoderm Patch p. 74, 76 Maxzide, Dyazide p. 49, 70
Lacrilube Ophthalmic Ointment p. 95 Linezolid p. 44 Meclizine p. 78
Lactulose p. 52, 62 Lioresal p. 66 Megace p. 56
Lanoxin p. 41 Lisinopril p. 66 Megestrol Acetate p. 56
Lansoprazole p. 73 Lomotil p. 45 Melatonin p. 75
Lantus p. 74 Loperamide p. 58, 68, 78, 87, 88 Meloxicam p. 81
Lasix p. 42, 52, 69 Lopressor p. 82 Memantine p. 37
Lorazepam (CIV)
Lortab

103 PDL Index

Drug Names PDL Page #s Drug Names PDL Page #s Drug Names PDL Page #s
Menthol/Camphor Lotion p. 86, 96 Mobic p. 81 Neomycin/Polymyxin/Bacitracin p. 96
Mephyton p. 38, 48 Monopril p. 42 Neosporin p. 96
Metamucil p. 61 Morphine (IR) (CII), ER/SR Neurontin p. 84
Methadone (CII) p. 55, 82, 85 Tablet (CII), SR Capsule (CII) p. 68, 69, 82, 83, 84 Nicardipine p. 45
Methylphenidate (CII) p. 64 Motrin Nifedipine p. 45
Metoclopramide p. 74, 78 MS Contin p. 71, 80 Nisoldipine p. 45
Metolazone p. 44, 52, 70 MSIR p. 82 Nitro-Bid, Nitro-Dur, Nitrostat, NitroMist p. 46
Metoprolol p. 45 Mucinex p. 68, 83 Nitrofurantoin p. 93
Metronidazole p. 91 Mupirocin p. 60 Nitroglycerin p. 46
Miacalcin p. 38 Mycostatin p. 96 Nizatidine p. 73
Micardis p. 49 Mylanta p. 76, 94 Norco p. 82
Microzide p. 43, 69 Mylicon p. 72 Normodyne p. 44
Midamor p. 39 NaCl 0.9% sterile for inhalation p. 67 Norpramin p. 63, 84
Milk of Magnesia p. 61 Nadolol p. 50, 60, 68 Nortriptyline p. 64, 85
Mineral Oil p. 61 Namenda p. 45 Norvasc p. 39
MiraLax OK p. 62 Naprosyn p. 37 Novolin70/30, Novolin R p. 74
Mirapex p. 54 Naproxen p. 72, 81 Nystatin Powder p. 76, 94, 96
Mirtazepine p. 56, 64, 75 Neo-Fradin p. 72, 81 Nystop p. 96
Neomycin p. 52
p. 52

104 Drug Names PDL Page #s PDL Index PDL Page #s Drug Names PDL Page #s
Olanzapine p. 59 p. 38 Phenobarbital (CIII) p. 58, 88
Olmesartan p. 48 Drug Names p. 38 Phenol Spray p. 94
Omeprazole p. 73 Pancreaze p. 38 Phenytek p. 88
Ondansetron p. 79 Pancreatic Enzymes p. 53 Phenytoin p. 88
Opium Tincture (CIII) p. 67 Pancrelipase p. 55, 63, 65, 87 Phytonadione (Tablet only) p. 38, 48
Oramorph SR p. 82 Parlodel p. 55, 63, 65, 87 Plavix p. 49
Oxazepam (CIV) p. 58 Paroxetine p. 91 Plendil p. 42
Oxybutynin p. 59 Paxil p. 91 Polyethylene Glycol (PEG) 3350 p. 62
Oxycodone SR (CII), Oxycodone Pen VK p. 73 Polysporin p. 96
(IR) (CII) - (Morphine Intolerant), p. 55, 69, 83, 84 Penicillin p. 66 Potassium Chloride p. 46, 70
Solution (IR) (CII) Pepcid p. 82 Pramipexole p. 54
Oxycodone/Acetaminophen (CII) p. 82 Pepto Bismol p. 51 Prednisone p. 56, 65, 69, 81
OxyContin p. 55, 84 Percocet p. 56 Prevacid, Prevacid SoluTab, OTC p. 73
OxyDose, OxyIR p. 69, 83 Perforomist p. 76 Prilosec p. 73
OxyFast p. 83 Periactin p. 42 Primsol p. 92
Oxymetazoline p. 60 Peridex p. 91 Prinivil p. 44
Paliperidone p. 59 Persantine p. 79 Procardia p. 45
Pamelor p. 64, 85 Phenazopyridine p. 63 Prochlorperazine p. 79
Phenergan
Phenergan with Codeine

105 PDL Index

Drug Names PDL Page #s Drug Names PDL Page #s Drug Names PDL Page #s
Procrit p. 55 Reglan p. 74, 78 Roxanol p. 68, 83
Promethazine p. 79 Remeron, Remeron SolTab p. 56, 64, 75 Roxicodone p. 83
Promethazine/Codeine (CV) p. 63 Requip p. 55 Rythmol p. 46
Propafenone p. 46 Restoril p. 75 Saline-Nebulized p. 50, 60, 68
Propranolol p. 46 Rifadin p. 93 Salivart p. 76
Proscar p. 38 Rifampin p. 93 Salmeterol p. 51
Proventil p. 49, 67 Rifaximin p. 53 Sani-supp p. 61
Prozac p. 64 Risperdal p. 58 Santyl p. 95
Pseudoephedrine p. 60 Risperidone p. 58 Sarna Lotion p. 86, 96
Psyllium (Fiber) p. 61 Ritalin p. 64 Scopolamine Patch p. 80, 89
Pyridium p. 91 Rivastigmine p. 37 Selegiline p. 53
Questran p. 52, 55, 66, 86 Robinul p. 79, 89 Senna, Senna S, Senna Plus p. 61
Quetiapine p. 54, 58 Robitussin p. 60 Sennosides/Docusate Sodium p. 62
Quinapril p. 47 Robitussin AC p. 63 Senokot p. 62
Qvar p. 50 Robitussin DM p. 63 Senokot S p. 62
Ramipril p. 47 Rocephin p. 93 Septra p. 92
Ranitidine p. 73 Rolaids p. 72 Serax p. 58
Razadyne, Razadyne ER p. 37 Ropinirole p. 55 Serevent Diskus p. 51

106 Drug Names PDL Page #s PDL Index PDL Page #s Drug Names PDL Page #s
Seroquel, Seroquel XR p. 54, 58 p. 53 Tobramycin Ophthalmic p. 95
Sertraline p. 65 Drug Names p. 38 Tobrex Ophthalmic p. 95
Silvadene p. 96 Symmetrel p. 94 Tolterodine p. 59
Silver Sulfadiazine (SSD) Cream p. 96 Tamsulosin p. 84, 87 Toprol XL p. 45
Simethicone p. 67 Tears Naturale p. 49 Torsemide p. 47, 52
Sinemet p. 53 Tegretol p. 75 Tramadol (IR) p. 82
Sinequan p. 64, 86 Telmisartan p. 39 Tramadol/Acetaminophen p. 82
Sodium Phosphate Enema/ Temazepam (CIV) p. 47 Trandate p. 44
Bisphosphonate Enema p. 62 Tenormin p. 62 Transderm Scop p. 80, 89
Soma Terazosin p. 91 Trazodone p. 65, 75
Sorbitol 70% Soln p. 77 Tessalon Perles p. 50 Triamcinolone Cream p. 96
Spiriva p. 62 Tetracycline p. 50 Triamterene p. 49
Spironolactone p. 51 Theo-Dur p. 67 Triamterene/HCTZ p. 49, 70
Stalevo p. 47, 52, 70 Theophylline p. 67 Triazolam (CIV) p. 75
Sucralfate p. 54 Thickening Agent p. 57, 74 Trilisate p. 81
Sudafed p. 73, 76 Thick-It p. 79 Trimethobenzamide p. 79
Sular p. 60 Thorazine p. 51 Trimethoprim p. 92
Sumycin p. 45 Tigan p. 77 Trimethoprim/Sulfamethoxazole p. 92
p. 91 Tiotropium
Tizanidine

107 PDL Index

Drug Names PDL Page #s Drug Names PDL Page #s Drug Names PDL Page #s
Trimox p. 89 Verapamil p. 48 Zinc Oxide p. 95
Triple Antibiotic Ointment p. 96 Vibramycin p. 91 Zithromax p. 90
Tums p. 72 Vicodin p. 82 Zofran, Zofran ODT p. 79
Tylenol p. 71, 80 Vistaril p. 57, 86 Zoloft p. 65
Tylenol #3 p. 82 Vitamin A+D Ointment p. 96 Zolpidem (CIV) p. 75
Tylox p. 82 Warfarin p. 38, 48 Zovirax p. 94
Ultracet p. 82 Wellbutrin SR/XL p. 65 Zyban p. 65
Ultram p. 82 Wound Care Kit p. 95 Zyloprim p. 74
Valium p. 57, 77, 87 Xanax p. 56, 67 Zyprexa, Zyprexa Zydis p. 59
Valproic Acid p. 58, 85, 88 Xenaderm Oint p. 95 Zyvox p. 93
Valsartan p. 48 Xifaxan p. 53
Vancocin p. 93 Xopenex p. 51
Vancomycin p. 93 Xylocaine p. 76, 94
Vaseline Ophthalmic p. 95 Zanaflex p. 77
Vasolex Oint p. 95 Zantac p. 73
Vasotec p. 42 Zaroxolyn p. 44, 52, 70
Venlafaxine p. 66 Zebeta p. 40
Ventolin p. 49, 67 Zestril p. 44

threeSSYYMMPPTTOOMM MMAANNAAGGEEMMEENNTT AALLGGOORRIITTHHMMSS Algorithms

Symptom Management Algorithms are provided in a clear and
concise format and are accompanied by written instructions
and tables for all drugs included in the algorithms. These
tables also provide dosing information, potential side effects,
and relative cost per day.

Anorexia/
Cachexia

Patient on Yes Discontinue agent.
any medications
that alters taste?

History of Yes Initiate metoclopramide
early satiety? 5-10mg po AC ± QHS.

History of Yes History of Yes History of
diabetes? depression neuropathic
or insomnia?
pain?

No Yes
No No
Initiate dexamethasone
2-4mg po Qday-BID Inititate mirtazapine
15mg po QHS.
OR prednisone
10-20mg po Qday

Initiate mirtazapine Initiate nortriptyline
7.5mg po QHS. 10-25mg po QHS.

Effective?

Initiate No Initiate dronabinol*
cyproheptadine* 2.5-5mg po BID-TID.
4-8mg po BID.
No
No Initiate megestrol*
80-200mg po BID-QID Effective?
Effective?
(titrate to 160-800mg *Requires CM approval
108
po Qday).

Anorexia/Cachexia

Some patients may benefit from appetite stimulation. If patient does not experience any
benefits within a week, either increase dose or discontinue the medication to avoid any
unnecessary side effects and expense.

Steroids – are helpful for appetite stimulation in patients with a short prognosis (<
3 months) or in those with other indications for steroid such as mood/energy, nausea/
vomiting, bone pain, or bronchospasms. Improvement in appetite is temporary (may only
last a few weeks) and is usually not associated with weight gain.

• Insulin dependent diabetic patients may still benefit from the use of a steroid as
insulin regimen can be adjusted if blood sugars increase

Nortriptyline – A tricyclic antidepressant that has been shown to increase appetite. May
also be beneficial for improved sleep and neuropathic pain.

Mirtazapine – Studies show Remeron induces weight gain, increases food intake, and is
associated with improved depression. It is also useful for patients with sleep disorders.

Cyproheptadine – An antihistamine which is shown to have mild appetite stimulation
with minimal weight gain. May also be useful to decrease nausea/emesis. Known to be
sedating and cause increased dizziness as well as anticholinergic effects.

Metoclopramide – Used for anorexia associated with early satiety and gastroparesis.

Megestrol – Effects may last for months (longer than steroids) and is generally associated
with weight gain (adipose tissue - not lean muscle), improved appetite, calorie intake
and nutritional status. An initial 2-4 week trial is recommended. Megace promotes clot
formation and should be avoided in patients with high thromboembolic risk or in non-
ambulatory patients. Doses above 800mg/day have no additional benefit.

Dronabinol – This drug may improve appetite and possibly lead to weight gain. Has also
been associated with improved mood and also has anti-nausea effects. A recent trial found
it to be inferior to megestrol acetate (Megace) for cancer associated anorexia but may be
indicated for patients who cannot tolerate Megace.

Less Commonly Used for Appetite Stimulation:

• NSAIDS like ibuprofen have been shown to have some beneficial effect on
anorexia/weight loss by mediating the inflammatory response of cytokines.
Ibuprofen 400mg po TID or or indomethacin 50mg po BID

• Melatonin has been shown to have some effect on weight loss by mediating
circulating tumour necrosis factor. Melatonin 20mg po QHS

• Omega 3 fatty acids have been shown to normalize metabolism and stabilize
weight. Eicosapentaenoic acid (EPA) 2.2 grams daily and docosahexaenoic
acid (DHA)

Commercially Drug Name Drug Name
Available Prednisone (Deltasone®) Cyproheptadine (Periactin®)
Formulations Tablet: 1mg, 2.5mg 5mg, 10mg, Tablet: 4mg
Usual Dose 20mg, 25mg Syrup: 2mg/5mL
Max Total Daily Solution: 5mg/5mL
Dose (TDD) 4-8mg po BID
Comments 10-20mg po QAM 32mg

Relative Cost/Day 80mg -Can cause confusion,
constipation, xerostomia,
-Can cause GI upset. Take difficulty urinating
with food or milk.
-Use with caution in patients Tier 2
with diabetes.
Tier 1

109

Anorexia/Cachexia (continued)

Commercially Drug Name Drug Name
Available
Formulations Mirtazapine (Remeron®) Megestrol (Megace®)

Usual Dose Tablet: 7.5mg, 15mg, 30mg, Tablet: 20mg, 40mg
Max Total Daily 45mg Suspension: 40mg/mL
Dose (TDD) SolTab (ODT): 15, 30, 45mg Suspension, ES: 125mg/mL
Comments
7.5-30mg po QHS 400-800mg po Qday
45mg 800mg

-Lower dosages are more -Promotes clot formation
effective for appetite induction especially in non-ambulatory
-Will also help with sleep and patients
mood

Relative Cost/Day Tablet:Tier 1 Tier 3
SoluTab:Tier 3

Commercially Drug Name Drug Name
Available Dronabinol (Marinol®)
Formulations Capsule: 2.5, 5, 10mg Metoclopramide (Reglan®)

Usual Dose 2.5mg po BID-TID Tablet: 5mg, 10mg
20mg Syrup: 5mg/5mL
Max Total Daily Injection, solution: 5mg/mL
Dose (TDD) -Monitor closely for adverse
psychotic reactions; this drug 5-10mg po QID
Comments is the psychoactive substance
in marijuana. 60mg; 20mg in renal
impairment
Relative Cost/Day Tier 3
-Doses greater than
40mg/day have been
associated with an increased
risk of EPS symptoms
-Avoid in patients with
Parkinson’s disease
-Monitor for agitation
-Give 30 minutes before
meals

Tier 1

110

Anorexia/Cachexia (continued)

Commercially Drug Name Drug Name
Available
Formulations Dexamethasone (Decadron®) Nortriptyline (Pamelor®)

Solution, oral [concentrate]: Tablets: 10mg, 25mg, 50mg,
1mg/mL 75mg, 100mg, 150mg
Tablet: 0.25mg, 0.5mg, 0.75mg,
1mg, 1.5mg, 2mg, 4mg, 6mg
Injection, solution, as sodium
phosphate: 4mg/mL, 10mg/mL

Usual Dose 2-4mg po BID 10-25mg po QHS
Max Total Daily
Dose (TDD) 40mg 200mg
Comments (150mg elderly)

Relative Cost/Day -Can cause GI upset, -Will also help with sleep
especially if not taken with and mood elevation
food, and may increase risk of -Least anticholinergic side
a GI bleed effects compared to other
-Use with caution in diabetes TCAs
-Give last dose before 2pm to
avoid insomnia

Tier 1 Tier 1

References:
• http://www.fraserhealth.ca/media/15FHSymptomGuidelinesNutritionCachexia.pdf

• Eduardo Bruera. ABC of Palliative Care: Anorexia, Cachexia, and Nutrition. BMJ: British
Medical Journal Vol. 315, No. 7117 (Nov. 8, 1997), pp. 1219-1222

• Salacz M. Megestrol Acetate for Cancer Anorexia/Cachexia. Fast Facts and Concepts. October
2003; 100. Available at: http://www.eperc.mcw.edu/fastfact/ff_100.htm.

• Wilner LS and Arnold R. Fast Facts and Concepts #93 Cannabinoids In The Treatment Of
Symptoms In Cancer And Aids. June 2003. End-of-Life Physician Education Resource Center
www.eperc.mcw.edu.

• Riechelmann RP, Burman D,Tannock IF, Rodin G, Zimmermann C. Phase II trial of mirtazapine
for cancer-related cachexia and anorexia. Am J Hosp Palliat Care. 2010 Mar;27(2):106-10

• Kardinal, Carl G. .“A controlled trial of cyproheptadine in cancer patients with anorexia and/or
cachexia”. Cancer 65(12), p.2657.

111

Anxiety

Rule out agitation/delirium.

Discuss Plan of Care with
patient and caregivier.

Effective? No
Yes
Anxiety Yes
Continue secondary to
patient-focused depression?
communication.

No

Yes Anxiety due Initiate SSRI such
to Parkinson’s
Disease? as sertraline 25-50mg po
QAM, OR paroxetine

10-20mg po QAM.

No Effective?

Initiate lorazepam 0.5mg No
po Q4h PRN anxiety, OR
trazodone 25mg po TID, OR Discontinue SSRI and
hydroxyzine 10-25mg po initiate venlafaxine 25mg
po BID, OR duloxetine
BID-QID.
30-60mg po Qday.
Age � 65?
Yes

No

Initiate haloperidol 0.5-1mg
po Q4h PRN anxiety, titrate

to lowest effective dose
(usually 1.5-5mg per day).

Effective? Consider risk vs. benefit
No of adding mood stabilizer

such as: valproic acid ER
500mg po Qday x 1 week,

then 500mg po BID.

112

Anxiety

Symptoms and signs of anxiety are comprised of three distinct categories:

1. Psychological
a. Apprehension, worry, inability to relax
b. Irritability with or without difficulty in concentrating
c. Difficulty falling asleep, lack of restful sleep, and nightmares

2. Motor tension
a. Muscular aches and pains
b. Jumpiness, exaggerated startle reflex
c. Tension headaches

3. Autonomic
a. Shortness of breath, palpitations, lightheadedness, dizziness
b. Sweating, dry mouth,“lump in throat”
c. Nausea, diarrhea, urinary frequency

After an effective medication is found it is good practice to monitor patient and identify
the lowest effective dose of the antianxiety agent and continue therapy.

See page 7 for the Benzodiazpine Medication Comparison Chart.

Commercially Drug Name Drug Name
Available Sertraline (Zoloft®)
Formulations Valproic Acid (Divalproex
Usual Dose Solution, oral [concentrate]: Sodium)
Max Total Daily 20mg/mL Depakote®, Depakote
Dose (TDD) Tablet: 25mg, 50mg, 100mg Sprinkles®
Comments
25-200mg po QAM Tablet DR: 125, 250, 500mg
Relative Cost/Day 200mg Tablet ER: 250, 500mg
Capsule, DR: 125mg
Syrup, oral: 250mg/5mL

250-500mg/kg/day po QHS

60mg/kg/day

-May cause insomnia or -Give with food; may open
somnolence and sprinkle capsules on food.
-Allow intervals of 1 week Info: divalproex sodium
between dosage changes ER and DR tabs not
-Initial dose: 25mg po Qday bioequivalent; incr. total daily
in elderly, hepatic dysfunction dose by 8-20% if switching
and anxiety/panic disorders from DR tab to ER tab.
Contraindicated in hepatic
Tier 1 disease/significant impairment.
May dilute syrup 1:1 with
water for use as retention
enema: 17-20 mg/kg initial
dose, then 10-15 mg/kg/dose
every 8 hours.

Tier 1

113

Anxiety (continued)

Commercially Drug Name Drug Name
Available
Formulations Paroxetine (Paxil®) Trazodone (Desyrel®)
Usual Dose
Max Total Daily Suspension Oral: 10mg/5mL Tablet: 50mg, 100mg, 150mg,
Dose (TDD) Tablet: 10mg, 20mg, 30mg, 300mg
Comments 40mg
Tablet, controlled-release:
Relative Cost/Day 12.5mg, 25mg, 37.5mg

10-40mg po QAM 25-50mg po TID (for anxiety)
600mg
Elderly: 40mg
Adults and children (unlabeled -Antidepressant doses not
use): 62.5 reached until minimum of
300mg TDD
-Caution in patients w/history -Initial dose: 25mg po TID for
or predisposition to seizures anxiety
-May cause insomnia or
somnolence
-Allow intervals of 1 week
between dosage changes
-Initial dose: 10mg po Qday
in elderly and anxiety/panic
disorder
-Dosage taper recommended
prior to discontinuation

Tier 1 Tier 1

Drug Name Drug Name

Lorazepam (Ativan®) Haloperidol (Haldol®)

Commercially Tablet: 0.5, 1, 2 mg Tablet: 0.5, 1, 2, 5, 10, 20 mg
Available
Formulations Solution, Oral: 2 mg/mL Solution as lactate, oral: 2mg/mL
Usual Dose
Max Total Daily Solution, INJ: 2 mg/mL, 4mg/mL Solution, INJ: 5 mg/mL
Dose (TDD)
Comments 0.5-2mg po Q4-6h 0.5-5mg po Q6-12h

Relative Cost/Day 10mg 100mg

-Intermediate-acting -Can be given PO, SL, PR, IM;
benzodiazepine; may useful when benzodiazepines
be given PO, SL, PR, SQ; fail; do not use in patients with
reduce dose if liver disease Parkinson’s; low sedation
present
Tier 1
Tier 1

Commercially Available Formulations Drug Name

Usual Dose Hydroxyzine (Atarax®)
Max Total Daily Dose (TDD)
Comments Capsule: 25mg, 50mg, 100mg
Relative Cost/Day Injection: 25mg/mL, 50mg/mL
Suspension, Oral: 25mg/5mL
Syrup: 10mg/5mL
Tablet: 10mg, 25mg, 50mg

25-100mg po Q4-6h

600mg

-Very likely to cause drowsiness

Tier 1

114

Anxiety (continued)

Commercially Drug Name Drug Name
Available
Formulations Venlafaxine (Effexor®) Duloxetine (Cymbalta®)

Usual Dose Tablet, immediate-release (IR): Enteric-coated capsule:
25mg, 37.5mg, 50mg, 75mg, 20mg, 30mg, 60mg
Max Total Daily 100mg
Dose (TDD) Tablet, sustained-release (SR):
37.5mg, 75mg, 150mg
Comments
Elderly: 25-75mg po Qday 20-60mg po Qday
Panic disorder: 37.5-75mg SR/
po Qday 120mg (generally doses
above 60mg/day have not
IR: 375mg been shown to be more
ER: 225mg effective and may have
increased side effects)
-Not recommended as a first-line
antidepressant due to safety in -Also effective for
overdose and cost-effectiveness neuropathic pain and stress
-May interact with haloperidol incontinence in women
increasing concentrations up to -Affected by strong
70% CYP1A2 inhibitors, e.g.,
-Allow intervals of 1 week ciprofloxacin; Strongly
between dosage changes recommended to avoid
-Dosage taper is recommended combination
prior to discontinuation -Not recommended for
-Contains the same active use in patients with CrCl
ingredient as desvenlafaxine less than 30mL/min
(Pristiq®), its isomer -Cannot be crushed or
opened

Relative Cost/Day IR Tablet:Tier 2 Tier 2
SR Tablet:Tier 3

References:
• Barraclough, Jennifer.“ABC of palliative care: depression, anxiety, and confusion.” BMJ 315.7119
(1997): 1365-1368.

• Wilson, Keith G., et al.“Depression and anxiety disorders in palliative cancer care.” Journal of
pain and symptom management 33.2 (2007): 118.

• Medscape online reference (http://www.medscape.com), accessed 3 February, 2013.

115

116

Bone
Pain

Yes Patient No
presenting

w/ bony

metastasis?

Severe bone Initiate APAP 650mg po Q4h
pain (already PRN pain OR if ineffective, initiate
No on opioids)?
ibuprofen 400-600mg po Q4h
PRN pain OR naproxen 500mg

po Q12h PRN pain.

Yes

History of Yes
GI Bleed /
History of No
GI Bleed / GERD?

GERD?

Yes No

Initiate choline
magnesium trisalicylate

500mg po TID OR
1000mg po BID.

Initiate ibuprofen
200-400mg po Q4h PRN
pain OR naproxen 220mg

po Q12h PRN pain.

Initiate ibuprofen

600-800mg po Q6-8h
PRN pain OR naproxen

500mg po BID-TID.

Effective? No

117

Bone
Pain

History of No
diabetes?

Yes Initiate dexamethasone 4mg
po Qday-BID OR prednisone
Initiate choline magnesium
trisalicylate 500mg po TID 10-20mg po Qday + GI
protection such as Prilosec
OR 1000mg po BID
OR OTC® 20mg po Qday.

Initiate meloxicam
7.5-15mg po Qday + GI
protection such as Prilosec
OTC® 20mg po Qday.

History of Yes
diabetes?

No Initiate dexamethasone Initiate meloxicam
4mg po Qday-BID OR 7.5-15mg po Qday.

prednisone 10-20mg

po Qday.

Above therapy
effective?

Initiate calcitonin No
nasal spray. 1 spray
(200 units) Qday, Above therapy
alternating nostrils. effective?

No Consider
bisphosphonates.

118

Bone Pain

NSAIDs – Should be first choice as analgesics for bone pain as these anti-inflammatory
drugs can reduce pain from bone metastases.There are no comparative controlled trials
demonstrating their efficacy but anecdotal evidence suggests that ~ 80% of patients show
a response to NSAIDs (about 20% complete, and 60% partial). If patients have history of
GERD/GIB – may add stomach protection such as ranitidine, omeprazole or famotidine.

• Another alternate may be to use Misoprostol (Cytotec) which is used for the
prevention of NSAID-induced gastric ulcers: Oral: 100-200mcg po QID with food

Steroids – Steroids are usually viewed as adjunctive therapy for bone pain and should
be tried if NSAIDS not effective or if patient already on opioids.The optimal duration
of steroid therapy is unknown. If no benefit is seen within 5-7 days the drug should be
discontinued. If beneficial, the drug should be continued at the lowest effective dose to
avoid long-term adverse effects.

• NOTE: Insulin dependent diabetic patients may still benefit from the use of a
steroid as insulin regimen can be adjusted if blood sugars increase

Bisphosphonates – Can be used for the treatment of cancer-related bone pain.
Currently there are 2 only medications that can be used which are both parentally
administered. However, recent studies have shown Boniva to be effective in reducing
bone pain in breast cancer patients.

Zometa (zoledronic acid) 4mg IV Q3-4 weeks
Aredia (pamidronate) 9mg IV Q3-4 weeks

Boniva (ibandronate) 50mg po daily

For NPO patients - Decadron can be given rectally. Diclofenac is available as a topical
cream or patch. Or, if available, may consider a compounded gel such as Ibuprofen or
decadron gel.

Commercially Drug Name Drug Name
Available
Formulations Ibuprofen (Motrin®, Advil®) Meloxicam (Mobic®)

Capsule/Gelcap/Tablet [OTC]: Tablet: 7.5mg, 15mg
200mg Suspension: 7.5mg/5mL
Tablets [Rx]: 400mg, 600mg,
800mg
Suspension, oral: 100mg/5mL
Suspension, oral drops:
40mg/mL
Tablet, chewable: 50mg, 100mg

Usual Dose 200-800mg po Q4-6h PRN 7.5-15mg po Qday
pain 15mg
Max Total Daily
Dose (TDD) 3200mg
Comments
-Take with food or milk to -DO NOT USE with
avoid GI upset hypersensitivity to aspirin or
-Monitor concomitant use other NSAIDs
with corticosteroids to avoid -Avoid with significant renal
GI bleed impairment (est ClCr less than
-Consider GI prophylaxis with or equal to 15 mL/min)
H2-receptor blocker (e.g. -Hepatically metabolized-(no
ranitidine, famotidine) dosage adjustment needed
-OK to crush with Child-Pugh Class A or B)

Relative Cost/Day Tier 1 Tier 1
119

Bone Pain (continued)

Commercially Drug Name Drug Name
Available Calcitonin (Miacalcin®)
Formulations Choline Magnesium
Trisalicylate (Trilisate®) Solution, intranasal: 200 units/
actuation
Liquid: 500mg/5mL

Usual Dose 1000mg po Q12h Intranasal: 200 units (1 spray)
4500mg in one nostril Qday
Max Total Daily
Dose (TDD) 200 units
Comments
-DO NOT USE with salicylate -Pump must be primed.To
or aspirin allergy administer, place nozzle into
-Side effects:Tinnitus nostril with head in upright
-Less GI effects compared position. Alternate nostrils
with NSAIDs daily
-OK to crush

Relative Cost/Day Tier 2 Tier 2

Commercially Drug Name Drug Name
Available Naproxen (Aleve®,
Formulations Naprosyn®) Dexamethasone (Decadron®)
OTC Tablet: 220mg
Usual Dose Tablet: 250, 375, 500mg Solution, oral [concentrate]: 1mg/
Max Total Daily Suspension: 125mg/5mL mL
Dose (TDD) Tablet: 0.25mg, 0.5mg, 0.75mg,
Comments 250-500mg po BID 1mg, 1.5mg, 2mg, 4mg, 6mg
1500mg Injection, solution, as sodium
phosphate: 4mg/mL, 10mg/mL
-250mg naproxen = 275mg
naproxen sodium 2-4mg po BID
CrCl <30: avoid use
40mg

-Can cause GI upset, especially
if not taken with food, and
may increase risk of a GI bleed
-Use with caution in diabetes

Relative Cost/Day Tier 1 Tier 1

120

Bone Pain (continued)

Drug Name
Prednisone (Deltasone®)

Commercially Available Tablet: 1mg, 2.5mg, 5mg, 10mg, 20mg, 50mg
Formulations Solution, oral: 1mg/mL
Solution, oral concentrate: 5mg/mL

Usual Dose 10-20mg po Qday
Max Total Daily Dose 80mg
(TDD)
Comments -CAUTION in patients with diabetes, monitor BG levels
when initiating and discontinuing
Relative Cost/Day -Side effects: GI upset, GI bleed
-May also improve appetite and dyspnea
-DRUG OF CHOICE for bone pain in non-diabetic
patients

Tier 1

References:
• Weinstein E, Arnold R. Bisphosphonates for Bone Pain. Fast Facts and Concepts. April 2004;
113. Available at: http://www.eperc.mcw.edu/fastfact/ff_113.htm.
• Weinstein D, Arnold R. Steroids in the Treatment of Bone Pain. Fast Facts and Concepts.
January 2005; 129. Available at: http://www.eperc.mcw.edu/fastfact/ff_129.htm.
• Ripamonti, C, Fulfaro, F. Malignant bone pain: Pathophysiology and treatments. Current Review
of Pain, June 2000,Volume 4, Issue 3, pp. 187 – 196

121

122

Complete
Bowel

Obstruction

Chief complaint consisting of any of
the below symptoms:

Inflammation Initiate dexamethasone

2-4mg po/IV/SubQ BID
(dose 4-16mg/day)íD/C

in 4-5 days if ineffective.

Pain Initiate Roxanol® 5mg po/SL
Nausea/Vomiting Q2h PRN pain OR if NPO:
morphine 1-3mg IV/SubQ

Q2h PRN pain.

Initiate haloperidol 1mg
IV/po/SubQ Q3h PRN N/V
OR if not complete obstruction:

initiate metoclopramide
5-10mg po/IM/IV QID

Cramping/Colicky Prognosis
Pain/Secretions > 1 week.

Yes No

Initiate hyoscyamine Initiate atropine 1% opth
0.125mg SL/po Q4h solution 1-4gtt SL Q1-4h
PRN cramping/colicky
PRN cramping/colicky
pain/secretions. pain/secretions

Effective?

No Effective? No Initiate octreotide*
50-100mg SubQ/IV
Initiate glycopyrrolate* BID-TID.
1-2mg po TID OR
*Requires CM approval
0.1-0.4mg SubQ/IV Q2-4h
PRN cramping/colicky
pain/secretions.

123

Complete Bowel Obstruction

The goal for medical management of CBO is to decrease pain, nausea and secretions
into the bowel in order eliminate the need for a nasogastric tube and IV hydration. Bowel
obstruction may be mechanical or functional, partial or complete, and may occur at one
or at many sites. Cholangiocarcinoma, pancreatic cancer, and gallbladder cancer, as well
as colon CA and ovarian CA are the most common tumors causing obstruction. In a
minority of patients, obstruction is unrelated to the cancer and is instead due to adhesions
arising from surgery, radiation therapy or internal hernias.

Symptoms include:

• Pain - constant, crampy or colicky resulting from the accumulation of secreted
bowel fluid
• Abdominal distension
• Nausea and vomiting –varies based on the obstruction (ex.- for example – in
obstructions of the stomach, duodenum, pancreas or jejunum – typically vomiting
develops early and in large volumes)
• Bowel sounds are usually altered and may be tympanic, high pitched, diminished
or absent.
• If complete obstruction - there will be no feces and flatus.
• Fatigue/Anorexia
• Diarrhea with partial obstruction (overflow diarrhea)

DRUGS - Treatment should be a combination of the following medications – parental
route is recommended if possible as absorption via PO route may be variable due to
obstruction

Opioids - Analgesics for pain may be given via PO (if patient able to tolerate),
SubQ, I.V. or transdermal route. Analgesics should not be avoided because of
fear of aggravating the obstruction. Opioids typically are effective for both the
continuous and colicky types of pain.

Anticholinergic drugs (e.g., atropine, hyoscyamine, glycopyrrolate
and scopolamine) - If colic persists despite the use of an opioid, anticholinergic
drugs can be administered in association with opioid. These help with the colicky
pain due to smooth muscle spasm and bowel wall distension.These medications
inhibit the promotility in the gut resulting in decreased GI fluid secretion and
decreased peristalsis of smooth muscle.

Anti-emetics - The dopamine antagonists, (e.g., haloperidol) are considered by
many palliative experts as the antiemetic of choice and can be administered
(intravenously or subcutaneously) to relieve pain and nausea. Some literature
supports a combination of antiemetics work best.

Steroids - Although controversial, steroids may help as both an antiemetics and
co-analgesics.They are thought to reduce inflammatory edema around tumorsites,
thereby palliating symptoms and helping resolve impending obstructions. As per
Cochrane review 2008, dosage range 6 to 16mg dexamethasone given intravenously/
subcutaneously may help with a low incidence of side effects. However, it is
important to note that steroids do not seem to affect the length of survival of these
patients and were found to work better in patient populations that were not already
taking steroids prior to the obstruction. Steroids should be discontinued if the
patient does not respond to treatment within 4 to 5 days. Corticosteroids may be
given orally, rectally, subcutaneously, or intravenously.

Somatostatin analogs (Octreotide) - Help to reduce secretions but lack the
adverse effects of anticholinergics. They inhibit the release and action of GI
hormones, slow intestinal motility, and decrease splanchnic blood flow. Octreotide
(Sandostatin) is administered as a SQ injection (starting at 50-100mcg Q8 hours) or
as continuous IV or SQ infusion, beginning at 10-20mcg/hr.The drug is titrated every
24 hours until nausea, vomiting, and abdominal pain are controlled.

Prokinetic drugs (e.g., metoclopramide) - May be beneficial if there is a
partial obstruction to help stimulate bowel and decrease nausea. However, if there
is total obstruction this should be discontinued as they may exacerbate crampy
abdominal pain.

124

Complete Bowel Obstruction (continued)

Drug Name Drug Name

Hyoscyamine (Levsin®) Haloperidol (Haldol®)

Commercially Solution, oral drops: Solution, oral [concentrate]:
Available 0.125mg/mL 2mg/mL
Formulations Solution: 0.125 mg/5mL Tablet: 0.5mg, 1mg, 2mg, 5mg,
Tablet: 0.15mg, 0.125mg, 10mg, 20mg
Usual Dose 0.375mg Injection, solution: 5mg/mL
Max Total Daily Tablet, orally disintegrating:
Dose (TDD) 0.125mg Injection: 0.5mg/mL
Comments
0.125-0.25mg po/sl Q4-6h 0.5-5mg po/sl Q6-12h PRN
Relative Cost/Day N/V

Commercially 1.5mg Titrated to optimal dose
Available based on individual patient
Formulations response and level of
tolerance
Usual Dose
Max Total Daily -Patients may experience -Initial dose for N/V associated
Dose (TDD) anticholinergic side effects with intestinal obstruction:
Comments such as blurred vision, urinary Haloperidol 1mg po/sl Q3h
retention, dry mouth and dry PRN N/V.
Relative Cost/Day eyes -Can be given PO, SL, PR, IM
-Confusion is less common -Avoid use in patient’s with
than with atropine Parkinsons’s disease
-Monitor for extra-pyramidal
symptoms (EPS)

Tier 1 Tier 1

Drug Name Drug Name
Dexamethasone (Decadron®)
Morphine sulfate, immediate
Solution, oral [concentrate]: release (Roxanol®)
1mg/mL
Tablet: 0.25mg, 0.5mg, 0.75mg, Solution, oral [concentrate]:
1mg, 1.5mg, 2mg, 4mg, 6mg 20mg/mL
Injection, solution, as sodium Solution, oral: 10mg/5mL,
phosphate: 4mg/mL, 10mg/mL 20mg/5mL
Tablet: 15mg, 30mg
4-16mg po BID Suppository, rectal: 5mg, 10mg,
20mg, 30mg
40mg
Dosing varies depending on
-Used in bowel obstruction indication and patient history
to relieve GI inflammation
associated with obstruction Titrated to optimal dose based
and/or inflammation caused on individual patient response
by malignancy and level of tolerance
-Can cause GI upset,
especially if not taken with -Initial dose for intestinal
food, and may increase risk of obstruction: Morphine sulfate
a GI bleed 5mg po/sl Q2h PRN pain
-Use with caution in diabetes -Use cautiously or avoid use in
Tier 1 patients with significant renal
or hepatic impairment

Tier 1

125

Complete Bowel Obstruction (continued)

Commercially Drug Name Drug Name
Available Atropine
Formulations Solution: 1% Glycopyrrolate (Robinul®)
Usual Dose
Max Total Daily Tablet: 1mg, 2mg
Dose (TDD) Injection, solution: 0.2mg/mL
Comments
1-4 gtts po/sl Q1-4h 1-2mg po TID,
Relative Cost/Day 0.1-0.4mg SubQ Q2-4h
4 applications daily
po 8mg
-May cause anticholinergic SubQ 0.8mg
induced delirium if used for an
extended length of time -Generally should be reserved
-May contribute or cause for patients who develop
mucous plugs intolerable side effects
or confusion with other
Tier 1 anticholinergic medications
-May contribute or cause
mucous plugs

Tier 3

Commercially Drug Name Drug Name
Available
Formulations Metoclopramide (Reglan®) Octreotide (Sandostatin®)

Tablet: 5mg, 10mg Injection, solution, as acetate: 0.2mg/
Syrup: 5mg/5mL mL, 1mg/mL
Injection, solution: 5mg/mL Injection, solution, as acetate
[preservative-free]: 0.05mg/mL,
Usual Dose 5-10mg po QID 0.1mg/mL, 0.5mg/mL

Max Total Daily 60mg; 20mg in renal Secretions: 50-200mcg IV/SubQ
Dose (TDD) impairment BID-TID

Comments -Doses greater than 40mg Titrated to optimal dose based on
/day have been associated individual patient response and level
with an increased risk of of tolerance
EPS symptoms
-Avoid in patients with -Clearance is reduced by
Parkinson’s disease approximately 50% in patients with
-Monitor for agitation renal failure requiring dialysis
-Depot formulations of octreotide
Relative Cost/Day Tier 1 may be appropriate for some
patients
-Octreotide may be more
efficacious than scopolamine
hydrobromide (patch formulation)
-Has been used with success in
children

Tier 3

References:
• Von Gunten CF, Muir JC. Medical Management of Bowel Obstructions, 2nd Edition.
Fast Facts and Concepts. August 2005; 45. Available at: http://www.eperc.mcw.edu/fastfact/
ff_045.htm.

• http://www.fraserhealth.ca/media/13FHSymptomGuidelinesMalignantBowelObstruction.pdf

• Thaker, Darshit A; Stafford, Bruce C; Gaffney, Luke S. Palliative management of malignant bowel
obstruction in terminally ill patient Indian journal of palliative care, 05/2010,Volume 16, Issue
2, pp. 97 – 100

• Roeland, Eric and von Gunten, Charles F Current concepts in malignant bowel obstruction
management. Current oncology reports, ISSN 1523-3790, 07/2009,Volume 11, Issue 4, pp.
298-303

126

Cough/
Congestion

Patient pre- Yes Wet, Yes
senting w/ productive
cough/lung
congestion? cough?

Yes No

No

Is congestion in Is patient too Dry
the nose? weak to non-productive
cough?
Yes cough?
Yes
Yes
Anticholinergics:

To dry congestion and Suppressants:
secretions see
Mild-moderate
SECRETIONS algorithm cough?
on 189.

Initiate normal saline Effective?
nasal spray 2-3 No

sprays each nostril
PRN congestion.

Initiate oxymetazoline Yes Cardiac No Initiate
nasal spray 2-3 sprays history or pseudoephedrine
each nostril BID (not to hyper tension?
30-60mg po Q4-6h
use for >3 days).
PRN congestion.

If runny, itchy nose, initiate
loratidine 10mg po Qday OR

diphenhydramine 25mg po

Q4-6h PRN runny, itchy nose.

127

Cough/
Congestion

Is sputum
Yes colored or are

other infection
symptoms
present?

No Yes
Consider therapy for
Expectorants: respiratory infection.

Initiate guaifenesin

10-20mL po Q4h PRN

congestion (Diabetic
Tussin® in diabetics) OR

Initiate guaifenesin LA Effective? No Initiate normal saline
600-1200mg po Q12h nebs* Q2-4h

PRN congestion. PRN congestion.

*Should use 10-15 minutes after bronchodilator

Initiate promethazine

Initiate dextromethorphan No + codeine
30mg/5mL 10mL po 6.25mg/10mg/5mL
Q12h PRN cough. Effective?
5-10mL po

Q4h PRN cough OR

May add benzonatate Initiate hydrocodone/
100-200mg po TID homatropine 5mg/1.5mg/5mL
to opioid therapy for 5-10mL po Q4h PRN cough.
additional benefit.
128

Cough/Congestion

Opioids are anti-tussive drugs and work by suppressing the brainstem cough center.They
are the first-line symptomatic treatment for severe, distressing cough. All opioid analgesics
have anti-tussive activity – however, there is no evidence that any one opioid works better
for cough. For patients already prescribed opioids for pain, it is unclear whether adding a
second opioid such as codeine for cough is effective.

Benzonatate - this is a peripherally acting, oral anaesthetic agent that inhibits cough
by anesthetizing stretch receptors in the respiratory tract.There have been no published
controlled studies with results showing it to be efficacious but multiple uncontrolled
studies support its use. It is usually recommended to add benzonatate to an opioid for
cough control.

Anticholinergics such as atropine and levsin are useful for copious upper respiratory
secretions leading to cough.

Expectorants - these medications help to thin bronchial secretions and ease
expectoration and are recommended for severe, chronic, wet coughs. Because they may
increase fluid in the respiratory tract, they are not recommended if the cough reflex is
diminished.

Nebulized local anesthetics are thought to work by anesthetizing afferent receptors
in the respiratory tract, although there have been no trials evaluating their effectiveness;
anecdotally they have been reported to be useful for refractory intractable cough.

• May precipitate bronchospasm in asthmatic patients.

• Gag reflex is inhibited after administration, so it is recommended to keep patient
NPO for 1 to 2 hours after using nebs and rinse and spit after nebulization to
minimize numbness of lips and tongue.

• Use a mouthpiece rather than a mask for inhalation.

• Bupivacaine 0.25% 5mL Q4h PRN cough

• Lidocaine 2% 2 to 5mL in 1mL of normal saline for 10min Q2-6h PRN cough
(max 10mL/24h)

Others - Paroxetine 10-40mg po daily, amitriptyline 10mg po daily, gabapentin 600mg po
BID-TID. These medications have been anecdotally reported to have been used to treat
chronic, refractory cough.

Commercially Drug Name Drug Name
Available Promethazine with Codeine
Formulations Hydrocodone and homatropine
Usual Dose Syrup: Promethazine (Hycodan/Hydromet®)
Max Total Daily hydrochloride 6.25mg and
Dose (TDD) codeine phosphate10 mg per Syrup: Hydrocodone bitartrate
Comments 5mL 5mg and homatropine
methylbromide 1.5mg per 5mL
Relative Cost/Day 5mL po Q4-6 hours PRN Tablet: 5-1.5mg
cough
1 tablet or 5mL po Q4-6 hours
30mL PRN cough

6 tablets or 30 mL

-Use the lowest effective dose -Homatropine is an

for the shortest period of time. anticholinergic agent, present

Not recommended for use in a subtherapeutic amount to

for cough control in patients discourage deliberate overdose

with a productive cough.

Dose should not be increased

if cough does not respond;

re-evaluate within 5 days for

possible underlying pathology.

Tier 1 Tier 1

129

Cough/Congestion (continued)

Commercially Drug Name Drug Name
Available Oxymetazoline (Afrin®)
Formulations Pseudoephedrine (Sudafed®) Solution, intranasal, as
hydrochloride [spray]: 0.05%
Usual Dose Tablet: 30mg, 60mg
Tablet, extended release: 120mg, 2-3 sprays/ nostril Q12h
Max Total Daily 240mg
Dose (TDD) Syrup: 30mg/5mL, 15mg/5mL N/A
Comments
30-60mg po Q4-6h
OR 120mg po Q12h
OR 240mg po Q24h

240mg

-May increase blood pressure and -Limit use to no more than
contribute to agitation 3-5 days of continuous use as
-Avoid bedtime dosing due to longer therapy may lead to
drug-induced insomnia rebound nasal congestion
-Available behind the counter
without a prescription; state limits
on amount that may be dispensed
without a prescription
-Extended-release tablets may not
dissolve completely and may be
seen in the stool

Relative Cost/Day Tier 1 Tier 1

Commercially Drug Name Drug Name
Available Normal saline for nebulization Normal saline for nose
Formulations (Bronchosaline®)
Usual Dose Solution, for inhalation [preservative Intranasal solution (mist, spray,
free]: 0.9% 3mL vial drops)
Max Total Daily Intranasal gel
Dose (TDD) 1 vial (3mL) inhaled Q2-4h PRN Intranasal: 2-3 sprays in each
Comments congestion nostril as needed congestion
150meq N/A
Relative Cost/Day
-Should be used 10-15min after N/A
bronchodilator
Tier 1 Tier 1

Drug Name

Loratidine (Claritin®)

Commercially Available Capsule/Tablet: 10mg Solution, oral: 5mg/5mL
Formulations
Chewable Tablet: 5mg
Usual Dose
Max Total Daily Dose (TDD) Tablet, orally disintegrating: 10mg
Comments
10mg po Qday
Relative Cost/Day
10mg

-Loratadine is a nonsedating antihistamine. Because
of its low incidence of side effects, it may be a good
choice in the elderly

Tier 1

130

Cough/Congestion (continued)

Commercially Drug Name Drug Name
Available Guaifenesin LA (Mucinex®)
Formulations Tablet, extended-release: Diphenhydramine (Benadryl®)
600mg
Usual Dose Capsule/Tablet: 25mg, 50mg
Max Total Daily 1-2 tabs po BID Elixir, as hydrochloride: 12.5mg/5mL
Dose (TDD) 2400mg Injection, solution: 50mg/mL
Comments Oral Dissolving Strips: 25mg

25-50mg po Q4-6h

400mg

-Encourage fluid intake -Use with caution in patient’s at risk
-DO NOT CRUSH for a fall
-May cause drowsiness/dizziness or
paradoxical excitation

Relative Cost/Day Tier 2 Tier 1

Commercially Drug Name Drug Name
Available Benzonatate (Tessalon®) Dextromethorphan (Delsym®)
Formulations Capsule: 100, 200mg Suspension, extended release:
Usual Dose 30mg/5mL
100-200mg po TID PRN
Max Total Daily cough 60mg po BID
Dose (TDD) 600mg
Comments 120mg
-Swallow capsule whole (do
Relative Cost/Day not break. chew, dissolve, -Contains alcohol
cut, or crush).
Tier 1 Tier 1

References:
• http://www.fraserhealth.ca/media/05FHSymptomGuidelinesCough.pdf
• Marks SM, Rosielle DA. Opioids for Cough. Fast Facts and Concepts. March 2008; 199.
Available at: http://www.eperc.mcw.edu/fastfact/ff_199.htm.
• Marks S, Ro ielle DA. Non-Opioid Anti-Tussives. Fast Facts and Concepts. March 2008; 200.
Available at: http://www.eperc.mcw.edu/fastfact/ff_200.htm.

131

Constipation

No Is the patient Yes

constipated?

Is the patient Is the
patient already
No receiving Yes Yes
on bowel
opioids? No medication?

Encourage non See chart on Consider titrating up to
pharmacologic next page for
prophylaxis. max doses of current
measures. regimen OR add to current

Initiate Senna-S regimen sorbitol 30mL po
1-8 tabs po Qday. BID OR MiraLax OTC®
If no BM x 24 hr,
17gm po Qday.

Initiate magnesium
hydroxide 30mL po
BID. If no BM x 48h,

Initiate bisacodyl 10mg
supp Qday OR glycerin

supp Qday.

If no BM x 72 hr,

Initiate rectal exam
± disimpaction.

Yes No Negative
Rectum bowel
full? High sounds?
impaction?
Initiate sodium Yes
phosphate enema Qday
R/O bowel obstruction.
PRN constipation. See COMPLETE

Initiate citrate of BOWEL OBSTRUCTION
magnesium 1/2 bottle algorithm on page 123.
now. May repeat other 1/2
bottle in 4 hr if no result. 132

Constipation

- Constipation is different for everyone and should be determined based on patient’s
regular bowel pattern and time since last bowel movement – 3 days without a bowel
movement typically requires intervention.

- For patients taking opioids, laxatives should be taken on a regular basis for all patients
- see below for prophylactic bowel regimen

- Fiber should be avoided in patients with poor oral fluid intake as it requires the patient
to take in 1.5 to 2 liters of fluid per day – also, fiber may worsen an obstruction.

Non pharmacologic bowel regimen – BOWEL SMOOTHIE:
Vanilla Yogurt (8 oz), bran 2-3 tbsp, prune juice 4 oz, orange or apple juice 4 oz & banana
(may substitute apple), blend into a smoothie with ice cubes to help w/ bowels.

Prophylactic bowel regimen for patients on opioids: When a patient is prescribed
scheduled opioids, Senna-S should be initiated for prophylaxis, if appropriate, and titrated
accordingly. This prophylaxis is preferable to treating established constipation. If a patient
comes on service and is already taking a scheduled opioid without bowel prophylaxis,
consider adding Senna-S.

This chart below is a guide for starting Senna-S for patients taking opioids on a regular
basis. It is not always recommended to start patients on the doses listed on the charts.
The amount of Senna-S should be based on patient-specific factors (history, clinical status,
comfort, number of BM per day, etc.) and titrated to the clinically appropriate dose for the
patient. While the charts may be a reasonable reference, it will not always prove reliable
due to inter-patient variability.

Senna-S Senna-S Senna-S Senna-S Senna-S
(1 Tablet (1 Tablet (2 Tablets (3 Tablets (4 Tablets
Daily) BID) BID) BID) BID)

Morphine �15mg 16-30mg 35-60mg 60-90mg �100mg
Oxycodone �10mg �20mg 25-40mg 40-60mg �70mg
Hydromorphone �4mg 8mg 9-16mg 17-24mg �25mg
Fentanyl 12mcg 12mcg 25mcg 50-75mcg �100mcg
Hydrocodone �15mg 16-30mg 35-60mg 60-90mg �100mg

Vaseline Balls:
If patient has high impaction, unable to be disimpacted and other therapies such as fleets
enema and mag citrate have failed, consider Vaseline balls. Mineral oil is an effective agent
for constipation as it will lubricate bowel and ease defecation. However, using it orally is
not preferred as there is a risk for mineral oil aspiration causing Aspiration Pneumonitis.
Instead, mineral oil may be given in the form of Vaseline balls to avoid aspirating the liquid.

• Freeze a dollop of Vaseline first.
• Roll/squeeze Vaseline into “pea-sized” balls.
• Roll in confectioners sugar or cocoa powder (for taste).
• Have patient swallow 1-2 balls Q3-4h until BM; may increase if no BM in 12 hours.

133

Constipation (continued)

Commercially Drug Name Drug Name
Available Bisacodyl (Dulcolax®)
Formulations Docusate and Senna
(Senokot-S®) Tablet: 5mg
Usual Dose Rectal suppository: 10mg
Tablet: Docusate sodium 50mg
Max Total Daily and sennosides 8.6mg
Dose (TDD)
1-2 tab po Qday -BID Oral: 5-15mg po single dose
Comments Rectal: 10mg dose
16 tablets
Oral: 30mg for complete bowel
-Stimulant laxative and stool evacuation
softener Rectal: 10 mg
-Initial dose can be 2 tablets,
consider half initial dose in -Stimulant laxative
elderly or debilitated patients -Avoid chronic dosing of
stimulants

Relative Cost/Day Tier 1 Tier 1

Commercially Drug Name Drug Name
Available Sorbitol
Formulations Glycerin Suppositories Solution, oral: 70%

Solution, oral: 50% lime flavor
Solution, rectal: 2.3g/2.3mL and
5.6g/5.5mL
Suppository, rectal: 82.5%, 1g,
1.2g, 2.1g, 2g, and 3g

Usual Dose 1 adult suppository 1-2 times Oral: 30-150mL po (as 70%
Max Total Daily PR a day as needed; 5-15mL solution)
Dose (TDD) PR enema Rectal enema: 120mL PR as
Comments (2) 15mL enema suppository’s 25% to 30% solution
-Osmotic laxative
Relative Cost/Day Titrated to optimal dose based
Tier 1 on individual patient response
and level of tolerance

-Osmotic laxative
-May cause GI side effects such
as diarrhea, dry mouth, nausea,
vomiting, xerostomia
-Monitor for fluid overload
and electrolyte disturbances.
-Preferred over
lactulose (reserved for
hyperammonemia levels)

Tier 1

134

Constipation (continued)

Drug Name Drug Name

Sodium Phosphate/ Magnesium Hydroxide (Milk of
Bisphosphonate Enema (Fleet Magnesia®)
Enema®)

Commercially Enema Liquid, oral: 400, 800mg/5mL
Available Rectal: 1 enema PR daily Tablet, chewable: 311mg
Formulations
15-30mL po daily PRN
Usual Dose constipation
60mL
Max Total Daily 1 enema
Dose (TDD) -Caution in patients with renal
Comments -May cause electrolyte impairment
imbalance Tier 1
Relative Cost/Day Tier 1

Drug Name Drug Name
PEG 3350 (MiraLax OTC®)
Citrate of Magnesia
(Magnesium Citrate)

Commercially Bottle: 300mL 1 Bottle: 527g
Available
Formulations 1 bottle po PRN constipation 17gm po daily PRN constipation
Usual Dose – in divided doses
300mL N/A
Max Total Daily
Dose (TDD) -May keep chilled in -Stir powder in 4-8 ounces of
Comments refrigerator; 300mL= water, juice, soda, coffee or tea
235meq Magnesium = 2.8g until dissolved; may take 2-4 days
Relative Cost/Day Magnesium to produce BM
Tier 1 Tier 2

References:
• http://www.fraserhealth.ca/media/04FHSymptomGuidelinesBowelCare.pdf

• Cherny N, Ripamonti C, Pereira J, et al. Strategies to manage the adverse effects of oral
morphine: an evidence-based report. Journal of Clinical Oncology, 2001.

• Clary P. Pharmacologic perals for end-of-life care. American Family Physician, 2009.

• Droney J, Ross J, Gretton S, et al. Constipation in cancer patients on morphine. Support Care
Center, 2208.

•. Lipman A, Jackson K,Tyler L. Evidence based symptom cotnrol in palliative care. 2000.

• Ross D, Alexander C. Management of common symptoms in terminally ill patients. American
Family Physician, 2001.

• Tywcross R,Wilcock A. Hospice and palliative care formulary usa. 2006.

135

Delirium

Step 1: Rule out any underlying cause.

Is delirium Yes Examples: anticholinergics,
medication Yes benzodiazepines, steroids,
induced?
opioids, NSAIDs, H2
No antagonists, metoclopramide,
stimulants, digoxin, theophylline.
Is delirium
pain induced? See NOCICEPTIVE PAIN
algorithm on page 181.
No Yes
Yes Social worker/
Is delirium chaplain consult.
psychological/
Examples: electrolyte imbalance,
spiritual liver failure, ischemia, renal
induced? failure, impaction, UTI, brain

No metastases, seizures, hypoglycemia,
hyperglycemia, EtOH or
Is delirium drug withdrawal.
due to other

cause?

136

Delirium

No Step 2: Yes

History of

Parkinson’s

disease?

Initiate haloperidol Initiate quetiapine
0.5-2mg po Q2-12h 12.5-25mg po BID.

PRN agitation. Titrate to effect.

Effective? Effective?

No No
Initiate chlorpromazine
Discontinue quetiapine.
12.5-50mg po
Q4-6h PRN agitation. Consider one of the following
alternatives: trazodone 25-50mg
Effective?
po Q4-6h PRN agitation OR
No hydroxyzine 10-50mg po
Discontinue Q4-6h PRN agitation OR
chlorpromazine.
valproic acid 250-500mg po
Consider one of the following: Q12h PRN agitation.
risperidone 0.25-1mg
po BID OR quetiapine
12.5-25mg po BID.

137

Delirium

Delirium is defined by an acute onset of disordered attention and cognition, as well as
disturbances of memory, psychomotor behavior and perception. Patients often will have
altered sleep/wake cycle, mumbling speech, and perceptual disturbances with delusions
and hallucinations. It is important to differentiate delirium/agitation from anxiety before
trying to treat as medication recommendations may vary based on symptom.

Benzodiazepines -These are not the drug of choice for agitation/delirium and should
be avoided if possible as these agents can cause “paradoxical” worsening of confusional
states. They can be used as adjunctive therapy when severe agitation is not controlled by
the neuroleptic.

Haloperidol - Antipsychotics are the first-line pharmacological agents for symptomatic
management of delirium. The best studied drug and the agent of choice for most patients,
is haloperidol, because it has a favorable side effect profile.

ACUTE AGITATION: For acute agitation, haloperidol can be given in a dose
escalation process similar to treating pain. Start haloperidol 0.5-2mg PO or IV
Q1hour PRN x 3 doses. If not effective, may titrate by 2 – 5 mg every 1hour
until patient calm - this total daily requirement can then be scheduled - given
in 2-3 divided doses per day.

Chlorpromazine - Chlorpromazine is indicated for patients in whom sedation is
desired, especially for terminal delirium.This ‘older’ drug is comparable to haloperidol in
controlling delirium but has a higher incidence of side effects: extrapyramidal reactions,
sedation, and hypotension.

ACUTE AGITATION: For acute agitation, thorazine can also be dosed similiarly
to haloperidol. Start thorazine 25 - 50mg po Q1h PRN x 3 doses. If not
effective, may titrate by 25 - 50mg every 1hour until patient calm - this total
daily requirement can then be scheduled - given in 2-3 divided doses per day.

Quetiapine - is associated with fewer drug-induced movement disorders than
haloperidol, and is considered the drug choice in patients with Parkinson’s disease and
related neuromuscular disorders, as well as patients with a history of extrapyramidal
reactions from neuroleptics.

Newer atypical antipsychotics ( Zyprexa®, Geodon®,Abilify®) - may also be
helpful in the treating delirium. However, there is little evidence supporting their use and
they should not be considered a first-line treatment.

Drug Name Drug Name
Trazodone (Desyrel®)
Commercially Hydroxyzine (Atarax®) Tablet: 50mg, 100mg, 150mg,
Available 300mg
Formulations Capsule: 25mg, 50mg, 100mg
Injection: 25mg/mL, 50mg/mL 25-50mg po Q4-6h
Usual Dose Suspension, oral: 25mg/5mL 400mg
Max Total Daily Syrup: 10mg/5mL
Dose (TDD) Tablet: 10mg, 25mg, 50mg -Also has benefit for insomnia
Comments and agitation
25-100mg po Q4-6h Tier 1

600mg

-Very likely to cause
drowsiness

Relative Cost/Day Tier 1

138

Delirium (continued)

Commercially Drug Name Drug Name
Available Haloperidol (Haldol®)
Formulations Chlorpromazine
Usual Dose Solution, oral concentrate: 2mg/ (Thorazine®)
Max Total Daily mL
Dose (TDD) Tablet: 0.5mg, 1mg, 2mg, 5mg, Tablet: 10mg, 25mg, 50mg,
Comments 10mg, 20mg 100mg, 200mg
Injection, solution: 5mg/mL Injection, solution: 25mg/mL
Relative Cost/Day 0.5-5mg po Q2-6h
Based on individual patient 25-100mg po Q4-6h
tolerance, symptoms
-Can be given PO, SL, PR, IM 1000mg/day
-Useful when benzodiazepines
fail -Can be given PO, PR, IM,
-Avoid use in patient’s with or IV
Parkinsons’s disease -May cause significant
-Monitor for extra-pyramidal hypotension. Patients
symptoms (EPS) receiving IV or IM injection
should remain in bed for at
Tier 1 least 1/2 h post-injection to
minimize hypotension.
- Monitor for extra-pyramidal
symptoms (EPS)
CAUTION: Do not confuse
with prochlorperazine
(Compazine®)

Tier 1

Drug Name Drug Name

Risperidone (Risperdal®) Quetiapine
(Seroquel®, Seroquel XR®)

Commercially Tablet: 0.25mg, 0.5mg, 1mg, Tablet, immediate release (IR):
Available 2mg, 3mg, 4mg 25mg, 50mg, 100mg, 200mg,
Formulations Solution, oral: 1mg/mL 300mg, 400mg
ODT: 0.25mg, 0.5mg, 1mg, 2mg, Tablet, extended-release (ER):
Usual Dose 3mg, 4mg 200mg, 300 mg, 400mg

Max Total Daily 0.25-3mg po BID 25-100mg po BID
Dose (TDD)
Comments 16mg Elderly: 400mg/day
Adults: 800mg/day
-Preferred atypical
antipsychotic -Preferred with Parkinson’s
disease.

Relative Cost/Day Tier 2 IR Tablet:Tier 2
ODT:Tier 3 ER Tablet:Tier 3

139