HUGs Book

Delirium (continued)

Commercially Available Drug Name
Formulations
Valproic acid (Depakene®, Depakote®)
Usual Dose
Max Total Daily Dose Capsule: 250mg
(TDD) Syrup (Depakene®): 250mg/5mL
Comments Tablet, delayed-release: 125mg, 250mg, 500mg

Relative Cost/Day 250mg po QHS x 7 days, then 500mg po QHS

Doses vary based on range of therapeutic serum levels.
Target 50-100mcg/mL for seizures and pain

-Somnolence
-Do NOT crush ER formulations
-Depakene (valproic acid syrup) can be given rectally

Tier 1

References:
• Quijada E, Billings JA. Pharmacologic Management of Delirium; Update on Newer Agents, 2nd
Edition. Fast Facts and Concepts. July 2006; 60. Available at: http://www.eperc.mcw.edu/fastfact/
ff_060.htm.

• http://www.fraserhealth.ca/media/07FHSymptomGuidelinesDelirium.pdf

• Breitbart W, Alici Y. Agitation and delirium at the end of life:“we couldn’t manage him”. JAMA
2008; 300:2898-2910.

• Jackson KC, Lipman AG.Drug therapy for delirium in terminally ill adult patients. Cochrane
Database of Systematic Reviews 2004, Issue 2. Art. No.: CD004770. DOI: 10.1002/14651858.
CD004770.

• Trzepacz P, Breitbart W, Franklin J, Levenson J, Martini DR,Wang P.Work Group on Delirium.
Practice guideline for the treatment of patients with delirium. APA Practice Guidelines. 1999

• Institute of Palliative Medicine at San Diego Hospice. Delirium Management

140

Depression

Is prognosis

< 2 months or

No immediate relief Yes*
needed?

Initiate methylphenidate
2.5-5mg po QAM, titrate by
2.5-5mg every 1-2 days (max

30mg) OR prednisone
10mg po Qday.

Does patient Yes Initiate mirtazapine 15mg po
have underlying QHS & titrate, OR initiate
trazodone 50mg po QHS (may
insomnia? titrate up every 3-5 days).

No Initiate desipramine OR
nortriptyline 10mg po QHS,
Does patient Yes double the dose Q72h PRN to
have underlying max of 30mg. If ineffective consider
duloxetine 30-60mg po Qday.
neuropathic
pain?

No

Does patient Yes Initiate paroxetine
have underlying 10mg po Qday.

anxiety?

No

If no other underlying
comorbidities, initiate
sertraline 25mg po Qday

*Can use these medications in combination with antidepressants.
141

Depression

Methylphenidate – commonly if patient has a short prognosis, a psychostimulant
can be started alone or can be added along with an SSRI together with the plan to
withdraw the stimulant while titrating up on the SSRI. This is because typically the onset
of antidepressants effect may take up to 2 to 4 weeks.

• Start methylphenidate at 2.5mg po BID. May increase 2.5 to 5mg every 1 or
2 days until desired effect is reached, or to a maximum daily dose of 30mg per
day. It is recommended not to give after 2pm as late day dosing can affect
nighttime sleep

TCA’s - Desipramine and nortriptyline – generally have fewer side effects, such
as sedation and anticholinergic effects (dry mouth, blurred vision, urinary hesitancy,
or retention, constipation) than the tertiary amines (imipramine, amitriptyline, and
doxepine) and are preferred. Adverse effects usually decrease 3 to 4 days after
initiation of a TCA or after increasing the dosage.

• Avoid TCA’s in patients with significant cardiac issues such as conduction
delays, coronary artery disease, or history of myocardial infarction in past six
months.

• Start at low doses (10 - 25mg po QHS) and increase by 10 - 25mg po every 4
days.

• May provide additional neuropathic pain benefits.

Others:
Wellbutrin® (bupropion) – Can be added to SSRI if needed.This antidepressant

is structurally different from all other marketed antidepressants and the primary

mechanism of action is thought to be dopaminergic and/or noradrenergic

• Tends to be activating/stimulating and has seizure-inducing potential.

Contraindicated in patients with a history of seizure, in those with concomitant

conditions predisposing to seizures, and in patients taking other drugs that

lower seizure threshold.

• Low incidence of sedative, hypotension and anticholinergic side effects.

• Can cause over stimulation.

• Initial: 100mg per day then maintenance: 200mg per day not to exceed 150mg
per dose

Effexor® (venlafaxine) – an SNRI (Serotonin/Norepinephrine Reuptake Inhibitor)

• With the most common side effects are headache, somnolence, dizziness,
insomnia, nausea, dry mouth, constipation, anorexia, and weakness.

• Venlafaxine is associated with an increased risk of hypertension and needs to
be used with caution with cardiac patients

• There is evidence that venlafaxine is effective in treating depression that has
not previously responded to SSRIs

NOTE: The sudden cessation of SSRI therapy when a patient is unable to swallow can
produce a withdrawal syndrome.

• Withdrawal risk is greater with short - half life drugs such as paroxetine and
venlafaxine, lowest with long-half life drugs such as fluoxetine, and are of
intermediate risk for other SSRI’s.

• Withdrawal symptoms include - Flu-like symptoms, Insomnia, Imbalance,
Sensory disturbances, Hyperarousal.

• Symptoms usually begin & peak within one week, last one day to three weeks,
& are usually mild

• If possible, antidepressants should be tapered over at least four weeks if taken
for at least eight weeks.

142

Depression (continued)

Commercially Drug Name Drug Name
Available Prednisone (Deltasone®)
Formulations Methylphenidate (Ritalin®) Tablet: 1mg, 2.5mg 5mg, 10mg,
Usual Dose 20mg, 25mg
Max Total Daily Tablets: 5mg, 10mg, 20mg Solution: 5mg/5mL
Dose (TDD) Oral solution: 5mg/5mL,
Comments 10mg/5mL 10mg po QAM
Highly variable
Relative Cost/Day 2.5mg-5mg po QAM
-Can cause GI upset. Take
60mg with food or milk
-Use in caution in patient with
-Can be used alone on in diabetes
combination with an SSRI or -Will also improve mood,
TCA. appetite and bone pain
-Last dose should be
administered prior to 2pm Tier 1
-Use in caution in cardiac
patients or in patients with
uncontrolled hypertension

Tier 1

Commercially Drug Name Drug Name
Available Trazodone (Desyrel®)
Formulations Mirtazapine (Remeron®) Tablet: 50mg, 100mg, 150mg,
Usual Dose 300mg
Max Total Daily Tablet: 7.5mg, 15mg, 30mg,
Dose (TDD) 45mg 50mg po QHS
Comments SolTab (ODT): 15, 30, 45mg 400mg

Relative Cost/Day 15mg po QHS -Also has benefit for insomnia
and agitation
45mg
Tier 1
-Will also help with sleep and
appetite
-Start at lowest dosage
possible.

Tablet: Tier 1
SoluTab:Tier 3

Drug Name Drug Name
Paroxetine (Paxil®) Desipramine (Norpramin®)

Commercially Tablets: 10mg, 20mg, 30mg, Tablets: 10, 25, 50, 75, 100,
Available 40mg 150mg
Formulations Suspension: 10mg/5mL
Tablets ER: 12.5mg, 25mg 10-150mg po QHS
Usual Dose Tablets CR: 37.5mg 300mg
Max Total Daily
Dose (TDD) 10mg po Qday

50-60mg
(40mg elderly)

Comments - Use lower dosages in renal -Also expected to improve
or hepatic impairment sleep and mood; least
anticholinergic effect; max in
Relative Cost/Day Tier 1 elderly is 150 mg per day
143
Tier 1

Depression (continued)

Drug Name
Sertraline (Zoloft®)

Commercially Available Tablets: 25, 50, 100mg
Formulations Solution, oral: 20mg/mL

Usual Dose 25-200mg po QAM
200mg
Max Total Daily Dose
(TDD) - Use lower dosages in patients with hepatic impairment

Comments

Relative Cost/Day Tier 1

References:
• http://www.fraserhealth.ca/media/08FHSymptomGuidelinesDepression.pdf

• Lauren Rayner, Annabel Price, Alison Evans, Koravangattu Valsraj, Matthew Hotopf and Irene
J Higginson. Antidepressants for the treatment of depression in palliative care: systematic
review and meta-analysis Palliat Med 2011 25: 36 originally published online 8 October
2010

144

Diarrhea

Non-pharmacologic interventions such
as fiber and fluids.

Does the Yes Initiate metronidazole
patient have 250mg po TID OR
c. difficile? vancomycin oral solution

No Yes 250mg po QID.
Yes
Does patient If impaction see
have diarrhea CONSTIPATION.
secondary to algorithm on page 132.
impaction or bowel
obstruction? If obstruction see
COMPLETE BOWEL

OBSTRUCTION
algorithm on page123.

No

Goal to add Yes Initiate fiber (psyllium) Effective?
bulk to stool? 1-2tsp po BID-TID.

No No

Goal to slow Initiate questran
motility? 1 packet (4gm) po

Qday-QID.

Yes No Initiate loperamide 4mg
Effective? po initial dose then 2mg
Mild/transitory diarrhea?
Bismuth subsalicylate after each loose stool.

15-30mL po BID-QID.

OR initiate opium OR initiate lomotil
tincture 0.6mL po Q4h (diphenoxolate/atropine)10mg po
initial dose then 2.5-5mg po Q6h
PRN diarrhea.
PRN diarrhea.
145

Diarrhea

Unlike constipation, where multiple drugs are used simultaneously, a single drug should be
used for diarrhea and care should be taken to avoid sub-therapeutic doses.

Fiber - Bulking of the feces (with methylcellulose or psyllium) can reduce the frequency
of diarrhea and establish a bowel routine

Bismuth salicylate – has an antimicrobial effect – 15-30mL po BID-QID

Loperamide – Drug of choice – is less likely to cross the blood brain barrier and
therefore less side effects. Although the package insert recommends a maximum of 16mg
in a 24-hour period, up to 54mg per day of loperamide has been used in palliative care
settings with few adverse effects

Octreotide -Octreotide is an effective therapy for severe persistent, secretory
refractory diarrhea. Octreotide 50mg SubQ Q8–12h, then titrate up to 500mg Q8h
SubQ, or higher

Others:

Aspirin 325mg po Q4-6h and cholestyramine 4gm TID can reduce the
diarrhea in radiation - induced enteritis, as can addition of a stool bulking agent
such as psyllium (MetamucilTM, others),

Mesalamine is good at treating flares of ulcerative colitis.

Pancrelipase is used for pancreatic insufficiency. 1-3 tab po with meals and 1
tab with snacks.

Cholestyramine binds C difficile toxin. May be used to manage diarrhea
associated with pseudomembranous colitis. Also binds to vancomycin, making
it ineffective; do not use in combination. Not absorbed from the GI tract.

Commercially Drug Name Drug Name
Available Psyllium (Metamucil®) Bismuth Subsalicylate
Formulations (Pepto Bismol®)
Usual Dose Capsules: 500mg Tablet, chewable: 262mg
Max Total Daily Powder: 454gm Liquid, oral: 262mg/15mL
Dose (TDD)
Comments Psyllium: 2.5-30gm po per day in 524mg po Q30-60min
divided doses PRN diarrhea
Relative Cost/Day 30gm 8 doses

-Drink at least 8 ounces of liquid with -May cause discoloration
each dose. Powder must be mixed in of the tongue (darkening),
a glass of water or juice grayish black stools
-Use with caution in patients who
may have insufficient fluid intake Tier 1
which may predispose them to fecal
impaction and bowel obstruction.
Tier 1

146

Diarrhea (continued)

Commercially Drug Name Drug Name
Available Cholestyramine (Questran®)
Formulations Powder, Packet & Scoop: 4g Opium Tincture, Paregoric
of Cholestyramine per 9gm
Usual Dose scoop/packet Tincture 10%, oral:
w/ anhydrous morphine
Max Total Daily 4gm po Qday-QID 10mg/mL [0.6mL = to morphine
Dose (TDD) 6mg; contains ethanol 19%]
Comments 24gm
Doses expressed in mg: 6mg
Relative Cost/Day -Dissolved in 4oz of water, of undiluted opium tincture po
juice or broth (10mg/mL) Q4h PRN diarrhea
-May also mix with applesauce.
Tier 1 N/A

-Opium Tincture contains 25
times more morphine than
paregoric.

Tier 2

Commercially Drug Name Drug Name
Available
Formulations Metronidazole (Flagyl®) Vancomycin (Vancocin®)

Tablet: 250mg, 500mg Powder for oral soln:
Capsule: 375mg 250mg/5mL, 500mg/6mL
Tablet ER: 750mg Oral capsules: 125mg, 250mg
Injection: 5mg/1mL Powder for injection: 500mg,
750mg, 1g, 5g, 10g,
Usual Dose 250-500mg po TID
4000mg 250mg oral soln. po QID
Max Total Daily
Dose (TDD) -May cause GI upset. 1gm
-NO ALCOHOL within 24hrs
Comments -Reconstituted vial for
injection given orally is most
Relative Cost/Day Tier 1 cost effective.

Tier 3

Commercially Drug Name Drug Name
Available Loperamide (Immodium® A-D) Diphenoxylate/atropine
Formulations (Lomotil®)
Usual Dose Caplet: 2mg Tablet: 2.5mg/0.025mg/5mL
Capsule: 2mg Solution: 2.5mg/0.025mg/5mL
Max Total Daily Solution: 1mg/5mL, 1mg/7.5mL
Dose (TDD) 2mg po after each loose stool 1-2 tab po after each loose stool
Comments PRN diarrhea PRN diarrhea
16mg 20mg
Relative Cost/Day
Avoid use in patients with C. Avoid use in patients with C. diff
diff associated diarrhea associated diarrhea
Tier 1 Tier 1

References:
Alderman J. Diarrhea in Palliative Care, 2nd Edition. Fast Facts and Concepts. October 2007; 96.
Available at: http://www.eperc.mcw.edu/fastfact/ff_096.htm.

147

Dyspepsia

Initiate non-pharmacologic
interventions

Is patient on No
an NSAID or
Identify etiology.
steroid?

Yes Cramping? Yes Initiate dicyclomine
10-20mg po Q6h PRN
Consider converting to GI secretions/cramps.
celecoxib* 200mg po
Qday-BID OR add No
omeprazole magnesium
20mg po Qday-BID. Yes Initiate simethicone
Gas? 80-160mg po TID
Gastric Yes
statsis? PRN gas.

No

Initiate metoclopramide 5-10mg po
QID (30 min before each meal

& at bedtime) OR if patient has a
movement disorder initiate erythromycin

125-250mg po QID.

No Initiate aluminum 200mg/
magnesium 200mg/
Hear tburn? Yes Effective?
simethicone 20mg per
5mL : 15-30mL po QID No
Assess renal function.
PRN dyspepsia.

Initiate ranitidine CrCl > *Requires CM approval
150mg po BID OR Yes 50mL/min.
famotidine 20mg po BID.

Effective? Initiate ranitidine Yes CrCl <
150mg po Qday. 50mL/min.
No
Discontinue ranitidine. Initiate No Rule out serious
omeprazole OTC 20mg po Effective? GI condition
Qday OR lansoprazole ODT* (ulcer, GERD).

30mg po Qday. 148

Dyspepsia (continued)

Commercially Drug Name Drug Name
Available Dicyclomine (Bentyl®)
Formulations Tablet: 20mg Simethicone (Mylicon®)
Capsule: 10mg
Usual Dose Syrup: 10mg/5mL Tablet, chewable: 80mg,
Max Total Daily Injection (IM only): 10mg/mL 125mg
Dose (TDD) Softgels: 125mg, 166mg,
Comments 10-20mg po Q6-8h 180mg
160mg Suspension, oral drops:
Relative Cost/Day 40mg/0.6mL

40-125mg po QID

500mg

-Anticholinergic medication N/A
that decreases secretions and Tier 1
bowel cramping.
-May cause anticholinergic
side effects including urinary
retention, blurry vision, dry
eyes and dry mouth

Tier 1

Commercially Drug Name Drug Name
Available
Formulations Famotidine (Pepcid®) Ranitidine (Zantac®)
Usual Dose
Max Total Daily Tablet: 10mg [OTC], 20mg Tablet: 75mg [OTC], 150mg
Dose (TDD) [OTC] [OTC], 300mg
Comments Syrup: 15mg/mL
Capsule: 150mg, 300 mg
Relative Cost/Day
10-20mg po Qday -BID 75-150mg po QHS-BID

40mg – usual 300mg
Up to 160mg po Q6h for
hypersecretory conditions -Maximum dosage
recommended in renal
-Maximum dosage insufficiency is 150mg/day.
recommended in renal -Well tolerated, can be
insufficiency is 20mg/day to crushed.
avoid delirium
-Pepcid Complete OTC also Tier 1
contains calcium carbonate
and magnesium hydroxide,
antacids which may be helpful
in relieving GI irritation

Tier 1

149

Dyspepsia

Commercially Drug Name Drug Name
Available
Formulations Omeprazole magnesium Lansoprazole (Prevacid®,
(Prilosec® OTC) Prevacid® Solu-Tab)
Usual Dose
Max Total Daily Tablet, delayed release: 20mg Capsule, delayed release:
Dose (TDD) [OTC] 15mg, 30mg
Comments Capsule, delayed-release, Rx Capsule, delayed release:
only: 10mg, 20mg, 40mg 15mg [OTC]
Granules, for oral suspension:
15mg/packet, 30mg/packet
Injection, powder for
reconstitution: 30mg
Tablet, orally disintegrating
(ODT): 15mg, 30mg

20mg po Qday-BID 30mg po/sl Qday

360mg 180mg

-Do not crush -Recommend to reserve
-Best results if taken 30-60 ODT for patients unable to
minutes prior to a meal swallow due to high cost

Relative Cost/Day OTC:Tier 1 OTC:Tier2
Rx:Tier 3 Cap:Tier 3
ODT:Tier 3

Commercially Drug Name
Available Aluminum/Magnesium (Mylanta® , Maalox®)
Formulations Liquid: Aluminum hydroxide 200mg, magnesium hydroxide
200mg, and simethicone 20mg per 5mL (360mL);
Usual Dose aluminum hydroxide 400mg, magnesium hydroxide 400mg,
and simethicone 40mg per 5mL (360mL)
Max Total Daily Tablet, chewable: Aluminum hydroxide 200mg, magnesium
Dose (TDD) hydroxide 200mg, and simethicone 25mg per tablet
Comments 15-30mL po 4 x daily PRN dyspepsia, or
2-4 tablets po 4x daily PRN dyspepsia
Relative Cost/Day N/A

-Avoid use in end stage renal disease

Tier 1

References:
• Berardi RR, McDermott JH, Newton GD, et al. Heartburn and dyspepsia and intestinal gas. In:
APhA Handbook of Non-prescription drugs. 14 th ed. Washington D.C.:
McGraw Hill;2004:317-65.

• Talley, NJ,Vakil N. Guidelines for the management of dyspepsia. Amer J Gastroenterol 2005;
100:2324-2337.

150

DyspneaIdentify etiology
if possible.
151
Blocked No No No COPD/ Yes Using
nasal Hypoxia? Secretions? pulmonary inhaler?
disorder?
passages?

Yes Yes Yes No No Yes

Initiate normal saline Initiate oxygen See algorithm Edema? Ensure patient
nasal spray 1-2 squirts per protocol. can manipulate
each nostril PRN SOB. for SECRETIONS correctly & respire
on page 189. deeply. Convert to
nebulizer therapy.

Resolved? Dyspnea/ Yes Initiate oxygen
Short of Breath per protocol.
No Initiate lasix 40-80mg po
Proceed to following page, Qday in divided doses.

Renal Insufficiency Step.

No Compression No No No Optimize nebulizer treatments.
(tumor Unknown? (Consider albuterol and/or
Edema Anxiety? Infection? ipatroprium nebulizers
continued progression, Q4h ATC or PRN SOB).
etc.)? Resolved?

No

Consider additional Start or optimize steroid, Initiate lorazepam 0.5mg Initiate anti-infective Renal Yes Initiate oxycodone IR
diuretic. prednisone 10mg po Qday po/SL Q2h PRN SOB & agent if appropriate. insufficiency? 5mg tab crushed, po/SL
or decadron 4mg po Qday. opioid (proceed to end). (CrCl <30mL Q1h PRN SOB.

per/min)

Initiate oxygen Initiate buspar No
per protocol. 10mg po BID.
Initiate Roxanol® 5mg po/SL
152 Q1h PRN SOB. Continue to
titrate to optimal dose OR

add a long-acting opioid
such as MS Contin.

Dyspnea/Short of Breath (SOB)

- Often regarded as the most distressing symptom at end of life, this symptom is
not isolated to patients with end-stage pulmonary disease (One study found that of all
patients entering hospice with dyspnea only 39% had primary lung problems)

- Pathophysiology may reflect regulation of breathing, the act of breathing, or the need
to alter breathing patterns because of increased activity or hypoxia

- Target treatment at the underlying cause (etiology), if known - if there is no known
etiology, then basic symptom management should be initiated

Opioids: Low dose opioids (generally morphine or oxycodone) given over frequent
intervals are the mainstay of symptom management and should be titrated to relief
– may need to treat aggressively with opioids as well as sedatives until comfort is
a chie ved
• Methadone should generally be avoided due to insufficient data

• Opioids help reduce inappropriate tachypnea (rapid breathing) and over-
ventilation of the large airways.They do not cause CO2 retention when used
in this way, and they can even reduce cyanosis by slowing ventilation and
making breathing more efficient.

• Nebulized opioids should generally be avoided due to conflicting data regarding
efficacy and safety
Corticosteroids are particularly indicated in the presence of bronchial obstruction
– and a steroid burst with high dose steroids could be considered if dyspnea has not
responded to other measures.

Anxiolytics such as Ativan should be added to opioid therapy for severe anxiety and
respiratory “panic attacks”.

Antipsychotics such as Haldol can be a useful adjuvant in chronic dyspnea, particularly If
the patient already feels drowsy.

Nebulized furosemide should generally be avoided due to conflicting reports
regarding efficacy

Promethazine 25mg PO/PR 4 to 5 times a day may be initiated if the aforementioned
options are initiated at optimal dose(s) but are still inadequate

Nonpharmacologic therapy

• Promote good air movement near the patient
• Cool room temperature
• Humidify air for some patients
• Avoid extreme temperature changes
• Minimize exertion
• Minimize stress
• Postural drainage for some patients

Commercially Drug Name Furosemide (Lasix®)
Available
Formulations Saline solution for nebulization Tablet: 20mg, 40mg, 80mg
(BronchoSaline®) Solution: 10mg/mL
Usual Dose
Vial: 0.9% solution sodium
Max Total Daily Dose chloride
(TDD)
Neb 3mL Q4h PRN SOB 20-60mg po Qday
Comments 150mEq of sodium chloride
600mg po
-Should be used 10-15min 6gm IV
after bronchodilator
-Monitor for hypokalemia

Relative Cost/Day Tier 1 Tier 1
153

Dyspnea/Short of Breath (SOB) continued

Drug Name Drug Name
Oxycodone (immediate
Commercially Morphine (immediate release) release)
Available (Roxanol®) (avoid use of MSIR (OxyIR®, Oxyfast®, Oxydose®)
Formulations as this is considered an unsafe
abbreviation by ISMP and the Capsule, immediate release:
Usual Dose Joint Commission) 5mg
Max Total Daily Solution, oral: 5mg/5mL
Dose (TDD) Solution, oral: 10mg/5mL, Solution, oral concentrate: 20mg/
20mg/5mL mL
Solution, oral concentrate: Tablet: 5mg, 15mg, 30mg
20mg/mL
Suppository, rectal: 5mg, 10mg, Dosed Q2-4h
20mg, 30mg Based on individual response
Tablet: 15mg, 30mg
-Preferred for patients with
Dosed Q2-4h renal or hepatic dysfunction
-Dosage for dyspnea generally
Based on individual response 5-10mg po/sl Q2h PRN SOB

Comments -Avoid in patients with severe Tier 1
renal or hepatic impairment
-Dosage for dyspnea generally
5-10mg po/sl Q2h PRN SOB

Relative Cost/Day Tier 1

Commercially Drug Name Drug Name
Available Lorazepam (Ativan®)
Formulations Morphine (sustained release)
Usual Dose (MS Contin®, Oramorph®, Solution, oral [concentrate]: 2mg/mL
Max Total Daily Avinza®, Kadian®) Tablet: 0.5mg, 1mg, 2mg
Dose (TDD) Injection, solution: 2mg/mL, 4mg/mL
Comments Tablet, Capsule CR/SR: 15mg,
30mg, 60mg, 100mg, 200mg 0.5-2mg Q4-6h po PRN SOB or
Relative Cost/Day Capsule, ER (Avinza®): 30mg, scheduled
60mg, 90mg, 120 mg
Based on individual response/
Dosed po Q12h; Avinza tolerance
dosed Q24h
-Can be given PO, SL, PR, SubQ
Based on individual -Reduce initial dose if liver disease
response/tolerance present
-Initial dose: 0.5mg po/sl Q4h PRN
-Avoid in patients with anxiety
severe renal or hepatic -May cause a paradoxical reaction,
impairment contributing to (instead of
-DO NOT CRUSH relieving) anxiety
-Can be given rectally
Tier 1
ER/SR Tablet:Tier 1
ER Capsule:Tier 3

154

Dyspnea/Short of Breath (SOB) continued

Commercially Drug Name Drug Name
Available
Formulations Prednisone (Deltasone®) Dexamethasone (Decadron®)

Tablet: 1mg, 2.5mg, 5mg, Solution, oral [concentrate]: 1mg/mL
10mg, 20mg, 50mg Tablet: 0.25mg, 0.5mg, 0.75mg, 1mg,
Solution, oral: 1mg/mL 1.5mg, 2mg, 4mg, 6mg
Solution, oral concentrate: Injection, solution, as sodium
5mg/mL phosphate: 4mg/mL, 10mg/mL

Usual Dose 10-20mg po Qday 2-4mg po BID
80mg 40mg
Max Total Daily
Dose (TDD) -CAUTION in patients -Can cause GI upset, especially
with diabetes, monitor BG if not taken with food, and may
Comments levels when initiating and increase risk of a GI bleed
discontinuing -Use with caution in diabetes
-Side effects: GI upset, GI -Give last dose before 2pm to
bleed avoid insomnia
-May also improve appetite
and dyspnea
-DRUG OF CHOICE for
bone pain in non-diabetic
patients

Relative Cost/Day Tier 1 Tier 1

References:
• Foral, PA, Malesker MA, Huerta G. et al. Nebulized opioids use in COPD. Chest 2004;
125:691-4.
• Newton, PJ, Davidson PM, Macdonald P, et al. Nebulized furosemide for the management of
dyspnea: does the evidence support its use? J Pain Symptom Manage 2008;36:424-41.
• Ross, DD and Alexander, CS. Management of common symptoms in terminally ill patients. Am
Fam Physician 2001;64:1019-26.
• Twycross R and Wilcock A. Hospice and palliative care formulary USA, 2nd ed. Nottingham,
United Kingdom: palliativedrugs.com, Ltd; 2008. P.235.
• http://www.fraserhealth.ca/media/Dyspnea.pdf

155

Edema

Eliminate any medication that may be
causing edema, if possible.

Initiate non-pharmecologic
therapy. If ineffective
identify etiology

Ejection Initiate loop diurectic
fraction < 30%
Patient Yes Yes such as furosemide 20-60mg
presenting po Qday.Titrate up to
w/CHF? (end stage
40mg Q8h & consider
disease).
potassium supplement.

No Yes
No
Patient
presenting Effective?
with nephrotic
syndrome Ejection Yes CrCL
(albumin fraction < 50mL?
> 30%.
low)? No

No Yes

No

CrCL Yes Initiate hydrochlorothiazide
> 50mL? 25-50mg po BID and/or
spironolactone 25-50mg
po Qday.

Patient Initiate furosemide 20-60mg
presenting po Qday up to 80mg Q8h
with cirrhosis/ and hydrochlorothiazide
ascites? 50-100mg po Q12h OR
metolazone 5-10mg po Qday.
Yes

Initiate spironolactone
50-100mg po Qday

(titrate up to
400mg Qday).

CrCL Yes
> 50mL?
Initiate hydrochlorothiazide
25-50mg po BID.

CrCL Initiate loop diuretic No
< 50mL? such as furosemide Effective?
40-80mg po Qday.
Yes

156

Edema

Medications that may cause or contribute to edema: Steroids, NSAIDs, potent
vasodilators such as minoxidil or diazoxide, calcium channel blockers, antidepressants,
estrogens, etc.

Non-pharmacologic therapy: Fluid restriction, limiting sodium intake to under 2g
per day, compression stockings, remaining face up on back with legs elevated for a few
periods throughout the day.

Metolazone: There are conflicting reports regarding the necessity to dose thiazides
(i.e. metolazone, hydrochlorothiazide, etc.) 30 minutes prior to the loop diuretic (i.e.
furosemide) when used to augment diuresis. It appears that this dosing is only indicated
when the patient has been prescribed a burst treatment – that is – for a short period
(as opposed to ongoing treatment).

Ethacrynic acid is the loop diuretic of choice for patients with a true sulfa allergy.
Ethacrynic acid 50 to 200mg per day in 2 divided doses is the standard starting dose,
and this dose should be titrated in increments of 25 to 50mg at intervals of several days
to a maximum of 400mg per 24 hours.

Diuretics - Malignant ascites generally does not respond to diuretic treatment
although no randomized trials have been performed, therefore, should be considered,
but have to be evaluated individually.

• Patients with malignant ascites secondary to hepatic metastases, those with
portal hypertension, as well as those with heart failure and cirrhosis, may
respond to diuretic therapy. Diuretics may be initiated after first abdominal
paracentesis.

• Spironolactone 100mg daily titrated slowly to 400mg daily – titrated to remove
enough fluid for comfort.

• Furosemide 40 to 120mg daily may be added to spironolactone to improve
the effect and prevent hyperkalemia.

• Patients receiving diuretics should be monitored for excessive diuresis,
dehydration, and electrolyte disturbances (especially hypokalemia).

“Chemical” paracentesis - First-line diuretic therapy for cirrhotic ascites is the
combined use of spironolactone (Aldactone) and furosemide (Lasix). Beginning dosages
are 100mg po daily – BID of spironolactone and 40-80mg po daily – BID of furosemide
by mouth daily. Plus adding decadron 4-8mg po BID (Source: Cleveland Clinic)

Octreotide in doses of 200 to 600mcg SubQ per day (in two to three divided doses)
has shown promise in cases of ascites refractory to paracentesis.

Commercially Drug Name Drug Name
Available Metolazone (Zaroxolyn®) Ethacrynic Acid (Edecrin®)
Formulations Tablet: 2.5, 5, 10mg Tablet: 25mg
Solution: 10mg/mL
Usual Dose 50-100mg po Qday-BID
2.5-20mg po Qday 400mg
Max Total Daily 20mg
Dose (TDD) -Loop diurectic of choice in
-Not a potent diuretic alone patients with true sulfa allergy
Comments -Used in combination with
loop diurectic Tier 3

Relative Cost/Day Tier 1

157

Edema (continued)

Commercially Drug Name Drug Name
Available Furosemide (Lasix®) Spironolactone (Aldactone®)
Formulations Tablet: 20mg, 40mg, 80mg Tablet: 25mg, 50mg, 100mg
Usual Dose Solution: 10mg/mL
Max Total Daily 25mg po Qday
Dose (TDD) 20-60mg po Qday 400mg
600mg po
Comments 6gm IV -Potassium sparing diuretic
-Especially useful in patients
Monitor for hypokalemia with ascites. Prevents third
spacing
Relative Cost/Day Tier 1
Tier 1

Commercially Drug Name Drug Name
Available
Formulations Potassium chloride Hydrochlorothiazide (HCTZ)

Usual Dose Tablet: 8mEq, 10mEq Capsule: 12.5mg
Max Total Daily Table, ER: 8mEq, 10mEq, Oral Solution: 50mg/5mL
Dose (TDD) 20mEq Tablet: 12.5mg, 25mg, 50mg
Oral Solution:20mEq/15mL,
Comments 40mEq/15mL

Dependent on deficiency 25-50mg po Qday
100mEq
50mg HTN
200mg edema

-May cause diarrhea, nausea/ -Use with caution in patients
vomiting or abdominal pain with severe renal impairment

Relative Cost/Day Tier 1 Tier 1

References:
• Cairns W, Malone R. Octreotide as an agent for the relief of malignant ascites in palliative care
patients. Palliative Medicine.
1999;13:429-30.

• Dipiro, JT,Talbert RL,Yee GC, et al. Pharmacotherapy a pathophysiologic approach. Disorders
of sodium and water homeostasis. 7th ed. New York, NY:McGraw-Hill;2008:845-860.

• Twycross R and Wilcock A. Hospice and palliative care formulary USA, 2nd ed. Nottingham,
United Kingdom: palliativedrugs.com, Ltd; 2008. P.235.

• LeBlanc K, Arnold RA. Palliative Treatment of Malignant Ascites. Fast Facts and Concepts.
March 2007; 177. Available at: http://www.eperc.mcw.edu/fastfact/ff_177.htm.

• :http://www.fraserhealth.ca/media/03FHSymptomGuidelinesAscites.pdf

158

Fever

Non-pharmacologic interventions such
as pat down patient with tepid water

and encourage fluid.

Effective? Yes
Continue to monitor.

No

Treat accordingly (UTI/
Yes other infections, serotonin
Are there any

underlying factors syndrome neuroleptic

to address? malignant syndrome, etc.)

No No Effective?
No
Is patient able Yes
to swallow po Initiate comfort care,
continue to monitor.
meds?

Yes Initiate APAP 650mg
supp PR Q4h PRN
Initiate APAP 650mg po fever (max 3gm/24h in
Q4h PRN fever (max elderly or hepatic impairment).
3gm/24h in elderly or
hepatic impairment).

Effective? Effective? Yes Continue to treat
and monitor.
No
No
Alternate with
ibuprofen 400-600mg Alternate with ASA
600mg supp Q4h
po Q4h PRN fever.
PRN fever.
159

Fever

1. Initiate non-pharmacological interventions such as sponge patient with tepid water
and encourage fluid.

2. Initiate acetaminophen 325-650mg po/PR Q4hr PRN fever.

3. If ineffective, then alternate acetaminophen with ibuprofen 400mg po Q4hr PRN
fever OR aspirin 600mg supp Q4hr PRN fever.

Commercially Drug Name Drug Name
Available
Formulations Acetaminophen (Tylenol®) Ibuprofen (Motrin®, Advil®)

Tablet: 325mg, 500mg Tablet, Chewable: 50mg, 100mg
Tablet ER: 650mg Capsules: 200mg
Tablet, Chewable: 80mg, 160mg Capsules (liquid filled): 200mg
Tablet, ODT: 80mg, 160mg Oral Suspension: 50mg/1.25mL,
Elixir: 160mg/5mL 100mg/5mL, 200mg/10mL
Capsule: 500mg Tablet: 200mg, 400mg, 600mg,
Oral solution: 120mg/5mL, 800mg
160mg/5mL, 500mg/5mL,
80mg/0.8mL

Usual Dose 325-650mg po Q4h PRN 400mg po Q4h PRN fever
fever 3,200mg
Max Total Daily
Dose (TDD) 4gm
Comments
-Max of 3000mg/day in the -May cause GI upset. Take
elderly with food or milk.
-Avoid use in ES liver disease -Monitor concomitant use
with cortisteroids

Relative Cost/Day Tier 1 Tier 1

Commercially Drug Name
Available
Formulations Aspirin

Rectal Suppository: 300mg, 600mg
Tablet, Chewable: 81, 325, 500, 650mg

Usual Dose 600mg suppository PR Q4h PRN fever
4gm
Max Total Daily Dose
(TDD) -Monitor for antiplatelet effects

Comments

Relative Cost/Day Tier 1

Reference:
• Tywcross R,Wilcock A. Hospice and Palliative Care Formulary USA. 2nd ed. Ashland, OH. BookMasters
Inc.;219-248.

160

Hiccups

If possible, eliminate any environmental cause/trigger,
& eliminate any medication that may be causing.
Initiate non-pharmacologic therapy.
If ineffective, identify etiology and treat accordingly.

Hiccups Yes Initiate simethicone
related to
80mg po TID-QID PRN
gas/bloating?
gas/bloating.

Hiccups Yes
related to See DYSPEPSIA
dyspepsia?
algorithm on page 148.

No Initiate metoclopramide
Yes 5-10mg po QID 30 mins before
Hiccups
related each meal & at bedtime. OR,
to gastric if patient has movement disorder,
stasis?
initiate erythromycin
No 125-250mg po QID.

Hiccups Yes Initiate nifedipine 10mg
related to local po TID w/food and
neural nerve
compression? titrate to optimal effect.

No

Unknown Yes Initiate baclofen 5-20mg No
etiology? po TID-QID a day.
Resolved?

Convert to chlorpromazine No Continue
10-25mg po QID. Consider adding or Effective? and monitor.
converting (based on patient specific
characteristics) gabapentin 300mg po *Requires CM approval.
TID (titrated to optimal effect) OR

methylphenidate 5mg po BID OR
olanzapine* 2.5-5mg po Qday.

161

Hiccups

Environmental causes: personal triggers, emotional issues, temperature change,
dehydration.

Non-pharmacologic therapy: slow or rapid consumption of cold liquid from the
opposite side of glass, eye ball compression, biting a lemon, slow bag breathing, eating or
licking a sugar and peanut butter paste, carotic massage.

Transient hiccups can generally be managed with non-pharmacologic therapy, but some
patients experience persistent/intractable hiccups lasting more than 48 hours. Intractable
hiccups generally require pharmacologic intervention. Etiologic treatment is ideal, but,
since many cases are of an unknown etiology, symptomatic treatment is warranted

Alternatives:

• Haloperidol – a useful alternative to chlorpromazine; give a 2-5mg (SubQ/PO)
loading dose followed by 1-4mg po TID.

• Gabapentin – doses of 300-400mg poTID have been described as effective in
multiple case reports.

• Phenytoin – reportedly effective in patients with a CNS etiology of their hiccups.
Dose: 200mg slow IV push followed by 300 - 400mg po daily.

• Valproic Acid 250-500mg po TID

• Nebulized sodium chloride 0.9%, 2mL given over 5 mins

Other drugs that have been tried with very limited success include: Carbamazepine,
benzotropine, carvediol, amitriptyline, sertraline, inhaled lidocaine, ketamine, edrophonium,
and amantidine.

Commercially Drug Name Drug Name
Available
Formulations Simethicone (Mylicon®) Phenytoin (Dilantin®, Penytek®)

Usual Dose Tablet, chewable: 80mg, 125mg Capsule, ER: 100, 200, 300mg
Softgels: 125, 166, 180mg Tablet, chewable: 50mg
Max Total Daily Susp, oral: 40mg/0.6mL PO Susp: 25mg/mL
Dose (TDD)
40-125mg po QID 200-400mg po Qday
Comments
500mg 400mg

N/A -Highly protein-bound.
Reduce dose in patients with
hypoalbuminemia
-Poor rectal absorption

Relative Cost/Day Tier 1 Tier 1

Drug Name Drug Name

Nifedipine (Procardia®, Adalat®) Gabapentin (Neurontin®)

Commercially Capsule: 10mg, 20mg, Capsule: 100, 300, 400mg
Available Tablet, ER: 30, 60, 90mg, Tablet: 600, 800mg
Formulations Soln, oral: 250mg/5mL

Usual Dose IR: 10-20mg po TID 100mg po TID.Titrate by
ER: 30-90mg po Qday 100mg/dose Q3days

Max Total Daily IR: 180 mg 3600mg
Dose (TDD) ER: 90mg

Comments -May cause constipation -May cause memory loss
-Do not crush ER tablet -Dosage adjustment required
-Abrupt withdrawal may cause in renal impairment
rebound angina in patients w/CAD

Relative Cost/Day Tier 1 Tier 1

162

Hiccups

Commercially Drug Name Drug Name
Available Baclofen (Lioresal®)
Formulations Tablet: 10mg, 20mg Chlorpromazine (Thorazine®)

Usual Dose 5-20mg po TID Tablet: 10mg, 25mg, 50mg, 100mg,
80mg 200mg
Max Total Daily Injection, solution: 25mg/mL
Dose (TDD) -May decrease seizure
threshold 10-50mg po Q4-6h
Comments -Avoid abrupt
withdrawal 2000mg

Relative Cost/Day Tier 1 -Can be given PO/SL/PR
-More sedating than haloperidol
-Avoid in patients with Parkinson’s
disease
-CAUTION: Do not confuse with
prochlorperazine (Compazine®)

Tier 1

Commercially Drug Name Drug Name
Available Metoclopramide (Reglan®)
Formulations Erythromycin (Ery-Tab®, E.E.S.®,
Er ythrocin®) Tablet: 5mg, 10mg
Usual Dose Syrup: 5mg/5mL
Max Total Daily Oral susp: 200mg/5mL; 400mg/5mL Injection, solution: 5mg/mL
Dose (TDD) Tablet, delayed-release, enteric coated,
Comments as base: 250, 333, 500mg 5-10mg po QID
Tablet, as base/stearate: 250, 500mg
Relative Cost/Day Tablet, as ethylsuccinate: 400mg 60mg; 20mg in renal
impairment
250mg po TID
-Doses greater than
Variable 40mg /day have been
associated with an
-Risk of QTc prolongation, increased risk of EPS
especially in combination with other symptoms
QTc prolonging agents -Avoid in patients with
-May cause GI upset and diarrhea; Parkinson’s disease
take with food -Monitor for agitation
-Avoid giving with milk or acidic Tier 1
beverages

Tier 1

References:
• Cunningham VL. Benztropine for the treatment of intractable hiccups: New indication for an
old drug? Canadian Journal of Emergency Medicine. 2001;Vol4(3): 205

• Marinella, MA. Diagnosis and management of hiccups in the patient with advanced cancer. J
Support Oncol 2009;7:122-7,30

• Regnard C. Hiccup. Oxford Textbook of Palliative Medicine. 3rd Edition;2004:477-9.

• Twycross R and Wilcock A. Hospice and palliative care formulary USA, 2nd ed. Nottingham,
United Kingdom: palliativedrugs.com, Ltd; 2008. P.235.

• Woelk, CJ. Palliative care files. Canadian Fam Phys. 2011;57:672-5.

• Farmer C. Management of Hiccups, 2nd Edition. Fast Facts and Concepts. October 2007; 81.
Available at: http://www.eperc.mcw.edu/fastfact/ff_081.htm.

163

164

InsomniaRule out secondary causePast orYesInitiate trazodone 25-50mg
(condition, medication, factor). present po QHS & increase every
165Initiate non-pharmacologic interventions.substance Effective?
abuse? 7 days until optimal effect
No
No (generally 150-300mg po QHS).
Initiate melatonin
3-5mg po QHS and/or

ramelteon* 8mg po
within 30 min of bedtime.

Identify type
of insomnia.

Difficulty Difficulty Mixed.
falling asleep staying asleep.

Under 65 65 Under 65 65 Initiate temazepam
or older or older 15-30mg po QHS

PRN insomnia.

Initiate trazodone Initiate zolpidem Initiate temazepam Initiate trazodone Re-evaluate every
25-50mg po QHS 5-10mg po QHS 15-30mg po QHS 50-100mg po QHS 1-2 weeks.
PRN insomnia OR PRN insomnia.
temazepam 15-30mg po PRN insomnia. PRN insomnia.
QHS PRN insomnia. Effective?
Effective?
Effective?
No Consider adding Effective? Yes
temazepam 15-30mg po

QHS PRN insomnia.

Effective?

No No No Effective? No

Convert to zolpidem Consider converting Convert to or add No Refractory insomnia:
5-10mg po QHS to temazepam trazodone 50-100mg Consider another agent
PRN insomnia. Consider adding based on patient specific
15-30mg po QHS po QHS. melatonin 3mg
PRN insomnia. characteristics.
po QHS .

166 *Requires CM approval.

Insomnia

Primary insomnia develops from an unknown etiology and is not attributed to a medical,
psychiatric, or environmental cause. Patients may present with difficulty falling asleep
(sleep latency), difficulty staying asleep (sleep maintenance), or poor sleep quality
(difficulty falling and staying asleep, early morning awakenings, etc.).

Eliminate unnecessary medications that may cause or contribute to insomnia: alcohol,
nicotine, caffeine, theophylline, amphetamines, decongestants, beta agonists, H2-blockers,
and certain antidepressants. Steroids should be scheduled at or before 2pm daily to
lessen the risk of nighttime insomnia. Diuretics should be given earlier in the day if
undesirable urinary urge or frequency occur after late day dosing.

Manage conditions that may cause or contribute to insomnia:
• Agitation
• Allergies
• Anxiety/stress
o Consider a longer-acting benzodiazepine
• Depression
o Consider mirtazapine due to noted sedative effects
o Consider adding trazodone to augment treatment with an SSRI
• Heart failure
• Overactive bladder, BPH, nocturia
• Pain
• Pulmonary conditions
• Restless Less Syndrome
o Consider gabapentin
o If gabapentin is ineffective even after appropriate titration, then consider
converting to carbamazepine
• Sleep apnea
• Sundowners
o Consider an antipsychotic such as haloperidol 1-2mg po QHS
o If haloperidol is ineffective, then consider converting to chlorpromazine
10-25mg po QHS, or Risperdal 0.25 - 0.5mg po QHS or Seroquel
25-50mg po QHS

Non-pharmacologic interventions
• Maintain sleep diary to identify triggers and patterns
• Improve sleep hygiene: relaxation techniques; reserve bed for sleep and sexual
activity only; arrange comfortable sleep environment if not already in place; and
avoid caffeine, nicotine, and alcohol within 4 hours of bed

For refractory insomnia, or insomnia that remains unresolved despite optimal therapy
with symptom-targeted treatment, consider a “drug holiday” from medications to which
tolerance may develop (i.e. benzodiazepines), an agent from another class, or one of the
non-preferred agents:

TCAS - Amitriptyline/Nortriptyline 10-25mg po QHS, Doxepin 10-25mg po QHS -
antidepressants commonly used for insomnia due to their sedative properties.

Chloral Hydrate - 500-1000mg po QHS - Has been shown to be moderately effective
in the short term efficacy but is more toxic than benzodiazepines and is usually used as
refractory therapy when all other therapies have failed.

OTC medications - Diphenhydramine and other OTC anti-histamines have sedative
properties, but they are generally not preferred in the elderly due to anticholinergic
properties and drug interactions. Diphenhydramine (25-100mg po QHS) has been shown
to increase sleep duration and quality; duration of action is 4-6 hours. Most over the

167

Insomnia

counter products contain diphenhydramine or Doxylamine 5mg po QHS.

Herbal remedy - Valerian oral extract 400-900mg po QHS was as shown in
one study to be effective as oxazepam.The major side effects are hepatotoxicity,
cardiotoxicity and delirium.

Others requiring Clinical Manager approval: Zaleplon (Sonata) - 10-20mg po
QHS, Eszopilone (Lunesta) 2-3mg po QHS, Ramelteon (Rozerem) 8mg po QHS.

Commercially Drug Name Drug Name
Available Trazodone (Desyrel®) Temazepam (Restoril®)
Formulations Tablet: 50mg, 100mg, 150mg, Capsule: 7.5mg, 15mg, 30mg
Usual Dose 300mg
Max Total Daily 7.5-30mg po QHS
Dose (TDD) 25-100mg po QHS 30mg
Comments 600mg
-15mg & 30mg strengths are
Relative Cost/Day -Onset of action is 1-3 available generically; others are not
hours for insomnia -Retrograde amnesia & paradoxical
-Doses for insomnia are excitation have been reported
typically lower than doses -Associated with increased fall risk
for depression in the elderly
15mg, 30mg = Tier 1
Tier 1 7.5mg = Tier 3

Commercially Drug Name Drug Name
Available Ramelton (Rozerem®)
Formulations Zolpidem (Ambien®, Ambien CR®) Tablet: 8mg
Usual Dose
Max Total Daily Tablet, immediate-release (IR): 5mg, 8mg po QHS
Dose (TDD) 10mg 8mg
Comments Tablet, controlled-release (CR):
6.25mg, 12.5mg -Do not take with a high fat
Relative Cost/Day meal (increased extent of
5mg po QHS absorption)
-Use caution with hepatic
10mg impairment
-Do not crush
Available generically (extended Tier 3
release and sublingual formulations
are NOT generic)
-Sleep agent unrelated to
benzodiazepines, or barbiturates

IR:Tier1 CR:Tier 3

References:
• Bain, KT,Weschules, DJ, Knowlton CH, et al.Toward evidence-based prescribing at end of life: a
comparative review of temazepam and zolipdem for the treatment of insomnia. Am J
Palliat Care. 2003;20(5):382-8.

• Miller, DD. Atypical antipsychotics: sleep, sedation, and efficacy. J Clin Psychiatry. 2004;6:3-7.

• Morin CM, Hauri PJ, Espie CA, et al. Nonpharmacologic treatment of chronic insomnia, Sleep
1999;22(8):1134-56.

• Schutte-Rodin, S, Borch, L, Buysse, D, et al. Clinical guideline for the evaluation and
management of chronic insomnia in adults. J Clin Sleep Med. 2008;4:487-504.

• Miller M, Arnold R. Insomnia: Pharmacologic Treatments. Fast Facts and Concepts. January
2004; 105. Available at: http://www.eperc.mcw.edu/fastfact/ff_105.htm.

168

Nausea/
Vomiting

Is N/V due to Yes Initiate metoclopramide
functional gastric Yes 5-10mg po QID
(AC & QHS).
stasis?
Initiate ondansetron
No 4-8mg po BID-TID ±
dexamethasone 2-8mg
Is N/V due
to palliative po Qday-BID.
chemotherapy?
Initiate metoclopramide
No Yes 5-10mg po QID. If ineffective or
contraindicated, then initiate either
Is N/V drug haloperidol 0.5-2mg po/SubQ
(opioid) Q6h PRN N/V OR promethazine
induced? 25mg po/PR Q4-6h PRN N/V.

No Yes Initiate meclizine 12.5-25mg
po Q6h PRN N/V OR
Is N/V
movement transdermal scopolamine*
induced? 1.5mg patch topically Q72h.

No Yes Initiate metoclopramide
Yes 5-10mg po QID. If ineffective
Is N/V post-
prandial / caused or contraindicated, then
by eating or GI initiate erythromycin

stasis 250mg po TID w/meals.

No Initiate lorazepam 0.5-2mg
po/SL Q4h PRN N/V OR
Is N/V related dronabinol* 2.5-5mg po BID.
to fear or
anxiety?

169

Nausea/
Vomiting

No

Is N/V Yes Initiate promethazine 25mg
persistent, ± po/PR Q4-6h PRN N/V ±
aggravated by
haloperidol 0.5-2mg
smells? po/SubQ Q6h PRN N/V.

No

N/V due to Yes Initiate dexamethasone
 intracranial 2-8mg po Qday or BID ±
promethazine 25mg po/PR
pressure w/
Q4-6h PRN N/V.
headache?

No

N/V due to Yes Initiate haloperidol 0.5-2mg
liver metastases? po/SubQ Q6h PRN N/V, OR
prochlorperazine 5-10mg po Q6h
No PRN N/V, OR prochlorperazine
25mg PR Q12h PRN N/V, OR
N/V due to Yes
GI irritation? (i.e., promethazine 25mg po/PR
from steroids or Q4-6h PRN N/V.

NSAIDS) Initiate HS blocker:
Ranitidine 150mg po BID, OR

famotidine 20mg po BID
OR initiate PPI:

omeprazole OTC 20mg po QAM

*Requires CM approval
170

Nausea / Vomiting

- The brain (chemoreceptor trigger zone, cerebral cortex, vestibular apparatus and
vomiting center) and the gastrointestinal tract are the key organs involved in nausea
and vomiting.

- Neurotransmitter receptors that mediate nausea and vomiting include those for
serotonin, dopamine, acetylcholine and histamine.

- In general, antiemetic dose should be titrated up to their full dose before adding
another agent.

- If nausea is not controlled with a specific agent after 48 hours, then add another
antiemetic with a different mechanism of action; do not discontinue the initial
medication.

- Consider routine dosing of these medications for patients experiencing constant
nausea and/or vomiting. Add a PRN “breakthrough” dose for exacerbation of
symptoms.

- Antiemetics should be ordered prophylactically to prevent nausea and vomiting in
patients receiving high doses of opiates and palliative chemotherapy.
- Metoclopramide (unless contraindicated, as in patients with Parkinson’s Disease) is
the usual first choice for nausea as it targets the common causes of nausea in advanced
disease

- For persistent nausea where other treatable causes have been ruled out:

• Haloperidol, 0.5 to 2mg given orally, intravenously or subcutaneously every
six hours, can be very effective.The dosage may be titrated if needed up to a
total of 10 to 15mg daily. Avoid Haloperidol in patients with a history of
Parkinson’s disease.

• If needed, an antihistamine (such as promethazine, hydroxyzine, or meclizine)
or a prokinetic agent (such as metoclopramide) may provide additional benefit.

- For severe, refractory nausea/vomiting that has not responded to conventional therapy,
consider olanzapine.

• Olanzapine is an antipsychotic with broad-spectrum antiemetic properties. It
acts at the dopaminergic, serotonergic, adrenergic, histaminic and muscarinic
receptors, most of which are involved in the emetic pathways. A dose of
2.5–5 mg/day olanzapine is recommended. Olanzapine is available as a tablet
that can be crushed. In cases of severe nausea, the orally dissolvable tablet*
may be an alternative.

- ABHR Gel* may be used in cases where the patient is no longer able to swallow and
IV administration of Haloperidol is not possible. ABHR gel is available through a
compounding pharmacy. Although we don’t promote its use, the two more commonly
used formulas are shown in the table below:

Component Formula 1 (mg/mL) Formula 2 (mg/mL)
2 4
A (Ativan or lorazepam) 50 100

B (Benadryl or 24
diphenhydramine) 40 80

H (Haldol or haloperidol)

R (Reglan or metoclopramide)

171

Nausea / Vomiting (continued)

Causes of Drug Induced Nausea/Vomiting

Mechanism Drug Causing N/V
Gastric Irritation
Gastric Stasis Antibiotics, Iron Supplements,
NSAIDS, Tranexamic Acid
Cerebral Cortex Stimulation
5HT3 Receptor Stimulation Antimuscasrinics, Opioids,
Phenothiazines,
Tricyclic Antidepressants

Antibiotics, Chemotherapy,
Digoxin, Imidazoles, Opioids

Antibiotics, Chemotherapy, SSRIs

Commercially Drug Name Drug Name
Available Haloperidol (Haldol®)
Formulations Ondansetron (Zofran®) Tablet: 0.5, 1, 2, 5, 10, 20mg
Usual Dose Solution as lactate, oral: 2mg/
Max Total Daily Tablet: 4mg, 8mg, 16mg, 24mg mL
Dose (TDD) ODT: 4, 8mg Solution, INJ: 5mg/mL
Comments Solution, oral: 4mg/5 mL 0.5-5mg po Q6-12h
Solution, INJ: 2mg/mL 100mg
Relative Cost/Day
4-8mg po Q8h -Can be given PO, SL, PR, IM;
useful when benzodiazepines
32mg fail; do not use in patients with
Parkinson’s; low sedation
-Tablets can be crushed and
given sublingually. Tier 1
May be given without regard
to meals.
IV ondansetron associated
with prolonged QT Interval

Tab:Tier 2
ODT Tab:Tier 3

Commercially Drug Name Drug Name
Available Dexamethasone (Decadron®) Transdermal scopolamine
Formulations (Transderm Scop®)
Solution, oral: 1mg/mL 1.5mg patch (releases 1mg
Usual Dose Tablet: 0.25, 0.5, 0.75, 1, 1.5, 2, over 72 hours)
Max Total Daily 4, 6mg
Dose (TDD) Solution, INJ: 4mg/mL and 1 patch topically Q3day
Comments 10mg/mL 3 patches
2-16mg po BID
Relative Cost/Day 40mg -Apply to hairless area of skin
behind the ear.
-GI upset, use with caution for -May cause blurred vision/
patients with diabetes due to confusion; difficult dose
resultant hyperglycemia. Give titration; do not use if phlegm
last dose by 2pm to avoid or mucus is present; may cause
steroid-induced insomnia. mucus plug.
Tier 3
Tier 1

172

Nausea / Vomiting (continued)

Commercially Drug Name Drug Name
Available Dronabinol (Marinol®)
Formulations Capsules, oral: 2.5, 5, 10mg Prochlorperazine(Compazine®)

Usual Dose Initial: 2.5-5mg po BID Tablet: 5, 10mg
Suppository, rectal: 25mg
Max Total Daily 20mg Solution, INJ: 5mg/mL
Dose (TDD)
Comments -Indicated for chemotherapy- PO/IM: 5-10mg po Q6-8h
associated nausea and PR: 25mg PR Q12h
Relative Cost/Day vomiting refractory to other
antiemetics and AIDS-related PO/IM: 40mg
anorexia. PR: 50mg
-Contains sesame oil.
-Do not use in patients with -Do not use in patients with
schizophrenia Parkinson’s Disease; may cause
extrapyramidal effects.
Tier 3 -May cause anticholinergic effects.
-Use with caution in patients
with dementia due to increased
aspiration risk.

Tier 1

References:
• Baines, Mary J.“ABC of palliative care. Nausea, vomiting, and intestinal obstruction.” BMJ: British
Medical Journal 315.7116 (1997): 1148.
• Inventory, Brief Fatigue.“Management of common symptoms in terminally ill patients: Part I.
Fatigue, anorexia, cachexia, nausea and vomiting.” Am Fam Physician 64.5 (2001): 807-815.

173

Abdominal Intestinal Opioid Raised
Radiotherapy distension Digoxin Intracranial
pressure
Gastric Cytotoxic Hypercalcemia Fear/ Movement
irritants Chemotherapy Uremia Anxiety Vertigo

Clonidine

? 5HT3 5HT1 D2 á2 Cerebral Cortex Vestibular Nuclei
Gut Wall
Chemoreceptor GABA H1
Trigger Zone
5HT AChm

AChm = anticholinergics Vomiting Center
5HT = serotonin type 2,3, & undefined
AChmm H1 Mu-opioid H2
D2 = dopamine type 2
H1 = histamine type 1 Gastric atony References:
GABA = gamma-aminobutyric acid Retroperistalsis Hospice & Palliative Care Formulary USA, 2nd edition
Thoracic & abdominal muscle contractions Reprinted with permission
á2 = alpha adrenergic type 2

174

Neuropathic
Pain

Patient describes pain as burning,
shooting, stabbing or radiating.

Does patient Patient Yes Follow methadone
have history prognosis safe use protocol.
of cardiac > 1 week.
Initiate capsaicin
disease? No
applied topically
Yes Patient
able to No to affected
No swallow.? area TID-QID OR
Yes
lidocaine 2% gel applied
Initiate tricyclic
antidepressant topically to affected area
(TCA): nortriptyline
25-100mg po QHS OR TID-QID.
desipramine 10-30mg

po QHS.

Effective?

No

Effective / well No Initiate lidocaine 5% patch*,
tolerated? Effective? apply topically up to 3 patches

No to painful area(s) Qday (12
hours on / 12 hours off).

Discontinue TCA and Discontinue duloxetine
initiate gabapentin+ and initiate anticonvulsant:
100-600mg po TID. carbamazepine 200mg po
TID, may gradually increase to
Effective? 400mg po TID OR phenytoin
100mg po TID up to 200mg
po BID OR valproic acid
250mg po QHS x 7 days, then
increase to 500mg po QHS.

Discontinue gabapentin and No

No initiate duloxetine 30-60mg Effective?
*Requires CM approval po Qday OR pregabalin*+

50-200mg po TID.

+Start with lowest dose & gradually increase until effective dose is attained

175

Neuropathic Pain

Tricyclic Antidepressants:

• The starting dose of antidepressant medications is in the range of 25mg at bedtime
and titrated to an effective dose.
• Common problems with TCAs include sedation and anticholinergic effects.
• Caution must be used with patients with heart disease

Gabapentin (Neurontin) is widely used for neuropathic pain and studies have shown
doses of 2400-3600mg/day has an efficacy similar to tricyclic antidepressants and
carbamazepine.

• Dosing started low and titrated to effect (typically 100mg to 300mg total daily) and
increased by 100 – 300mg every 1-3 days to effect with the usual effective total daily
dose is 900-3600mg, administered in three divided doses per day. Higher doses may
be needed.Titration should proceed more slowly in elderly patients.
• Adverse Reactions -Sedation, confusion, dizziness, and ataxia are the most common
side effects, especially with rapid dose titration.Tolerance to these effects appears
to develop within a few days if the dose is held at the highest tolerated dose until
symptoms improve or stabilize

Duloxetine has been shown to be effective treating diabetic peripheral neuropathy
at doses of 60mg daily. Onset of analgesia is at about 1 week, with maximum effect at
about 4 weeks. A dose of 60mg BID may lead to increased analgesia but at the expense
of an increased risk of side-effects, particularly nausea, sedation, constipation, sweating, and
insomnia.

Capsaicin has shown to have analgesic benefits in post-herpetic neuralgia, painful
polyneuropathies including diabetic and HIV-related neuropathy by causing temporary
neurolysis, although it may take weeks of application to achieve significant benefit.

• There is no well-defined limit to the body surface area which can be treated with
capsaicin cream. Capsaicin should not be used on open wounds. Major side effects
are localized and include erythema and uncomfortable burning, stinging, or itching
which may decrease with repeated use. Patients are advised to use gloves while
applying the cream, avoid contact with eyes and mucous membranes, and wash
hands after application

Ketamine is a short acting anesthetic agent that has analgesic properties at sub-
anesthetic doses. A synergistic effect between ketamine and opioids has been observed
in patients who have lost an analgesic response to high doses of opioids. Ketamine is
usually used in pain that has failed to respond fully to opioids despite escalating doses and
combination with appropriate adjuvants. It may be particularly helpful in neuropathic pain.

• A typical starting dose of oral Ketamine is 10 to 25mg every 8 hours.
• Doses are usually increased in steps of 10 to 25mg per dose every 3-4 days until the
desired dose is reached up to a usual maximum of 50mg every 6 hours (maximum
reported dose 200mg every 6 hours).
• The only commercially available formulation of Ketamine is an injection (50mg/mL
and 100mg/mL multidose vials).To prepare a 100mL oral solution of Ketamine
(10mg/mL) – the injection formulation must be compounded into an oral solution
with a final product concentration Ketamine 1000mg100mL or 50mg/5mL.This
should be stored in the refrigerator with an expiration date of 7 days from
compounding date. Ketamine Oral Solution may have a bitter taste if flavoring not
used but each dose may be disguised in juices such as orange juice and cola drinks

176

Neuropathic Pain

Commercially Drug Name Drug Name
Available
Formulations Gabapentin (Neurontin®) Valproic acid (Depakene®,
Depakote®)
Usual Dose Capsule: 100mg, 300mg,
400mg Capsule: 250mg
Max Total Daily Solution, oral: 250mg/5mL Syrup (Depakene®): 250mg/5mL
Dose (TDD) Tablet: 100mg, 300mg, Tablet, delayed-release: 125mg,
400mg, 600mg, 800mg 250mg, 500mg
Comments
100mg po TID, titrate up 250mg po QHS x 7 days, then
Q72h (in elderly) 500mg po QHS
300mg po TID, titrate up
Q72h (in non-elderly)

1800-3600mg; some Doses vary based on range of
evidence that doses greater therapeutic serum levels. Target
than 1800mg TDD show 50-100mcg/mL for seizures and
no greater benefit at pain pain
relief
-Somnolence
-Must be titrated up and -Do NOT crush ER formulations
down -Depakene (valproic acid syrup)
-Can cause memory loss, can be given rectally1
GI upset and can be very
sedating

Relative Cost/Day Tier 1 Tier 1

Commercially Drug Name Drug Name
Available Lidocaine (Lidoderm®) 5%
Formulations patch Capsaicin cream/lotion
(Capzasin®, Zostrix®, Icy Hot®
Usual Dose Transdermal system, 5% Arthritis therapy gel)
patch topically
0.025 - 0.25% cream

1-3 patches, apply patch Variable, must apply topically
topically 12h on, then 12h TID-QID every day for
off effectiveness

Max Total Daily Variable, based on patient Variable, based on patient
Dose (TDD) response response

Comments -Apply patch to most -Burning-type pain and redness
painful area subside after continual use, which
-Patches may be cut is when the medication becomes
-Half-life prolonged in most effective
patients with CHF, liver -For creams and lotions, apply
disease and severe renal with gloves
disease -Avoid touching eyes and
other sensitive body areas after
Relative Cost/Day Tier 3 application

Tier 1

177

Neuropathic Pain

Commercially Drug Name Drug Name
Available
Formulations Methadone (Dolophine®) Desipramine (Norpramin®)

Tablet: 5mg, 10mg, 40mg Tablet: 10mg, 25mg, 50mg, 75mg,
Solution, oral concentrate: 100mg, 150mg
10mg/mL
Solution, oral: 5mg/5mL,
10mg/5mL

Usual Dose Variable 10-50mg po QHS
Max Total Daily 300mg; 150mg in geriatric
Dose (TDD) Variable based on patients
Comments individualized patient
response -Use caution and avoid if possible
Relative Cost/Day in patients with family history of
-Excellent treatment sudden cardiac death or cardiac
option for nociceptive and conduction disturbances as
neuropathic pain medication may increase the risk
-Preferred for patients with of dysrhythmias and death in this
renal or hepatic impairment patient population
-Contact Clinical
Pharmacist for dosing Tier 1
recommendations
-Can be crushed and/or
administered PO, PR, SL,
PV, IV
-CII controlled substance

Tier 1

Commercially Drug Name Drug Name
Available
Formulations Nortriptyline (Pamelor®) Pregabalin (Lyrica®)

Capsule: 10, 25, 50, 75mg Capsule: 25, 50, 75, 100, 150, 200,
Solution, oral: 10mg/5mL 225, 300mg
Solution, oral: 20mg/5mL

Usual Dose 10-150mg po QHS 75mg po BID or
150mg 50mg po TID
Max Total Daily
Dose (TDD) 600mg
Comments
-Also expected to improve -Schedule V controlled substance;
sleep and mood; start at Dosage adjustment required in
lowest dose possible patients with renal impairment
(GFR < 60).

Relative Cost/Day Tier 1 Tier 3

178

Neuropathic Pain

Commercially Drug Name Drug Name
Available Duloxetine (Cymbalta®)
Formulations Carbamazepine (Tegretol®) Capsule, DR: 20, 30, and 60mg

Usual Dose Tablet, chewable: 100mg
Max Total Daily Tablet ER: 100, 200, 400mg
Dose (TDD) Suspension, oral: 100mg/5mL
Comments
100-400mg po BID-QID 60mg po Qday
1600mg 120mg

-May be given rectally; -Do not crush, chew, or sprinkle;
-Do not crush ER tablets; -GFR < 30: Do not use
-Give with food;
-CrCl < 10: decrease dose
25%

Relative Cost/Day Tier 1 Tier 2

References:
• Fallon, Marie, Geoffrey Hanks, and Nathan Cherny.“ABC of palliative care: principles of
control of cancer pain.” BMJ: British Medical Journal 332.7548 (2006): 1022.

• Gilron, Ian, et al.“Morphine, gabapentin, or their combination for neuropathic pain.” New
England Journal of Medicine 352.13 (2005): 1324-1334.

• Perron,Vincent, and Ronald S. Schonwetter.“Assessment and management of pain in
palliative care patients.” Cancer Control 8.1 (2001): 15-24.

• Kishore A, King L,Weissman DE. Gabapentin for Neuropathic Pain, 2nd Edition. Fast Facts
and Concepts. August 2005; 49. Available at: http://www.eperc.mcw.edu/fastfact/ff_049.htm.

• Hawley P. Non-Tricyclic Antidepressants for Neuropathic Pain. Fast Facts and Concepts.
September 2007; 187. Available at: http://www.eperc.mcw.edu/fastfact/ff_187.htm.

• Groninger H, Schisler RE. Capsaicin for neuropathic pain. Fast Facts and Concepts. July 2012;
255. Available at: http://www.eperc.mcw.edu/fastfact/ff_255.htm.

179

180

Nociceptive
Pain

Assess patient to determine the following:
• Onset and temporal pattern (frequency of pain, constant vs. intermittent)
• Location (single vs. multi-site)
• Description (achy, throbbing, dull vs. sharp, tingling, pins & needles)
• Intensity (0-10 scale)
• Aggravating & relieving factors (rest vs. motion, sitting vs. standing)
• Previous treatment, if any

Mild Pain Moderate Pain Severe Pain
Patient rates pain at Patient rates pain at Patient rates pain at

1-3 / 10 4-7 / 10 8-10+ / 10

Initiate acetaminophen No
500mg 1-2 tabs po PO route?
Q8h PRN pain.
Initiate hydrocodone/APAP Yes
Effective? 5/35mg OR 10/325mg
tablet 1-2 tabs po Q4h No

PRN pain. (Do not exceed
3 grams/day APAP)

GFR � 30?

No Effective? Yes
Discontinue
acetaminophen. No Initiate Roxanol® 10-
30mg po/SL Q1-2h PRN
Discontinue Initiate nortriptyline
hydrocodone/APAP. 25-100mg po QHS breakthrough pain.
See Severe Pain top
right for next steps. OR gabapentin Titrate to
100-600mg po TID. effective dose.
No
Effective? No

181 Effective? Convert to morphine sulfate
No ER Q12h and Roxanol® Q1h
PRN breakthrough pain based

on previous dose.

Initiate prednisone
10-20mg po Qday OR

dexamethasone 2-4mg

po Qday-BID.

Nociceptive
Pain

Initiate fentanyl
transdermal patch* Q72h.
Titrate as follows: 50-75mcg/day.

GFR � 30? No Initiate hydromorphone
SubQ or IV infusion.

No Yes
Yes
Initiate morphine SubQ
No or IV infusion.
Cachectic?

Initiate oxycodone IR Convert to oxycodone
No 5-20mg po Q1-2h PRN ER* po Q12h and oxycodone
IR po Q1h PRN breakthrough
breakthrough pain. pain based on previous dose.
Titrate to effective dose.

Effective?

Reduce current opioid Yes No Initiate anti-anxiety agent
dose by 30-50% and lorazepam 0.5-2mg IV/po
Q4h PRN anxiety.
add ketamine*

10-25mg po TID.

Psychiatric History No
side effects?
of cardiac Effective?
Yes
arrhythmia or
Initiate haloperidol
2-5mg po QHS OR pacemaker?
diazepam 5mg po
No Methadone per
QHS-TID. safe use protocol.

*Requires CM approval 182

Nociceptive Pain

MSContin - This tablet can be given rectally (dosed the same way as orally) in
divided doses to maintain long acting pain control in patients who cannot swallow

• Avoid morphine in significant renal impairment (GFR <30) due to potential
accumulation. Watch for increased confusion, agitation,and myoclonus, as these may
be related to morphine accumulation and/or toxicity.

Oxycontin - CANNOT be given rectally due as its long acting formulation is different
than MSContin and has not been studied
• Patients receiving OxyContin may pass an intact matrix “ghost” in the stool or via
colostomy; these ghosts contain little or no residual drug and are of no clinical
consequence.

Tramadol - Tramadol is used for moderate pain and may be considered a good opioid
to start patients who are not ready/willing to try a stronger opioid such as morphine.

• Tramadol is a synthetic opioid with analgesia provided via a weak OP3 (mu)
receptor effect, and via inhibition of serotonin and noradrenaline reuptake
• Considered to have a low incidence of constipation, nausea and dizziness
compared to other opioids
• May cause seizures; use cautiously in patients with epilepsy, head trauma, brain
metastases, metabolic disorders, alcohol or drug withdrawal, CNS Infections

• Due to its inhibition of serotonin and noradrenaline reuptake – need to be
cautious with interacting drugs, such as SSRI’s,TCA’s
• Max daily dose of 400mg/day and 300mg in the elderly

Fentanyl - Transdermal patches may not be appropriate for patients with fever,
diaphoresis, cachexia, morbid obesity, ascites or opioid-naïve patients as these conditions
can effect the absorption, blood levels and clinical effects of the drug.

• Fentanyl transdermal patches require changing Q72h but some patients may
require changing Q48h
• The clinical effects of the fentanyl patch will occur between 12-18 hours after
first patch application and will remain in the body 12-18 hours after patch is
removed. Most commonly, full clinical effects will occur between 24 and 48 hours
after patch application.
• The patch cannot be cut due to the reservoir membrane-controlled patch
delivery system. If cut, it will affect the rate the drug is released, and risk a toxic
skin reaction and overdose

Methadone - is a potent opioid that also has N-methyl-d-aspartate (NMDA) receptor
antagonist actions making it the opioid of choice for neuropathic pain management

• It has unpredictable and variable interpatient pharmacokinetics which makes
dosing and titration difficult
• Half life varies from 15 to 60 hours up to 120 hours in cancer patients and makes
it a long acting medication with a dosing frequency of Q6h, Q8h or Q12h
• Due to its variable kinectics, there is a poorly defined equinanalgesic potency and
a consult with a Procare pharmacist is required for patient specific dosing
• Methadone has no active metabolites making it an option in renal impairment and
for use in dialysis patients
• Methadone can prolong the QTc interval which can lead to torsades de pointes
(a type of paroxysmal ventricular tachycardia), ventricular fibrillation and sudden
cardiac death and needs to be dosed with extreme caution in patients are at
risk in the presence of heart disease,and while using selected drugs that are
associated with prolonged QT interval and torsades des pointes

183

Nociceptive Pain (continued)

Topical Opioids - Have been used in managing pain of superficial decubitus or malignant
skin ulcers. Several case series have shown relief using topical opioids in patients with pain
due to skin infiltration of tumor, skin ulcers of malignant and non-malignant origin, severe
oral mucositis, knee arthritis, and tenesmoid pain. Most studies have evaluated morphine;
methadone has also shown efficacy.

• Topical opioid gels and mouthwashes are not available commercially and need to
be prepared by a compounding pharmacist.

• Gel: Most studies used a mixture of the morphine sulfate injection with Intrasite gel.
Patients cover the wound with the gel (usually using 5-10 mL) and then loosely
dress it with gauze. Duration of analgesia varies widely; preparations usually need to
be applied one to three times per day.This morphine gel has been found to
be stable irrespective of temperature and light exposure for up to 28 days.

• Mouthwash: Morphine mouthwash has been studied is an oral rinse 0.2%
morphine solution. Patients should hold the mouthwash in their mouth for 2
minutes then spit out and not to swallow the mouthwash to avoid systemic effects
from the morphine. This is most useful for patients with predominantly oral (not
esophageal) pain.

Drug Name Drug Name

Acetaminophen (Tylenol®) Ibuprofen (Motrin®, Advil®)

Commercially Caplet/gelcap: 500mg Capsule/Gelcap/Tablet [OTC]:
Available
Formulations Caplet/gelcap, extended release: 200mg

Usual Dose 650mg Tablets [Rx]: 400mg, 600mg,

Liquid, oral: 500mg/15mL, 800mg

160mg/5mL Suspension, oral: 100mg/5mL

Suppository, rectal: 80mg, Suspension, oral drops: 40mg/

120mg, 325mg, 650mg mL

Suspension, oral: 160mg/5mL, Tablet, chewable: 50mg, 100mg

80mg/0.8mL

Tablet: 325mg, 500mg

Tablet, chewable: 80mg, 160mg

500-1000mg po Q4h PRN 400-800mg po Q4-6h PRN
pain pain

Max Total Daily 3000mg 3200mg
Dose (TDD)
Comments -Maximum of 3000mg if liver -Take with food or milk to
disease present avoid GI upset
Relative Cost/Day -DRUG OF CHOICE for mild -Monitor concomitant use
arthritic pain with corticosteroids to avoid
-Consider all sources of GI bleed
acetaminophen when dosing -Consider GI prophylaxis
with H2-receptor blocker
Tier 1 (e.g., ranitidine, famotidine) or
Proton Pump Inhibitor (e.g.,
omeprazole, pantoprazole)

Tier 1

184

Nociceptive Pain (continued)

Drug Name Drug Name

Hydrocodone/APAP (Vicodin®, Oxycodone/APAP (Percocet®,
Lortab®, Norco®) Tylox®, Rocicet®)

Commercially Tablet, various - common: 5/325mg, Tablet, various – common:
Available 5/500mg, 5/325mg, 5/500mg, 10/325mg
Formulations 7.5/750mg, 10/650mg Solution: 5/325mg per 5mL
Elixir: 7.5/500mg per 15mL
Usual Dose Solution, oral: 7.5/325mg per 15mL
Max Total Daily
Dose (TDD) 1-2 tabs po Q4-6h PRN pain 1-2 tabs po Q4-6h PRN pain
Comments
Maximum based on APAP Maximum based on APAP
component: 3000-4000mg component: 3000-4000mg

-Monitor APAP intake -Monitor APAP intake
-Side effects: GI upset, nausea, -Side effects: GI upset,
vomiting, constipation, dizziness, nausea, vomiting, constipation,
somnolence are common – dizziness, somnolence are
titrate based on patient response common – titrate based on
patient response

Relative Cost/Day Tier 1 Tier 1

Drug Name Drug Name

Morphine (immediate release) Oxycodone (immediate release)
(Roxanol®, avoid use of MSIR (OxyIR®, Oxyfast ®, Oxydose®)
as this is considered an unsafe
abbreviation by ISMP and the
Joint Commission)

Commercially Solution, oral: 10mg/5mL, Capsule, immediate release: 5mg
Available 20mg/5mL Solution, oral: 5mg/5mL
Formulations Solution, oral concentrate: 20mg/ Solution, oral concentrate: 20mgmL
mL Tablet: 5mg, 15mg, 30mg
Usual Dose Suppository, rectal: 5mg, 10mg,
Max Total Daily 20mg, 30mg
Dose (TDD) Tablet: 15mg, 30mg
Comments
Dosed po/sl Q4-6h PRN pain Dosed po/sl Q4-6h PRN pain

Based on individual response Based on individual response

-Avoid in patients with severe -Preferred for patients with renal
renal or hepatic impairment or hepatic dysfunction
-Dosage for dyspnea generally -Dosage for dyspnea generally
5-10mg po Q2h PRN SOB 5-10mg po Q2h PRN SOB

Relative Cost/Day IR Tablet:Tier 1 IR Tablet:Tier 1
ER/SR Tablet:Tier 1 Oral solution:Tier 1
Oral solution:Tier 1 ER/SR Tablet:Tier 3
ER Capsule:Tier 3

References:
• Caraceni, Augusto, Alessandra Pigni, and Cinzia Brunelli.“Is oral morphine still the first choice opioid
for moderate to severe cancer pain? A systematic review within the European Palliative Care
Research Collaborative guidelines project.” Palliative Medicine 25.5 (2011): 402-409.

• Care, Palliative.“Morphine and alternative opioids in cancer pain: the EAPC recommendations.”
British Journal of cancer 84.5 (2001): 587-593.

• Perron,Vincent, and Ronald S. Schonwetter.“Assessment and management of pain in palliative care
patients.” Cancer Control 8.1 (2001): 15-24.

• http://www.fraserhealth.ca/media/16FHSymptomGuidelinesOpioid.pd
• Jacobsen J.Topical Opioids for Pain. Fast Facts and Concepts. August 2007; 184. Available at:
http://www.eperc.mcw.edu/fastfact/ff_184.htm. f

185

Pruritus

General Measures:
• Sarna lotion applied topically as needed
• Hydroxyzine 25mg po BID-QID PRN itching

Is itching due Yes Initiate paroxetine
to end stage 10mg po QAM.
renal disease?

No Initiate cholestyramine 4gm
po Qday-BID OR initiate
Is itching due Yes ondansetron 8mg po x 1 dose
to end stage initially, then 4mg po Q8h

liver Initiate clotrimazole /
disease? betamethasone cream.
Apply topically to affected area
No
BID until resolved.
Is itching due Yes
to topical fungal
Initiate gabapentin 100mg po
infection? TID, increase by 100mg per dose
weekly up to max 600mg po TID OR
No initiate pregabalin* 75mg po BID,
increase to 150mg po BID after
Is itching due
to neuropathic 1 week if needed.

pruritus? Yes

No Initiate prednisone
20mg po QAM x 7
days & taper as needed.

Is itching due Yes Effective?
to paraneoplastic No

pruritus or
unknown

cause?

Prednisone burst: 10mg po TID x 2 days, 10mg po Initiate doxepin
10-30mg po QHS.
BID x 2 days, 10mg po QAM x 2 days, 5mg po
QAM x 2days, then discontinue, OR initiate medrol *Requires CM approval.
186
4mg dosepak x 6 days per pkg instructions.

Pruritis

Dry skin is a common cause and may exacerbate other causes. Generally, the treatment is
to hydrate the skin.

Moisturizers - (Note: Most OTC moisturizers are made mostly of water.) Severely dry
skin requires emollients and moisturizers (such as petroleum jelly) applied after bathing,
over damp skin, with a superficial covering.
Cooling agents/Anesthetics - (e.g., Calamine and/or Menthol in aqueous cream, 0.5%-
2%) are mildly antipruritic.They may act as a counterirritant or anesthetic.

Antihistamines may be helpful in relieving itch when associated with histamine
release. Morphine causes non-immune mediated histamine release from mast cells and is
commonly associated with pruritus.

• Hydroxyzine 25mg po Q4h PRN itching or diphenhydramine 12.5mg po Q4h
PRN itching or loratidine 10mg po daily PRN itching (non sedating)
• There is limited data supporting the combination of H1 and H2 receptor subtype
antihistamines.These may have central effects as well as peripheral
antihistaminergic effects.
• Doxepin (10-30mg PO at bedtime), a tricyclic antidepressant, is a very potent
antihistamine and may help in more refractory cases.

Topical steroids may be helpful in the presence of skin inflammation.They are best
applied as an ointment instead of a cream formulation to alleviate dryness.

• Hydrocortisone ointment 1% or triamcinolone ointment 0.025%-0.1% - topically
2-4x/day

Systemic steroids have been used in refractory cases.

• Prednisone burst: 10mg po TID x 2 days, 10mg po BID x 2 days, 10mg po QAM x
2 days, 5mg po QAM x 2 days, then D/C, or
• Medrol 4mg Dosepak x 6 days per package instructions

Immersion in an oatmeal bath, such as Aveeno, may also be tried in refractory patients.

Commercially Drug Name Drug Name
Available
Formulations Ondansetron (Zofran®, Zofran Betamethasone &
ODT®) Clotrimazole (Lotrisone®)

Tablet: 4, 8, 16, 24mg Cream: clotrimazole 1% -
ODT: 4, 8mg Betamethasone 0.05%: 15g,
Solution, oral: 4mg/5mL 45g
Solution, INJ: 2mg/mL Lotion: clotrimazole 1% -
Betamethasone 0.05%: 30mL

Usual Dose 4-8mg po Q8h Apply topically BID x 4 weeks
Max Total Daily N/A
Dose (TDD) 32mg
Comments -Do not use on open wounds.
-Tablets can be crushed and -Do not cover with occlusive
Relative Cost/Day given sublingually. dressings.
-May be given without regard
to meals. Tier 1
-IV ondansetron associated
with prolonged QT Interval

Tab:Tier 2
ODT Tab:Tier 3

187

Pruritis (continued)

Commercially Drug Name Drug Name
Available Pregabalin (Lyrica®)
Formulations Mirtazapine (Remeron®,
Capsule: 25, 50, 75, 100, 150, Remeron SolTab®)
200, 225, 300mg
Solution, oral: 20mg/mL Tablet: 7.5, 15, 30, 45mg
SolTab (ODT): 15, 30, 45mg

Usual Dose 75mg po BID or 7.5-30mg po QHS
Max Total Daily 50mg po TID 45mg
Dose (TDD) -Also expected to improve
Comments 600mg sleep and mood

Relative Cost/Day -Schedule V controlled Tab:Tier 1
substance; SoluTab:Tier 3
-Dosage adjustment required
in patients with renal
impairment (GFR < 60).

Tier 3

Commercially Drug Name
Available Doxepin (Sinequan®)
Formulations
Capsule: 25, 50, 75, 100, 150mg
Usual Dose Solution, oral: 10mg/mL
Max Total Daily
Dose (TDD) 10-30mg po QHS
Comments 300mg

-Caution in elderly; OK if bedbound; causes drowsiness

Relative Cost/Day Tier 1

References:
• Noble, Simon.“Other problems in palliative care.” Medicine 39.11 (2011): 668-673.

• Seccareccia, Dori, and Nadine Gebara.“Pruritus in palliative care Getting up to scratch.”
Canadian Family Physician 57.9 (2011): 1010-1013.

• Regnard, Claud, Sarah Allport, and Lydia Stephenson.“ABC of palliative care: Mouth care, skin
care, and lymphoedema.” BMJ 315.7114 (1997): 1002-1005.

• Von Gunten CF, Ferris F. Pruritus, 2nd Edition. Fast Facts and Concepts. July 2005; 37. Available
at: http://www.eperc.mcw.edu/fastfact/ff_037.htm.

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Secretions

Non-pharmacologic interventions such
as suctioning and limiting fluid intake.

Is prognosis > 7
days?

No Yes

Initiate atropine 1% opth Initiate hyoscyamine
drops 1-4gtt po/sl Q1-4h 0.125-0.25mg po/SL
Q4h PRN secretions.
PRN secretions.

Not effective or
CNS effects?

Yes

Initiate glycopyrrolate* 1-2mg
po Q4-12h PRN secretions

OR 0.2-0.4mg SubQ/IV
Q4-12h PRN secretions.

Initiate scopolamine*
1.5mg topically Q72h
PRN secretions (up to

3 patches).

*Requires CM approval
189