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Palliative Care Nurse Practitioner Sydney Adventist Hospital

DRUG FORMULARY for JULIE EDWARDS

Palliative Care Nurse Practitioner



The formulary provides for the poisons and restricted substances that may be possessed, used, supplied or prescribed by JULIE EDWARDS as a Nurse Practitioner under Section 17A of the Poisons and Therapeutic Goods Act 1966 (1) and the Poisons and Therapeutics Goods Regulation 2008 (2) It is the Nurse Practitioners responsibility to use this formulary in conjunction with the most recent MIMS/MIMS Online (3), Australian Medicines Handbook (4) and Therapeutic Guidelines: Palliative Care (5). Any alteration must be submitted to the Chief Nursing and Midwifery Officer (CNMO) NSW for approval. This document is invalid if any alterations or amendments are made without the approval from the CNMO NSW.. Introduction: The Palliative Care Nurse Practitioner (PCNP):

• Has the authority to prescribe, administer, use, supply and possess medications detailed in this PCNP Drug Formulary.

• Will utilise the most recent and appropriate resources to obtain information on compatibilities of drugs used in continuous subcutaneous infusions.

• May prescribe end of life medications on the community medication chart prior to discharge, for patients returning home, after consultation with and approval from the patients treating specialist.

• May convert routes of administration

• Will document in the medical records whenever a medication change is made. A physical assessment will be included as part of the documentation process.

• Will seek advice from the palliative care consultant to discuss appropriate management for complex patients and for those patients not responding as expected to treatment changes.

Acknowledgement:This Formulary has been adapted from previous work developed by Judith Jacques - Nurse Practitioner Palliative Care - CCLHD; Pauline Davis – Nurse Practitioner Palliative Care SWSLHD;Debbie White – Nurse Practitioner Palliative Care MNCLHD; Pauline Wilson - Palliative Care Nurse Practitioner SWCN.



Dosages are in accordance with the Therapeutic Guidelines Palliative Care and Australian Medicines Handbook.

PO = Oral; SL = Sublingual; SC = Subcutaneous; IM = Intramuscular; IV = Intravenous; PR = Per Rectum; TOP = Topical.

Drug (Generic name) Route Therapeutic Class Clinical Presentation Poisons Schedule

Analgesia

Non-opioid

Paracetamol

Tablet/ caplet

500mg

PO Simple analgesic

Antipyretic

1. Mild pain

2. Co-analgesic

3. Fever

S2

Paracetamol

Tablet

(modified release 665mg)

PO Simple analgesic

Antipyretic

1. Mild to moderate pain

2. Osteoarthritis

S2

Paracetamol

Suppositories

500mg

PR Simple analgesic

Antipyretic

1. Mild to moderate pain (when oral route not available)

2. Co-analgesic

3. Fever

S2




Analgesia Opioid

Paracetamol/Codeine Phosphate

Tablet

500mg/ 8mg

PO Combination Simple Analgesic Mild to moderate pain S3

Paracetamol/Codeine Phosphate

Tablet

500mg/ 30mg

PO Opioid analgesic Moderate – Severe Pain S4

Fentanyl

Lozenge

Various strengths

PO Opioid Analgesic Moderate – severe breakthrough pain

S8

Fentanyl

Transdermal Patch

Various strengths

TOP Opioid Analgesic Severe pain

Patient education on placement and changing of patch.

S8




HYDROmorphone

Liquid

Tablet

PO Opioid Analgesic 1. Severe pain

2. Breakthrough pain

S8

HYDROmorphone

Sustained release tablet

PO Opioid Analgesic 1. Severe pain

S8

HYDROmorphone

Injection

SC Opioid Analgesic 1. Severe pain


3.Pain management; end of life care

S8

Morphine

(Immediate Release)

Liquid / Tablet

PO Opioid Analgesic 1. Moderate to severe pain


3. Dyspnoea

S8

Morphine

(Sustained Release)

Tablet / Granules


2. Dyspnoea

S8




Morphine Sulphate

Injection

SC Opioid Analgesic 1.Moderate to severe pain


3. Dyspnoea

S8

Morphine Tartrate Injection SC Opioid Analgesic 1. Moderate to severe pain


3. Dyspnoea

S8

Morphine 0.1%

Infused hydrogel

TOP Opioid Analgesic 1. Painful wound

2. Painful pressure area

S8

Oxycodone

IR (immediate release)

Tablet / capsule/ liquid

Various strengths



S8

Oxycodone

SR (sustained release)

Tablet

Various strengths

PO Opioid Analgesic Moderate to severe pain S8




Oxycodone hydrochloride and naloxone hydrochloride dehydrate (Targin)

Tablet

Various strengths

PO Opioid Analgesic Moderate to severe pain S8

Opioid Antagonist

Naloxone

Injection

IM/SC/ IV Opioid Antagonist Reversal of opioid overdose; opioid induced respiratory depression: respirations < 8 min

NB: Before use consider other causes of sedation or delirium (eg: sepsis) (American Pain Society)

S4

Anti-infectives

Amphotericin

Lozenge

PO Antifungal Oral/oesophageal candidiasis S4

Fluconazole

Capsule

PO Antifungal Systemic candidiasis S4

Miconazole 20mg/ ml

Gel (Daktarin)

PO Antifungal Oropharyngeal candidiasis S3




Nystatin 100,000 units/ml

Suspension

PO Antifungal Oral / oesophageal candidiasis S3

Sodium Bicarbonate Mouthwash

TOP Mouthwash Oral candidiasis Unscheduled

Sodium Hyaluronate Gel

(Gelclair)

TOP Antifungal oral lesions, oral mucositis/stomatitis S3

Clotrimazole

Vaginal Cream

TOP Antifungal Vulvovaginal candidiasis S3

Clotrimazole 1% Hydrocortisone 1%

TOP Antifungal Fungal infections, dermatitis S3

Metronidazole Gel TOP Antibacterial Malodorous malignant wounds S4

Amoxycillin

Capsule, suspension

PO Penicillin

Broad spectrum

Exacerbation chronic bronchitis; pneumonia; sinusitis

S4

Amoxycillin with Clavulanic Acid

Tablet; suspension

PO Penicillin

Broad spectrum

URTI; Pneumonia, sinusitis,

UTI

S4




Cephalexin

Capsule; suspension

PO Cephalosporin

Moderate Spectrum

Staphylococcal and streptococcal infection in people with mild – moderate penicillin allergy

UTI

S4

Metronidazole

Tablet / suspension

PO Antibacterial Systemic management of malignant malodorous wounds

S4

Roxithromycin

Tablet

PO Macrolides Upper and lower respiratory tract infection S4

Trimethoprim

Tablet

PO Antibacterial Acute uncomplicated urinary tract infection.

S4

Anticholinergics

Glycopyrrolate

Injection

SC Anticholinergic 1. Patients not responding or unlikely to respond to Hyoscine; for management of respiratory secretions in the terminal phase.

2. Management of respiratory secretions in conscious and alert patients.

3. Management of drooling in MND patients

S4




HyoscineButylbromide

Injection

SC Antispasmodic Anticholinergic 1. Management of respiratory secretions in the conscious patient.

2. Management of painful colic in malignant bowel obstruction

3. Reduction of gastric secretions

S4

HyoscineHydrobromide

Injection

SC Anticholinergic Management of terminal respiratory secretions S4

Antidiarrhoeals

Diphenoxylate 2.5 mg

Atropine Sulphate 25mcg

Tablet

PO Antidiarrhoeal Diarrhoea S3

Loperamide

Capsules

PO Antidiarrhoeal Diarrhoea S2

Antiemetics

Cyclizine PO/ SC Antihistamine Nausea and Vomiting

S4




Dexamethasone

Tablet / Injection

PO/SC Corticosteroid Nausea and vomiting S4

Domperidone

Tablet

PO Antiemetics Nausea and vomiting

Reflux

S4

Haloperidol

Tablet / Injection

PO/SC/ IV Antipsychotic

Butyrophenone

Nausea and vomiting

S4

Lorazepam SL Anxiolytic Anticipatory Nausea and vomiting

S4D

Levomepromazine

Injection

SC Antipsychotic, antiemetic 1. Nausea and Vomiting

2. Terminal agitation

S4

Metoclopramide

Tablet / Injection

PO/ SC/ IV Antiemetic 1. Nausea and vomiting

2. Persistent hiccups

3. Reflux

S4




Prochlorperazine

Tablet / Suppositories

PO/ PR/ SC/ IM

Antiemetic Nausea and vomiting

S4

Antihistamine

Promethazine

Tablet

PO/ IM/ SC Antihistamine 1. Pruritis

2. Nausea and vomiting

S3

Anti-inflammatory Steroidal

Dexamethasone

Injection

Tablet

PO/ SC/ IV Corticosteroid 1. Pain associated with tumour related oedema

2. Cerebral Oedema

3. Spinal cord compression

4. Superior vena cava obstruction

5. Acute airways obstruction / dyspnoea

6. Malignancy related gastrointestinal obstruction

7. Appetite stimulant and feeling of well being

S4




Prednisone

Tablet

PO Corticosteroid 1. Airways obstruction / dyspnoea

2. Inflammatory disease

3. Appetite stimulate

S4

Anti-inflammatory Non steroidal

Celecoxib

Capsule

PO Non-steroidal anti-inflammatory

Selective COX-2 Inhibitor

1. Pain

2. Co-analgesic

S4

Cyclizine PO/ SC Antihistamine nausea and vomiting

S4

Diclofenac

Tablet


Nonselective

1. Pain

2. Co-analgesic

S4

Diclofenac

Suppository

PR Non-steroidal anti-inflammatory

Nonselective

1. Pain

2. Co-analgesic

S4

Ibuprofen

Tablet


Nonselective

1. Pain

2. Co-analgesic.

3. Fever

S2




Ketoralac

Injection

SC/ IM Non-steroidal anti-inflammatory

Nonselective

Severe pain

Always cover with PPI. Avoid if renal impairment, peptic ulcer, oesophagitis, GORD

S4

Meloxicam

Tablet

PO COX 2 inhibitor

Non-steroidal anti-inflammatory

Pain S4

Naproxen

Tablet

PO/ PR Non-steroidal anti-inflammatory

Nonselective

Pain – co-analgesic

Related to inflammation, bony pain

S4

Antipsychotics

Haloperidol

Tablet / Injection

PO

Antipsychotic Delirium S4

Antispasmodics

Hyoscinebutylbromide

Injection

SC Antispasmodic and motility agent Colic related to bowel obstruction S4




Hyoscinebutylbromide

Tablet

PO Antispasmodic and motility agent Colic related to bowel obstruction S4

Anxiolytics Benzodiazepines

Alprazolam

Tablet

PO Anxiolytic Anxiety or panic associated with dyspnoea

Anticipatory nausea

S4D

Clonazepam

Liquid/ injectable

SL/ SC Anticonvulsant

Anxiolytic

Sedative

1. Anxiety

2. Myoclonus

3. Seizure – prophylactic and acute treatment

4. Terminal agitation

S4D

Diazepam

Tablets

PO Anxiolytic

Muscle relaxant

Anticonvulsant

1. Anxiety

2. Pain associated with skeletal muscle spasm

3. Seizure

S4D




Lorazepam

Tablet

PO/ SL Anxiolytic 1. Anxiety or panic associated with dyspnoea

2. Agitation related to delirium not responding to Haloperidol alone

S4D

Midazolam

Injection

SC Anxiolytic

Hypnotic

Sedative

1. Terminal restlessness

2. Seizure

3. Myoclonus

4. Agitation related to delirium

5. Sudden catastrophic event

6. Dyspnoea

S4D

Laxatives Always prescribed with Opioids

Prophylaxis and Treatment of Constipation

Bisacodyl

Tablet

PO Laxative

Stimulant

Constipation Unscheduled

Bisacodyl

Suppository

PR Laxative

Stimulant

Constipation

Soft faeces on rectal examination not responding to oral laxatives

Unscheduled




Docusate

Tablet

PO Laxative

Stool softener


Docusate + sennoside B tablets

(Coloxyl with Senna) Tablet

PO Laxative

Softener+ stimulant


Glycerol

Suppositories

PR Laxative

Osmotic

Constipation

Hard faeces on rectal examination

Unscheduled

Lactulose

Syrup

PO Laxative

Osmotic

Constipation

Unscheduled

Liquid Paraffin

(Agarol)

PO Laxative

Softener


Macrogol 3350, Potassium Chloride, Sodium Bicarbonate, Sodium Chloride

(Movicol) Powder

PO Laxative

Polyethylene glycol

1. Constipation

2. Faecal Impaction

Unscheduled

Macrogol 3350

(Osmolax)

PO Laxative

Osmotic

1. Constipation

2. Faecal impaction

Unscheduled




Methylnaltrexone

Injection

SC Laxative Opioid induced constipation that has not responded to other laxatives

S4

Sorbital 3.125g, sodium citrate 450mg, sodium lauryl sulfoacetate 45mg;(Microlax

enema)

PR Laxative

Osmotic

1. Constipation

2. Faecal impaction

Unscheduled

Sodium Phosphate

(Fleet ready-to-use enema)

PR Laxative

Osmotic

Constipation unresponsive to other treatments Unscheduled

Neuropathic Agents

Gabapentin

Tablet

PO Antiepileptic 1. Refractory neuropathic pain

2. Uraemic pruritus 2° to renal failure

3. Restless legs syndrome 2° to renal failure

S4

Nortriptyline

Tablet

PO Antidepressant Neuropathic Pain

S4




Pregabalin

Tablet

PO Antiepileptic Neuropathic pain S4

Sodium Valproate

Tablet

PO Anticonvulsant Neuropathic Pain S4

Protein-pump inhibitors

Esomeprazole

Tablet/ Injection

PO/ IV Proton Pump Inhibitor 1. Gastro-oesophageal reflux disease

2. Protection from gastrointestinal irritation from anti-inflammatory medication

S4

Omeprazole

Tablet/ Injection



S4

Pantoprozole

Tablet/ Injection



S4




Miscellaneous

Baclofen

Tablets

PO Skeletal muscle relaxant 1.Pain associated with skeletal muscle spasm – particularly in MND

2. Hiccups

S4

Normal Saline 0.9%

For infusion

SC/ IV 1. Dehydration

2. Comfort measures

Normal Saline 0.9%

KCL 30 mmol

For infusion

SC/ IV 1. Rehydration

2. Physiological K+ replacement

Oxygen Dyspnoea, breathlessness

Tranexamic Acid

Tablet

PO

Antifibrinolytic 1. Profuse bleeding from malignant wound

2. Haemoptysis; vaginal or rectal bleeding secondary to local tumour invasion

S4



Notes:

1. Patients in the terminal phase of their disease will have the reduced ability or inability to swallow medications. The Palliative Care Nurse Practitioner will reduce or cease oral medications and change to an alternate route as appropriate. This process is undertaken in an informative, collaborative manner with the patient, family, carers and the treating Medical Practitioner(s). The same approach will also be taken for the cessation of artificial nutrition and/or hydration.

References:

1. Poisons and Therapeutic Goods Act (1966) Section 17A http://www.austlii.edu.au/au/legis/nsw/consol_act/patga1966307/

2. Poisons and Therapeutic Regulation (2008) http://www.legislation.nsw.gov.au/sessionalview/sessional/sr/2008-392.pdf

3. MIMS Online: http://proxy36.use.hcn.com.au/Search/Search.aspx

4. Australian Medicines Handbook (2011) AMH Adelaide

5. Therapeutics Guidelines, Palliative Care Version 3 (2010)

eviQ Opioid Calculator https://www.eviq.org.au/OpioidCalculator.aspx

Therapeutic Guidelines, Analgesia Version 5 (2007)

Therapeutic Guidelines, Psychotropic Version 6 (2008)



Available Opioid Formulations and Equivalency

https://www.eviq.org.au/OpioidCalculator.aspx

The following is a list of the currently available opioid formulations in Australia. Preparations are available as immediate release or as modified released formulations.

Modified-release formulations should never be crushed or chewed, as this destroys their release properties and can result in a large dose being absorbed over a short period.

Please note that all conversions listed are a guide only and may vary according to the clinical situation, condition of the patient and previous analgesic requirements.

Opioid Trade name Release Rate Formulation Oral morphine (PO) equivalent dose*

Buprenorphine Norspan® Slow Release 5, 10 and 20 mcg/hr transdermal (TD) patch

50 mg PO morphine = 20 mcg TD patch

Codeine

Codeine Immediate 30 mg tablets 7.5 mg PO morphine = 60 mg PO codeine

Codeine/Paracetamol eg.Panadeine Forte®**

Immediate 30/500 mg tablets 2 tablets = 7.5 mg PO morphine

Codeine/Paracetamol eg.Panadeine®**

Immediate 8/500 mg tablets 2 tablets = 2 mg PO morphine

Fentanyl

Durogesic® Slow Release 12, 25, 50, 75 and 100 mcg/hr transdermal (TD) patch

Conversions from transdermal fentanyl to other opioids are imprecise and poorly studied. The calculator uses conversion figures provided by the manufacturer.

Fentanyl

Sublimaze

Immediate 50 mcg/ml injection 25 mg PO morphine= 100 mcg fentanyl



Hydromorphone

Dilaudid® Immediate

2, 4 and 8 mg tablets

1 mg/ml oral liquid

2 mg/ml and 10 mg/ml injection

10 mg PO morphine = 1.67 mg PO Dilaudid

10 mg PO morphine = 1.67 mg PO Dilaudid

20 mg PO morphine = 1 mg IV Dilaudid

Dilaudid-HP® Immediate 10 mg/ml injection 20 mg PO morphine= 1 mg IV Dilaudid

Jurnista® *** Slow Release 4, 8, 16, 32 and 64 mg tablets 4 mg PO Jurnista = 24 mg PO morphine

Morphine

Sevredol® Immediate 10 and 20 mg tablets Direct equivalent

Anamorph® Immediate 30 mg tablets Direct equivalent

Ordine® Immediate 1mg, 2mg, 5mg and 10mg/ml oral solution

Direct equivalent

Kapanol® Slow Release 10, 20, 50 and 100 mg capsules Direct equivalent

Momex-SR® Slow Release 10, 30, 60, 100 mg tablets Direct equivalent

MS Mono® Slow Release 30, 60, 90 and 120 mg capsules Direct equivalent

MS Contin Suspension®

Slow Release 20, 30, 60, 100 and 200 mg sachets Direct equivalent

MS Contin® Slow Release 5, 10, 15, 30, 60, 100 and 200 mg tablets

Direct equivalent

Morphine sulfate Immediate 5, 10, 15, 30 mg/ml injection 25 mg PO morphine = 10 mg IV morphine

Morphine tartrate Immediate 80 mg/ml injection 25 mg PO morphine = 10 mg IV morphine

Oxycodone

Endone® Immediate 5 mg tablets 15 mg PO morphine = 10 mg PO Endone

OxyNorm® Immediate

5, 10, and 15 mg capsules

1 mg/ml oral solution

15 mg PO morphine = 10 mg PO OxyNorm

OxyContin® Slow Release 5, 10, 15, 20, 30, 40 and 80 mg 15 mg PO morphine = 10 mg PO OxyContin



tablets

OxyNorm® Immediate 10 mg/ml and 20 mg/2ml injection 20 mg PO morphine = 8 mg IV OxyNorm

Tramadol

Tramal®

Zydol®

Immediate 50 mg capsules 10 mg PO morphine = 50 mg PO Tramadol

Tramal® Immediate 50 mg/ml injection 10 mg PO morphine = 50 mg PO Tramadol

Tramal SR® Zydol®

12 hour

Slow Release

50, 100, 150 and 200 mg tablets 10 mg PO morphine = 50 mg PO Tramadol

Durotram XR®

24 hour

Slow Release

100, 200 and 300 mg tablets 10 mg PO morphine = 50 mg PO Tramadol

* Based on the conversions used in the eviQ Opioid Calculator

** Combination products are not in the eviQ calculator as there is no conclusive evidence that combination analgesics containing lower doses of codeine with paracetamol, aspirin or ibuprofen have any benefits over these non-opioids alone.

*** The safety and efficacy of Jurnista in children and adolescents under the age of 18 has not been established. Until further experience is gained, Jurnista must not be used in this population



CONVERSION OF MORPHINE Q4H TO A FENTANYL PATCH

Oral morphine range q4h Fentanyl dose mcg/hr

< 20mg 25mcg patch

20-35mg 50mcg patch

35-50mg 75mcg patch

50-65mg 100mcg patch







• Ensure patch is calculated using q4h morphine dose To determine the appropriate Fentanyl patch, divide the 24hr oral dose by 3



NURSE PRACTITIONER FORMULARY ENDORSEMENT:

Approved By: Name Signature Date:

Nursing Council Chairperson Moran Wasson

Pharmacy and Drug Committee Chairperson

Dr Jeanette Conley

Palliative Care Specialist (Collaborative arrangement)

Dr Gillian Rothwell

Medical Advisory Committee Chairperson

Dr L Giutronich

Executive Committee Chairperson

Dr Leon Clark