Berkshire West Integrated Care System Representing Berkshire West Clinical Commisioning Group Royal Berkshire NHS Foundation Trust Berkshire Healthcare NHS Foundation Trust Berkshire West Primary Care Alliance Berkshire Adult Palliative Care Guidelines Best Practice Document [APC ClinDoc 016a] F For the latest information on interactions and adverse effects, always consult the latest version of the Summary of Product Characteristics (SPC), which can be found at: http://www.medicines.org.uk/ A Approval and Authorisation Approved by Job Title Date Area Prescribing APC Chair November 2019 Committee C Change History Version Date Author Reason v.2.0 01/10/2018 Specialist Palliative Care Medical Updated APC Category Teams East Berkshire (Thames Hospice/HWPH) and West Berkshire (Sue Ryder Duchess of Kent and Nettlebed and RBHFT) This prescribing guideline remains open to review considering any new evidence This guideline should only be viewed online and will no longer be valid if printed off or saved locally POLICY DEVELOPMENT ADULT PALLIATIVE CARE GUIDELINES SECTION 1: PAIN – BEST PRACTICE DOCUMENT SECTION 2: OTHER SYMPTOMS – BEST PRACTICE DOCUMENT SECTION 2: OTHER SYMPTOMS – BEST PRACTICE DOCUMENT History These guidelines cover all services in Berkshire including Wexham Park Hospital, Royal Berks Hospital, BHFT, East Berkshire CCGs, Sue Ryder Hospices & Thames Hospice. They are to be read in conjunction with Organisational Policies on Medicines Management, Prescribing and administration of medicines and use of Oxygen appropriate to each organization. Original Policy Consultants Dr. Paul Howard, Palliative Care Consultant Sue Ryder Dr. Fiona Lisney, Palliative Care Consultant Wexham Park Hospital Fiona Dorrington, Specialist Palliative Care Pharmacist Cathy Goddard, Lead Pharmacist Palliative Care, West Berkshire Rosemary Martin, End of Life Care Lead BHFT Dr Anant Sachdev, GPSI End of Life Care Anne Gates, District Nurse Team Leader Viv Tight, District Nurse Policy Review Jan – August 2015 by Specialist Palliative Care Medical Teams East Berkshire (Thames Hospice/HWPH) and West Berkshire (Sue Ryder Duchess of Kent and Nettlebed and RBHFT) Edited by: Fiona Dorrington, Macmillan Specialist Pharmacist, East Berkshire Dr Jane Bywater, Consultant in Palliative Care, Sue Ryder West Berkshire Cathy Goddard, Lead Pharmacist Palliative Care, West Berkshire Policy review February 2018 – January 2019 by Specialist Palliative Care Teams: Thames Hospice (Drs C Wright, S Price, S Mulumudi, G Gupta, C Harris, A Martin. F Dorrington Macmillan Pharmacist) Sue Ryder Hospices (Duchess of Kent and Nettlebed) Wexham Park Hospital Dr F Lisney Royal Berkshire Hospital Edited by: Fiona Dorrington Macmillan Principal Pharmacist (Thames Hospice and Wexham Park hospital) Dr Jane Bywater, Consultant in Palliative Care, Sue Ryder West Berkshire Substantive Changes as a result of Review 1 Addition of Guidance on Hepatic and Renal insufficiency 2. Addition of Appendix: Anticipatory Prescribing Guidance 3. Addition of Appendices Opioid Patient information leaflets 4. Update of advice on oral to subcutaneous Cyclizine Use 5. Information of use of subcutaneous Ranitidine 6. Information of use of subcutaneous Levetiracetam 7. Advice on management of fits 2 | P a g e NHS Author Dr J Bywater Date of production: Jan 2019 Job Title Consultant in Palliative Medicine Review Date May 2022 Protocol Lead Consultant in Palliative Medicine Version v.3 Table of Contents Page 3 - 4 Who are these guidelines intended for? 5 Where to get advice and further information 6 Section One PAIN 1. Introduction to pain management 7 - 8 1.1 Pain assessment: how and why? 7 1.2 Pain treatment: The WHO ladder versus problem-specific approaches 8 2. Broad-spectrum analgesics 9 - 20 2.1 WHO ladder drugs 9 Paracetamol and weak opioids 9 Strong opioids: starting; titrating 10 - 12 NSAIDs 13 2.2 Difficulties with opioids: adverse effects and switching between opioids 14 Assessing opioid-responsiveness and managing opioid adverse effects 15 Switching opioids (opioid conversion ratios) 16 - 17 2.3 Opioids in Chronic Pain 18 - 19 2.4 Opioid induced hyperalgesia 20 3. Pain amenable to specific approaches 21 - 30 3.1 Neuropathic pain 21 1st line drugs: amitriptyline, gabapentin 21-22 2nd line drugs: nortriptyline, pregabalin, carbamazepine, duloxetine, sodium valproate 23 Non-drug approaches (TENS, acupuncture) 24 Topical approaches (capsaicin, lidocaine patches) 24 3.2 Skeletal muscle spasm 25 - 26 3.3 Smooth muscle spasm (colic) 27 3.4 Malignant bone pain 28 3.5 Incident pain and other episodic pains 29 - 30 4. Difficult circumstances 31 - 37 4.1 Driving and analgesia (including a patient information leaflet) 32 4.2 Pain with concurrent drug misuse 33- 34 4.3 Pain assessment in cognitive impairment 35 -36 4.4 Checklist for analgesic-resistant pain 37 References 38 - 43 3 | P a g e NHS Author Dr J Bywater Date of production: Jan 2019 Job Title Consultant in Palliative Medicine Review Date May 2022 Protocol Lead Consultant in Palliative Medicine Version v.3 Section Two OTHER SYMPTOMS 1. Respiratory ............................................................................................................................ 44- 49 1.1 Breathlessness ................................................................................................................ 44 - 47 Opioids for breathlessness ............................................................................................. 45 Medication for anxiety and panic .................................................................................. 46 Nebulisers ...................................................................................................................... 46 Oxygen therapy ............................................................................................................. 47 1.2 Cough ............................................................................................................................... 48 - 49 Dry cough ....................................................................................................................... 49 Wet cough ...................................................................................................................... 49 Viscous sputum .............................................................................................................. 49 EOLC and retained secretions ........................................................................................ 49 2. Gastrointestinal ...................................................................................................................... 50 - 66 2.1 Hiccup…………………………………………………………………………………………………………… ............. 50 - 51 2.2 Nausea and Vomiting ....................................................................................................... 52 - 56 Choosing an Antiemetic ................................................................................................. 53 - 54 Specific causes: .............................................................................................................. 54 - 56 Gastric stasis Chemical/ toxic Other causes GI Obstruction ................................................................................................................ 57 - 59 2.3 Mouth .............................................................................................................................. 60 - 61 2.4 Constipation…………………………………………………………………………………………………… ............ 62 - 64 2.5 Diarrhoea ......................................................................................................................... 65 - 66 3. Skin ……………………………………………………………………………………………………………………… ............. 67 - 77 3.1 Lymphoedema ……………………………………………………………………………………………… ............ 67 - 72 3.2 Cellulitis .......................................................................................................................... 73 - 74 3.3 Itching ............................................................................................................................. 75 - 77 4. Emergencies and cancer related complications……………………………………………………… ........... 78 - 87 4.1 Hypercalcaemia …………………………………………………………………………………………… ............. 78 4.2 Spinal Cord Compression……………………………………………………………………………… ............. 79 4.3 Superior vena cava obstruction ...................................................................................... 79 4.4 Bronchial obstruction ..................................................................................................... 80 4.5 Ascites ………………………………………………………………………………………………………… .............. 81 - 82 4.6 Haemorrhage……………………………………………………………………………………………… ............. 85 4.7 Seizures ........................................................................................................................... 86 – 87 5. Prescribing in Renal Insufficiency ........................................................................................... 88 – 92 6. Prescribing in Hepatic Insufficiency ........................................................................................ 93 – 95 Appendix 1 –Summary of Anticipatory Prescribing Guidance .................................................... 96 Appendix 2 – Patient Information Leaflets- Morphine, Oxycodone, Fentanyl ........................... 97 - 108 References……………………………………………………………………………………………………………… ........... 109 - 113 4 | P a g e NHS Author Dr J Bywater Date of production: Jan 2019 Job Title Consultant