North East and North Cumbria Formulary


	North East and North Cumbria ICS Formulary

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Formulary Chapter 21: Palliative Care Formulary - Full Chapter

Notes:

NENC Palliative and End of Life Care Symptom Control Guidelines for cancer and non-cancer patients

NICE CG140: Palliative care for adults: strong opioids for pain relief

NICE CSG4: Improving supportive and palliative care for adults with cancer

Details...

Palliative Care Formulary Drugs

21.01

Pain

Alfentanil
(palliative care)

Formulary

1mg in 2ml, 5mg in 10ml & 5mg in 1ml injection ampoules - approved for initiation by specialists in palliative care

Codeine
(palliative care)

Formulary

First line: 15mg tablets

Second line: 30mg tablets

Codeine linctus 15mg/5ml - approved for cough suppression in palliative care patients unable to take tablets

MHRA Drug Safety Update (February 2024): Codeine linctus (codeine oral solutions): reclassification to prescription-only medicine

Ketamine
(palliative care)

Formulary

Buprenorphine
(palliative care)

Alternatives

200microgram sublingual tablets
300microgram in 1ml injection
Buprenorphine patches (Preferred brand - Butec®) are approved for use in palliative care when fentanyl 12 microgram/hr transdermal patches exceed the patient’s analgesic requirements.

Fentanyl
(palliative care)

Alternatives

12, 25, 37.5, 50, 75 & 100 microgram/hour transdermal patches
- Prescribe by brand. Mezolar® has replaced Matrifen® as the first choice brand. Patients who currently use Matrifen® can continue to do so if managing well.
Fentanyl sublingual tablets (Abstral®) restricted to use for breakthrough / rescue pain relief in palliative care on recommendation of a pain specialist or palliative care team.

MHRA Drug Safety Update (Oct 2018): Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children

MHRA Drug Safety Update (Sep 2020): Transdermal fentanyl patches for non-cancer pain: do not use in opioid-naive patients

Transdermal fentanyl – MHRA Drug Safety Update (July 2014): Transdermal fentanyl “patches”: reminder of potential life threatening harm from accidental exposure, especially in children

Oxycodone
(palliative care)

Alternatives

Approved only for use in patients who are intolerant of morphine.
Note: Oxycodone 50mg in 1ml injection is also approved for use, but is restricted to controlled circumstances in palliative patients following risk assessment by individual organisations.
The OxyPro® branded generic is preferred (most cost effective option).
The oral solution should be used instead of immediate release tablets.

21.02

Respiratory Secretions

Glycopyrronium injection
(palliative care)

Formulary

200 microgram in 1ml
600 microgram in 3ml injections

for End of Life use in line with NENC Palliative and End of Life Care Symptom Control Guidelines

21.03

Terminal Restlessness

Midazolam
(palliative care)

Formulary

Palliative care

10mg/2ml injection

Levomepromazine (methotrimeprazine)
(palliative care)

Alternatives

Levomepromazine 25mg in 1ml injection is approved for use in palliative care.

Note: Methotrimeprazine / Levomepromazine 6mg tablets are unlicensed

21.04

Agitation

Haloperidol
(palliative care)

Formulary

Palliative Care

MHRA Drug Safety Update Dec 2021: Haloperidol (Haldol): reminder of risks when used in elderly patients for the acute treatment of delirium

NICE NG10: Violence and aggression: short-term management in mental health, health and community settings

TEWV Rapid Tranquilisation Policy

21.05

Nausea and Vomiting

Metoclopramide INJECTION
(palliative care)

Formulary

Palliative care use

Ondansetron INJECTION
(palliative care)

Formulary

Palliative care use

MHRA Drug Safety Alert (Jul 2013): Ondansetron for intravenous use: dose-dependent QT interval prolongation

MHRA Drug Safety Update (Jan 2020): Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy

21.06

Seizure Control

Levetiracetam (category 3)
(palliative care)

Formulary

Injection is also approved for use in palliative care

21.07

Other

Sodium Fluoride
(palliative care)

Formulary

Sodium fluoride 0.619% (75ml) toothpaste (Duraphat® 2800 ppm)
Sodium fluoride 1.1% (51g) toothpaste (Duraphat® 5000 ppm)
Sodium fluoride 0.05% mouthwash - approved for use within the dental hospital.

In line with NHS England’s guidance on conditions for which over the counter items should not be routinely prescribed, the ICB does not support the routine prescribing of medicines or preparations for dental conditions (including toothpastes such as Duraphat®, ulcer healing preparations, antibiotics and analgesics) on GP FP10 prescriptions except in the following circumstances:
- After head and neck cancer treatment on the recommendation of a Head & Neck or Restorative Dental Consultant.
- For patients receiving palliative care as part of ongoing symptom control.

Dentists must signpost patients to purchase products or issue prescriptions (NHS or private) for medicines to meet the identified dental needs of their patients. If a patient receives treatment as a private patient, they must always be given a private prescription.

....

Key

	Restricted Drug
	Unlicensed
	Link to adult BNF
	Link to children's BNF
	Link to SPCs
	Cytotoxic Drug
	Controlled Drug

	High Cost Medicine
	NHS England
	Homecare
	ICB
	Low carbon footprint
	Medium carbon footprint
	High carbon footprint

Status	Description
	Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing.
	Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. These medicines are considered suitable for primary care prescribing following specialist initiation of therapy and stabilisation, with ongoing communication between the primary care prescriber and specialist as set out in the associated shared care guideline (SCG). Shared care should be initiated by the specialist, which includes consultant, suitably trained specialist non-medical prescriber or GPwER within a secondary, tertiary, or primary care clinic. The specialist should send the primary care prescriber a copy of the NENC Clinical Effectiveness and Governance (CEG) Subcommittee approved SCG to sign. The primary care prescriber should sign the SCG or indicate reasons why they are unable to accept the agreement and return a copy back to the specialist, as soon as possible. SCGs are available or are being developed for most of the drugs listed as AMBER.
	Drugs normally recommended or initiated by a hospital specialist who is a prescriber, a GP with an extended role [GPwER], or a specialist within primary care which can be safely maintained in primary care and monitored in primary care. In some cases, a further restriction for use may be defined. The primary care prescriber must be familiar with the drug to take on prescribing responsibility or must obtain the required information from the specialist. Therefore, provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by primary care prescriber or provide information re stopping criteria. These are considered suitable for primary care prescribing following specialist assessment and recommendation of therapy, with ongoing communication between the primary care prescriber and specialist, if necessary. In some case these drugs require specialist initiation and short to medium term monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist review the patient may be transferred to primary care for ongoing prescribing. Ongoing prescribing by primary care can include, if required, additional dose titrations and assessment of efficacy, with ongoing communication between the primary care prescriber and specialist, if necessary. If the drug requires urgent initiation, it is expected that the specialist provides the first prescription from the inpatient/outpatient setting, of sufficient supply for a patient’s immediate needs. The quantity provided should cover at least up to the point where the discharge/clinic letter has reached the GP, plus reasonable time for the practice to manage the document and issue further supplies. A GREEN+ drug can only be recommended to primary care for initiation if it does not need to be initiated urgently, taking into account clinical need.
	Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible.
	Self-care – available OTC, can be purchased as part of self-care for self-limiting conditions as per NHSE policy guidance
	UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review.
	Drugs that have been considered by the NENC Clinical Effectiveness and Governance (CEG) Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria ICS. These may also include all medicines with a “not NHS” or “DLCV” classification in the BNF, those agents as included within the NICE “Do not do” list, and those agents included with the NHS England: Items which should not routinely be prescribed in primary care.