Guidelines for the Use of

Subcutaneous Medications in
Palliative Care

Dec 2009
Review Dec 2011

1
Acknowledgments

These guidelines have been adapted for local use with kind permission from NHS
Greater Glasgow and Clyde.

Drug compatibility data has been extracted from the revised (2009) version of the
Lanarkshire Palliative Care Guidelines.

2
Contents

Part 1 - Bolus Administration

1. Rationale and Indications 5

2. Advantages and disadvantages of Subcutaneous (SC) route 5
3. S/C cannula insertion sites 6
4. Choice of cannula 7
5. Preparation of patient for insertion of SC cannula 7
6. Removal of cannula 8
7. Information on drugs given SC in Palliative Care 9
8. Drug Administration Table (drugs commonly given by SC bolus) 10

Part 2 - Continuous Subcutaneous Infusion (CSCI)

1. Rationale and Indications 12
2. Choice of cannula and infusion set 13
3. Potential problems with CSCI 13
4. Frequently asked questions 14
5. Compatibility and stability of drugs 15
6. Commonly used drugs given SC in Palliative Care 15
7. Single drugs for SC infusion 16
8. Morphine: Drug combinations for SC infusion 19
9. Diamorphine: Drug combinations for SC infusion 21
10. Oxycodone: Drug combinations for SC infusion 23
11. Drug conversions 25
12. Breakthrough analgesia 26
13. References 27

Appendix 1 - Contact details for Palliative Care Teams 28

Appendix 2 - Contributors 29

3
 Part 1
Bolus Administration

4
1. Rationale and indications
When the oral route is unavailable to patients the subcutaneous (SC) route is the
preferred method of drug administration. Intravenous (IV) injections should be
avoided because they are invasive and no more effective than the subcutaneous
route. Intramuscular (IM) injections should be avoided, as they are painful,
particularly in patients who are cachectic.
The SC route should not only be reserved for use in a dying patient. Consider this
route for the treatment of pain and/or other symptoms when other routes of
administration are inappropriate. Listed below are possible reasons why the SC
route could be used:

Unable to take by mouth

Nausea and vomiting

Poor absorption, e.g. ileostomy.

The SC route will not give better analgesia than the oral route unless there is a
problem with absorption or administration.

2. Advantages and disadvantages of SC route

Advantages:

Can be used when patients can no longer tolerate oral therapy due to
nausea, vomiting or dysphagia

Increased patient comfort, avoiding the need for repeated injections

Suitable for patients who are very drowsy, comatose or semi-comatose

Avoids the administration of an excessive number of tablets

Cannula can be left in for 72 hours or longer if no redness/inflammation,
therefore less demanding on nursing resources.

Disadvantages:

Possible inflammation or irritation at infusion site

Possible leakage of SC site

Possible allergic reaction (rare occurrence)

5
3. SC cannula insertion sites

Acceptable SC cannual insertion sites (see diagram):

Anterior aspect of the upper arms or anterior abdominal wall

Anterior aspect of the thigh

The scapula if the patient is distressed and/or agitated

Anterior chest wall

Sites not suitable for injection

Skin folds and breast tissue

Directly over a tumour site

Lymphoedematous limb or oedema – absorption may be reduced

The abdominal wall if ascites present

Bony prominences – little SC tissue, absorption reduced

Previously irradiated skin – skin may be sclerosed, poor blood supply

Sites near a joint – uncomfortable, increased risk of displacement

Infected, broken or bruised skin

If a local reaction occurs, the cannula should be resited using a fresh cannula and
administration set. If this recurs, consider further diluting the drug(s). The site
need not be changed for up to 72 hours, or longer if the site is viable (sites
may last for 7 days or longer).

6
4. Choice of cannula
The BD Saf-T-Intima™ cannula, shown below, is the choice of cannula for SC
medications. The rationale behind this preference is:
• Site reactions are less common
• Insertion is less traumatic
• Needle stick injury is reduced to patient and staff
• Less expensive than alternatives
• Can remain in situ longer than other devices.

BD Saf-T-Intima™ 22 Gauge cannula (blue), code number FSP319.

Note
The BD Saf-T-Intima™ cannula has a dead space of 0.2ml. Drugs therefore
require to be flushed through with at least 0.2ml of appropriate diluent. The diluent
used will depend on the medication being given. For guidance please refer to Drug
Administration Table, page 12.
If a patient is started on a continuous SC infusion they may require a separate BD
Saf-T-Intima™ cannula for bolus medications.
It is highly recommended that a luer lock syringe is used for all bolus
injections and flushes to avoid possible leakage.

5. Preparation of patient for insertion of SC cannula

• BD Saf-T-Intima™ 22 Gauge cannula (blue), code number FSP319
• Alcohol impregnated swab
• Occlusive dressing
• Non-sterile gloves

7
Procedure
1. Wash hands as per hand hygiene policy.
2. Explain procedure to patient and gain consent.
3. Clean skin with an alcohol-impregnated swab. Allow to dry for a minimum of
30seconds.
4. Put on gloves.
5. Remove and dispose of clamp on the BD Saf-T-Intima™ to avoid accidental
occlusion.
6. Rotate white safety barrel to loosen needle.
7. Remove clear needle cover.
8. Grasp pebbled side wings, pinching firmly.
9. Pinch skin between thumb and forefinger to ensure SC tissue is identified.
10. Insert cannula at a 45-degree angle.
11. Cover the insertion site and wings with a transparent semi-permeable dressing
e.g. Tegaderm.
12. Hold wings of the cannula firmly and remove introducer (needle) by pulling
back in a smooth single movement. This should leave injectable bung in-situ.
13. Dispose of needle in sharps container as per local policy.
14. Document date, time and place of cannula insertion in nursing notes.
15. Wash hands as per hand hygiene policy.

Notes:

Check site 4 hourly (daily in community setting) for erythema, pain or swelling.
Document findings of check on monitoring sheet.

If insertion is unsuccessful use another cannula. Do not reinsert

If blood appears in the cannula insert a new one in another site.

If the cannula is being used to deliver a subcutaneous infusion remove the
bung and attach an anti-siphon extension set (e.g. McKinley 100-172S)

If the cannula is being used to deliver subcutaneous bolus injections remove
the bung and cap

6. Removal of cannula
The SC cannula can remain in situ for up to 72 hours or longer if there is no pain,
swelling or erythema at the insertion site.
• Document removal of cannula in nursing notes
• Once the cannula is removed cover the site with a small elastoplast if any
leakage appears.
Note: Before discontinuing SC route and removing cannula, symptoms must be
well controlled and patient able to tolerate oral medications.

8
7. Information on drugs given SC in Palliative Care
It is common in palliative care to use licensed medicines for an unlicensed
indication, route or dose. Such use can be supported by experience in clinical
practice and accepted reference sources such as The Oxford Textbook of
Palliative Medicine or the Palliative Care Formulary. The licensing process
regulates the activities of pharmaceutical companies and not the prescribing
practice of a qualified prescriber.
The marketing authorisation for many of the injectable drugs used in palliative care
does not specifically cover SC administration. This is indicated on the chart on
page 12. In palliative care the SC route is preferred as it is less painful than IM and
can also be utilised as a continuous infusion.

Clinicians administering a drug that they have not previously used by the SC
route, should be aware that:
• Absorption may be slower than by IM route
• Irritant drugs may cause a greater inflammatory reaction SC than IM
• The total volume for a bolus injection is not too great (recommended
maximum is 1ml)
• Absorption will be severely limited in patients who are ‘shocked’ or
hypovolaemic.

The commonly used drugs listed below must not be given by the SC route as
they may cause tissue necrosis:
• Antibiotics.
• Diazepam.
• Chlorpromazine.
• Prochlorperazine (stemetil®).

If you have any queries or concerns please see contact details documented in
Appendix 1.

9
8. Drug Administration Table
All of the drugs below are commonly given by subcutaneous bolus or infusion in
palliative care patients regardless of their licensed routes of administration
Note: If administering cyclizine or haloperidol ensure line is flushed before
and after use with water for injection.
Licensed Licensed Licensed Licensed After injection FLUSH
Drug
for CSCI for SC inj. for IM inj. for IV inj. cannula/ line with:

Alfentanil X X X Sodium Chloride 0.9%

Cyclizine X X Water for injection

Dexamethasone-
X Sodium Chloride 0.9%
Organon brand
Dexamethasone-
X X Sodium Chloride 0.9%
Mayne brand

Diamorphine Water for injection

Glycopyrronium X X Sodium Chloride 0.9%

Haloperidol X X Water for injection

Hydromorphone X X X X Sodium Chloride 0.9%

Hyoscine
X X Sodium Chloride 0.9%
Butylbromide
Hyoscine
X X Sodium Chloride 0.9%
Hydrobromide

Ketamine X X Sodium Chloride 0.9%

Ketorolac X X Sodium Chloride 0.9%

Levomepromazine X Sodium Chloride 0.9%

Metoclopramide X X Sodium Chloride 0.9%

Midazolam- Roche
X X Sodium Chloride 0.9%
brand
Midazolam- Phoenix
X X X Sodium Chloride 0.9%
brand

Morphine sulphate X Sodium Chloride 0.9%

Octreotide X X Sodium Chloride 0.9%

Oxycodone X Sodium Chloride 0.9%

10
 Part 2

Use of Continuous
Subcutaneous Infusions
(CSCI)

11
Rationale and Indications
Continuous subcutaneous infusions using a syringe pump are popular in palliative
care as a method of delivering a wide range of medications when other methods of
drug delivery are no longer available, or are unacceptable to the patient. Using the
SC route avoids having to intravenously cannulate a terminally ill patient although
the use of a CSCI should not be reserved for the dying patient. The medication is
administered into the fatty tissue under the skin and is absorbed systemically.
A CSCI infusion allows for a continuous infusion of drugs over a calculated period
of time and can provide constant dosing for a range of commonly used agents
including opioid analgesics (primarily morphine and diamorphine in the UK),
antiemetics, anxiolytic sedatives, corticosteroids, non-steroidal anti-inflammatory
drugs (NSAIDs) and anticholinergic drugs.
A significant advantage of subcutaneous infusion over other drug delivery
methods is that plasma levels of a drug are much more stable, and appropriate
symptom control can be achieved without the toxic effects of the peaks and
troughs resulting from episodic drug administration. It can give relief of multiple
symptoms including pain, nausea and vomiting, restlessness, confusion and
excess respiratory secretions.
Note: All drugs to be given by CSCI must be prescribed on the medicine
kardex and the SC infusion chart.

Indications for use of a CSCI

• Severe dysphagia /swallowing difficulties
• Mouth, throat and oesophageal lesions
• Intestinal obstruction
• Profound weakness
• Poor absorption of oral drugs
• Unacceptable number of oral medications or volumes of syrups which make
ingestion difficult
• Unconscious patient
• Intractable symptoms that are not well controlled by oral methods
• Rectal route is inappropriate.

Sites may last for up to 72 hours or longer if there are no local reactions. However,
these should be checked and documented every four hours (daily in primary care
settings) on the CSCI monitoring chart. The entire administration set should be
replaced if a new mixture of drugs is used.

12
2. Choice of cannula and infusion set
The Saf-T-Intima™ is the cannula of choice for the administration of SC
medications. The rationale behind this preference is:

• Less likely to cause site reactions

• Insertion is less traumatic
• Needle stick injury is reduced
• Less expensive
• Can remain in situ longer than other devices.

Other considerations
Resite cannula if there are local reactions – use a new administration set each
time. If skin reactions are persistent the choice of drug(s) may have to be reviewed.
When in doubt contact a member of the specialist palliative care team.

Note: When delivering a CSCI an anti-syphon administration set (e.g. McKinley

100-172S) is strongly recommended, as there is a risk of ‘free flow’.

3. Potential problems with CSCI

Problem Possible cause Suggested action

Inappropriate or inadequate
medication. Reassess patient’s symptoms
Medication being administered is
Check that infusion is running Request medical or palliative care
not controlling or managing
– e.g. is there any team review.
symptoms. Patient comfort is not
crystallization. Set up new infusion using a fresh
maintained.
Check that the syringe pump administration set and needle.
is working.
Irritation of skin. Due to subcutaneous Check that drugs are reconstituted
medication in correct diluent and in appropriate
volume. Resite cannula.
Confusion Adverse effects due to opioid Stop infusion. Contact medical staff
Pin point pupils toxicity. to review:
Agitation and restlessness - patient
Semi purposeful movements Incorrect rate set on pump - dosage and choice of drug
Visual and auditory hallucinations - dosage and choice of other
Drowsiness Malfunction of pump resulting medication
Vivid dreams or nightmares in over infusion. The correct dose relieves pain
Twitching or plucking at the air without adverse side effects. Ensure
Myoclonic jerks adequate hydration. Sedation may
Seeing shadows at periphery of be present until symptoms resolve.
vision
Leakage at subcutaneous site. Inflammation at the site. Resite infusion changing the whole
set.

13
Frequently asked questions

Which diluent should be used?

(Please consult page18 for the diluent table on single drug infusions)

For cyclizine, higher doses of diamorphine, haloperidol and drug combinations, the
diluent is usually water for injection.
For drug combinations, it is important to check for stability information.

When should the CSCI be started?

If the patient is in pain and not currently on a modified or slow release opioid, e.g.
¨
MST or Oxycontin, the CSCI can be started immediately. If the patient is on a
modified or slow release opioid preparation, start the CSCI when the next dose of
oral modified or slow release opioid is due. If the patient is on a fentanyl patch,
refer to the fentanyl patch algorithm, or consult the palliative care pharmacist or
another member of the palliative care team for advice. If the patient has pain or
other symptoms, e.g. nausea or distress, at the time of commencing the infusion,
consider giving an initial breakthrough dose (by subcutaneous bolus route) as it
may take several hours for the infusion to have an effect.

When should the CSCI be stopped if oral treatment is to be re-started?

The CSCI can be stopped as soon as the oral modified release dose of opioid is
due to be given. The patient should have oral breakthrough medication prescribed
as this may be required until the modified release dose reaches a therapeutic level.

What is the usual number of drugs that can be mixed together?

It is common to use two or three drugs mixed in a syringe. Before mixing drugs
together it is important to check for stability information. This can be found on the
attached charts or by consulting a pharmacist or palliative care specialist, or by
contacting Medicines Information (contact numbers listed in Appendix 1).
Information is also available from the following resources:
• The Oxford Textbook of Palliative Medicine
• Palliative Care Formulary
• The Syringe Driver -continuous subcutaneous infusions in palliative care

14
5. Compatibility and stability of drugs
‘Instability’ or ‘incompatibility’ refers to chemical reactions that occur when diluting
or mixing drugs, resulting in the formation of different chemicals that can be
therapeutically inactive or possibly toxic to the patient. Sometimes there are
visible signs of incompatibility such as cloudiness, change in colour or the
appearance of crystals. However, some reactions will not be identified through
changes in appearance. If in doubt, contact the palliative care pharmacist or
another member of the palliative care team. Factors that affect stability include
light, heat, pH, time and volume of diluent. Therefore, if a solution is to be given by
CSCI, it is important to know that it will be stable in a suitable volume for 24 hours
at room temperature.

6. Commonly used drugs given SC in Palliative Care

It is important to understand that the licensing process regulates the activities of
pharmaceutical companies and not the prescribing practice of a qualified
prescriber. If an untoward incident occurs with a licensed product in an approved
clinical situation, depending on the circumstances, any liability arising
subsequently may in part or whole be transferred to the license holder. Due to
licensing restrictions, it is common in palliative care to use licensed medicines for
an unlicensed indication, by an unlicensed route or in an unlicensed dose. This is
‘off-label’ use of a medicine with a UK marketing authorization. In this case the
manufacturer is unlikely to be found liable if the patient is harmed. The prescriber
and the clinical pharmacist assume responsibility for ensuring appropriate use of
medication and patient safety. Nursing staff who administer ‘off-label’
medications also have a duty of care to the patient. ‘Off-label’ use of medication
can be supported by experience in clinical practice and accepted reference
sources such as The Oxford Textbook of Palliative Medicine or the Palliative
Care Formulary or local/national guidelines.
(See table in Part 1, Section 8)

15
7. Single drugs for SC infusion
Note: The Palliative Care Team may recommend doses in excess of those
mentioned in this table.
Single agent Indications and dose range Comments
MORPHINE Indications: Opioid responsive • 1st line opioid analgesic
10mg, 30mg in 1ml pain, breathlessness
60mg in 2ml Dose: No max dose limit
DIAMORPHINE Indications: Opioid responsive • Can be diluted in a small
10mg, 30mg, pain, breathlessness volume
100mg, 500mg Dose: No max dose limit • Preferred for high opioid
powder ampoules doses
OXYCODONE Indications: Opioid responsive • 2nd line opioid analgesic if
10mg in 1ml pain, breathlessness morphine/ diamorphine not
20mg in 2ml Dose: No max dose limit tolerated
ALFENTANIL Indications: Opioid responsive • 3rd line opioid; seek
1mg pain, breathlessness specialist advice
(1000micrograms) Dose: No max dose limit • 1st line in stages 4 /5
in 2ml, 5mg in 10ml chronic kidney disease
Antiemetics
CYCLIZINE Indications: nausea and vomiting • Anticholinergic; reduces
50mg in 1ml (bowel obstruction or intracranial peristalsis
disease) • Can cause redness, irritation
Dose: 50-150mg / 24 hours at site
METOCLOPRAMIDE Indications: nausea and vomiting • Prokinetic
10mg in 2ml (gastric stasis/outlet obstruction, • Avoid if complete bowel
opioid) obstruction or colic
Dose: 20-120mg / 24 hours
HALOPERIDOL Indications: opioid or metabolic • Long half life: can be given
5mg in 1ml induced nausea, delirium as a once daily SC injection
10mg in 2ml Dose: 2.5-5mg / 24 hours
Antiemetic
Dose: up to 30mg
Agitation
LEVOMEPROMAZINE Indications: Complex nausea, • Lowers blood pressure
25mg in 1ml terminal delirium/ agitation • Reduces seizure threshold;
Dose: 5-25mg / 24 hours - combine with a
antiemetic benzodiazepine if risk of fits
Dose: 25-100mg / 24 hours - • Long half life: can be given
terminal sedation as a once or twice daily SC
injection

16
Anticholinergics for chest secretions or bowel colic
HYOSCINE Indications: chest secretions, • First line; non-sedative
BUTYLBROMIDE bowel obstruction (colic,
20mg in 1ml vomiting)
Dose: 40-120mg / 24 hours
GLYCOPYRRONIUM Indications: chest secretions • Second line; non-sedative
200microgram in 1ml or colic • Longer duration of action
600microgram in 3ml Dose: 600-1200 micrograms than hyoscine
/24 hours
HYOSCINE Indications: chest secretions • Second line; sedative
HYDROBROMIDE Dose: 400-1200 • Can precipitate delirium
400microgram in 1ml micrograms / 24 hours
600microgram in 1ml
Sedative
MIDAZOLAM Indications: anxiety, muscle •Anxiolytic (5-10mg/ 24
10mg in 2ml spasm/ myoclonus, seizures, hours)
terminal delirium/ agitation • Muscle relaxant (5-20mg/ 24
hours)
Dose: titrate according to • Anticonvulsant (20-30mg/ 24
symptoms and response hours)
• First line sedative (20-80mg
/ 24 hours)
Other medication occasionally given by SC route in palliative care
DEXAMETHASONE Indications: bowel obstruction, • SC dose is the same as oral
4mg in 1ml raised intracranial pressure or • Available as different dose
intractable nausea and formulations. Check
vomiting preparation
Dose: 2-16mg / 24 hours • Mixes poorly with other drug
• Can be given as a daily SC
injection (in the morning)
KETAMINE Indication: Complex pain • Specialist supervision only
KETOROLAC Indication: bone/ inflammatory • Specialist supervision only
10mg in 1ml pain if patient in last days of • Give an oral PPI if still able
30mg in 1ml life to swallow
Dose: 10- 30mg / 24 hours • Long half life particularly in
frail patients: given as a
twice daily SC injection
OCTREOTIDE Indications: intractable • Some formulations very
200micrograms/ml vomiting due to bowel expensive
(5ml multi-dose vial) obstruction, fistula discharge • Potent antisecretory agent
Dose: 300–900 micrograms • Does not treat nausea
/ 24 hours • Limit fluid intake to 1-1.5
litre/ 24 hrs

17
Diluent

Single Drug
Water for Injection is the diluent of choice for most drugs. There are exceptions,
however, and these drugs are listed below.

Drug Preferred Diluent

Dexamethasone Sodium chloride 0.9%
Ketamine (specialist advice only) Sodium chloride 0.9% or Dextrose 5%
Ketorolac (specialist advice only) Sodium chloride 0.9% or Dextrose 5%
Levomepromazine Sodium chloride 0.9%
Octreotide Sodium chloride 0.9%

Important
Cyclizine is incompatible with sodium chloride 0.9%.

Two or more Drugs

When two or more drugs are mixed in a syringe the diluent is usually water for
injection. If compatibility/stability data is available for an alternative diluent then
that diluent should be used

18
8. Morphine: Drug combinations for subcutaneous infusion that are
stable for 24 hours
• These are not clinical doses to prescribe. Most patients will not need
high doses. Read the relevant guidelines.
• Only use this table to check for concentrations that are stable
• Refer to Table 1 for the usual dose range for each of the medications. Use
the minimum effective dose and titrate according to response
• Monitor closely for visible signs of incompatibility such as the solution
becoming cloudy, changing colour or the appearance of crystals

Drug Combination Maximum concentrations of two drug

combinations that are physically stable
17ml in 20ml syringe 22ml in 30ml syringe
Morphine Sulphate 300mg
Cyclizine 150mg
Morphine Sulphate 300mg
Glycopyrronium bromide 1200micrograms
Morphine Sulphate 400mg
Haloperidol 10mg
Morphine Sulphate 300mg
Hyoscine butylbromide 120mg
Morphine Sulphate 450mg
Hyoscine hydrobromide 1200micrograms
Morphine Sulphate 300mg
Levomepromazine 100mg
Morphine Sulphate 120mg 160mg
Metoclopramide 60mg 80mg
Morphine Sulphate 300mg 380mg
Midazolam 30mg 40mg
Morphine Sulphate 400mg 500mg
Octreotide 400micrograms 500micrograms

19
Drug Combination Maximum concentrations of three drug
combinations that are physically stable
17ml in 20ml syringe 22ml in 30ml syringe
Morphine Sulphate 40mg
Cyclizine 100mg
Haloperidol 2.5mg
Morphine Sulphate 100mg 130mg
Haloperidol 5mg 6.5mg
Midazolam 20mg 25mg
Morphine Sulphate 50mg 60mg
Hyoscine butylbromide 40mg 50mg
Midazolam 60mg 75mg
Morphine Sulphate 50mg 60mg
Metoclopramide 30mg 40mg
Midazolam 7.5mg 10mg
Morphine Sulphate 270mg
Glycopyrronium 1200micrograms
Haloperidol 10mg

20
9. Diamorphine: Drug combinations for subcutaneous infusion
that are stable for 24 hours
• These are not clinical doses to prescribe. Most patients will not need
high doses. Read the relevant guidelines.
• Only use this table to check for concentrations that are stable
• Refer to Table 1 for the usual dose range for each of the medications. Use
the minimum effective dose and titrate according to response
• Monitor closely for visible signs of incompatibility such as the solution
becoming cloudy, changing colour or the appearance of crystals

Drug Combination Maximum concentrations of two drug

combinations that are physically stable
17ml in 20ml syringe 22ml in 30ml syringe
Diamorphine 340mg
Cyclizine 150mg
Diamorphine 425mg
Glycopyrronium bromide 1200micrograms
Diamorphine 800mg
Haloperidol 10mg
Diamorphine 1200mg
Hyoscine butylbromide 120mg
Diamorphine 1200mg
Hyoscine hydrobromide 1200micrograms
Diamorphine 90mg
Ketorolac 30mg
Diamorphine 850mg
Levomepromazine 100mg
Diamorphine 2550mg 3300mg
Metoclopramide 85mg 110mg
Diamorphine 560mg 720mg
Midazolam 80mg 100mg
Diamorphine 425mg
Octreotide 900 micrograms

21
Drug Combination Maximum concentrations of three drug
combinations that are physically stable
17ml in 20ml syringe 22ml in 30ml syringe
Diamorphine 340mg
Cyclizine 150mg
Haloperidol 10mg
Diamorphine 800mg 1000mg
Haloperidol 7.5mg 10mg
Midazolam 65mg 80mg
Diamorphine 120mg 150mg
Hyoscine butylbromide 80mg 100mg
Midazolam 20mg 25mg
Diamorphine 850mg
Levomepromazine 100mg
Metoclopramide 50mg
Diamorphine 850mg 1100mg
Levomepromazine 50mg 60mg
Midazolam 30mg 40mg
Diamorphine 420mg 540mg
Metoclopramide 60mg 70mg
Midazolam 20mg 25mg

The following combinations are not stable:

• Diamorphine, dexamethasone and levomepromazine
• Diamorphine, dexamethasone and midazolam
• Diamorphine, cyclizine and metoclopramide
• Octreotide and levomepromazine
• Octreotide and cyclizine
• Octreotide and dexamethasone

22
10. Oxycodone: Drug combinations for subcutaneous infusion
that are stable for 24 hours
• These are not clinical doses to prescribe. Most patients will not need
high doses. Read the relevant guidelines.
• Only use this table to check for concentrations that are stable
• Refer to Table 1 for the usual dose range for each of the medications. Use
the minimum effective dose and titrate according to response
• Monitor closely for visible signs of incompatibility such as the solution
becoming cloudy, changing colour or the appearance of crystals

Drug Combination Maximum concentrations of two drug

combinations that are physically stable
17ml in 20ml syringe 22ml in 30ml syringe
Oxycodone Do not mix - Do not mix -
Cyclizine Incompatible Incompatible
Oxycodone 140mg
Haloperidol 10mg
Oxycodone 140mg 180mg
Hyoscine butylbromide 40mg 50mg
Oxycodone 130mg
Hyoscine hydrobromide 1200micrograms
Oxycodone 85mg
Ketorolac 30mg
Oxycodone 120mg
Levomepromazine 100mg
Oxycodone 80mg 100mg
Metoclopramide 40mg 50mg
Oxycodone 80mg 100mg
Midazolam 40mg 50mg
Oxycodone 80mg 100mg
Octreotide 400micrograms 500micrograms

23
Drug Combination Maximum concentrations of three drug
combinations that are physically stable
17ml in 20ml syringe 22ml in 30ml syringe
Oxycodone 80mg 100mg
Haloperidol 2.5mg 5mg
Hyoscine butylbromide 100mg 120mg
Oxycodone 80mg 100mg
Haloperidol 2.5mg 5mg
Hyoscine hydrobromide 1000micrograms 1200micrograms
Oxycodone 80mg 100mg
Haloperidol 2.5mg 5mg
Midazolam 15mg 20mg
Oxycodone 80mg 100mg
Levomepromazine 20mg 25mg
Hyoscine butylbromide 100mg 120mg

24
11. Drug Conversions

Converting to Diamorphine or Morphine

Diamorphine and Morphine are the opioids of choice for moderate to severe pain.
Diamorphine is particularly suitable for use in a syringe pump because it is highly
soluble in small volumes. 1g of diamorphine can be dissolved in 1.6 ml of water (21
ml of water are needed to dissolve 1g of morphine sulphate). However, when dose
requirement is low morphine can be used equally well.For advice please contact
Hospital Palliative Care Team or St Andrew's Hospice. (Refer to Appendix 1, for
contact details).
Subcutaneous diamorphine is 3 times the potency of oral morphine.
i.e. 30mg oral morphine = 10mg subcutaneous diamorphine.
To convert from oral morphine to subcutaneous diamorphine:
The total 24-hour dose of oral morphine should be divided by 3.

Subcutaneous morphine is 2 times the potency of oral morphine.

i.e. 30mg oral morphine = 15mg subcutaneous morphine.
To convert from oral morphine to subcutaneous morphine:
The total 24-hour dose of oral morphine should be divided by 2.

Example:
Patient is on MST 120mgs twice daily.
Breakthrough dose is 1/6th of total 24hour dose
i.e. 120 mg + 120 mg = 240 mg ÷ 6 = 40 mg.

Patient has required 3 doses of breakthrough medication in preceding 24 hours.

Total 24 hours oral morphine dose:

120 mg + 120 mg + 40 mg + 40 mg + 40mg = 360 mg.
360 mg divided by 3 = 120 mg of diamorphine subcutaneously over 24 hours.
OR
360mg divided by 2 = 180 mg of morphine subcutaneously over 24 hours.

Subcutaneous diamorphine is 1.5 x as potent as subcutaneous morphine.

i.e. 10mg subcutaneous diamorphine = 15mg subcutaneous morphine.

25
12. Breakthrough analgesia
Breakthrough analgesia should still be prescribed subcutaneously when a
continuous infusion is in use. The dose should normally be approximately 1/6th of
the current 24hr opioid. If the dose is difficult to calculate, round up or down to the
nearest easy dose to achieve. To avoid repeated injections a separate BD Saf-T-
Intima™ cannula can be left in situ at a SC site, secured with a dressing. Extra
doses can be administered via this SC route followed by a 0.2ml flush of sodium
chloride 0.9% or water for injection. Please refer to diluent table on page 10.

Caution: Breakthrough analgesia given for movement related pain or incident pain
in a patient whose background pain is satisfactorily controlled should not normally
be added into the regular 24hour dose as toxicity may ensue. Continue to give as
breakthrough in anticipation of incident related pain.

26
References

Back I (2001) Palliative Medicine Handbook BPM Books Cardiff.

British National Formulary (2009), March
Dickman A., Scheider J., Varga J (2005) 2nd Ed. Syringe Driver Handbook Oxford
UniversityPress Oxford
Twycross R., Wilcock A., Thorp S. (2007) 3rd Ed. Palliative Care Formulary
Radcliffe Oxon.
Watson M., Lucas C., Hoy A., Back I (2005) Oxford Handbook of Palliative Care
Oxford University Press Oxford.
Scottish Intercollegiate Guidelines Network (2008). Control of pain in adults with
cancer. Scottish Intercollegiate Guidelines Network, Edinburgh
Lanarkshire Palliative Care Guidelines (2009)

27
Appendix 1

Hospital Palliative Care Teams

Hairmyers Hospital
Clinical Nurse Specialist 01355 584656
Medicines Information 01355 584879
Palliative Care Pharmacist 01355 584887

Monklands Hospital
Clinical Nurse Specialist 01236 712156
Medicines Information 01236 712555

Wishaw General Hospital

Clinical Nurse Specialist 01698 366053
Medicines Information 01698 367065

Primary Care

Community Macmillan Nursing Team

North team 01698 723282
South team 01698 723299

St Andrew's Hospice

24hour Advice 01236 766951

Macmillan Area Lead Pharmacist- Palliative Care 01236 772021

Strathcarron Hospice

24hour Cumbernauld area 01324 826222

28
Appendix 2

Contributors

Linda Johnstone, Macmillan Area Lead Pharmacist- Palliative Care, NHS

Lanarkshire

Gillian Muir, Macmillan Palliative Care Clinical Nurse Specialist, NHS Lanarkshire

Adam Russell, Senior Clinical Pharmacist, NHS Lanarkshire

29
30