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Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Oxycodone

Green – For medicines routinely initiated and used by generalists

Introduction

Description: Potent, synthetic opioid analgesic; used second line.

Preparations

Tables are best viewed in landscape mode on mobile devices

Route

Preparation

Dosage

Oral

Immediate release oxycodone Shortec® capsules other brands also available

Shortec®, OxyNorm® and generic liquid and concentrate

5mg, 10mg, 20mg

 

1mg/ml, 10mg/ml

 

Modified release (long acting) oxycodone - 12 hourly preparation (twice daily)

Longtec® and other brands available

Note: depending on brand not all strengths available

 

24 hourly preparation (once daily)

Onexila XL® 

 

 

5mg, 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg, 120mg (refer to local guidance for preferred brand - not all strengths may be stocked)

 

10mg, 20mg, 40mg, 80mg

(non-formulary, risk of wrong preparation being prescribed)

Injection

Oxycodone injection

Shortec®, OxyNorm® and generic injection available

10mg/ml, 20mg/2ml, *50mg/ml (*non‑formulary in some NHS boards)

 

Indications

  • Second line oral and injectable analgesic for moderate to severe opioid responsive pain in patients unable to tolerate oral morphine, subcutaneous morphine or diamorphine due to persistent side effects (for example sedation, confusion, hallucinations, itch).
  • Refer to Pain management and Choosing and changing opioids guidelines.

 

Cautions

  • Immediate release, modified release and injection preparations have similar names. Take care when prescribing, dispensing or administering oxycodone.
  • Frail or elderly patients need smaller doses less frequently and slower titration.
  • Liver impairment - reduced clearance.
    • Avoid in patients with moderate to severe liver impairment.
  • Renal impairment - reduced excretion.
    • Titrate slowly and monitor carefully in mild to moderate renal impairment. Avoid in chronic kidney disease stages 4 to 5 (eGFR less than 30ml/min). 

Drug interactions

  • No clinically significant pharmacokinetic drug interactions.

 

Side effects

  • Opioid side effects similar to morphine. Monitor for opioid toxicity.
  • Prescribe a softener+/-stimulant laxative and an anti-emetic as needed (for example metoclopramide).

 

Dose and administration

  •  Immediate release oral oxycodone:
    • Prescribe 4 hourly regularly and use 1/6th to 1/10th of the 24 hour dose as required for breakthrough pain.

or

  • Modified release (long acting) oral oxycodone.
    • Prescribe 12 or 24 hourly depending on preparation, with 1/6th to 1/10th  of the 24 hour dose as immediate release oral oxycodone for breakthrough pain.
    • Biphasic action; a rapid release is followed by a controlled release phase. If the patient has pain when the dose of modified release (long acting) oxycodone is given, wait an hour before giving a breakthrough dose of immediate release oxycodone.

 

  • Oxycodone injection:
    • Continuous subcutaneous infusion in a CME T34 syringe pump over 24 hours.
    • In addition, prescribe 1/6th to 1/10th  of the 24 hour infusion dose subcutaneously, 1 to 2 hourly as required for breakthrough pain. If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review.  If more than 6 doses are required in 24 hours seek advice or review.
    • With higher subcutaneous infusion doses, consideration needs to be given to the volume of breakthrough medication. Typically an upper limit of 2ml (for example 20mg oxycodone) is acceptable by the subcutaneous route in a single site. Consider use of the high strength oxycodone injection form if available or an alternative opioid, for example diamorphine for doses greater than 20mg.
    • Dilutent: water for injections.
    • Dose conversions are given below. Seek advice if patient needs more than three ‘as required’ doses in 24 hours for breakthrough pain without acceptable benefit.

 

  • Stability and compatibility – refer to syringe pump subcutaneous infusion tables.

 

Dose conversions

Oxycodone is approximately twice as potent as morphine

Tables are best viewed in landscape mode on mobile devices

Oxycodone dose conversions

≈ oral morphine 30mg

≈ oral oxycodone 15mg

≈ subcutaneous oxycodone 7-8mg

Subcutaneous morphine 30mg

≈ subcutaneous oxycodone 15mg

Subcutaneous diamorphine 20mg

≈ subcutaneous oxycodone 15mg

 

  • As with all opioid conversions, these are approximate (≈) doses. Opioid conversions and ratios may vary depending on the resource used. These conversions are a consensus of use in practice in Scotland and based on manufacturers’ conversion factor.
  • Dose conversions should be conservative and doses rounded down.
  • Monitor the patient carefully so that the dose can be adjusted if necessary.
  • If the patient has opioid toxicity, reduce the dose by 1/3rd when changing opioid (refer to Choosing and changing opioids guideline).

 

References

King SJ et al. A systematic review of oxycodone in the management of cancer pain. Palliative Medicine 2011;25(5):454-470.

Caraceni A et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EPAC. Lancet Oncology 2012;13:e58-68.

Hanks G et al. The Oxford Textbook of Palliative Medicine (Fourth edition). Oxford University Press, 2010.

Twyross R et al. Palliative Care Formulary (Fourth edition. Palliativedrugs.com, Nottingham, 2011.

Electronic Medicines Compendium, Napp Pharmaceuticals Ltd. Oxynorm capsules, liquid & solution for injection and Oxycontin tablets. Summary of Product Characteristics. Updated September 2009-July 2011.

Shah S, Hardy J. Oxycodone: a review of the literature. European J Palliative Care 2001; 8: 93-96.