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Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 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.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   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

 

 

Red – For medicines normally initiated and used under specialist guidance

Introduction

Description: Potent opioid.
Fourth-line opioid: only for use with specialist advice.

 

Preparations

Tables are best viewed in landscape mode on mobile devices

Route Preparation Available strengths
Oral Immediate release hydromorphone Palladone® capsules 1.3mg, 2.6mg
Modified release (long acting) hydromorphone Palladone SR® capsules 2mg, 4mg, 8mg, 16mg, 24mg

Immediate release† hydromorphone liquid

10mg/ml (other strengths can be made on
request)

Unlicensed preparation but can be made to order (contact local non-sterile pharmacy production
unit via specialist pharmacist)
Injection

Palladone injection®

Used as a subcutaneous infusion or as a subcutaneous bolus injection.

2mg/ml 10 mg/ml 20 mg/ml 50 mg/ml

Licensed preparation available via wholesalers (made by NAPP Pharmaceuticals)

Non formulary in some NHS boards

Indications

Must have specialist input. Fourth-line oral and injectable analgesic for moderate to severe opioid responsive pain in patients unable to tolerate oral morphine/oxycodone, subcutaneous diamorphine/morphine or oxycodone due to persistent side effects (for example sedation, confusion, hallucinations, itch).

 

Cautions

  • Immediate release and modified release capsules have similar names. Some NHS boards recommend prescribing by brand name to avoid confusion.
  • Frail or elderly patients need smaller doses less frequently and slower titration.

 

  • Liver impairment:
    • Reduced clearance (may need reduced dosing frequency). Note that the summaries of product characteristics (SPC) list hepatic impairment as a contra-indication, but this would not preclude its use in palliative care. Patients with moderate hepatic impairment should be started at a lower dose and closely monitored during dose titration.
  • Renal impairment:
    • Reduced excretion (may need reduced dosing frequency). 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). Check renal handbook.
  • Drug interactions:
    • Similar to other strong opioids such as morphine/oxycodone. Hydromorphone may be expected to have additive effects when used in conjunction with alcohol, other opioids, or drugs that cause central nervous system (CNS) depression (for example sedatives, hypnotics, general anaesthetics, phenothiazines, tranquilisers). Respiratory depression, hypotension and profound sedation or coma may occur. 
  • Side effects:
    • Opioid side effects similar to morphine/oxycodone - monitor for opioid toxicity.
    • Constipation: prescribe a laxative to be taken regularly and anti-emetic as needed (for example metoclopramide).
    • Drowsiness: hydromorphone may cause drowsiness, impairing mental and/or physical ability. If affected do not drive or operate machinery. Avoid alcohol.

 

Dose and administration

Immediate release oral hydromorphone

  • Prescribe 4 hourly regularly and use the same dose as required for breakthrough pain.

  • The capsules can be opened and the contents sprinkled on cold, soft food.

Modified release (long acting) oral hydromorphone (Palladone SR®)

  • Prescribe 12 hourly, with a 1/6th to 1/10th of the 24-hour dose as immediate release oral hydromorphone for breakthrough pain.

  • Palladone SR® capsules can be opened (if difficulty when swallowing the SR capsules) and the contents sprinkled on cold, soft food, but the granules should NOT be broken, chewed, dissolved or crushed as this could lead to a rapid release of the drug and a potential overdose. Seek pharmacy advice if the patient has a feeding tube.

Hydromorphone injection

  • Continuous subcutaneous infusion in a 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 (max 6 doses in 24 hours).

  • Diluent: water for injection.

  • Refer to stability and compatibility tables in Syringe pump guideline.

  • Sodium chloride 0.9% can also be used as a diluent. Seek specialist palliative care/pharmacy advice.

Dose conversions

Hydromorphone is approximately 7.5 times more potent than morphine.

Tables are best viewed in landscape mode on mobile devices

Morphine dosage Hydromorphone dosage
Oral morphine 10mg ≈oral hydromorphone 1.3mg
Oral hydromorphone 10mg ≈subcutaneous hydromorphone 5mg
Subcutaneous morphine 30mg ≈subcutaneous hydromorphone 4mg
Subcutaneous diamorphine 20mg ≈subcutaneous hydromorphone 4mg
  • As with all opioid conversions, these are approximate (≈) doses.
  • 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.

 

Practice points

  • The GP, community pharmacist, district nurse and unscheduled care service should be informed that the patient is receiving this fourth-line opioid, for example via eKIS.
  • Hydromorphone can be prescribed by the patient’s GP for the indications/uses listed in liaison with local palliative care specialists.
  • Patients should receive an initial supply on discharge to allow adequate time for the community pharmacist to order the preparation(s) required.
  • At high background maintenance doses of long acting hydromorphone, the burden of the number of immediate release hydromorphone capsules for the breakthrough analgesic dose should be considered.

 

References

Ashley C, Currie A.  Renal Drug Handbook.  3rd Edition. Radcliffe Publishing. 2009.

Dickman A, Schneider J. The Syringe Driver. 4th ed: Oxford University Press; 2016.

Summary of Product Characteristics (SPC) http://www.medicines.org.uk/emc/search

Twycross R, Wilcock A, Howard P. Palliative Care Formulary PCF6. 6th ed. England: Pharmaceutical Press; 2017.