Alternatives to regular medication normally given via a syringe pump or subcutaneous route when this is not available

Supportive and palliative care temporary guideline - Additional considerations during pandemic coronavirus - patients who are dying of causes other than COVID-19

Please contact your local palliative care team if you require advice. There may also be local guidelines available to which you should refer.

Background

The COVID-19 pandemic is expected to put pressure on healthcare systems across Scotland. It is important that, despite this, all people who are approaching the last days of life continue to have good symptom management.

In addition to the people who are in the last weeks or days of life at present, it is expected that some people who are in the last months of life or are very frail may become infected with COVID-19, and these people may or may not have the reserve to recover from this illness. It is important that these people have access to appropriate care for potentially reversible conditions, but also that their symptoms are managed as far as possible.

This guideline aims to support professionals who are already skilled in providing generalist palliative care in identifying alternatives to usual drugs and routes of administration, when usual drugs or syringe drivers are not available. We recognise that the vast majority of palliative care happens in the community, in people’s homes, in care homes, and in hospital, and we wish to support those who provide excellent care for people to continue to do so with confidence.

In addition to managing symptoms with medications, it is important to address reversible causes of deterioration and to use non-pharmacological methods to help symptoms where possible. Further advice is available here.

Note that the use of fans for the treatment of breathlessness is not recommended during the COVID-19 outbreak. Portable fans used in clinical areas have been linked to cross infection in health and social care facilities, although there is no strong evidence yet. Portable fans are not recommended for use during outbreaks of infection or when a patient is known or suspected to have an infectious agent.

As the situation changes, there may be changing availability of drugs. We aim to keep these guidelines updated in view of this.

Management

Anticipatory prescribing

The aim of anticipatory prescribing is to ensure that patients with advancing illness and uncontrolled symptoms have timely access to medications to improve their physical comfort. Guidance for this is available in the Scottish Palliative Care Guidelines. The following guidelines are for use when usual measures are not available and will be available on a temporary basis during the Scottish COVID-19 response.
Use oral medication or a syringe pump where this is possible as per usual guidance - see Scottish palliative care guidelines.
Alternative syringe pump (e.g. Graseby) may be used during the COVID-19 response, however non-syringe driver alternatives may be preferable to using unfamiliar equipment. Please liaise with your local team regarding this.
The use of medicinal products off-label or unlicensed medication is widely accepted practice within palliative care. Where possible we would recommend using licensed products but many of the recommendations below are off-label use either due to route, dose or indication. Our recommendations are based on available evidence and reflect a consensus of opinion about good practice in the management of adult patients with life-limiting illness.
Depending on the setting, it may be more appropriate to administer regular injections (see below for starting dose/frequency) or use alternative routes such as buccal, transdermal, rectal or nasogastric (NG) administration.

Alternatives to syringe pumps - non injectable

In the event that syringe pumps are not available, consider if any of the following options would be appropriate for your patient when they are unable to swallow.
Some drugs can be used for more than one indication; try to minimise polypharmacy where possible.
If the patient has an eGFR <30ml/min morphine should be used with caution due to risk of toxicity. Oxycodone may be a reasonable alternative.
Some medicines are available as buccal preparations – moistening a dry mouth helps absorption. Some injectable preparations can be administered by the buccal or sublingual route.
Drugs given by the sublingual or buccal route can also be dispersed in water and administered down an NG tube where this is in place.

Medication

Pain/breathlessness/cough/pyrexia

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Pain/breathlessness/cough/pyrexia
Medicine	Route	Dose	Administration/ Comments
Paracetamol suppositories 500mg and 1g	Rectal SHORT ACTING	500mg to 1g every 4-6 hours (max 4g/24hrs)	Use 500mg dose if: Weight <50kg, hepatic impairment, eGFR<30ml/min, history of alcohol excess.
Opioid patches (see https://www.palliativecareguidelines.scot.nhs.uk for conversions). Opioid patches are recommended for stable pain. Used patches still contain opioid; after removal, fold the patch with the adhesive side inwards and discard in a sharps container (hospital) or dustbin (home), and wash hands. Ultimately, any unused patches should be returned to a pharmacy. It is important to bear in mind that fever will increase the rate of absorption of opioids from patches – it may be necessary to use a reduced dose and change the patch more frequently. It may also impact on how well patches adhere to skin, and tape (e.g. Micropore®) can be applied to the edges to improve this. Buprenorphine is the drug of choice in opioid naïve patients. 5micrograms/hr buprenorphine patch is approximately equivalent to 12mg oral morphine/24 hr. Matrix (not reservoir) 12micrograms/hr fentanyl patches (approximately equivalent to 30mg to 60mg oral morphine/24hr) can also be cut in half (diagonally) to provide a lower starting dose†. Refer to: Fentanyl patches Buprenorphine patches
Buprenorphine Patch – 5 and 10micrograms/hr Larger doses available for converting from other opioids 15, 20, 35, 52.5, 70micrograms/hr	Transdermal LONG ACTING	Opioid naïve – 5 micrograms/hr patch – equivalent to 12mg oral morphine/24hr On regular opioid – 20micrograms/hr patch equivalent to 48mg oral morphine/24hr	Apply patch to dry, hairless skin. Note: some brands are 7 day patches and some 3 or 4 day patches.
Fentanyl matrix patch 12, 25, 50, 75, or 100micrograms/hr	Transdermal LONG ACTING	Convert from current regular opioid (12 micrograms/hr patch equivalent to 30mg to 60mg of oral morphine in 24 hours)	Apply patch and change every 3 days. 12micrograms/hr patch can be halved (diagonally) to give a 6micrograms/hr dose†. Do not half reservoir patches.
Morphine sulphate MR Capsules: Zomorph® 10mg, 30mg, 60mg, 100mg, 200mg) Please note: MST Continus suspension sachets have been discontinued	Enteral feeding tube LONG ACTING	Convert from current opioid dose and give every 12 hours	Zomorph® capsules can be opened and the contents given via enteral tubes with a diameter of more than 16 FG. Rinse with 30mL to 50mL of water†.
MST Continus® tablets can be given rectally†.	Rectal LONG ACTING	Convert from current oral opioid dose	MST tablets can be given rectally although the absorption is not as reliable as orally. Dose as per oral MST dose.
Diclofenac sodium suppositories 25mg, 50mg, 100mg	Rectal LONG ACTING	75mg to 150mg daily in two divided doses
Rapid acting fentanyl: nasal sprays, such as Pecfent®, or buccal/sublingual tablets, such as Abstral® and Effentora®, may be used under specialist palliative care advice.

Nausea and vomiting

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Nausea and vomiting
Medicine	Route	Dose	Administration/ Comments
QT †Prochlorperazine 3mg buccal tablets (eg Buccastem®)	Buccal SHORT ACTING	3mg to 6mg every 6 to 12 hours	Maximum 12mg per day
QT †Ondansetron 4mg oro-dispersible tablets	Oro-dispersible SHORT ACTING	4mg every 6 to 8 hours, maximum 16mg/day	Place on tongue and allow to dissolve Mouth must be moist
†Hyoscine hydrobromide 300microgram tablets (eg Kwells®)	Sublingual or buccal SHORT ACTING	300 micrograms every 6 hours	Watch for delirium Maximum 1.2mg/24hr
QT †Levomepromazine injection 25mg/ml	Sublingual or buccal LONG ACTING	2.5mg every 4 to 6 hours as required	The injection solution can be administered by the off label sublingual or buccal route
†Hyoscine hydrobromide 1.5mg patches (1mg in 72 hr) (e.g. Scopoderm®)	Transdermal patch LONG ACTING	1 to 4 patches every 72 hours	Ideally placed on the skin behind the ear Hyoscine hydrobromide may cause agitation/delirium – monitor for this and remove patches should this occur
QT †Olanzapine oro-dispersible tablets 5mg, 10mg	Sublingual LONG ACTING	2.5mg stat dose and every 2 to 4 hours if required up to 10mg daily	Place on or under tongue and allow to dissolve 5mg tablet can be halved and the other half discarded safely

Respiratory secretions

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Respiratory secretions
Medicine	Route	Dose	Administration/ Comments
†Hyoscine hydrobromide 1.5mg patches (1mg in 72 hr) (e.g. Scopoderm®)	Transdermal patch LONG ACTING	1 to 4 patches every 72 hours	Ideally placed on the skin behind the ear Hyoscine hydrobromide may cause agitation/ delirium – monitor for this and remove patches should this occur
†Hyoscine hydrobromide 300microgram tablets (e.g. Kwells®)	Sublingual or buccal SHORT ACTING	300 micrograms every 6 hours	Watch for delirium Maximum 1.2mg/24hr
†Atropine 1% eye drops	Sublingual SHORT ACTING	2 to 4 drops every 4 hours	Watch for delirium Caution in cardiac disease Do not administer via eyes
†Glycopyrronium bromide injection 200micrograms/ml	Sublingual SHORT ACTING	200 microgram every hour as required	Maximum 1.2mg/24hr Can use higher doses under specialist advice
†Ipratropium 2 puffs via inhaler and spacer or 250micrograms via nebuliser	Inhaled SHORT ACTING	Every 4 to 6 hours

Anxiety and distress, for example associated with breathlessness

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Anxiety and distress, for example associated with breathlessness
Medicine	Route	Dose	Administration/ Comments
†Lorazepam 1mg tablets (blue, scored tablets – Genus, PVL or TEVA brands- can be halved and administered sublingually)	Sublingual SHORT ACTING	500 micrograms every 4 hours, as required	Put half a tablet under the tongue and leave to dissolve
†Midazolam Buccal preparation or midazolam injection 10mg/2ml	Buccal SHORT ACTING	2.5mg every hour as required	Note: Epistatus® is double the concentration of Buccolam® Buccolam® (5mg/ml, 2.5mg; 5mg; 7.5mg and 10mg syringes available) or Epistatus® (10mg/ml)
Diazepam 2.5mg, 5mg or 10mg rectal tubes	Rectal SHORT ACTING	2.5 to 5mg every 4 to 6 hours†.
Note: fans are not recommended for breathlessness in the context of COVID-19.

Delirium and agitation

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Delirium and agitation
Medicine	Route	Dose	Administration/ Comments
QT †Levomepromazine injection 25mg/ml	Sublingual or buccal LONG ACTING	5mg every 2 to 4 hours as required	The injection solution can be administered by the off label sublingual or buccal route May be advised to give higher doses or more frequently on specialist advice
QT †Olanzapine oro-dispersible tablets 5mg, 10mg	Sublingual LONG ACTING	2.5mg at night and2.5mg every 4 hours as required, up to maximum 10mg in 24 hours	Place on or under tongue and allow to dissolve 5mg tablet can be halved and the other half discarded safely
QT †Risperidone oro-dispersible tablets 500micrograms, 1mg, 2mg, 3mg, 4mg	Sublingual LONG ACTING	Start with 500micrograms every 12 hours	Place on or under tongue and allow to dissolve
QT Aripiprazole oro-dispersible tablets 10mg and 15mg	Sublingual LONG ACTING	Start with 10mg every 24 hours	Place on or under tongue and allow to dissolve
If antipsychotics are contraindicated, midazolam can be given via the buccal route, however benzodiazepines can worsen delirium so are not used first line. Benzodiazepines can be used first line for agitation.
†Midazolam Buccal preparation or midazolam injection 10mg/2ml	Buccal SHORT ACTING	2.5mg every hour as required	Note: Epistatus® is double the concentration of Buccolam® Buccolam® (5mg/ml, 2.5mg, 5mg, 7.5mg and 10mg syringes available) or Epistatus® (10mg/ml)
Note: withdrawal of oral drugs which cannot be directly replaced as patients are approaching the last days of life, such as gabapentin or antidepressants, may contribute to delirium and agitation, and may require higher doses of the above medications to be prescribed.

Seizures

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Delirium and agitation
Medicine	Route	Dose	Administration/ Comments
QT †Levomepromazine injection 25mg/ml	Sublingual or buccal LONG ACTING	5mg every 2 to 4 hours as required	The injection solution can be administered by the off label sublingual or buccal route May be advised to give higher doses or more frequently on specialist advice
QT †Olanzapine oro-dispersible tablets 5mg, 10mg	Sublingual LONG ACTING	2.5mg at night and2.5mg every 4 hours as required, up to maximum 10mg in 24 hours	Place on or under tongue and allow to dissolve 5mg tablet can be halved and the other half discarded safely
QT †Risperidone oro-dispersible tablets 500micrograms, 1mg, 2mg, 3mg, 4mg	Sublingual LONG ACTING	Start with 500micrograms every 12 hours	Place on or under tongue and allow to dissolve
QT Aripiprazole oro-dispersible tablets 10mg and 15mg	Sublingual LONG ACTING	Start with 10mg every 24 hours	Place on or under tongue and allow to dissolve
If antipsychotics are contraindicated, midazolam can be given via the buccal route, however benzodiazepines can worsen delirium so are not used first line. Benzodiazepines can be used first line for agitation.
†Midazolam Buccal preparation or midazolam injection 10mg/2ml	Buccal SHORT ACTING	2.5mg every hour as required	Note: Epistatus® is double the concentration of Buccolam® Buccolam® (5mg/ml, 2.5mg, 5mg, 7.5mg and 10mg syringes available) or Epistatus® (10mg/ml)
Note: withdrawal of oral drugs which cannot be directly replaced as patients are approaching the last days of life, such as gabapentin or antidepressants, may contribute to delirium and agitation, and may require higher doses of the above medications to be prescribed.

Regular administration of bolus subcutaneous medication to replace regular long acting oral medication

Regular bolus SC administration of a single medication or a combination of medications is an effective way to manage symptoms when:

There is no syringe pump available
There are no/insufficient staff present who are trained to set up or maintain a syringe pump
Trained nursing staff are available to give regular medication or in some areas family carers can be trained to give regular medication

When giving SC opioid injections, the maximum volume is 2ml. If a patient needs a dose that is in an injection volume above 2ml – seek advice

As required medication can be given in addition to this regular dosing.

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Opioids Note: If a patient is already on a regular opioid, use the as required subcutaneous dose of the same opioid regularly at intervals as below.
Drug	Dose	Frequency	Comments
Morphine sulfate	2mg	Every 4 hours	These doses are for opioid naïve patients. If the patient is already on an oral opioid, see www.palliativecareguidelines.scot.nhs.uk for appropriate dosing and conversions. Lower dose or less frequent administration should be used when the patient has renal impairment
Oxycodone	1mg	Every 4 hours
Diamorphine	2mg	Every 4 hours
Anti-Emetics Note: If a patient is already on a regular anti-emetic, use the as required subcutaneous dose of the same anti-emetic regularly at intervals as below
Cyclizine	50mg	Every 8 hours	If a patient is already on an oral anti-emetic, use the same medication subcutaneously where possible
QT †Haloperidol	500 micrograms	Daily or every 12 hours
QT †Levomepromazine	2.5mg	Every 12 hours
QT Metoclopramide	10mg	Every 8 hours
Anticholinergics for chest secretions or bowel colic
†Hyoscine butylbromide	20mg	Every 4 to 6 hours
†Glycopyrronium	200 micrograms	Every 6 to 8 hours
†Hyoscine hydrobromide	400 micrograms	Every 6 hours
Non Steroidals (NSAIDS) Drugs for Pain
†Diclofenac	50mg	Every 8 hours
†Ketorolac	15mg	Every 8 hours
Drugs for Agitation
Midazolam	2mg	Every 4 to 6 hours	May be advised to give higher doses or more frequently on specialist advice
QT †Levomepromazine	5mg	Every 12 hours
Miscellaneous
Dexamethasone	3.3mg subcutaneously is equivalent to 4mg orally	Daily	Dose depending on indication; convert from oral dose
†Levetiracetam	500mg or the same dose as oral maintenance dose	Every 12 hours	Dilute in 100ml sodium chloride 0.9% and infuse subcutaneously over 30 minutes. 1:1 conversion from oral to subcutaneous
†Octreotide	100 micrograms	Every 12 hours
†Ranitidine	75mg	Every 12 hours

Alternatives to regular medication normally given via a syringe pump - condensed information

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Pain/breathlessness/cough/pyrexia
Medicine	Route	Dose	Administration/ Comments
Paracetamol suppositories 500mg and 1g	Rectal Short acting	500mg to 1g every 4 to 6 hours (max 4g/24hrs)	Use 500mg dose if: Weight <50kg, hepatic impairment, eGFR<30ml/min, history of alcohol excess.
Buprenorphine Patch – 5micrograms/hr 10micrograms/hr Larger doses available for converting from other opioids – 15, 20, 35, 52.5, 70 micrograms/hr	Transdermal Long acting	Opioid naïve – 5 micrograms/hr patch – equivalent to 12mg oral morphine/24 hr On regular opioid – 20micrograms/hr patch equivalent to 48mg oral morphine/24 hr	Note: some brands are 7 day patches and some 3 or 4 day patches.
Fentanyl matrix patch 12, 25, 50, 75, or 100micrograms/hr	Transdermal Long acting	Convert from current regular opioid. 12 micrograms/hr patch equivalent to 30mg to 60mg of oral morphine in 24 hours	Change every 3 days 12micrograms/hr patch can be halved (diagonally) to give a 6micrograms/hr dose†. 6micrograms/hr equivalent to 15mg to 30mg oral morphine in 24 hours.
MST Continus® tablets can be given rectally†.	Rectal Long acting	Convert from current oral opioid dose	MST tablets can be given rectally although the absorption is not as reliable as orally. Dose as per oral MST dose.
Diclofenac sodium suppositories 25mg, 50mg, 100mg	Rectal Long acting	75mg to 150mg daily in two divided doses	Avoid in renal impairment. Use with caution in Covid-19 patients.
Nausea and vomiting
QT †Prochlorperazine 3mg buccal tablets (Buccastem®)	Buccal Short acting	3mg to 6mg every 6 to 12hr	Maximum 12mg per day.
QT †Ondansetron 4mg orodispersible tablets	Oro-dispersible Short acting	4mg 6 to 8 hourly, up to maximum 16mg/24hrs.	Place on tongue and allow to dissolve. Mouth must be moist.
QT †Levomepromazine injection 25mg/ml	Sublingual or buccal Long acting	2.5mg every 4 to 6 hours as required	The injection solution can be used off label by the sublingual or the buccal route
†Hyoscine hydrobromide 1.5mg patches (1mg in 72 hr) (Scopoderm®)	Transdermal patch Long acting	1 to 4 patches every 72 hours	Apply behind ear. Watch for delirium.
QT †Olanzapine oro-dispersible tablets 5mg, 10mg	Sublingual Long acting	2.5mg stat dose and every 2 to 4 hours if required. Maximum dose 10mg daily	Place on or under tongue and allow to dissolve 5mg tablet can be halved and the other half discarded safely.
Respiratory secretions
Medicine	Route	Dose	Administration/ Comments
†Hyoscine hydrobromide 1.5mg patches (1mg in 72 hr)	Transdermal patch Long acting	1 to 4 patches every 72 hours	Apply behind ear. Watch for delirium.

†Hyoscine hydrobromide Kwells®)300microgram tablets	Sublingual or buccal Short acting	300 micrograms every 6 hours	Watch for delirium Maximum 1.2mg/24hrs
†Atropine 1% eye drops	Sublingual Short acting	2 to 4 drops every 4 hours	Watch for delirium. Caution in cardiac disease. Do not administer via eyes.
†Glycopyrronium bromide injection 200microgram/ml	Sublingual Short acting	200 microgram every hour as required	Maximum 1.2mg/24h. Higher doses can be used under specialist advice.
†Ipratropium 2 puffs via inhaler and spacer or 250micrograms via nebuliser	Inhaled Short acting	Every 4 to 6 hours
Anxiety and distress, for example associated with breathlessness
†Lorazepam 1mg tablets (blue, scored tablets)	Sublingual Short acting	500 micrograms every 4 hours as required	Put half a tablet under the tongue and leave to dissolve.
†Midazolam Buccal preparation or midazolam injection 10mg/2ml	Buccal Short acting	2.5mg every hour as required	Buccolam® or Epistatus® (NB. Buccolam® 5mg/ml as 2.5mg, 5mg, 7.5mg and 10mg or Epistatus® 10mg/ml)
Diazepam 2.5mg, 5mg or 10mg rectal tubes	Rectal Short acting	2.5mg to 5mg every 4 to 6 hours†
Delirium and agitation
QT †Levomepromazine injection 25mg/ml	Sublingual or buccal Long acting	5mg or 6mg every 2 to 4 hours as required	The injection solution can be used off label by the sublingual or the buccal route May be advised to give higher doses or more frequently on specialist advice.
QT †Olanzapine oro-dispersible tablets 5mg, 10mg	Sublingual Long acting	2.5mg at night and 2.5mg every 4 hours as required Up to maximum 10mg in 24 hours	Place under tongue and allow to dissolve. 5mg tablet can be halved and the other half discarded safely.
QT †Risperidone oro-dispersible tablets 500micrograms, 1mg, 2mg, 3mg, 4mg	Sublingual Long acting	Start with 500 micrograms every 12 hours	Place under tongue and allow to dissolve.
If antipsychotics are contraindicated, midazolam can be given via the buccal route, however benzodiazepines can worsen delirium so are not used first line. Benzodiazepines can be used first line for agitation.
†Midazolam Buccal preparation or midazolam injection 10mg/2ml	Buccal Short acting	2.5mg every hour as required	Buccolam® or Epistatus® (NB. Buccolam® 5mg/ml as 2.5mg, 5mg, 7.5mg and 10mg or Epistatus® 10mg/ml)
Seizures
Midazolam Buccal preparation or midazolam injection 10mg/2ml	Buccal Short acting	10mg as required for seizure. Can repeat after 15 minutes	Buccolam® or Epistatus® (NB. Buccolam® 5mg/ml as 2.5mg, 5mg, 7.5mg and 10mg or Epistatus® 10mg/ml)
Diazepam 5mg or 10mg rectal tubes	Rectal Short acting	10mg in event of seizure
Carbamazepine suppositories 125mg, 250mg	Rectal Long acting	Convert previous oral dose and give twice daily – not for use in new seizures	Administer rectally. 125mg suppository equivalent to 100mg orally.