GGC Medicines - Anticipatory Medicines

Anticipatory prescribing

In all patients the following should be prescribed in the 'when required' section of the kardex. For the patient with stage 4-5 acute or chronic kidney disease, refer to Renal Disease in Last Days of Life guideline.

Table 1: Anticipatory subcutaneous medications - initial dose suggestions

Symptom	Initial dose suggestion
Pain	If patient is receiving oral morphine or on a step 2 analgesic (including co-codamol 30/500mg or equivalent) an appropriate SC breakthrough dose of morphine should be available (1/6th to 1/10th of 24 hour equivalent dose). If opioid naive, consider morphine 2mg SC hourly as required (max 6 doses in 24 hours). N.B. If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.
Nausea and vomiting	If patient is receiving an oral anti-emetic and this is effective, then that drug should be available for SC use. If patient is not on an anti-emetic, consider levomepromazine 2.5mg (TWO point FIVE milligrams) SC 12 hourly as required. N.B. Levomepromazine can prolong QT interval. See note below.
Agitation / restlessness	Prescribe midazolam 2mg SC hourly as required for anxiety / distress (max 6 doses in 24 hours). N.B. If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.
Breathlessness (dyspnoea)	If patient is receiving oral morphine or a step 2 analgesic (including co-codamol 30/500 or equivalent) an appropriate SC breakthrough dose of morphine should be available (1/6th to 1/10th of 24 hours equivalent dose). If opioid naive, consider morphine 2mg SC hourly as required (max 6 doses in 24 hours). N.B. If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review. It patient is breathless and anxious, consider using midazolam 2mg SC hourly as required (max 6 doses in 24 hours). N.B. If ≥3 doses are required within 4 hours with little or no benefit, seek urgent advice or review. If >6 doses are required in 24 hours, seek advice or review.
Respiratory secretions	Prescribe hyoscine butylbromide 20mg SC hourly as required (max 6 doses in 24 hours).
If the patient is reaching maximum dose of any anticipatory medicines then seek advice from the Palliative Care Team. For further information on anticipatory prescribing see the Scottish Palliative Care guidelines. Levomepromazine: can prolong QT interval and contraindications include: patients with prolonged QTc interval and in combination with other drugs that prolong QT interval. Where possible modifiable risk factors for QT interval prolongation should be minimised e.g. discontinue other drugs known to prolong QT interval. There may be certain circumstances when it may be used despite contraindications (e.g. distressed individual with an incurable condition at the end of life). Seek senior advice before prescribing. A list of drugs which prolong QT interval can be found at http://crediblemeds.org and further information can also be found in Medicines Update Extra (MUE 08) Drug Induced QT Prolongation article at www.ggcmedicines.org.uk. Guideline reviewed: July 2021 Page last updated: December 2021