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 – 5micrograms/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.

12micrograms/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

300micrograms 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

200microgram 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

500micrograms  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 500micrograms 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.