Palliative Care Guidelines - NHS Lanarkshire

Palliative Care Guidelines: LevomepromazineLevomepromazine in Palliative CareDescriptionA phenothiazine used widely in palliative care to treat intractable nausea or vomiting, and forsevere delirium/ agitation in the last days of life.PreparationsOralInjection6mg scored tablet25mg scored tablet25mg/ml1ml ampouleNamed patient preparation. Allow time for pharmacist to order.Disperses well in water.Listed in BNF but rarely used in palliative care as too high adose for most patients.Used by subcutaneous injection or continuous subcutaneousinfusion.Indications• Second line, broad spectrum antiemetic for intractable nausea/ vomiting.• Potent sedative used to manage severe delirium/ agitation in a dying patient.Cautions• Lowers blood pressure and can cause significant postural hypotension in ambulant patients.Check blood pressure before starting treatment and then daily until dose stable.Additive hypotensive effect if combined with other antihypertensives.• Additive sedative effect if combined with other sedating drugs.• Liver impairment: dose reduction and careful titration. Inhibits cytochrome P450 metabolism– check BNF for drug interactions.• Rarely causes prolonged QT interval in cardiac disease or hypokalaemia.• Parkinsonism, epilepsy (lowers seizure threshold).Side effects• Skin irritation at infusion site; add more diluent when preparing syringes.• Cover syringe containing the infusion as degrades in sunlight (purple colouration).• Drowsiness, dry mouth, dystonia, neuroleptic malignant syndrome (rarely).Dose & Administration• Low doses for nausea/ vomiting and higher doses for delirium/ agitation.• SC dose is half the oral dose.• Each dose can last 12-24 hours; once or twice daily SC injection is an alternative to acontinuous subcutaneous infusion.Antiemetic (see: Nausea / Vomiting, Subcutaneous medication)• Oral starting dose: 3mg once or twice daily.• SC starting dose: 2.5-5mg (0.1-0.2ml) once or twice daily, or as a continuous SC infusion.• Usual dose range: 3-25mg / 24 hours.Sedative: (see: Last days of life)• Second line added to a benzodiazepine (midazolam SC 30mg/ 24hours or diazepam PR5mg, 8hourly) if the patient is dying and agitated. Exclude other causes of terminal deliriumparticularly opioid toxicity, urinary retention. (see: Delirium)• Injections will be needed to gain control of agitation while a SC infusion takes effect and maybe needed if agitation worsens; use 12.5-25mg SC, 6-12 hourly.• Subcutaneous infusion dose: 25-100mg over 24 hours.Further informationPalliative Care Drug Information online: http://www.palliativedrugs.comFurther reading: http://www.palliativecareguidelines.scot.nhs.uk© NHS Lothian Issue date: January 2009 Review date: March 20121