Palliative Care Guidelines - NHS Lanarkshire

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© NHS Lothian Issue date: January 2009 Review date: March 2012A guide to opioid doses for dying patients with acute renal impairment or stage 4-5 chronic kidney disease (GFR < 30ml/min)• Use this chart as a guide. The doses are approximate and not exact equivalent doses.• Always prescribe an appropriate opioid drug and dose for breakthrough pain.• Avoid renally excreted opioids (codeine, dihydrocodeine, morphine, diamorphine, oxycodone)• Check the information about individual drugs: see Fentanyl patch, Alfentanil.• Reduce the dose by up to 30% when changing opioid if the patient is opioid toxic, frail or elderly and re-titrate.• Particular care is needed when changing between opioids at higher doses or when the dose of the first opioid has been rapidly increased asthese patients are at greater risk of adverse effects.Monitor the patient carefully; if in doubt – seek adviceChange to alfentanil or fentanylOpioids of choice in moderate to severe renal impairmentMorphine 1 Diamorphine 1 Oxycodone 1 Alfentanil 2, 3Fentanylinjectionpatch 44 hourlyoraldose24 hourtotal oraldose24 hourtotal SCdose4 hourlySCdose24 hourtotal SCdose4 hourlyoraldose24 hourtotal oraldose24 hourtotal SCdose 1SC as requireddose, hourly,in micrograms24 hour SCdriver/ pump dosePatchstrengthmicrograms/ hour2 - 3mg 15mg 7 - 8mg 1mg 5mg 1 - 2mg 7 - 8mg 5mg 100-200 500 micrograms Do not use5mg 30mg 15mg 2mg 10mg 2 - 3mg 15mg 7 - 8mg 200-250 1mg (1000 micrograms) 1210mg 60mg 30mg 2.5mg 20mg 5mg 30mg 15mg 300-500 2 mg 2515mg 90mg 45mg 5mg 30mg 7 - 8mg 45mg 20mg 500 3 mg 3720mg 120mg 60mg 7.5mg 40mg 10mg 60mg 30mg Seek advice 4mg 5030mg 180mg 90mg 10mg 60mg 15mg 90mg 45mg Seek advice 6mg 6240mg 240mg 120mg 10mg 80mg 20mg 120mg 60mg Seek advice Seek advice 751If it is not possible to obtain alfentanil, a single 4 hourly dose of morphine SC, diamorphine SC or oxycodone SC may be given as an interimmeasure but should not be repeated. A continuous subcutaneous infusion should not be used.2Alfentanil clearance is reduced in liver impairment; reduce dose and titrate.3Alfentanil is supplied as 500micrograms/ ml. If higher SC breakthrough doses or a SC infusion dose over 6mg are needed – seek advice.4Fentanyl is approximately four times more potent than alfentanil and longer acting. Fentanyl clearance may be reduced in severe liverimpairment, and it can accumulate in chronic kidney disease.Fentanyl SC injections can be used for breakthrough symptom control if alfentanil is ineffective due to its short duration of action.The low concentration of the fentanyl preparation limits the SC injection dose to a maximum of 50 micrograms (1ml).Fentanyl SC 50 micrograms is approximately equivalent to alfentanil SC 200-250 micrograms. Seek advice.Palliative Care Guidelines: Renal Palliative Care - Last Days of Life3
Palliative Care Guidelines: Renal Palliative Care - Last Days of LifeCompatibility Table: Subcutaneous Alfentanil Infusion in a Syringe DriverDiluent: Water for injections• These are not clinical doses to prescribe. Most patients do not need high such doses.Refer to the prescribing guide above.• Use this table to check for concentrations that are stable.• Read the guideline: Subcutaneous infusion of medication in Palliative Care.• Use the minimum effective dose and titrate according to response.Drug CombinationAlfentanilCyclizineAlfentanilGlycopyrronium bromideAlfentanilHaloperidolAlfentanilHyoscine butylbromideAlfentanilHyoscine hydrobromideAlfentanilLevomepromazineAlfentanilMetoclopramideAlfentanilMidazolamAlfentanilOctreotideDrug CombinationAlfentanilHaloperidolMidazolamAlfentanilHyoscine butylbromideLevomepromazineAlfentanilMetoclopramideMidazolamAlfentanilLevomepromazineMidazolamMaximum concentrations of two drug combinations thatare physically stable14ml in 20ml syringe3mg100mg4mg1100 micrograms6mg10mg4.5mg90mg6mg1200 micrograms6mg35mg2.5mg45mg3mg40mg5mg700 micrograms17ml in 30ml syringe4mg150mg5.5mg1200 micrograms7.5mg10mg5.5mg120mg7.5mg1200 micrograms7.5mg40mg2.5mg60mg3.5mg50mg6mg800 microgramsMaximum concentrations of three drug combinationsthat are physically stable14ml in 20ml syringe3.5mg5mg30mg4mg90mg20mg2mg30mg20mg3mg65mg25mg17ml in 30ml syringe4.5mg5mg35mg5mg120mg25mg3mg35mg20mg3.5mg80mg30mg4 Issue date: January 2009 Review date: March 2012 © NHS Lothian
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Palliative Care Guidelines - NHS Lanarkshire

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