What medications are used in palliative medicine for symptom management?

Medications for Symptom Management in Palliative Medicine

The cornerstone medications for palliative symptom management include opioids (particularly morphine as first-line), benzodiazepines (midazolam), antipsychotics (levomepromazine, chlorpromazine), and adjuvant medications tailored to specific symptoms. 1, 2

Pain Management

WHO Analgesic Ladder Approach

The World Health Organization (WHO) analgesic ladder provides a systematic approach to pain management:

1. Mild Pain (1-3/10)

   • Acetaminophen and/or NSAIDs

2. Moderate Pain (4-6/10)

   • Weak opioids (codeine, dihydrocodeine) plus acetaminophen/NSAIDs
   • Adjuvant medications as needed

3. Severe Pain (7-10/10)

   • Strong opioids plus acetaminophen/NSAIDs
   • Adjuvant medications as needed 1

Strong Opioids for Pain

• Morphine: First-line strong opioid of choice 1, 2
• Other strong opioids: Diamorphine, buprenorphine, hydromorphone, fentanyl, oxycodone, methadone 1
• Administration: Regular around-the-clock dosing with breakthrough dosing (typically 1/6 of daily requirement) 1, 3
• Conversion: When changing between opioids, use established conversion tables (e.g., 10mg parenteral morphine = 30mg oral morphine) 4, 5

Adjuvant Analgesics

• Neuropathic pain: Anticonvulsants (e.g., pregabalin)
• Bone pain: Bisphosphonates
• Very-low-dose methadone: Can help prevent opioid hyperalgesia when used with other opioids 6

Dyspnea Management

• Opioids: First-line for unrelieved dyspnea
• Benzodiazepines: When dyspnea is associated with anxiety
• Oxygen therapy: For hypoxemic patients 2

Delirium Management

• First-line: Antipsychotics
  • Levomepromazine: 12.5-25mg starting dose, up to 300mg/day continuous infusion
  • Chlorpromazine: 12.5mg IV/IM every 4-12h or 25-100mg rectally every 4-12h 1, 2

Important: Opioids or benzodiazepines as initial treatment can worsen delirium 1, 2

Sleep Disturbances

• Insomnia medications:

  • Trazodone: 25-100mg PO at bedtime
  • Olanzapine: 2.5-5mg PO at bedtime
  • Zolpidem: 5mg PO at bedtime
  • Mirtazapine: 7.5-30mg PO at bedtime
  • Chlorpromazine: 25-50mg PO at bedtime
  • Quetiapine: 2.5-5mg PO at bedtime
  • Lorazepam: 0.5-1mg PO at bedtime 1

• Daytime sedation management:

  • Caffeine: 100-200mg PO q6h (last dose by 4 PM)
  • Methylphenidate: 2.5-20mg PO BID
  • Dextroamphetamine: 2.5-10mg PO BID
  • Modafinil: 100-400mg PO each morning 1

Palliative Sedation for Refractory Symptoms

Medications for Palliative Sedation

• Benzodiazepines:

  • Midazolam: First-line, 0.5-1mg/h starting dose, 1-20mg/h usual effective dose 1, 2

• Neuroleptics/Antipsychotics:

  • Levomepromazine: 12.5-25mg starting dose, especially for delirium 1
  • Chlorpromazine: 12.5mg IV/IM every 4-12h 1

• Barbiturates and anesthetic agents (for refractory cases):

  • Phenobarbital: 1-3mg/kg SC/IV bolus, followed by 0.5mg/kg/h infusion
  • Propofol: 20mg loading dose, followed by 50-70mg/h infusion 1

End-of-Life "Anticipatory" Medications

The "4 A's" approach ensures medications are available for common end-of-life symptoms:

• Analgesic: For pain (morphine)
• Anti-emetic: For nausea/vomiting
• Anxiolytic: For anxiety (midazolam)
• Anti-secretory: For respiratory secretions 5

Important Prescribing Considerations

• Route of administration: Adapt to patient's condition (oral → subcutaneous → intravenous)
• Breakthrough medication: Always prescribe alongside regular medications
• Pre-existing medications: Continue pain medications unless adverse effects occur 1, 2
• Dose titration: Titrate based on symptom response and breakthrough medication requirements 1, 4

Common Pitfalls to Avoid

• Inadequate pain assessment: Use validated tools (visual analog scales, numerical rating scales)
• Delayed escalation: Don't delay moving up the analgesic ladder when pain is inadequately controlled
• Inappropriate opioid reduction: Don't reduce opioids solely for decreased vital signs when necessary for symptom control
• Neglecting breakthrough dosing: Always provide for breakthrough symptoms alongside regular medications
• Forgetting adjuvant medications: Use acetaminophen/NSAIDs at all steps of the analgesic ladder 1, 2, 5
• Mismanaging delirium: Don't use opioids or benzodiazepines as first-line for delirium 1, 2

High-dose morphine use in palliative care has been shown to be safe and does not adversely affect patients' life expectancy when properly titrated for symptom control 7.