What are the standard medications used in palliative care?

Standard Medications Used in Palliative Care

Opioids are the cornerstone of palliative care medication management, particularly for pain and dyspnea, with morphine being the first-line agent for both symptoms. 1

Pain Management Medications

First-Line Agents

• Opioids: Primary medications for moderate to severe pain
  • Morphine: Gold standard, starting dose 2.5-5 mg orally every 4 hours or 1-2.5 mg subcutaneously every 4 hours 2
  • Hydromorphone: Alternative when morphine is contraindicated, starting dose 1.3 mg orally every 4 hours or 0.2-0.5 mg subcutaneously every 4 hours 2
  • Oxycodone: Alternative opioid option
  • Fentanyl: Useful for transdermal administration in stable pain

Adjuvant Analgesics

• For mild pain (1-3/10): Acetaminophen and/or NSAIDs 1
• For neuropathic pain:
  • Gabapentin
  • Carbamazepine
  • Pregabalin 2, 1
• For bone pain in cancer patients: Bisphosphonates 1

Administration Considerations

• Regular around-the-clock dosing with breakthrough dosing (typically 1/6 of daily requirement) 1
• Bowel regimen must be prescribed when starting opioids:
  • Stimulant laxatives (e.g., senna)
  • Osmotic laxatives (e.g., lactulose) 2
• For opioid-naïve patients, start with lower doses than for pain management 2
• For patients already on opioids for pain, increase dose by 25-50% for additional symptom management 2

Dyspnea Management

First-Line Agents

• Opioids: Primary medications for unrelieved dyspnea
  • Same agents as for pain management but often at lower starting doses 2, 1

Second-Line Agents

• Benzodiazepines: For dyspnea with anxiety component
  • Lorazepam: 0.5-1.0 mg every 6-8 hours orally or sublingually 2
  • Midazolam: 2.5-5 mg every 4 hours subcutaneously or 10-30 mg/24 hours continuous subcutaneous infusion 2

Specific Indications

• Steroids: Effective for dyspnea caused by:
  • Lymphangiosis carcinomatosa
  • Radiation pneumonitis
  • Superior vena cava syndrome
  • Inflammatory component
  • Airway obstruction 2

Anxiety and Delirium Management

Anxiety Medications

• Benzodiazepines:
  • Lorazepam: 0.5 mg twice daily 1
  • Midazolam: For terminal agitation or when rapid effect needed 2, 3

Delirium Medications

• Antipsychotics:
  • Haloperidol: Most commonly used 3
  • Levomepromazine and chlorpromazine: First-line treatments 1

End-of-Life Care Medications

Most Frequently Prescribed at End-of-Life

1. Morphine: Used in 87% of patients at end-of-life 3
2. Midazolam: Used in 58% of patients at end-of-life 3
3. Haloperidol: Used in 50% of patients at end-of-life 3

Route of Administration

• At admission: 89% oral route 3
• At end-of-life: 94% subcutaneous route 3

Palliative Sedation

• Used for intractable symptoms (pain, dyspnea, delirium, cough, existential distress)
• Medications:
  • Benzodiazepines: First-line agents
  • Barbiturates: Alternative options 2
• Dose is titrated to patient comfort, may require deep sedation

Common Pitfalls in Palliative Medication Management

• Inadequate pain control: Often due to underdosing from fears of respiratory depression 1
• Failure to prevent constipation: Always prescribe bowel regimen with opioids 2
• Inappropriate continuation of non-essential medications: Discontinue medications that don't contribute to symptom management 1
• Fear of opioid side effects: Concerns about hypotension, respiratory depression, and addiction often exaggerated 2
• Delayed response to symptoms: Ensure PRN medications are readily available 1
• Inappropriate route selection: Switch from oral to subcutaneous route as swallowing ability declines 3

Special Considerations

• Renal impairment: Avoid morphine in severe renal insufficiency; adjust dosage and intervals for all μ-opioids 2
• Pharmacokinetic changes: Terminal illness alters drug absorption, distribution, metabolism, and elimination 4
• Opioid rotation: Consider when side effects are intolerable or analgesia is inadequate 5
• Non-pharmacological approaches: Consider cognitive behavioral therapy, positioning, airflow, relaxation techniques 1

By following these medication guidelines and being aware of common pitfalls, clinicians can provide effective symptom management for patients receiving palliative care.