What medications should be included in a palliative care P (Preferred) drug list?

Essential Medications for Palliative Care P-Drug List

A comprehensive palliative care P-drug list should include morphine, midazolam, haloperidol, and an antimuscarinic agent as the core essential medications, with additional medications for specific symptom management based on patient needs. 1

Core Essential Medications

Pain Management

• Morphine - First-line opioid for moderate to severe pain
  • Starting dose: 5 mg PO every 4 hours for opioid-naive patients; 10 mg PO every 4 hours for patients previously on weak opioids 2
  • For acute progressive dyspnea: 2.5-10 mg PO every 2 hours PRN or 1-3 mg IV every 2 hours PRN 3
  • Patients on chronic opioids may need dose increases of approximately 25% 3
  • Available in multiple formulations: oral solution, tablets, injectable forms 4

Anxiety, Agitation, and Sedation

• Midazolam - First-line benzodiazepine for anxiety, agitation, and palliative sedation
  • Starting dose: 0.5-1 mg/hour continuous infusion or 1-5 mg PRN 3
  • Usual effective dose: 1-20 mg/hour 3
  • Advantages: Rapid onset, can be administered IV or SC, can be co-administered with morphine or haloperidol 3
  • For refractory symptoms requiring sedation: Can be titrated to achieve desired level of sedation 5

Delirium and Nausea

• Haloperidol - First-line antipsychotic for delirium and nausea
  • Effective for managing signs and symptoms of delirium 1
  • Can help with nausea and vomiting 1
  • Alternative neuroleptics include:
    • Levomepromazine: Starting dose 12.5-25 mg, with usual effective dose of 12.5-25 mg every 8 hours 3
    • Chlorpromazine: Starting dose 12.5 mg IV/IM every 4-12 hours or 25-100 mg rectally 3

Respiratory Secretions

• Antimuscarinic agent - For managing respiratory tract secretions
  • Options include:
    • Scopolamine: 0.4 mg subcut every 4 hours PRN or 1.5 mg patches (1-3 patches every 3 days) 3
    • Atropine: 1% ophthalmic solution 1-2 drops SL every 4 hours PRN 3
    • Glycopyrrolate: 0.2-0.4 mg IV or subcut every 4 hours PRN 3

Additional Essential Medications by Symptom

Dyspnea Management

• Oxygen therapy - For symptomatic hypoxia 3
• Benzodiazepines - For dyspnea associated with anxiety
  • Lorazepam: 0.5-1 mg PO every 4 hours PRN 3

Gastrointestinal Symptoms

• Laxatives for constipation prevention and management

  • Senna with docusate: 2-3 tablets BID-TID 3
  • Bisacodyl: 10-15 mg daily-TID 3
  • Methylnaltrexone: 0.15 mg/kg SC every other day for opioid-induced constipation 3

• Anti-diarrheals

  • Loperamide: 4 mg PO initially, then 2 mg after each loose stool (max 16 mg/day) 3
  • Diphenoxylate/atropine: 1-2 tablets PO every 6 hours PRN (max 8 tablets/day) 3

• Antiemetics

  • Metoclopramide: 10-20 mg PO QID for nausea and as prokinetic agent 3, 6
  • Ondansetron: For chemotherapy-induced nausea

Sleep Disturbances

• Trazodone: 25-100 mg PO at bedtime 3
• Mirtazapine: 7.5-30 mg PO at bedtime 3
• Zolpidem: 5 mg PO at bedtime 3

For Refractory Symptoms Requiring Deep Sedation

• Phenobarbital

  • Starting dose: 1-3 mg/kg SC or IV bolus, followed by infusion of 0.5 mg/kg/hour 3
  • Usual maintenance dose: 50-100 mg/hour 3
  • Advantages: Rapid onset, anticonvulsant properties 3

• Propofol

  • For cases where benzodiazepines and barbiturates are ineffective
  • Loading dose of 20 mg, followed by infusion of 50-70 mg/hour 3
  • Requires specialized monitoring and administration 3

Practical Considerations

• Medications for symptom palliation should be continued unless ineffective or causing distressing side effects 3
• Medications inconsistent with comfort goals can be discontinued 3
• Route of administration should be adjusted based on patient's condition (oral, IV, SC, rectal) 3
• Provision for breakthrough symptom management should always be included 3
• Pharmacokinetics may be altered in terminally ill patients due to physiological changes at end of life 7
• Consider dose adjustments for patients with renal or hepatic impairment 6

Common Pitfalls to Avoid

• Failing to distinguish between anxiety and delirium (benzodiazepines can worsen delirium) 3
• Using opioids alone for dyspnea when anxiety is a significant component 3
• Inadequate breakthrough dosing for pain and other symptoms 3
• Abrupt discontinuation of medications, especially opioids and benzodiazepines 3
• Prescribing liquid opioids in milliliters instead of milligrams when multiple concentrations are available 8
• Not making clear the indication and intended duration for steroids 8
• Using oxygen for symptomatic relief of breathlessness in the absence of hypoxia 8