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GUIDELINES & PROTOCOLSADVISORY COMMITTEE

Palliative Care for the Patient with Incurable Cancer or Advanced DiseasePart 2: Pain and Symptom Management

Effective Date: September 30, 2011

Introduction

This guideline presents strategies for the assessment and management of cancer pain, and symptoms associated with advanced disease. The guideline is divided into seven sections, providing recommendations for evidence-based symptom management (Palliative Care Guidelines, Part 2). The recommendations are algorithm-based to facilitate quick access to the information required. It is intended for use in patients 19 years of age or older.

Key symptom areas addressed are: Pain Dyspnea Nausea and Vomiting Constipation Delirium Fatigue and Weakness Depression

Diagnostic Code: Neoplasm of unspecified nature: 239

BRITISHCOLUMBIA

MEDICALASSOCIATION

Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html, Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html



Pain ManagementEffective Date: September 30, 2011

Scope

This section presents assessment and management strategies for dealing with cancer pain and pain associated with advanced disease.

Salient Principles in this Section: • Opioid management principles • Utilizing adjuvant medication for pain-specific management

Included in this Section: A - Pain management algorithm B - Tables for opioid conversion C - Analgesic medication reference tables

Pain Assessment (Refer Appendix A - Cancer Pain Management Algorithm) a) Symptom assessment. Use the OPQRSTUV mnemonic to assess pain:

b) Physical exam: Look for signs of tumor progression, trauma, or neuropathic etiology: hypo- or hyper-esthesia, allodynia (pain from stimuli not normally painful).

Pain Management Strategies (Refer Appendix A) • Continuous pain requires continuous analgesia; prescribe regular dose versus prn. • Start with regular short-acting opioids and titrate to effective dose over a few days before switching to slow release opioids. • Once pain control is achieved, long-acting (q12h oral or q3days transdermal) agents are preferred to regular short-acting oral preparations for better compliance and sleep. • Always provide appropriate breakthrough doses of opioid medication, ~10% of total daily dose dosed q1h prn. • Incident pain (e.g., provoked by activity) may require up to 20% of the total daily dose, given prior to the precipitating activity. • Use appropriate adjuvant analgesics at any step (e.g., NSAIDs, corticosteroids). • Record patient medications consistently.

O Onset e.g., When did it start? Acute or gradual onset? Pattern since onset?P Provoking / palliating What brings it on? What makes it better or worse, e.g., rest, meds?Q Quality Identify neuropathic pain (burning, tingling, numb, itchy, etc.)R Region / radiation Primary location(s) of pain, radiation pattern(s)S Severity Use verbal descriptors and/or 1-10 scaleT Treatment Current and past treatment; side effectsU Understanding Meaning of the pain to the sufferer, “total pain”V Values Goals and expectations of management for this symptom

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Palliative Care for the Patient with inCurable CanCer or advanCed disease - Part 2: Pain and symPtom management3

Opioid Selection

a. Fentanyl is primarily (75%) cleared as inactive metabolites by the kidney and methadone is cleared hepatically. b. Morphine is the least preferred in renal failure because of renally cleared active metabolites.c. Meperidine (Demerol®) should not be used for the treatment of chronic pain.d. If a patient in your practice is started on methadone by a palliative care physician, in order to renew prescriptions, it is possible to obtain individual

patient methadone prescribing authorization through the College of Physicians and Surgeons of British Columbia.e. Injectable methadone may be obtained through the Health Canada Special Access Program at www.hc-sc.gc.ca/dhp-mps/acces/drugs-drogues/index-

eng.php. Consultation with a palliative care physician is suggested prior to initiation.

Opioid Switching (“rotation”) • Switch to another opioid when inadequate analgesia is obtained despite dose-limiting adverse effects (AEs). This allows for clearance of opioid metabolites and possibly more effective opioid receptor agonist profile from the new drug. • Switch to an equianalgesic dose of the second opioid, bearing in mind that published ratios are only a guide and that reassessment and dose modification are required. • When switching because of AEs (e.g., delirium or generalized hyperalgesia), determine the equianalgesic dose and reduce this dose by 25%. Observe closely, allowing for onset of the new and wearing-off of the previous drug. • Refer Appendix B – Equianalgesic Conversion for Morphine.

Opioid AEs (switch if not managed symptomatically and AE persists for > 1 week) • Constipation: Stepwise escalation of regular oral stimulant or osmotic laxative on opioid initiation. Consider methylnaltrexone* for refractory cases. Refer to Part 2 Section: Constipation, and the associated Appendix A – Constipation Management Algorithm. • Nausea: Resolves after ~ 1 week. Consider metoclopramide* first line; avoid dimenhydrinate (Gravol®). • Sedation: Stimulants may be helpful if sedation persists, e.g., methylphenidate, dextroamphetamine, or modafanil. • Myoclonus: May respond to benzodiazepines but may be a sign of opioid toxicity requiring hydration, opioid dose reduction or rotation. • Delirium: Assess for other causes, e.g., hypercalcemia, UTI. • Pruritus, sweating: Try opioid rotation.

*Cancer, GI malignancy, GI ulcer, Ogilvie’s syndrome and concomitant use of certain medications (e.g. NSAIDs, steroids, and bevacizumab) may increase the risk of GI perforation in patients receiving methylnaltrexone. [Health Canada MedEffect Notice: www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/relistor_hpc-cps-eng.pdf]

Issue Preferred Opioid Medication AvoidDifficult constipation fentanyl transdermal or methadonea

Renal failure fentanyl transdermal or methadonea morphineb, codeine, meperidinec

Compliance & convenience

time release formulations, e.g., morphine, hydromorphone, oxycodone

Neuropathic pain oxycodone or methadoned (anecdotal evidence)

Opioid naïve low dose morphine, hydromorphone or oxycodone

fentanyl transdermal patch(risk of delayed absorption and overdose potential), sufentanil

Injection route (e.g., SC) morphine, hydromorphone, (methadonee: second line)

oxycodone (injectable) is not available in Canada

Palliative Care for the Patient with inCurable CanCer or advanCed disease - Part 2: Pain and symPtom management

4

Adjuvant Analgesics • Select based on type of pain and AE profile. Optimize dosing of one drug before trying another. Discontinue adjuvant drug if ineffective.

Severe opioid-resistant cancer pain • Consult a palliative care specialist for advice.

AbbreviationsAEs adverse effectsGI gastrointestinalNSAIDs non-steroidal anti-inflammatory drugsSC subcutaneousTENS transcutaneous electrical nerve stimulationUTI urinary tract infection

AppendicesAppendix A – Cancer Pain Management AlgorithmAppendix B – Equianalgesic Conversion for MorphineAppendix C – Medications Used in Palliative Care for Pain Management

This guideline is based on scientific evidence current as of the Effective Date.

The guideline was developed by the Family Practice Oncology Network and the Guidelines and Protocols Advisory Committee. The guideline was approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

A mobile version of this and other guidelines is also available at www.BCGuidelines.ca

DISCLAIMERThe Clinical Practice Guidelines (the “Guidelines”) have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.

Contact InformationGuidelines and Protocols Advisory CommitteePO Box 9642 STN PROV GOVTVictoria BC V8W 9P1E-mail: [email protected] site: www.BCGuidelines.ca

The principles of the Guidelines and Protocols Advisory Committee are to:

• encourage appropriate responses to common medical situations

• recommend actions that are sufficient and efficient, neither excessive nor deficient

• permit exceptions when justified by clinical circumstances

Appendix A: Cancer Pain Management Algorithm

• History

• Physical exam

• Appropriate investigations

• Psychosocial assessment

• Addiction screening

Pain Assessment

Non-cancer

Treat as

appropriate

Cancer pain

Start opioid therapy:Morphine, hydromorphone, oxycodone

• Treat underlying disease if possible

(e.g., radiotherapy for bony metastases)

• Psychosocial support

• Consider non-pharmacologic therapies,

e.g., massage, relaxation, acupuncture, TENS

Add adjuvants appropriate to type of pain

NOCICEPTIVEPAIN

BONE

Cementoplasty

NSAIDs*

Bisphosphonates

Calcitonin

Acetaminophen

Corticosteroids*

SOFT TISSUE

NSAIDs*

Corticosteroids*

Skeletal muscle relaxants

NEUROPATHIC PAIN

Tricyclic antidepressants

Anticonvulsants

Clonazepam

Cannabinoids

Corticosteroids*

Sodium channel blocker

VISCERAL PAIN

Corticosteroids*

Anti-spasmodics

OPIOID SWITCHMorphine, hydromorphone, fentanyl, oxycodone, methadone for neuropathic pain

Lidocaine infusion or ketamine

Consider Anesthesia ConsultEpidural, intrathecal, anesthetic nerve block, neurolysis

*Use gastric cytoprotection (refer Appendix C - Medications Used in Palliative Care: Gastric Cytoprotection)

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Opioid Equianalgesic Dose For 20 mg Oral Morphine(for chronic dosing)

DRUG SC/IV (mg) PO (mg) COMMENTSmorphine 10 20*codeine 120 200 metabolized to morphine

fentanyl patch see table below – useful when PO / PR routes not an optionfentanyl 0.1 (100 mcg) usually dosed prn

less than 1 hour effecthydromorphone 2 4

methadone available through Special Access Programme

1(1-7)

variable equivalence: palliative or pain consultation advised

oxycodone not available in Canada 13.3(6.7-20)

variable equivalence

sufentanil 0.02 (20 mcg) usually dosed prn less than 1 hour effect

Appendix B: Equianalgesic Conversion for Morphine

* Clinical experience in chronic pain suggests that 10 mg SC/IV is equivalent to 20 to 30 mg PO morphine (1:2 to 1:3 conversion ratio). In practice, many centers use the conversion of 10 mg SC/IV = 20 mg PO (1:2). In 2010 Health Canada recommended using the conversion of 10 mg SC/IV morphine = 30 mg PO (1:3) particularly when converting from morphine to fentanyl transdermal systems. In addition, Health Canada advises that there is insufficient data available to guide conversion to fentanyl transdermal systems from IV/IM morphine doses greater than 90 mg and such conversions should be done carefully and conservatively. Refer http://hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/fentanyl_2_hpc-cps-eng.pdf

MorphinePO (mg/day)

Hydromorphone PO (mg/day) OxycodonePO (mg/day)

Fentanyl Patch(mcg/hr)

60 – 134 12 – 26 40 – 89 25135 – 179 27 – 35 90 – 119 37.5180 – 224 36 – 44 120 – 149 50225 – 269 45 – 53 150 – 179 62.5270 – 314 54 – 62 180 – 209 75315 – 404 63 – 80 210 – 269 100405 – 494 81 – 98 270 – 329 125495 – 584 99 – 116 330 – 389 150585 – 674 117 – 134 390 – 449 175675 – 764 135 – 152 450 – 509 200765 – 854 153 – 170 510 – 569 225855 – 944 171 – 188 570 – 629 250

945 – 1034 189 – 206 630 – 689 2751035 – 1124 207 – 224 690 – 749 300

‡The Dose Conversion Guidelines are to be used to convert adult patients from their current oral or parenteral opioid analgesic to the fentanyl patch only. The Dose Conversion Guidelines are unidirectional for use in chronic pain only. They should not be used to convert patients from the fentanyl transdermal system to other opioids, as this may result in overdose and toxicity. Refer to Health Canada website: http://hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/fentanyl_2_hpc-cps-eng.pdf

Fentanyl Transdermal Equianalgesic Conversion Chart‡

Approximate Breakthrough Doses Recommended for Fentanyl Transdermal PatchBreakthrough should be 10% of the total daily opioid dose

Patch Strengthmcg/hour

Oral Morphine Immediate Release (mg)

Oral Hydromorphone Immediate Release (mg)

Oral Oxycodone Immediate Release (mg)

12* 5 1 2.5 to 5 25 10 2 5 to 7.5 50 20 4 10 to 15 75 30 6 15 to 25 100 40 8 20 to 30

* fentanyl patch is labelled 12 mcg/hr but delivers 12.5 mcg/hrTables adapted from: Analgesic approximate equivalence charts. Fraser Health Hospice Palliative Care Clinical Practice Committee, May 30, 2005 [document on file] and Fraser Health Hospice Palliative Care Program. Principles of Opioid Management. November 24, 2006. [cited September 7, 2010]. Available from: www.fraserhealth.ca/media/16FHSymptomGuidelinesOpioid.pdf

Opioid Equianalgesic Dose For 20 mg Oral Morphine(for chronic dosing)

DRUG SC/IV (mg) PO (mg) COMMENTSmorphine 10 20*codeine 120 200 metabolized to morphine

fentanyl patch see table below – useful when PO / PR routes not an optionfentanyl 0.1 (100 mcg) usually dosed prn

less than 1 hour effecthydromorphone 2 4

methadone available through Special Access Programme

1(1-7)

variable equivalence: palliative or pain consultation advised

oxycodone not available in Canada 13.3(6.7-20)

variable equivalence

sufentanil 0.02 (20 mcg) usually dosed prn less than 1 hour effect

MorphinePO (mg/day)

Hydromorphone PO (mg/day) OxycodonePO (mg/day)

Fentanyl Patch(mcg/hr)

60 – 134 12 – 26 40 – 89 25135 – 179 27 – 35 90 – 119 37.5180 – 224 36 – 44 120 – 149 50225 – 269 45 – 53 150 – 179 62.5270 – 314 54 – 62 180 – 209 75315 – 404 63 – 80 210 – 269 100405 – 494 81 – 98 270 – 329 125495 – 584 99 – 116 330 – 389 150585 – 674 117 – 134 390 – 449 175675 – 764 135 – 152 450 – 509 200765 – 854 153 – 170 510 – 569 225855 – 944 171 – 188 570 – 629 250

945 – 1034 189 – 206 630 – 689 2751035 – 1124 207 – 224 690 – 749 300

Approximate Breakthrough Doses Recommended for Fentanyl Transdermal PatchBreakthrough should be 10% of the total daily opioid dose

Patch Strengthmcg/hour

Oral Morphine Immediate Release (mg)

Oral Hydromorphone Immediate Release (mg)

Oral Oxycodone Immediate Release (mg)

12* 5 1 2.5 to 5 25 10 2 5 to 7.5 50 20 4 10 to 15 75 30 6 15 to 25 100 40 8 20 to 30

Appendix C: Medicationsα Used in Palliative Care for Pain ManagementAnalgesics GI Medications Other

Acetaminophen, NSAIDsOpioidsNeuropathic Pain AdjuvantsAntispasmodics, Skeletal Muscle Relaxants

Gastric Cytoprotection and Dyspepsia Bone Pain Adjuvants

αRefer to guideline and/or algorithm for recommended order of use.

ACETAMINOPHEN, NSAIDsGeneric Name Trade Name Available Dosage

FormsStandard Adult DoseA Drug Plan CoverageB Approx. cost

per 30 daysPalliative Care

Fair PharmaCare

acetaminophen Tylenol®, Panadol®, G

IR tabs, caplet: 325, 500 mg

325 to 650 mg PO q4-6 h Yes, LCA No $2-5 (G) $11-34

SR tabs: 650 mg 650 to 1300 mg PO q8h Yes No $6-12C (G) $11-21C

Supps: 325, 650 mg 650 mg PR q4-6h [max: 4 g PO/PR per day]

Yes No $99-149(G)

celecoxib Celebrex® Caps: 100, 200 mg 100 to 200 mg PO bid Yes Special Authority

$42-84

diclofenac Voltaren®, G IR tabs: 25, 50 mg 25 to 50 mg PO tid Yes, LCA Yes, RDP $26-38 (G) $82

SR tabs: 75, 100 mg 75 to 100 mg PO once daily Yes, LCA Yes, RDP $18-26 (G) $38-54

Supps: 50, 100 mg 50 mg PR tid Yes, LCA Yes, LCA $60 (G) $124

ibuprofen Advil®, Motrin®, G

Tabs: 200, 300, 400, 600 mg

200 to 400 mg PO q4h [max: 2400 mg per day]

Yes, LCA Yes, LCA $5-9 (G) $31-61

indomethacin G Caps: 25, 50 mg 25 to 50 mg PO tid No Yes, RDP $15-24 (G)Supps: 50, 100 mg 50 to 100 mg PR bid No Yes $53-58 (G)

ketorolac Toradol®, G Tabs: 10 mg 10 mg PO qid [limit duration] No No $10 (G) $15 per 5 days

Inj: 10, 30 mg per mL 10 to 30 mg IM/IV*/SC* q6h [limit duration]

No No $34 (G) $19-58 per 2 days

naproxen Naprosyn®, G IR tabs: 250, 375, 500 mg

250 to 500 mg PO bid Yes, LCA Yes, LCA $7-14 (G) $17-31

EC tabs: 250, 375, 500 mg

Yes, RDP Yes, RDP $13-31(G) $27-63

SR tab: 750 mg 750 mg PO daily Yes, RDP Yes, RDP $33 (G), $42Supp: 500 mg 500 mg PR bid Yes, LCA Yes, LCA $ 56 (G)

Abbreviations: caps capsules; EC enteric coated; G generics; IM intravenous; inj injection; IR Immediate Release; IV intravenous; LCA subject to low cost alternative program; max maximum dose; PO by mouth; PR per rectum; RDP subject to reference drug program; SR slow release; SC subcutaneous; supps suppositories (rectal); tabs tablets

A Preferred route of administration for NSAIDs is oral or rectal.B PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations in Palliative Care Part 2 - Information About Provincial Drug CoverageC Retail cost (without prescription)* This route of administration is used in practice, but not approved for marketing for this indication by Health Canada.

Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages; consult the most current product monograph for this information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

OPIOIDSGeneric Name Trade Name Available Dosage

FormsStandard Adult DoseA Drug Plan CoverageB Approx. cost


Fair PharmaCare

fentanyl Duragesic MAT®, G

Patch: 12, 25, 37, 50, 75, 100 mcg per h

12 to 100 mcg per h applied to skin every 72 hours

Yes, LCA Special Authority, LCA

$24-186 (G) $113-372C

G Inj: 50 mcg per mL 25 to 100 mcg sublingual* per dose PRN

Yes No $2-4 (G) per dose

hydromorphone Dilaudid®, G IR tabs: 1, 2, 4, 8 mg 2 to 8 mg PO q4h Yes, LCA Yes, LCA $28-62 (G) $28-69

Hydromorph Contin®

SR caps: 3, 6, 12, 18, 24, 30 mg

3 to 30 mg PO q12h Yes Special authority

$42-242

Dilaudid®, G Inj: 2, 10, 20, 50, 100 mg per mL

2 to 10 mg SC q4h Yes, LCA Yes, LCA $184-455 (G) $221-541

morphine M.O.S.®, MS-IR®, Statex®, G

IR tabs: 5, 10, 25, 30, 40, 50, 60 mg

5 to 60 mg PO q4h Yes, LCA Yes, LCA $21-114 (G) $24-343

M-Eslon®, M.O.S. SR®, MS Contin®, G

SR tabs: 10, 15, 20, 30, 60, 100, 200 mg

10 to 200 mg PO q12h Yes, LCA Yes, LCA $18-84 (G) $18-156

G Inj: 1,2, 5, 10,15, 25, 50 mg per mL

2 to 25 mg SC q4h Yes Yes $171-512 (G)

methadone Metadol™ Tabs: 1, 5, 10, 25 mg 1 to 25 mg PO q8h Yes No $16-161

Metadol™, compounded

Oral Solution: 1, 2, 5, 10, 20, 25 mg per mL

Yes No,Yes

$2-8 (compounded) $4-88

oxycodone Oxy.IR®, Supeudol®, G

IR tabs: 5, 10, 20 mg 5 to 20 mg PO q4h Yes, LCA Yes, LCA $25-64 (G) $51-130

OxyContin® SR tabs: 5, 10, 15, 20, 30, 40, 60, 80 mg

5 to 80 mg PO q12h Yes Special Authority

$40-270

sufentanilD G Inj: 50 mcg per mL For incident pain: 12.5 mcg sublingual*D /dose PRN; incremental doses titrated q2h PRN up to 75 mcg

Yes Yes $7 (G) per dose

Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages; consult the most current product monograph for this information:

Abbreviations: G generics; h hour; inj injection; IR Immediate Release; PO by mouth; PRN as needed; SC subcutaneous; SR slow release; tabs tablets

A Dosage requirements may go beyond range shown in table i.e. there is no maximum dose for opioids, unless limited by side effects or toxicity.B PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations in Palliative Care Part 2 - Information on Provincial Drug CoverageC Lower cost of range represents 25 mcg Duragesic® patchesD Sufentanil is a potent opioid, initiation by a primary care provider for opiate naïve patients is not recommended, instead refer for Palliative Care Consult. Sublingual sufentanil may be considered for patients receiving at least 60 mg PO morphine equivalents over the last 7 days. Refer to Fraser Health Guideline: Sublingual sufentanil for management of incident pain in palliative patients (this is expected to be available in the future at http://fraserhealth.ca/EN/hospice_palliative_care_symptom_guidelines/).

* This route of administration is used in practice, but not approved for marketing for this indication by Health Canada.

NEUROPATHIC PAIN ADJUVANTSGeneric Name Trade Name Available Dosage

FormsStandard Adult Dose Drug Plan CoverageA Approx. cost


Fair PharmaCare

cannabidiol, D-9-T

Sativex® Buccal spray: single combination product strength

1 spray buccally/sublingual BID, increase by 1 spray per day up to 8 to 12 sprays per day

No No $652-978

clonazepam† Rivotril®, G Tabs: 0.25, 0.5, 1, 2 mg

0.5 mg PO at bedtime, up to 2 mg qid

Yes, LCA Yes, LCA $3-22 (G) $6-44

desipramine† G Tabs: 10, 25, 50, 75, 100 mg

10 to 25 mg PO at bedtime; increase q3-7 days up to 150 mg per day

Yes, LCA Yes, LCA $12-58 (G)

dexamethasone† G Tabs: 0.5, 0.75, 2, 4 mg

2 mg PO/SC‡ daily to 8 mg bid (am & noon)


Inj: 4, 10 mg per mL Yes, LCA Yes, LCA $55-83 (G)

duloxetine† Cymbalta® Caps: 30, 60 mg 30 to 60 mg PO daily No No $59-118

gabapentin† Neurontin®, G Tabs: 100, 300, 400, 600, 800 mg

300 to 1200 mg PO tid Yes, LCA Yes, LCA $49-176 (G) $99-353

nortriptyline† Aventyl®, G Caps: 10, 25 mg 10 to 150 mg PO at bedtime Yes, LCA Yes, LCA $4-43 (G) $7-87

pregabalin† Lyrica® Caps: 25, 50, 75, 150, 300 mg

75 mg PO bid, increase q7 days up to 300 mg bid

No No $102-140

topiramate† Topamax®, G Tabs: 25, 100, 200 mg

25 mg PO daily increase q7 days up to 200 mg bid

No Yes, LCA $20-115 (G) $41-229

Sprinkle caps: 15, 25 mg

No Yes $39-622

valproic acid† Depakene®, G Caps/tabs: 250, 500 mg

250 mg PO at bedtime increase q3 days up to 500 mg tid

Yes, LCA Yes, LCA $8-48 (G) $18-106


Abbreviations: caps capsule; G generics; inj injection; LCA subject to low cost alternative program; PO by mouth; SC subcutaneous; tabs tablets, D-9-T Delta-9-Tetrahydrocannabinol

A PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations in Palliative Care Part 2 - Information on Provincial Drug Coverage

† This indication (i.e. neuropathic pain) not approved by Health Canada; duloxetine approved for treating diabetic neuropathy.‡ This route of administration is used in practice, but not approved by Health Canada.

ANTISPASMODICSGeneric Name Trade Name Available Dosage



Fair PharmaCare

belladonna & Opium

G Supps: Belladonna 15 mg, Opium 65 mg

1 supp PR qid Yes Yes $330 (G)

hyoscine butylbromide

Buscopan® Tabs: 10 mg 10 mg PO qid up to 60 mg per day

Yes Yes $42-63

Buscopan®, G Inj: 20 mg per mL 10 to 20 mg SC q6h [max: 100 mg per day]

Yes, LCA Yes, LCA $511 (G) $557

tizanidine Zanaflex®, G Tabs: 4 mg 2 mg PO daily increase q3-4 days up to 4 to 12 mg tid

No Special Authority, LCA

$6-107 (G) $12-221

SKELETAL MUSCLE RELAXANTSbaclofen Lioresal®, G Tabs: 10, 20 mg 5 mg PO bid increase q3

days up to 20 mg tidYes, LCA Yes, LCA $9-55 (G)

$21-124cyclobenzaprine Flexeril®B, G Tabs: 10 mg 5 mg PO tid to 10 mg qid No Yes, LCA $18-49 (G)


Abbreviations: G generics; inj injection; LCA low cost alternative program; max maximum dose; PO by mouth; SC subcutaneous; supps suppositories (rectal); tabs tablets

A PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations in Palliative Care Part 2 - Information on Provincial Drug CoverageB Flexeril® brand no longer available

GASTRIC CYTOPROTECTION and DYSPEPSIAGeneric Name Trade Name Available Dosage



Fair PharmaCare

esomeprazole Nexium® DR Tabs: 20, 40 mg 20 mg to 40 mg PO daily No Special Authority

$68

DR Granules: 10 mg $136-272

lansoprazole Prevacid®, G DR Caps: 15, 30 mg 15 mg to 30 mg PO daily No Special Authority, LCA

$27 (G), $65

FasTabs: 15, 30 mg $65

misoprostol G Tabs: 100, 200 mcg 100 to 200 mcg PO qid No Yes $33-56

omeprazole Losec®, G DR caps: 10, 20 mg 20 mg PO daily No Special Authority, LCA

$36 (G), $36

omeprazole magnesium

Losec®, G DR tabs: 10, 20 mg 20 mg PO daily No $36 (G) $72

pantoprazole Pantoloc®, G EC Tabs: 40 mg 40 mg PO daily Yes, LCA Special Authority, LCA

$33 (G) $66

Inj: 40 mg 40 mg IV daily No No $444

pantoprazole magnesium

Tecta® EC Tabs: 40 mg 40 mg PO daily Yes Special Authority

$45

rabeprazole Pariet®, G EC Tabs: 10, 20 mg 10 to 20 mg PO daily Yes, LCA Special Authority, LCA

$11-21 (G) $22-43

ranitidine Zantac®, G Tabs: 75, 150, 300 mg

150 mg PO bid NSAID cytoprotection: 300 mg PO bid

Yes, LCA Yes, LCA $12-23 (G) $12-23

Inj: 25 mg per mL 50 mg SC† q8h Yes, LCA Yes, LCA $246 (G) $272


Abbreviations: caps capsule; DR delayed release; EC enteric coated; FasTabs delayed-release tablets; G generics; inj injection;IV intravenous; PO by mouth; SC subcutaneous; tabs tablets


† This route of administration is used in practice, but not approved for marketing for this indication by Health Canada

BONE PAIN ADJUVANTS for Nociceptive bone pain (without hypercalcemia)

For treating malignancy related hypercalcemia see www.bccancer.bc.ca/HPI/ChemotherapyProtocols/SupportiveCare/default.htmGeneric Name Trade Name Available Dosage



Fair PharmaCare

calcitonin Miacalcin® Nasal spray: 200 units per spray

Nociceptive bone pain: one nasal spray daily up to two sprays bid

No No $69-277

Calcimar® Inj: 200 units per mL (2 mL multi-dose vial)

Nociceptive bone pain: 50 units SC* at bedtime up to 200 units bid

No Yes $215 - 1723

Caltine® Inj: 100 units per 1 mL ampule

$253 - 1013

clodronate Bonefos®, Clasteon®

Caps: 400 mg 800 mg PO bid or 1600 mg PO daily [max: 3200 mg per day]

Yes, LCA Yes, LCA $157 (Clasteon®) $242 (Bonefos®)

pamidronate Aredia®, G Inj: 90 mg per 10 mL 90 mg IV monthly Yes, LCA Special Authority, LCA

$281 (G) $523

zoledronic acid Zometa® Inj: 4 mg per 5 mL 4 mg IV monthly Yes No $598


Abbreviations: caps capsules; G generics; inj injection; IV intravenous; LCA low cost alternative program; max maximum dose; PO by mouth; SC subcutaneous


* Caltine® not approved for subcutaneous route for marketing for this indication by Health Canada.

ReferencesCardario. Drug Information Reference. Vancouver: The BC Drug and Poison Information Centre, 2003.Fraser Health [page on the internet]. Vancouver: Fraser Health; c2009 [cited 2010 Aug 11]. Hospice Palliative Care Symptom Guidelines. Available from: www.fraserhealth.ca/professionals/hospice_palliative_care/Hospital Pharmacists’ Special Interest Group in Palliative Care. Care Beyond Cure: Management of Pain and Other Symptoms. Montreal: Association des pharmaciens des etablissements de santé du Quebec, 2009.Repchinsky C, editor. Compendium of Pharmaceuticals and Specialties. 2010. Toronto: Canadian Pharmacists Association, 2010.Rostom A, Dube C, Wells GA, Tugwell P, Welch V, Jolicoeur E, McGowan J, Lanas A. Prevention of NSAID-induced gastroduodenal ulcers. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD002296. DOI: 10.1002/14651858.CD002296. [Content updated 2010].Semla TP, Beizer JL, Higbee MD. Geriatric dosage handbook. 15th ed. Hudson(OH):Lexi-Comp, 2010.Twycross R, Wilcock A, Dean M, et al. Palliative Care Formulary. Canadian Edition. Nottingham: Palliativedrug.com Ltd, 2010.



DyspneaEffective Date: September 30, 2011

Drug CommentsOpioids (drugs of first choice)

• If opioid naïve, start with morphine 2.5-5 mg PO (SC dose is half the PO dose) q4h or equianalgesic dose of hydromorphone or oxycodone.• Breakthrough should be half of the q4h dose ordered q1h prn.• If opioid tolerant, increase current dose by 25-50%.• When initiating, start an antiemetic (metoclopramide) and bowel protocol.• Therapeutic doses used to treat dyspnea do not decrease oxygen saturation or cause differences in respiratory rate or CO2 levels.3

• Nebulized forms have NOT been shown to be superior to oral opioids and are not recommended.6

ScopeThis section presents assessment and management strategies for dealing with dyspnea occurring in patients with cancer or advanced disease.

Salient Principle in this Section: • Use opioids first line for pharmacological management of dyspnea

Included in this Section: A - Dyspnea management algorithm B - Dyspnea medication reference tables

Dyspnea Management (Refer Appendix A - Dyspnea Management Algorithm)

Definition: Breathing discomfort that varies in intensity but may not be associated with hypoxemia, tachypnea, or orthopnea. Occurs in up to 80% of patients with advanced cancer.1

Dyspnea Assessment • Ask the patient to describe dyspnea severity using a 1-10 scale. • Identify underlying cause(s) and treat as appropriate.2

• History and physical exam lead to accurate diagnosis in two-thirds of cases.3

• Investigations: CBC/diff, electrolytes, creatinine, oximetry +/- ABGs and pulmonary function, ECG, BNP when indicated. • Imaging: Chest X-ray and CT scan chest when indicated.

Dyspnea Management Strategies • Proven therapy includes opioids for relief of dyspnea. Oxygen is only beneficial for relief of hypoxemia.4 • Adequate control of dyspnea relieves suffering and improves a patient’s quality of life.5

• Treat reversible causes where possible and desirable, according to goals of care. • Always utilize non-pharmacological treatment: education and comfort measures. • Pharmacological treatment: Opioids, +/- benzodiazepines or neuroleptics, +/- steroids.

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14

References

Drug CommentsBenzodiazepines • Prescribe prn for anxiety and respiratory “panic attacks”.

• Lorazepam 0.5-2 mg SL q2-4h prn.• Consider SC midazolam in rare cases

Neuroleptics • Methotrimeprazine 2.5-5 mg PO/SC q8h, then titrate to effect.

Corticosteroids • Dexamethasone 8-24 mg PO/SC/IV qam depending on severity and cause of dyspnea.• Particularly for bronchial obstruction, lymphangetic carcinomatosis, and SVC syndrome; also for bronchospasm, radiation pneumonitis and idiopathic interstitial pulmonary fibrosis.

Supplemental O2 • Indicated only for hypoxia (insufficient evidence of benefit otherwise).5

1. Kobierski, L et al. Hospice Palliative Care Program. Symptom Guidelines. Fraser Health Authority. 2009 April. Available at: www.fraserhealth.ca/professionals/resources/hospice_palliative_care/hospice_palliative_care_symptom_guidelines

2. Schwartzstein RM, King TE, Hollingsworth H. Approach to the patient with dyspnea. UpToDate. 2009 Jan 1;17.1.

3. Membe SK, Farrah K. Pharmacological management of dyspnea in palliative cancer patients: Clinical review and guidelines. Health Technology Inquiry Service. Canadian Agency for Drugs & Technologies in Health. 2008 July.

4. Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;148(2):141-6.

5. Kobierski et al, “Dyspnea”, Hospice Palliative Care Program Symptom Guidelines, Fraser Health Authority, 2006.

6. Fraser Health Authority. Hospice Palliative Care Symptom Guidelines - Dyspnea. 2009. Available at www.fraserhealth.ca/media/Dyspnea.pdf

AbbreviationsABG arterial blood gasBNP brain natiuretic peptideCT computed tomographyECG electrocardiogramIV intravenousPO by mouthSC subcutaneousSL sublingualSVC superior vena cava

AppendicesAppendix A – Dyspnea Management AlgorithmAppendix B – Medications Used in Palliative Care for Dyspnea and Respiratory Secretions










Appendix A: Dyspnea Management Algorithm

Reversible Causes of Dyspnea

Cardiovascular Anemia Arrythmia CHF Deconditioning Myocardial Ischemia Pericardial Effusion Pulmonary emboli

Respiratory Bronchial Obstruction Bronchospasm/Asthma COPD/Emphysema Infection Interstitial Fibrosis Lymphangitic carcinomatosis Pleural Effusion Radiation pneumonitis

Other Anxiety/panic disorder Ascites Cachexia Neuromuscular disease

Dyspnea screen(0-10 scale)

Assessment

Treat reversible causes if present

• Air flow (fan) / environment• Positioning• Loose clothing• Relaxation• Modify Lifestyle

Pharmacological treatment

• History • Physical Assessment• Laboratory investigation• Imaging

Treat hypoxemia if present

Treat symptom of dyspnea

Comfort measures

• Breath control• Energy conservation

• Use of breakthrough medications• Proper Inhaler technique

Opioid+/- Benzodiazepine+/- Neuroleptic+/- Steroid

Timed Opioid (PO/SC/SL)+/- Benzodiazepine (SC/SL)

Opioid (IV/SC)& Benzodiazepine (IV/SC)

Education (patient and caregiver)

Baseline dyspnea Incident dyspnea Crisis dyspnea

Refractory dyspnea

Palliative Care Consult

Palliative sedation

Unremitting dyspnea

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OPIOIDS*Generic Name Trade Name Available Dosage

FormsStandard Adult Dose

(opioid-naïve)ADrug Plan CoverageB Approx. cost


Fair PharmaCare

hydromorphone Dilaudid®, G IR tabs: 1, 2, 4, 8 mg 0.5-1 mg PO q4h Yes, LCA Yes, LCA $7-15 (G)$8-17

morphine M.O.S.®, MS-IR®, Statex®, G

IR tabs: 5, 10, 25, 30, 40, 50, 60 mg

2.5-5 mg PO q4h Yes, LCA Yes, LCA $10-21 (G)$11-24

G Inj: 1, 2, 5, 10, 15, 25, 50 mg per mL

Crisis dyspnea: 5 mg IV/SC q5-10 min. Double dose if no effect every third dose

Yes Yes $1amp(10mg/ml)

oxycodone Oxy IR®, Supeudol®, G

IR tabs: 5, 10, 20 mg 2.5-5 mg PO. Titrate to q4h Yes, LCA Yes, LCA $23 (G) – 50

Appendix B: Medicationsα Used in Palliative Care for Dyspnea and Respiratory SecretionsαRefer to guideline and/or algorithm for recommended order of use.

Tailor dose to each patient. Those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages. Consult most current product monograph for information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

BENZODIAZEPINESGeneric Name Trade Name Available Dosage

FormsStandard Adult Dose Drug Plan CoverageB Approx. cost

Palliative Care

Fair PharmaCare

lorazepam Ativan®, G Tabs: 0.5, 1, 2 mg 0.5-2 mg PO/ sublingual q2-4h PRN

Yes, LCA Yes, LCA $0.04-0.08 (G)$0.08-0.16 per tablet

Sublingual tabs: 0.5, 1, 2 mg

Yes Yes $0.12-0.23 per tablet

Inj: 4 mg per mL 0.5-2 mg SC+ q2-4h PRN Yes Yes $2.93 per vial

midazolam G Inj: 1 mg per mL, 5 mg per mL

2.5-5 mg SC+ q5-15 min prn Yes No $1.45/mL (1 mg/mL vial)$3.92/mL (5 mg/mL vial)

NEUROLEPTICSGeneric Name Trade Name Available Dosage

FormsStandard Adult Starting Dose

Drug Plan CoverageB Approx. costper 30 daysPalliative

CareFair PharmaCare

metho-trimeprazine

Nozinan®, G Tabs: 2, 5, 25, 50 mg 2.5-5 mg PO q8h, titrate to effect


Nozinan® Inj: 25 mg/mL 6.25 mg SC q8h, titrate to effect

Yes Yes $3.5/amp (25 mg/mL)

Tailor dose to each patient. Those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages. Consult most current product monograph for information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

CORTICOSTEROIDSGeneric Name Trade Name Available Dosage

FormsStandard Adult

DoseDrug Plan CoverageB Approx. cost


Fair PharmaCare

dexamethasone G Tabs: 0.5, 0.75, 2, 4 mg

8-24 mg PO/SC/IV every morning, taper if possible


Inj: 4, 10 mg per mL

$101-304 (G)

MEDICATIONS FOR RESPIRATORY SECRETIONSGeneric Name Trade Name Available Dosage

FormsStandard Adult

DoseDrug Plan CoverageB Approx. costPalliative Care

Fair PharmaCare

atropine G Inj: 0.4, 0.6 mg per mL

0.2-0.8 mg SC q4h and q1h PRN Yes Yes $1.5-2 (G) per dose

Drops: 1% solution 1 to 4 drops sublingual+ q4h prn No Yes $3.15 per 5 mL bottle

glycopyrrolate G Inj: 0.2 mg per mL 0.2-0.4 mg SC+/sublingual+/PO+ q4h to q8h

Yes Yes $11-45 (G) per 24 h

Abbreviations: G generics; h hour; inj injection; IR Immediate Release; PO by mouth; PRN as needed; SC subcutaneous; SR slow release; tabs tablets

* Not an exhaustive list. Other opioids may be appropriate.A For opioid-tolerent patients, increase current dose by 25-50%.B PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations in Palliative Care Part 2 - Information about Provincial Drug Coverage+ This route of administration is used in practice, but not approved for marketing for this indication by Health Canada


Scope

This section presents assessment and management strategies for dealing with nausea and vomiting occurring in patients with cancer or advanced disease.

Salient Principle in this Section: • Select antinausea medication based on the etiology of the nausea and vomiting

Included in this Section: A – Nausea and vomiting management algorithm B – Hypodermoclysis protocol C – Antinausea medication reference tables

Nausea and Vomiting Management (Refer Appendix A - Nausea and Vomiting Management Algorithm)

Assessment • Common, but can be controlled with antiemetics. • Identify and discontinue medications that may be the cause. • Further assessment may include lab tests and imaging to investigate, e.g., GI tract disturbance, electrolyte / calcium imbalance, intracranial disease, and sepsis. • Good symptom control may require rehydration which can be carried out in the home, hospice, or residential care facility using hypodermoclysis, a simple, safe and effective technique that avoids venous access (refer Appendix B - Hypodermoclysis Protocol).

Management Strategies • Non-pharmacological: modifications to diet (e.g., small bland meals) and environment (e.g., control smells and noise), relaxation and good oral hygiene, acupressure (for chemotherapy-induced acute nausea but not for delayed symptoms). • Pharmacological: match treatment to cause, e.g., if opioid-induced, metoclopramide (sometimes IV or SC initially) and domperidone are most effective. Most drugs are covered by the BC Palliative Care Drug Plan except olanzapine and ondansetron (refer Appendix C – Medications Used in Palliative Care for Nausea and Vomiting). • Consider pre-emptive use of anti-nauseates in opioid-naive patients.

AbbreviationsGI gastrointestinalIV intravenousN&V nausea & vomitingSC subcutaneous

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Nausea and Vomiting (N&V)Effective Date: September 30, 2011



AppendicesAppendix A – Nausea and Vomiting Management AlgorithmAppendix B – Hypodermoclysis ProtocolAppendix C – Medications Used in Palliative Care for Nausea and Vomiting

19










Appendix A: Nausea and Vomiting Management Algorithm

• History

• Physical examination

• Appropriate investigations (bloodwork + investigations as required)

• Non-pharmacological measures e.g., environmental modification (consider smells, noise, etc.); good oral hygiene; acupressure; fizzy drinks; visualization, distraction, relaxation• Consultation with a Registered Dietitian at www.healthlinkbc.ca/dietitian/• General supportive measures, e.g., food modification, restricted intake, sips, cool and bland food, avoiding lying flat after eating

e.g., hypercalcemia, urosepsis, constipation, uremia, intracranial pressure, bowel obstruction, dehydration, medication adverse effects

i.e., match medication to etiology

Distension or lumen compression:• metoclopramide• domperidone• methotrimeprazineObstruction• haloperidol• octreotideOpioid-induced• metoclopramide• domperidone• methylnaltrexoneOther vagal stimuli:• methotrimeprazine• prochlorperazine• ondansetron

• haloperidol

• prochlorperazine

• methotrimeprazine

• ondansetron

• granisetron

• dimenhydrinate

• scopolamine

Emotional/anxiety:• lorazepam• nabiloneIncreased ICP:• dexamethasone• dimenhydrinate

• haloperidol

• methotrimeprazine

• metoclopramide

• Consider increasing dose, trying another drug from the same class, or adding another class of drug.

• Re-evaluate patient’s status and hydration.

Ongoing comprehensive assessment

Patient and family education

Treat underlying causes

Treat disease-specific issues

Re-evaluate drug effect

Gastroenterological Chemical(drugs/toxins)

Vestibular &motion-related CNS Cause unknown

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Appendix B: Hypodermoclysis Protocol

Hypodermoclysis is a simple, safe and effective technique for subcutaneously administering fluids to a patient who requires hydration. It avoids the need for venous access in patients who, at the end of life, often have very poor veins. In the home/hospice/residential care facility settings, it can be carried out without the need for fully IV credentialed nursing staff. Refer to the local Home and Community Care office (refer Palliative Care Part 2 - Resources) for when and how to refer.

There are two critical considerations regarding initiating hypodermoclysis in palliative patients:

1. Objectives and timelines must be clear and agreed upon by the family and caregivers.2. Will adding fluids to a patient whose organ function is failing precipitate cardiac failure and/or cause or worsen lung secretions?

Procedure:

• A 23-25 gauge butterfly needle is inserted under the skin at a 30-45 degree angle. Ask patients which site is preferred of the following choices:

– For ambulatory patients, consider using chest (subclavicular area), back (infrascapular area) and upper abdominal wall (avoiding waist). – For bed-bound patients, use medial or lateral thighs or upper abdomen. – Avoid previously irradiated skin, anterior or lateral thigh if edema is present, abdomen if ascites is present, breast tissue, lateral placement near the shoulder, arms, and perineum/groin.

• The fluids used are commonly normal saline (0.9%), normal saline/dextrose (2/3-1/3) and Ringer’s Lactate. Dextrose cannot be used as a hypodermoclysis solution.

• The infusion rate can be up to 75 ml/hr. Solutions are infused by gravity, i.e., a pump is usually not necessary.

• Some patients may only require 1 litre 3-4 times per week, rather than daily administration. A smaller volume (1 liter per day) is often adequate to maintain hydration in terminally ill patients requiring hydration for symptom control.

• Potassium chloride up to 40 mEq per litre may be added to the solution. Do not mix hypodermoclysis solutions with other medications. If medications are being administered by the SC route, use separate site(s).

• Change the solution bag every 24 hours. Change the tubing every 72 hours. Change the SC site if painful, red, hard or leaking.

Subcutaneous hypodermoclysis sites may last up to 7 days. Daily assessment of client condition and insertion site is necessary.

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ANTI-EMETICSGeneric Name Trade Name Available Dosage

FormsStandard Adult Dose Drug Plan CoverageB Approx. cost


Fair PharmaCare

dexamethasone G Tabs: 0.5, 0.75, 2, 4 mg

2 mg PO/SC*/IV daily to 8 mg bid (AM & noon)


Inj: 4, 10 mg per mL

$55-83 (G)

dronabinol (D-9-T)

Marinol® Caps: 2.5, 5, 10 mg Chemotherapy related nausea and vomiting: 2.5 to 5 mg PO qid

No Special Authority

$256-511

dimenhydrinate Gravol®, G IR caps/tabs: 15, 50 mg

50 mg PO q6h to q4h Yes, LCA No $3-4 (G)

L/A caplets: 100 mg

100 mg PO q12h to q8h Yes No $28-43

Inj: 50 mg per mL 50 mg IM/IV/SC* q6h to q4h Yes, LCA No $93-140 (G) $112-167

Supps: 25, 50, 100 mg

50 to 100 mg PR q12h to q8h

Yes No $28-44 (G)$52-64

domperidone G Tab: 10 mg 10 to 20 mg PO tid to qid Yes, LCA Yes, LCA $12-31 (G)

granisetron Kytril®, G Tab: 1 mg 1 mg to 2 mg PO/IV/SC* daily or 1 mg bid


$437-875 (G) $583-1166

Inj: 1 mg per mL No No $2268-4536

haloperidol† G Tabs: 0.5, 1, 2, 5, 10 mg

0.5 mg PO/SC*/IV bid to 2.5 mg q6h


Inj: 5 mg per mL Yes, LCA Yes, LCA $257-513 (G)

methotrimeprazine G Tabs: 2, 5, 25, 50 mg

5 to 12.5 mg PO q4h to q24h

Yes, LCA Yes, LCA $3-25

Nozinan® Inj: 25 mg per mL 6.25 to 25 mg SC* q4h to q24h

Yes Yes $104-622

metoclopramide G Tab: 5, 10 mg 5 to 20 mg PO qid Yes, LCA Yes, LCA $7-15 (G)

Inj: 5 mg per mL 10 to 20 mg SC*/IV q6h Yes, LCA Yes, LCA $320-640 (G)

nabilone Cesamet® Caps: 0.25, 0.5, 1 mg

1 to 2 mg PO bid No Yes $402-804

Appendix C: Medicationsα Used in Palliative Care for Nausea & VomitingαRefer to guideline and/or algorithm for recommended order of use.Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages ; consult most current product monograph for this information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

octreotide† Sandostatin®, G

Inj: 50, 100, 200, 500 mcg per mL

50 to 200 mcg SC q8h Yes, LCA No $243-881 (G) $485-1761

Sandostatin LAR®

Inj LAR:10, 20, 30 mg per vial

LAR: 10 to 30 mg IM every 4 weeks

No No $1362-2258

ondansetron Zofran®, G IR tabs: 4, 8 mg 4 to 8 mg PO/SC q8h to q12h


$434-994 (G) $868-1987

ODT: 4, 8 mg $848-1941

Inj: 2mg per mL $857-2570 (G) $1279-3838

prochlorperazine G Tabs: 5, 10 mg 5 to 10 mg PO/IM/IV/PR tid-qid


Inj: 5 mg per mL $67-179 (G)

Supp: 10 mg $81-108 (G)

scopolamine† Transderm V® Patch: 1.5 mg 1 to 2‡ patches applied to skin every 72 hours

Yes No $46-91

Abbreviations: caps capsules; D-9-T Delta-9-Tetrahydrocannabinol; G generics; inj injection; IM intramuscular; IR immediate release; IV intravenous; LCA subject to low cost alternative program; L/A Long acting (combined immediate and sustained release); LAR slow release (injection); PR per rectum; ODT orally disintegrating tablet; PO by mouth; SC subcutaneous; supps suppositories (rectal); tabs tablets

A PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations here: Information on Provincial Drug Coverage† This indication (i.e. nausea and vomiting) used in practice, but not approved for marketing by Health Canada.‡ Dose of 2 patches of scopolamine transdermal patch (applied simultaneously) used in practice, but not approved for marketing by Health Canada.* This route of administration commonly used in Palliative Care, but not approved by Health Canada


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ConstipationEffective Date: September 30, 2011

Scope

This section presents assessment and management strategies for dealing with constipation occurring in patients with cancer or advanced disease.

Salient Principle in this Section: • Prevent constipation by ordering a bowel protocol when regular opioid medication is prescribed

Included in this Section: A – Constipation management algorithm B – Laxation medication reference tables C – Hypertext link to BCCA bowel protocol

Constipation Management (Refer Appendix A - Constipation Management Algorithm)

Constipation Assessment • Understand the patient’s bowel habit, both current and when previously well, e.g., frequency of bowel movements (BMs), stool size and consistency, ease of evacuation. • Goal is to restore a patient’s normal BM frequency, consistency, and ease of passage. • For lower performance status patients (e.g., reduced food intake and activity), lower BM frequency is acceptable as long as there is no associated discomfort.

Constipation Management Strategies • There are many etiologies, e.g., reduced food/fluid/mobility and AEs of medications. • Avoid rectal interventions (enemas, suppositories, manual evacuation) except in crisis management. Contraindicated when there is potential for serious infection (neutropenia) or bleeding (thrombocytopenia), or when there is rectal/anal disease. • Exclude impaction when a patient presents already constipated. Abdominal X-ray can be useful when physical examination is inconclusive. • When risk factors are ongoing, as they are in most cancer patients, suggest laxatives regularly versus prn. Adjust dose individually. Laxatives are most effective when taken via escalating dose according to response, termed “bowel protocol”. • Sennosides (e.g., Senokot®) are the first choice of laxative for prevention and treatment. Patients with irritable bowel syndrome may experience painful cramps with stimulant laxatives and often prefer osmotic laxatives such as lactulose or polyethylene glycol (PEG). There is weak evidence that lactulose and sennosides are equally effective;1 however lactulose can taste unpleasant and also cause bloating. • If rectal measures are required, generally a stimulant suppository is tried first, then an enema as the next option. • BC Palliative Care Drug Plan covers laxatives written on a prescription for eligible patients.

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• For patients with opioid-induced constipation, after a trial of first-line recommended stimulant laxatives and osmotic laxatives, methylnaltrexone may be helpful. Cancer, GI malignancy, GI ulcer, Ogilvie’s syndrome and concomitant use of certain medications (e.g., NSAIDs, steroids and bevacizumab) may increase the risk of GI perforation in patients receiving methylnaltrexone. [Health Canada MedEffect Notice: www.hc-sc.gc.ca/dhp- mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/relistor_hpc-cps-eng.pdf] • Patient handouts on constipation and bowel protocol are available at www.bccancer.bc.ca/HPI/FPON

References1. Agra Y, Sacristán A, González M, et al. Efficacy of senna versus lactulose in terminal cancer patients treated with opioids. J Pain Symptom Manage. 1998;15(1):1-7.

AbbreviationsAEs adverse effectsBM bowel movementGI gastrointestinalNSAIDs non-steroidal anti-inflammatory drugsPEG polyethylene glycol

AppendicesAppendix A – Constipation Management AlgorithmAppendix B – Medications Used in Palliative Care for Constipation










Appendix A: Constipation Management Algorithm

Assess Cause

Yes

Constipation?

Obstructed bowel?

α available at www.bccancer.bc.ca/HPI/FPON* contraindicated in patients with renal failure† cancer, GI malignancy, GI ulcer, Ogilvie’s syndrome and concomitant use of certain medications (e.g. NSAIDs, steroids and bevacizumab) may increase the risk of GI perforation in patients receiving methylnaltrexone. [Health Canada MedEffect Notice: www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/relistor_hpc-cps-eng.pdf]

No

No

Yes

No Yes

NoYes

NoSuccess

NoSuccess

No Success

PEG = polyethylene glycolBM = bowel movementWBC = white blood cell countPlt = platelet count

• Normal bowel habit• Current bowel performance o Stool frequency o Stool consistency o Ease of evacuation

Assessment

Irritable Bowel Syndrome

Osmotic Laxative• Lactulose or sorbitol• PEGEscalating doses until satisfactory BM

• Escalating doses until satisfactory BM.• Maximum senna dose 36 mg tid.• Add rectal measures at any time if indicated and no contraindications.

PREVENTIONneeded

Sennosides-based Protocol

e.g., ascites, autonomic neuropathy, abdominal cancer

Consider prokinetic agente.g., domperidone, metoclopramide

Add or switch to osmotic laxative


Hypomobility

Manage according to FPON guideline, Medical Management of Malignant Bowel Obstructionα

TREATMENTneeded

1. Rectum empty; or 2. Contraindications to rectal intervention i.e. neutropenia (WBC <0.5) or thrombocytopenia (Plt <20)

Manual disimpaction (if indicated)Glycerin suppBisacodyl suppMicrolax enemaFleet enema*Warm water enemaOil enema

followed by sennosides-based protocol

Opioid-induced

Switch to less constipating opioid e.g., fentanyl or methadone

Add or switch to osmotic laxative

Rectal Measures

Consider methylnaltrexone†

LAXATIVESGeneric Name Trade Name Available Dosage


Palliative Care

Fair PharmaCare

bisacodyl Dulcolax®, G Tabs: 5 mg 5 to 10 mg PO x 1 dose Yes, LCA No $0.05 (G) $0.21per tab

Supps: 10 mg 10 mg PR x 1 dose $0.51 (G) per supp

glycerin supp G Supps: 2.65 g 1 supp PR x 1 dose Yes No $0.25 (G)B

per supp

glycerin-sodium citrate-sodium lauryl sulfoacetate-sorbic acid-sorbitol

Microlax® Micro-enema: 5 mL

5 mL PR x 1 to 2 doses Yes No $1.80B per micro-enema

lactulose G Oral solution: 667 mg per mL

15 mL PO daily to 30 mL PO bid

Yes, LCA Special Authority, LCA

$7-28 (G) per 30 days

methylnaltrexoneC Relistor® Inj: 12 mg per 0.6 mL

8 to 12 mg SC every 2 days No No $616 per 30 days

mineral oil enema Fleet enema mineral oil®

Enema: 130 mL 120 mL PR x 1 dose Yes No $8B per enema

phosphates enemaD

Fleet enema®, G

Enema: 22 g per 100 mL

120 mL PR x 1 dose Yes No $6B (G) $8B per enema

polyethylene glycol 3350 (PEG)

Lax-A-Day®, Pegalax™, RestoraLAX™, G

Powder: 17g sachets

17 grams in 250 mL fluid PO daily

No No $27-51B per 30 days

sennosides Senokot®, G Tabs: 8.6, 12 mg 2 tabs PO at bedtime to 3 tabs tid

Yes, LCA No $3-14 (G) $10-47 per 30 days

Oral syrup: 8.8 mg per 5 mL

10 mL PO at bedtime to 15 mL tid

$14-86 per 30 days

sorbitol G Oral solution: 70% 15 to 45 mL PO daily to qid No No $10-119B (G) per 30 days

Appendix B: Medicationsα Used in Palliative Care for ConstipationαRefer to guideline and/or algorithm for recommended order of use.Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages; consult most current product monograph for this information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

Abbreviations: G generics ; LCA subject to low cost alternative program; PO by mouth; PR per rectum; SC subcutaneous; supps suppositories (rectal); tabs tablets

A PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated, as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations here: Information on Provincial Drug CoverageB Approximate retail cost (without prescription)C Cancer, gastrointestinal malignancy, gastrointestinal ulcer, Ogilvie’s syndrome and concomitant use of certain medications (e.g. NSAIDs, steroids and bevacizumab) may increase the risk of GI perforation in patients receiving methylnaltrexone. [Health Canada MedEffect Notice: www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2010/relistor_hpc-cps-eng.pdf]D contraindicated in patients with renal failure


Scope

This section presents assessment and management strategies for dealing with delirium occurring in patients with cancer or advanced disease.

Salient Principles in this Section: • Look for and treat reversible causes of delirium • Utilize neuroleptics first line for pharmacological treatment

Included in this Section: A – Delirium management algorithm B – Delirium medication reference tables

Delirium Management (Refer Appendix A - Delirium Management Algorithm)

Definition: A state of mental confusion that develops quickly, usually fluctuates in intensity, and results in reduced awareness of and responsiveness to the environment. It may manifest as disorientation, incoherence and memory disturbance.

Delirium Assessment • May be hypoactive, hyperactive or mixed • Look for underlying reversible cause (refer Fraser Health Authority. Hospice Palliative Care Symptom Guidelines - Delirium/Restlessness)α

• Ascertain stage of illness and whether delirium is likely to be reversible or terminal and irreversible • Review advanced care plan and discuss goals of care with substitute decision maker • Refer patient/family to Home and Community Care (refer Palliative Care part 2 - Resources) or timely access to caregiver support and access to respite and/or hospice care

Delirium Management Strategies • Treat reversible causes if consistent with goals of care • Avoid initiating benzodiazepines for first line treatment • Refer to Appendix A - Delirium Management Algorithm • Avoid use of antipsychotics in patients diagnosed with Parkinson’s disease or Lewy Body Dementia.

AbbreviationsIM intramuscularIV intravenousPO by mouthSC subcutaneous



Delirium ManagementEffective Date: September 30, 2011

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αavailable at www.fraserhealth.ca/media/07FHSymptomGuidelinesDelirium.pdf Palliative Care Part 1: Approach to Care is available at www.bcguidelines.ca/guideline_palliative1.html, Palliative Care Part 3: Grief and Bereavement is available at www.bcguidelines.ca/guideline_palliative3.html


AppendicesAppendix A - Delirium Management AlgorithmAppendix B - Medications Used in Palliative Care for Delirium and Terminal Agitation

29










Appendix A: Delirium Management Algorithm

Diagnosis

Delirium*Depression* Dementia*

Assessment• Level of consciousness• Presence of hallucinations• Fluctuation of mental confusion

Treat as appropriate(refer to Palliative Care Part 2 - Depression - Appendix A - Depression Management Algorithm)

Non-pharmacologicalInterventions

• Environment• Lighting• Safety

Treat as appropriate

Assess and treat all reversible causes

• Full physical exam• History• Medication review• Investigations as appropriate

Pharmacological Treatments

Antipsychotic• Start with least sedating most sedating until agitation controlled • haloperidol • risperidone • loxapine • olanzapine • quetiapine • methotrimeprazine• AVOID benzodiazepines• Reassess frequently

• AVOID sedatives• Haloperidol: minimum effective dose to control hallucinations

Sedate with benzodiazepine temporarily in addition to antipsychotic treatment and Palliative Care Consult


Palliative sedation therapy • Reassess frequently

Hypoactive (obtunded) patient Hyperactive (agitated) patient Hyperactive (agitated) patient and compromised patient or staff safety

Delirium not reversible

*For clinical features of dementia, depression and delirium, refer to Cognitive Impairment in the Elderly - Recognition, Diagnosis and Management at www.bcguidelines.ca/guideline_cognitive.html

Karen

Inserted Text

Appendix B: Medicationsα Used in Palliative Care for Delirium and Terminal Agitation

ANTIPSYCHOTICSGeneric Name Trade Name Available Dosage


Palliative Care

Fair PharmaCare

haloperidol G Tabs: 0.5, 1, 2, 5, 10 mg

Mild restlessness: 0.5 to 1.5 mg PO tid


Delirium and agitation: 0.5 to 5 mg PO q8h to q4h

$4-29 (G)

Inj: 5 mg per mL Mild restlessness: 0.25 to 0.75 mg SC* tid

Yes, LCA Yes, LCA $385 (G)

Delirium and agitation: 0.5 to 5 mg SC* q8h to q4h

$385-770 (G)

loxapine† G Tabs: 2.5, 5, 10, 25, 50 mg

2.5 to 10 mg PO/SC* daily to twice daily


Inj: 50 mg per mL Yes Yes $222-445 (G)

metho-trimeprazine†

G Tabs: 2, 5, 25, 50 mg

Delirium: 10 to 50 mg SC* q30min until relief then 10 to 50 mg PO/SC* q8h to q4h.


Nozinan® Inj: 25 mg per mL Yes Yes $311-1244

olanzapine† Zyprexa®, G Tabs: 2.5, 5, 7.5, 10, 15, 20 mg

2.5 to 10 mg PO daily to twice daily

No Special AuthorityB, LCA (20 mg only)

$ 41-328 (G) $58-466

Zyprexa Zydis® Oral dissolving tabs: 5, 10, 15, 20 mg


$49-194 (G) $116-463

quetiapine† Seroquel®, G Tabs: 25, 100, 200, 300 mg


No Yes, LCA $7-27 (G) $16-64

risperidone† Risperdal®, G Tabs: 0.25, 0.5, 1, 2, 3, 4 mg


Yes Yes $11-62 (G) $11-62

Risperdal® M-tab: 0.5, 1, 2, 3, 4 mg

Yes Yes $24-132

OTHER phenobarbital‡ G Inj: 30 mg per mL,

120 mg per mLEpilepsy/terminal agitation: 60 mg SC* bid up to 120 mg tid

Yes Yes $22-459 (G)

αRefer to guideline and/or algorithm for recommended order of use.Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages ; consult most current product monograph for this information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

Abbreviations: G generics; inj Injection; LCA subject to low cost alternative program; M-tabs oral disintegrating tablets; PO by mouth; SC subcutaneous; tabs tabletsA PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated, as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations here: Information on Provincial Drug CoverageB Olanzapine 20 mg is the only strength of regular tablets (not oral dissolving tablets) which are covered with Special Authority† This indication (i.e. delirium) used in practice, but not approved for marketing by Health Canada‡ This indication (i.e. terminal agitation) used in practice, but not approved for marketing by Health Canada* This route of administration used in practice, but not approved for marketing by Health Canada.


Scope

This section presents assessment and management strategies for dealing with fatigue and weakness occurring in patients with cancer or advanced disease.

Salient Principle in this Section: • Except when a patient is dying, recognize that fatigue is a treatable symptom with a major impact on quality of life

Included in this Section: A – Fatigue and weakness management algorithm B – Medications used for fatigue and weakness reference tables

Fatigue and Weakness Management (Refer to Appendix A – Fatigue and Weakness Management Algorithm)

Definition: Fatigue is a subjective perception/experience related to disease, emotional state and/or treatment. Fatigue is a multidimensional symptom involving physical, emotional, social and spiritual well-being and affecting quality of life.1

Fatigue Assessment • Assess whether symptom is fatigue or weakness (generalized or localized) • Distinguish fatigue from depression • Look for reversible causes of fatigue or weakness (refer Fraser Health, Hospice Palliative Care Symptom Guidelines, Fatigue, available at www.fraserhealth.ca/media/11FHSymptomGuidelinesFatigue.pdf)

Fatigue Management Strategies • After treating reversible causes and providing non-pharmacological treatment recommendations, consider pharmacological treatment (Refer Appendix B), if consistent with patient’s goals of care • Refer Fatigue and Weakness Management Algorithm

References 1.Ferrell BR, Grant M, Dean GE, Funk B, Ly J. Bone tired: The experience of fatigue and impact on quality of life. Oncology Nursing Forum. 1996;23(10):1539-47.

AppendicesAppendix A – Fatigue and Weakness Management AlgorithmAppendix B – Medications Used in Palliative Care for Fatigue



Fatigue and WeaknessEffective Date: September 30, 2011

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Appendix A: Fatigue and Weakness Management Algorithm

Palliative Care Consult for refractory symptoms

Terminal phase of illness

Fatigue Screen Numeric Rating Scale

(0-10 scale)

No Yes

Fatigue Assessment• History• Physical Exam• Labs

Assess for persisting pain, dyspnea, nausea contributing to fatigue and treat

Assess for other causes of fatigue and treat if appropriate

• Reversible causes of fatigue*• Depression• Muscle weakness

General measures• Individualized graded exercise program• Nutrition • Assessment by Home and Community Care for support in the home†

Education of patient and caregivers• Normalize• Energy conservation• Sleep hygiene• Fatigue scale

Stress management• Cognitive behavioural interventions• Support Groups

Non-pharmacological Treatments

Consider Pharmacological Treatments

MethylphenidateorDextroamphetamineorModafanil (only if fatigue > 6/10)

Steroids(may be useful)

Muscle Weakness

Localized Weakness• Cerebral metastases• Cerebral vascular accident• Radiculopathy

Generalized Weakness• Deconditioning• Paraneoplastic syndrome• Polymyalgia• Polymyositis• Steroid induced myopathy• Steroid withdrawal, abrupt

See Palliative Care Part 2 - Depression - Appendix A: Depression Management Algorithm

Fatigue rating > 3/10

†Refer to “Guide to Your Care” at www.health.gov.bc.ca/library/publications/year/2007/Guide_to_Your_Care_Booklet2007_Final.pdf

* Reversible Causes of Fatigue

AnemiaDehydrationHypokalemiaHyponatremiaHypomagnesemiaHypo/HypercalcemiaHypothyroidismMedication inducedAlcohol/drug abuseInfectionSleep disorderObstructive Sleep ApneaChronic Fatigue Syndrome

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Appendix B: Medicationsα Used in Palliative Care for Fatigue

PSYCHOSTIMULANTSGeneric Name Trade Name Available

Dosage FormsStandard Adult Dose

(note age specific recommendations)Drug Plan CoverageA Approx. cost


Fair PharmaCare

methylphenidate† Ritalin®, G IR tabs: 5, 10, 20 mg

Age over 65 years: Not recommended

Yes, LCA Yes, LCA $6-16 (G)$11-32

Age 18 to 65 years: Start: 5 mg PO bid (AM and noon); use 2.5 mg for frail patients Max: 15 mg PO bid (AM and noon)

Biphentin® SR caps: 10, 15, 20, 30 mg

Once dose stabilized on IR, give equivalent daily dose as SR or XR form once daily in AM

No No $21-54

Concerta® XR tabs: 18, 27, 36, 54 mg

No Special AuthorityB

$68 - $89

Ritalin® SR, G SR tabs: 20 mg No Yes, LCA $ 10 (G)$20

dextro-amphetamine†

Dexedrine® IR tabs: 5 mg Age over 65 years: Not recommended

No Yes $20 - $156

Age 18 to 65 years: Start: 2.5 mg PO bid (AM then in 4 to 6 h) Max: 20 mg PO bid (AM then in 4 to 6 h)

SR caps: 10, 15 mg

Once dose stabilized on IR, give equivalent daily dose as SR form once daily in AM

No Yes $28 - $112

modafinil† Alertec®, G Tabs: 100 mg Age over 65 years: Start: 100 mg PO qAM Max: 100 mg PO bid (AM and noon)

No Special AuthorityC, LCA

$32 -60 (G)$42-83

Age 18 to 65 years: Start: 100 mg PO bid (AM and noon) Max: 200 mg PO bid (AM and noon)

$60-120 (G)$83-167

αRefer to guideline and/or algorithm for recommended order of use.Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages ; consult most current product monograph for this information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

Abbreviations: caps capsules; G generics; h hours; IR immediate release; LCA subject to low cost alternative program; max maximum dose; PO by mouth; qAM every morning; SR sustained release; tabs tablets; XR extended release

A PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated, as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations here: Information on Provincial Drug CoverageB Special authority required to obtain coverage for Concerta® for ADHD as second line treatment C Special authority required to obtain coverage for modafinil for patients with narcolepsy† This indication (i.e. depression) used in practice, but not approved for marketing by Health Canada


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DepressionEffective Date: September 30, 2011

Scope

This section presents assessment and management strategies for dealing with depression occurring in patients with cancer or advanced disease.

Salient Principles in this Section: • Before diagnosing and treating major depressive disorder, first effectively treat pain and other symptoms, then differentiate the symptom of depression from normal grieving • When prescribing antidepressants for this group of patients, select antidepressants with the least drug interactions

Included in this Section: A – Depression management algorithm B – Antidepressant medication reference tables

Depression Management (Refer Appendix A: Depression Management Algorithm)

Assessment • Depression occurs in 13-26% of patients with terminal illness1,2 can amplify pain and other symptoms, and is often recognized too late in a patient’s life. • Patients are at high risk of suicide and have an increased desire for hastened death.3 • A useful depression screening question is, “Have you been depressed most of the time for the past two weeks?”4 • A diagnosis of depression in the terminally ill may be made when at least two weeks of depressed mood is accompanied by symptoms of hopelessness, helplessness, worthlessness, guilt, lack of reactivity, or suicidal ideation. • DSM-IV criteria for depression are not very helpful because vegetative symptoms like anorexia, weight loss, fatigue, insomnia, and impaired concentration may accompany end stage progressive illness. • Risk factors include: personal or family history of depression, social isolation, concurrent illnesses (e.g., COPD, CHF), alcohol or substance abuse, poorly controlled pain, advanced stage of illness, certain cancers (head and neck, pancreas, primary or metastatic brain cancers), chemotherapy agents (vincristine, vinblastine, asparagines, intrathecal methotrexate, interferon, interleukin), corticosteroids (especially after withdrawal), abrupt onset of menopause (e.g. withdrawal of hormone replacement therapy, use of tamoxifen).

Management Strategies • Non-pharmacological treatments are the mainstay of treatment for the symptom of depression without a diagnosis of primary affective disorder. • Treatment of pain and other reversible physical symptoms should occur before initiating antidepressant medication. • If a diagnosis of primary affective disorder is uncertain in a depressed patient, consider psychiatric referral and a trial of antidepressant medication (refer Appendix B). Consider drug interactions, adverse side effect profiles, and beneficial side effects when choosing an antidepressant. • In the terminally ill, start with half the usual recommended starting dose of antidepressant.5

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1. Lloyd-Williams M, Friedman T. Depression in palliative care patients – a prospective study. Eur J Cancer Care 2001;10:270-4.

2. Fraser Health Authority. Hospice Palliative Care Symptom Guidelines. Depression. c2006. Available from: http://www.fraserhealth.ca/professionals/hospice_palliative_care/

3. Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA 2000;284:2907-11.

4. Chochinov HM, Wilson KG, Enns M, et al. “Are you depressed?” Screening for depression in the terminally ill. Am J Psychiatry 1997;154:674-6.

5. Rodin G, Katz M, Lloyd N, et al. The management of depression in cancer patients: A clinical practice guideline. Cancer Care Ontario. 2006 Oct. Available at: www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13930

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• First line therapy is with a selective serotonin reuptake inhibitor (SSRI)2 or selective serotonin norepinephrine reuptake inhibitor (SSNRI) or noradrenergic and specific serotonergic antidepressant (NaSSA). • Tricyclic antidepressants (especially nortryptiline and desipramine) can be considered due to their co-analgesic benefit for neuropathic pain (refer Appendix B - Medications Used in Palliative Care for Depression). Avoid with constipation, urinary retention, dry mouth, orthostatic hypotension, or cardiac conduction delays. • When anticipated survival time is short, consider psychostimulants due to their more immediate onset of effect,2 but avoid them in the presence of agitation, confusion, insomnia, anxiety, paranoia, or cardiac comorbidity. • If life expectancy is 1-3 months, start a psychostimulant and an antidepressant together and then withdraw the stimulant while titrating the antidepressant upwards.

References

AbbreviationsCHF congestive heart failureCOPD chronic obstructive pulmonary diseaseDSM-IV Diagnostic and Statistical Manual of Mental Disorders 4th editionNaSSA noradrenergic & specific serotonergic antidepressantSSRI selective serotonin reuptake inhibitorSSNRI selective serotonin norepinephrine reuptake inhibitorTCA tricyclic antidepressant

AppendicesAppendix A – Depression Management AlgorithmAppendix B – Medications Used in Palliative Care for Depression










Appendix A: Depression Management Algorithm

Vegetativesymptoms(due to progressive life

limiting illness)

• Insomnia

• Anorexia

• Weight loss

• Fatigue

• Impaired concentration

Depression screening question“Have you been depressed most of the

time for the past two weeks?”

Depression

Assess for and managepain and other symptoms

Palliative Care Consultfor refractory symptoms

PsychiatryConsult

Assess if depression

• Hopelessness

• Helplessness

• Lack of reactivity

• Suicidal ideation

• Worthlessness

• Guilt

• Unsure of

diagnosis or

• Suicidal or

• Delusional

Normal Grief(vs. depression)

ReferPalliative CareGuideline Part 3Appendix I -

Distinguishing Grief

and Depression

Non-pharmacological Treatment for Depression• Exercise, rest, nutrition, social and spiritual support

• Psychotherapy

• Cognitive Behavioural Therapy

Pharmacological Treatment for Depression

Psychostimulant

• for rapid onset

• not if agitation, confusion,

insomnia, anxiety,

paranoia, cardiac

co-morbidity

Combination Treatment

Psychostimulant+

Antidepressant

Antidepressant

Modafanil Methylphenidate ordextroamphetamineor modafanil

First line: SSRI or SSNRI or NaSSA (Begin with half usual starting doses)

Second line: TCA

Life expectancy

Age > 65 yrs

< 1 month > 3 months

1-3 months

Yes No

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ANTIDEPRESSANTSA

Generic Name Trade NameAvailable

Dosage Forms

Standard Adult Dose(palliative)B

Drug Plan CoverageC Approx. costper 30 days

Therapeutic ConsiderationsPalliative

CareFair PharmaCare

NaSSA: Noradrenergic and Specific Serotonergic Antidepressant

mirtazapine Remeron®, GRemeron RD® Tabs: 15, 30, 45 mgRD: 15, 30, 45 mg

Start: 7.5 to 15 mg PO at bedtime

Goal: 15 to 45 mg PO at bedtime

Max: 60 mg† PO at bedtime

Yes, LCA Yes, LCA $6-19 (G)$20-60

• Useful for night-time sedation• Rapid dissolve formulation

SSNRI: Selective Serotonin Norepinephrine Reuptake Inhibitors

fuloxetine Cymbalta® Caps: 30 mg, 60 mg

Start: 30 mg PO qAM

Goal: 30-60 mg PO qAM

Max: 60 mg PO qAM

No No $59-118 • Effective for diabetic neuropathy• Should not be given to individuals with chronic hepatic disease or excessive alcohol consumption

venlafaxine XR Effexor XR®, G XR caps: 37.5, 75, 150 mg

Start: 37.5 mg PO qAM

Goal: 75 to 225 mg PO qAM

Max: 375 mg† PO daily

Yes, LCA Yes, LCA $30-60 (G)$59-121

• May cause nausea

SSRI: Selective Serotonin Reuptake Inhibitors

citalopram Celexa®, GTabs: 10, 20, 40 mg

Start: 10 mg PO qAM


Max: 60 mg PO qAM

Yes, LCA Yes, LCA $12-$22 (G)$27-43

• Least pharmacokinetic drug interactions

escitalopram Cipralex® Tabs: 10, 20 mg

Start: 5 mg PO qAM


Max: 30 mg† PO qAM

Yes Yes $27-$56

TCA: Tricyclic Antidepressants

desipramine G Tabs: 10, 25, 50, 75, 100 mg

Start: 10 to 25 mg PO qAMD

Goal: 50 to 75 mg PO qAMD

Max: 200 mg PO qAMD

Yes, LCA Yes, LCA $22-29 (G) • increase dose every 3 to 7 days until goal reached• may help neuropathic pain• useful for night-time sedation• anticholinergic side effects• desipramine and nortriptyline least anticholinergic of TCAs• monitor for postural hypotension

nortriptyline Aventyl®, G Caps: 10, 25 mg

Start: 10 to 25 mg PO at bedtime

Goal: 50 to 75 mg PO at bedtime

Max: 150 mg PO at bedtime

Yes, LCA Yes, LCA $14-22 (G)$29-43

Appendix B: Medicationsα Used in Palliative Care for DepressionαRefer to guideline and/or algorithm for recommended order of use.Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages; consult most current product monograph for this information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

Abbreviations: caps capsules; G generics available; IR immediate release; LCA subject to low cost alternative program; max maximum dose; PO by mouth; qAM every morning; RD oral disintegrating tablet; SR sustained release; tabs tablets; XR extended release

A Not a complete list of antidepressantsB Start doses listed are recommended starting doses for geriatric patients (half the recommended doses for adults), except for duloxetineC PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated, as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations here: Information on Provincial Drug CoverageD Bedtime dosing may be appropriate for patients experiencing sedation with desipramine† This maximum dose used in palliative care, but not approved for marketing by Health Canada

PSYCHOSTIMULANTSGeneric Name Trade

NameAvailable Dosage

FormsStandard Adult Dose

(note age specific recommendations)Drug Plan CoverageA Approx. cost


Fair PharmaCare

methylphenidate† Ritalin®, G IR tabs: 5, 10, 20 mg

Age over 65 years: Not recommendedAge 18 to 65 years: Start: 5 mg PO bid (AM and noon); use 2.5 mg for frail patients Max: 15 mg PO bid (AM and noon)

Yes, LCA Yes, LCA $6-16 (G)$11-32

Biphentin® SR caps: 10, 15, 20, 30 mg

Once dose stabilized on IR, give equivalent daily dose as SR or XR form once daily in AM

No No $21-54

Concerta® XR tabs: 18, 27, 36, 54 mg

No Special AuthorityB

$68 - $89

Ritalin® SR, G

SR tabs: 20 mg No Yes, LCA $10 (G)$20

dextro-amphetamine†

Dexedrine® IR tabs: 5 mg Age over 65 years: Not recommendedAge 18 to 65 years: Start: 2.5 mg PO bid (AM then in 4 to 6 h) Max: 20 mg PO bid (AM then in 4 to 6 h)

No Yes $20 - $156

SR caps: 10, 15 mg

Once dose stabilized on IR, give equivalent daily dose as SR form once daily in AM

No Yes $28 - $112

modafinil† Alertec®, G Tabs: 100 mg Age over 65 years: Start: 100 mg PO qAM Max: 100 mg PO bid (AM and noon)Age 18 to 65 years: Start: 100 mg PO bid (AM and noon) Max: 200 mg PO bid (AM and noon)

No Special AuthorityC, LCA

$32-60 (G)$42-83

$60-120 (G)$83-167

Abbreviations: caps capsules; G generics; h hours; IR immediate release; LCA subject to low cost alternative program; max maximum dose; PO by mouth; qAM every morning; SR sustained release; tabs tablets; XR extended release

A PharmaCare coverage and cost as of November 2010 (subject to revision). Cost does not include dispensing fee. Generic and brand name cost separated, as indicated by (G). Obtain coverage, eligibility, medication coverage information and explanations here: Information on Provincial Drug CoverageB Special authority required to obtain coverage for Concerta® for ADHD as second line treatment C Special authority required to obtain coverage for modafinil for patients with narcolepsy† This indication (i.e. depression) used in practice, but not approved for marketing by Health Canada


Tailor dose to each patient; those who are elderly, cachectic, debilitated or with renal or hepatic dysfunction may require reduced dosages ; consult most current product monograph for this information: http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp

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ResourcesEffective Date: September 30, 2011

Allied Health Care and Supports (Refer Palliative Care 1 - Approach to Care - Management at www.bcguidelines.ca/gpac/guideline_palliative1.html#management)

Consider referral to Home Nursing Care when patient’s Palliative Performance Scale (PPS) at www.bcguidelines.ca/pdf/palliative1_appendix_a.pdf is transitioning from 70% to 60% or lower.

Consider an application to the BC Palliative Care Drug Plan - (Plan P) when patient is in the last 6 months of life and has a PPS of 50% or less.

Physician and Patient Resources

BC Provincial Palliative Care Consult Line (available for physicians only, 24/7): 1-877-711-5757

Family Practice Oncology Network: www.bccancer.bc.ca/HPI/FPON/Guidelines+and+Protocols.htmProviding comprehensive support for family physicians caring for cancer patients including the development of useful resources and tools. Information to supplement this guideline, includes expanded sections on pain, dyspnea, nausea and vomiting (including Medical Management of Malignant Bowel Obstruction), and constipation. Additional informa-tion includes Patient Daily Opioid Dosing Record, Methadone Licence Application Form, Bowel Performance Scale, BC Cancer Agency Bowel Protocol, Patient Bowel Protocol Handout and Compounded Formulations for the Symptomatic Management of Mucositis.

General Practice Services Committee (GPSC) – Palliative Care Initiative: www.gpscbc.ca/family-practice-incentive/palliative-care-initiative HealthLink BC: www.HealthLinkBC.caDial 8-1-1 to speak to a nurse, a pharmacist, or dietician, for free information and resources for B.C. residents. TTY (deaf and hearing-impaired) call 7-1-1.

Home and Community Care - www.health.gov.bc.ca/hcc/Home and community care services provide a range of health care and support services for eligible residents who have acute, chronic, palliative or rehabilitative health care needs. For more information, refer to A Guide to Your Care, available at http://www.health.gov.bc.ca/library/publications/year/2007/Guide_to_Your_Care_Booklet2007_Final.pdf

Practice Support Program (PSP): www.practicesupport.bc.ca/psp/practice-support-program The PSP program offers focused, accredited training sessions for BC physicians to help them improve practice efficiency and to support enhanced delivery of patient care. The PSP have developed an End of Life Care Module with training materials, available at www.gpscbc.ca/psp/EOLtrainingmaterials . The End of Life Algorithm includes information on services and forms to support the coordination and delivery of community-based palliative care, available at www.gpscbc.ca/system/files/EOL_PSP_algorithm_final.pdf

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1. Kobierski, L et al. Hospice Palliative Care Program. Symptom Guide-lines. Fraser Health Authority. 2009 April. Available at: www.fraserhealth.ca/professionals/resources/hospice_palliative_care/hospice_palliative_care_symptom_guidelines

2. Schwartzstein RM, King TE, Hollingsworth H. Approach to the patient with dyspnea. UpToDate. 2009 Jan 1; 17.1.

3. Membe SK, Farrah K. Pharmacological management of dyspnea in palliative cancer patients: Clinical review and guidelines. Health Tech-nology Inquiry Service. Canadian Agency for Drugs & Technologies in Health. 2008 July.

4. Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan;148(2):141-6.

5. Rodin G, Katz M, Lloyd N, et al. The management of depression in cancer patients: A clinical practice guideline”. Cancer Care Ontario. 2006 Oct. Available at: www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13930

6. Brietbart W, Dickerman AL. Assessment and management of depres-sion in palliative care. UpToDate. 2008 Jan 31; 16.1.

7. Lorenz KA, Lynn J, Dy SM, et al. Evidence for improving palliative care at the end of life: A systematic review. Ann Intern Med. 2008 Jan 15;148(2):147-159

42

References

AbbreviationsAEs adverse effectsABG arterial blood gasBM bowel movementBNP brain natiuretic peptideCHF congestive heart failureCOPD chronic obstructive pulmonary diseaseCT computed tomographyDSM-IV Diagnostic and Statistical Manual of Mental Disorders 4th editionECG electrocardiogramGI gastrointestinalIV intravenousN&V nausea & vomiting NaSSA noradrenergic & specific serotonergic antidepressant

NSAIDs non-steroidal anti-inflammatory drugs PEG polyethylene glycol SC subcutaneousSL sublingualSSRI selective serotonin reuptake inhibitorSSNRI selective serotonin norepinephrine reuptake inhibitorSVC superior vena cavaSUPP suppositoryTENS transcutaneous electrical nerve stimulationTCA tricyclic antidepressantUTI urinary tract infection










INFORMATION ABOUT PROVINCIAL DRUG COVERAGE

WHO IS ELIGIBLE FOR COVERAGE UNDER THE BC PALLIATIVE CARE DRUG PLAN (PLAN P)?

❖ BC PharmaCare offers coverage of palliative care medications to all B.C. residents who:■ have a life expectancy of up to six months ■ are living at home* ■ have been diagnosed with a life-threatening illness or condition, and■ consent to the focus of care being palliative rather than treatment aimed at a cure.

* “Home” is defined as wherever the person is living, whether in their own home or living with family or friends, or living in a supportive living residence or hospice that is not covered under PharmaCare Plan B (for residents of Licensed Residential Care Facilities).

❖ For guidance in determining patient’s medical eligibility, please refer to Appendix A – BC Palliative Care Benefits Program Physician Guide at www.health.gov.bc.ca/pharmacare/outgoing/palliative-physguide.pdf

❖ Residents of residential care facilities covered under PharmaCare Plan B (Permanent Residents of Licensed Care Facilities) are not eligible for Plan P.

❖ Individuals admitted to residential care facility hospice beds for short-term stays, who meet the palliative care medication coverage criteria, are eligible for Plan P.

❖ New B.C. residents, from other provinces, may qualify for coverage under Plan P. For more information, contact Health Insurance B.C. (HIBC) at the phone numbers below.

HOW TO APPLY?

❖ Once a physician has determined that a patient meets the medical criteria, the physician completes a B.C. Palliative Care Benefits Program Application (HLTH 349) available at www.health.gov.bc.ca/pharmacare/outgoing/palliative.html and faxes it to Health Insurance BC (HIBC) at 250-405-3587.

❖ Since the B.C. Palliative Care Drug Plan (Plan P) covers only specific drugs for palliative care treatment, patients should be encouraged to register for Fair PharmaCare to obtain optimal coverage for other eligible drugs.

❖ Registration for Fair PharmaCare can be completed by patients or their family members, online at www.health.gov.bc.ca/pharmacare/fpcreg.html or by calling Health Insurance B.C. (HIBC) at 604-683-7151 (Vancouver and the Lower Mainland) or 1-800-663-7100 (toll-free, for the rest of B.C.).


WHAT MEDICATIONS ARE COVERED?

❖ A list of the items covered by PharmaCare Plan P is available at www.health.gov.bc.ca/pharmacare/outgoing/palliative-formulary.pdf. Medications covered by Plan P are subject to PharmaCare’s Low Cost Alternative (LCA) program.

UNDERSTANDING THE PHARMACARE BENEFIT STATUS OF MEDICATIONS

❖ Regular benefit drugs do not require Special Authority. Patients may receive full or partial coverage since some of these drugs are included in the Low Cost Alternative (LCA) program or Reference Drug Program (RDP).

❖ Low Cost Alternative (LCA) Program focuses coverage on lower-priced (usually generic) drugs. Under this program, drugs with the same active ingredient(s) are placed in LCA categories. A price is set for each LCA category. Generic products priced in excess of the set price for the applicable category are not covered by PharmaCare. Brand name products are covered up to the set price for the applicable LCA category. For more information, visit: www.health.gov.bc.ca/pharmacare/lca/lcaindex.html.

❖ Reference Drug Program (RDP) encourages cost-effective first-line prescribing for common medical conditions. PharmaCare coverage is based on the cost of the reference drug(s) in a therapeutic category. Reference drugs are considered to be medically effective and the most cost-effective in that category. Patients receive full coverage for the reference drug(s). Other drugs not designated as the reference drugs are reimbursed based on the price of the reference drugs and patients are required to pay the difference. For more information, visit: www.health.gov.bc.ca/pharmacare/sa/criteria/rdpcategoriesindex.html.

❖ Limited Coverage Drugs are not generally considered first-line therapies, or have more cost-effective alternatives. PharmaCare Special Authority approval of coverage is required, and the drugs are subject to LCA rules if a lower cost alternative exists.

❖ Special Authority grants full benefit status to a medication that would otherwise be a partial benefit or a limited coverage drug. All requests for Special Authority coverage must be submitted by a health care practitioner. For more information, visit: www.health.gov.bc.ca/pharmacare/policy.html#10

❖ Information on which products PharmaCare covers can be obtained using the B.C. PharmaCare Formulary Search. For more information, visit: www.health.gov.bc.ca/pharmacare/benefitslookup.

❖ In all cases, coverage is subject to drug price limits set by PharmaCare and to the patient’s PharmaCare plan rules and deductibles.

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