Anticipatory medication

These are the common doses of drugs prescribed in anticipation of the commonly experienced symptoms by patients entering the terminal phase given by the subcutaneous (SC) route if needed when unable to take by oral route.

Drug: Morphine Sulfate
If eGFR <30 consider either opioid switch below, or dose reduction

Dose: 2.5mg – 5mg

Route: Subcutaneous injection


Notes: If patient already taking regular morphine the PRN dose is usually 1/6th of the 24 hour opioid dose. For patients receiving alternative opioids please contact the palliative care team or pharmacist for advice.

See Pain section in Guidelines for more information

Drug: See specialist algorithm for either Fentanyl or Alfentanil

Drug: Midazolam

Dose: 2.5mg – 5mg
*(If eGFR <30 dose reduction to 1.25mg – 2.5mg)

Route: Subcutaneous injection


Notes: To be given hourly as required.
Maximum 60mg in 24hrs.

N.B. if eGFR <30 Maximum 30mg in 24hrs

Drug: Levomepromazine

Dose: 2.5mg – 5mg

Route: Subcutaneous injection


Notes: Four hourly as required.

Maximum dose 25mg in 24 hours

Drug: Hyoscine butylbromide

Dose: 20mg

Route: Subcutaneous injection


Notes: Two hourly as required.

Maximum dose 120mg in 24 hours

Drug: Morphine Sulphate

Dose: 2.5-5mg -2.5mg (ANNA – CHECK. This seems wrong to me)
*(If eGFR <30 dose reduction to 1.25mg – 2.5mg)

Route: Subcutaneous injection


Notes: Two hourly as required.

Maximum dose 120mg in 24 hours

In Renal Impairment

Starting dose of fentanyl CSCI
This should be based on prior opioid requirements and titrated upwards according to the amount of subsequent PRN doses required in addition to the continuous infusion – there is no upper limit provided the pain is responding well to the opioid and there are no symptoms or signs of adverse effects or toxicity.

Breakthrough analgesia accompanying fentanyl CSCI
The use of fentanyl for ‘as required’ doses is limited by the volume of solution required at higher doses – do not give more than 100 micrograms at once. An alternative is to use low dose alternative subcutaneous opioid e.g. morphine.

Starting dose of Alfentanil CSCI
This should be based on prior opioid requirements and titrated upwards according to the amount of subsequent PRN doses required in addition to the continuous infusion – there is no upper limit provided the pain is responding well to the opioid and there are no symptoms or signs of adverse effects or toxicity.

Breakthrough analgesia accompanying alfentanil CSCI
Alfentanil subcutaneous bolus injection has a rapid onset of action (within 10 minutes) but short duration of action (30 minutes or less). Breakthrough subcutaneous analgesia should therefore be the appropriate lower dosage of an alternative opioid e.g. morphine.

Alfentanil bolus injection may be helpful for anticipated breakthrough pain where rapid onset is required e.g. wound dressings, positioning and daily care. Seek specialist palliative care advice: If converting from alternative strong opioids, if analgesia requirements are escalating, distressing opioid side effects, if clinician is unclear about appropriate choice of opioid or an alternative opioid is prescribed. Preparations: two alfentanil concentrations are available – 500microgram/ml and 5mg/ml. The 5mg/ml is used in intensive care settings – prescribers are advised to take care when prescribing it, as it is 10 times more potent than the other preparation. It may be required when there are volume issues to be considered when prescribing for use in a syringe driver.

Seek Specialist Palliative Care Advice: If converting from alternative strong opioids, if analgesia requirements are escalating, distressing opioid side effects, if clinician is unclear about appropriate choice of opioid or an alternative opioid is prescribed.

Disclaimer (SPAGG - Rewrite)

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.