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Many drugs used in Palliative Care are used outside of the product licence (the Summary of Product Characteristics of a drug) and the recommendations of the manufacturer: this may be referred to as an “unlicensed use” or “off-label”. For example: a drug may be given by a route that is not recommended in the product licence by being given subcutaneously instead of intravenously or intramuscularly, or it may be given for a different indication that it is not strictly licensed for. An example of this is some antidepressants being used for neuropathic pain, as opposed to depression. Practitioners should be aware, when using drugs in this manner, that they should be able to support their actions either by peer review (the drug is commonly used, and there is wide experience of using it in this way in palliative care) or with literature references. However, the responsibility for prescribing is taken by the Doctor or prescribing practitioner.
Further advice can be obtained from your local hospice helpline, hospital pharmacy Medicines Information Service, or the Regional Medicines Information Service Centre at Ipswich. When in doubt, information should be checked against published literature or another specialist sources.
Useful reference resources are:
British National Formulary, bnf.nice.org.uk/. Pain management with opioids’ in the ‘Prescribing in palliative care section’ provides guidance on specific routes for pain management. The ‘Equivalent doses of opioid analgesics’ table has been expanded to include more drugs and routes; also included is a buprenorphine patch conversion table and a fentanyl patch conversion table (use with care).
Palliative Care Formulary (PCF6) 6th Edition (UK) ISBN: 978-0-9928467-4-9 Editors: Robert Twycross, Andrew Wilcock, and Paul Howard. The content is also accessible on-line at www.palliativedrugs.com but a subscription is required to access any content now, including syringe driver compatibility charts or the facility to search for syringe driver combinations.
The Syringe Driver: Continuous Subcutaneous Infusions in Palliative Care. Dickman & Schneider. 4th edition. Oxford University Press ISBN: 9780198733720. Contains comprehensive information about two or more admixtures of commonly used subcutaneous infusion combinations.
Palliative Care Adult Network Guidelines-Plus (PANG). book.pallcare.info. Website aiming to offer up-to-date, evidence based information and guidance on professional aspects of palliative care. Developed by a collaboration of UK cancer networks, Royal College of GPs and the Welsh Palliative Care Implementation Board. Includes: an interactive opioid dose calculator and syringe driver compatibility database (but use with care).
Clinical Knowledge Summaries: Palliative Care at cks.nice.org.uk. Very useful and practical sections on palliative care (see in Specialities tab).
Scottish Palliative Care Guidelines at www.palliativecareguidelines.scot.nhs.uk. This has been developed by a multidisciplinary group of professionals working in Scottish community, hospital and specialist palliative care services, and designed for healthcare professionals from any care setting.
Marie Curie at www.mariecurie.org.uk. Website provides information for people with cancer and terminal illnesses, including information sheets on managing symptoms.