Nottingham Renal and Transplant Unit

Transcription

1 Nottingham Renal and Transplant Unit GUIDELINES FOR PRESCRIBING ANTICIPATORY MEDICINES FOR PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE APPROACH END OF LIFE Author: Contact Name and Job Title Directorate & Speciality Date of submission 7 th January 2015 Dr S.D. Roe, Consultant Nephrologist Sr V. Hinton, Renal Palliative Care Nurse Specialist Ian Hogg, Renal Specialist Pharmacist Cancer and Associated Specialities (Renal/Transplant) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Patients with advanced chronic kidney disease (estimated glomerular filtration rate < 30 ml/min) approaching end of life who require prescription of anticipatory medicines. Those dying from a life limiting illness such as cancer who develop significant renal impairment. Version 1.0 If this version supersedes another clinical guideline please be explicit about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) Evidence level 5 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a 2b 3a 3b meta analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Produced January Review date January

2 Consultation Process Ratified by: Date: Target audience These guidelines were developed in conjunction with medical and nursing staff within the renal unit. They have been ratified at the Renal Unit Senior Staff Meeting. Renal Unit Senior Staff Meeting July 2014 Medical and nursing staff within the Renal and Transplant Unit; GP s and community staff caring for patients with advanced CKD in the community Review Date: (to be applied by the Integrated Governance Team) A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date; however this must be managed through Directorate Governance processes. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Audit Plans Percentage of staff trained to use T34 syringe driver Staff feedback of experience using guideline/care bundle Use of renal anticipatory medication and syringe drivers Communication between medical and nursing staff and with patients and their carers regarding end of life decisions and symptom control at end of life Training and implementation The guidelines will be available on both renal wards. The guidelines are also available on the NUH clinical guidelines database. New members of staff will be made aware of the guidelines as part of their induction programme. T34 syringe driver training Ongoing one to one training as required for staff Produced January Review date January

3 Introduction It is recognised that most patients with kidney disease do not always die directly from kidney failure but from other medical problems. However, renal impairment, even if not the primary problem, is an important consideration when considering prescribing drugs in these patients. This is particularly the case for opioids, as metabolites can and do accumulate in renal impairment and may lead to significant toxicity if this is not recognised. These guidelines are designed to optimise the risk / benefit ratio of these drugs. It is important to be aware that the risks of toxicity and side effects increase cumulatively as GFR falls. These guidelines are aimed at controlling symptoms once it is recognised that the patient is dying and in the last days of life. If further information or advice is needed contact the Renal Pharmacist or Renal Palliative Care Team. These guidelines are based on the Guidelines for LCP Drug Prescribing in Advanced Chronic Kidney Disease (published June 2008; Marie Curie Palliative Care Institute, Liverpool). Produced January Review date January

4 Management of Pain Pain Patient in pain Patient s pain is controlled Is patient already taking oral opioids? Is patient already taking oral opioids? Yes No Yes No If patient is already taking strong opioids, Contact the Specialist Palliativ e Care Team for Adv ice, if they are not available then please see conv ersion chart on page 6. Fentanyl 25 micrograms s/c prn If fentanyl is temporarily unav ailable see below * If patient is already taking strong opioids, Contact the Specialist Palliativ e Care Team for Adv ice, if they are not available then please see conv ersion chart on page 6. Fentanyl 25 micrograms s/c prn If fentanyl is temporarily unav ailable see below* If three or more doses are required over 24 hours consider starting a S/C Syringe Driver of Fentanyl Fentanyl micrograms in a syringe driver over 24 hrs, Prn dose should be 1/8 th of the 24 hr dose. EXAMPLE: 100 micrograms/24 hrs give 12.5 micrograms prn, for 200 micrograms/24 hrs give 25 micrograms prn. If three or more doses are required over 24 hours consider starting a S/C Syringe Driver of Fentanyl Fentanyl micrograms in a syringe driver over 24 hrs, Prn dose should be 1/8 th of the 24 hr dose. EXAMPLE: 100 micrograms/24 hrs give 12.5 micrograms prn, for 200 micrograms/24 hrs give 25 micrograms prn. Supporting Information To convert from other strong opioids contact Specialist Palliative Care Team / Pharmacy for further advice & support as needed. *If fentanyl is temporarily unavailable give: Oxycodone 1-2 milligrams S/C prn Or Morphine milligrams S/C PRN Many of the opioid analgesics and their metabolites may accumulate in Renal Failure causing toxicity with myoclonic jerks, profound acidosis and respiratory depression. Morphine and its metabolites are most likely to cause toxicity. Fentanyl and Alfentanil are less likely to cause these problems, as the metabolites are not active. The duration of the effect from Morphine and Oxycodone may last longer than in a patient with normal renal function. (See conversion table on page 5). If symptoms persist contact the Specialist Palliative Care Team. Anticipatory prescribing in this manner will ensure that in the last hours / days of life there is no delay responding to a symptom if it occurs. Produced January Review date January

5 For patients already on Fentanyl or Buprenorphine patches it is usually recommended that the patch is not removed. Continue to change the patch at prescribed intervals. Additional opioid is given, as appropriate, via the syringe pump. Do not forget to calculate the prn opioid dose based on the total 24 hours opioid dose (i.e. patch and syringe pump doses added together). In patients with low egfr it is not imperative to immediately switch opioid if symptoms are well controlled on their current regime. Produced January Review date January

6 OPIOID CONVERSION TABLE Opioid equivalent doses (Note: There is no exact equivalence between opioids therefore starting low and titrating upwards is recommended safe practice) Approximately equivalent opioid doses for PRN ( as required ) ORAL MORPHINE DIAMORPHINE INJECTION MORHINE INJECTION FENTANYL ALFENTANIL INJECTION OXYCODONE INJECTION 4 milligrams orally 1.25 milligrams 2 milligrams 25 micrograms 125 micrograms 1 milligram 8 milligrams orally 2.5 milligrams 4 milligrams 50 micrograms 250 micrograms Note: alfentanil is not ideal for prn use since it has a very short half-life and doses may only last 1-2 hours 2 milligram Note: Do not use these equivalent doses for larger doses without specialist palliative care advice, as the small numbers entailed have been rounded up. Approximately equivalent opioid doses for starting doses in continuous subcutaneous infusions (Starting doses 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. Most patients with renal failure require only low doses if the dose is escalating, advice should be sought from the palliative care team) DIAMORPHINE INJECTION MORHINE INJECTION FENTANYL ALFENTANIL INJECTION OXYCODONE INJECTION 5 10 milligrams 8 16 milligrams Do not use diamorphine in continuous infusion because of the high risk of accumulation and adverse effects Do not use morphine in continuous infusion because of the high risk of accumulation and adverse effects micrograms 500 micrograms to 1 milligram 4 8 milligrams Produced January Review date January

7 Management of terminal restlessness and agitation Terminal restlessness & agitation Present Absent MIDAZOLAM 2.5 milligrams S/C prn MIDAZOLAM 2.5 milligrams S/C prn Review the required medication after 24 hrs; if three or more prn doses have been required then consider a S/C syringe driver over 24 hrs (Midazolam 5 10 milligrams S/C). Continue to give prn dosage accordingly Supporting Information If symptoms persist contact the Specialist Palliative Care Team. Anticipatory prescribing in this manner will ensure that in the last few hours / days of life there is no delay in responding to a symptom if it occurs. Produced January Review date January

8 Management of excessive respiratory tract secretions Excessive respiratory tract secretions Present Absent Hyoscine butylbromide 20mg s/c prn Hyoscine butylbromide 20mg s/c prn Continue to give prn accordingly If three or more doses of prn hyoscine butylbromide are required then consider a S/C syringe driver with mgs S/C over 24 hrs Supporting Information If symptoms persist contact the Specialist Palliative Care Team. Anticipatory prescribing in this manner will ensure that in the last few hours / days of life there is no delay in responding to a symptom if it occurs. Hyoscine Hydrobromide is not usually recommended. Produced January Review date January

9 Management of nausea and vomiting Nausea and/or vomiting Present Absent Levomepromazine 6.25 milligrams s/c prn Levomepromazine 6.25 milligrams s/c prn Continue to give prn accordingly Review after 24 hours. If three or more doses of prn levomepromazine are required then consider a S/C syringe driver with 6.25 milligrams S/C over 24 hrs Supporting Information If symptoms persist contact the Specialist Palliative Care Team. Cyclizine is not usually recommended. Haloperidol milligrams S/C prn is a suitable alternative second line drug (if syringe driver is required then consider milligrams S/C in a syringe driver over 24 hours). Anticipatory prescribing in this manner will ensure that in the last few hours / days of life there is no delay in responding to a symptom if it occurs. Produced January Review date January

10 Management of dyspnoea Dyspnoea Present Absent Is patient already taking oral opioids for breathlessness? Yes No Fentanyl 25 micrograms S/C prn If Fentanyl is unavailable: Morphine milligrams S/C prn Or Oxycodone 1 2 milligrams S/C prn If patient is already taking strong opioids, Contact the Specialist Palliative Care Team for advice, if they are not available then please see conversion chart on page 6 Fentanyl 25 micrograms S/C prn If Fentanyl is unavailable: Morphine milligrams S/C prn Or Oxycodone 1 2 milligrams S/C prn If three or more doses are required over 24 hours consider starting a S/C Syringe Driver of Fentanyl Fentanyl micrograms in a syringe driver over 24 hours, prn dose should be 1/8 th of the 24 hour dose EXAMPLE: 100 micrograms / 24 hrs give 12.5 micrograms prn, for 200 micrograms /24 hrs give 25 micrograms prn Supporting Information If symptoms persist contact the Specialist Palliative Care Team. To convert from other strong opioids contact Specialist Palliative Care Team / Pharmacy for further advice & support. If the patient is breathless and anxious consider Midazolam 2.5 milligrams S/C prn. *If Fentanyl is temporarily unavailable give: Oxycodone 1 2 milligrams S/C prn or Morphine 1.25 milligrams S/C prn Many of the opioid analgesics and their metabolites may accumulate in renal failure causing toxicity with myoclonic jerks, profound narcosis and respiratory depression, Morphine and its metabolites are most likely to cause toxicity. Fentanyl and Alfentanil are less likely to cause these problems, as the metabolites are not active. The duration of the Produced January Review date January

11 effect from Morphine and Oxycodone may last longer than in a patient with normal renal function. Produced January Review date January

12 References Bunn R, Ashley A, (eds). The Renal Handbook. Oxford: Racliffe Medical Pres; 2004 Chambers EJ, Germain, M, Brown E, (eds). Supportive Care for the Renal Patient. Oxford. Oxford University Press; 2004 Davison S. Chronic Pain in End Stage Renal disease. Adv chronic Kidney Dis 2005; 12(13): Dean M. Opioids in Renal Failure and Dialysis Patients. J Pain Symptom Manage 2004; 28(5): Department of Health. The National Service Framework for Renal Services Part Two: Acute Renal Failure Chronic Kidney Disease and End of Life. London Humphreys BD, Soiffer RF, Magee CC. Renal Failure associated with cancer and its treatment: An update. J AM Soc Nephrol 2005: 16: Kurella M, Bennett WM, Chertow GM. Analgesia in Patients with End Stage Renal Disease: A Review of Available Evidence. Am J Kidney Dis 2003, 42(2): Mercadante S, Arcuri E. Opioids and Renal Function. J Pain 2004, 5(1): Murtagh F, Addlington-Hall J, Higginson I. The Prevalence of Symptoms in End-Stage Renal Disease: A Systematic Review. Advances in Chronic Kidney Disease. 2007; 14(1): Scholz J, Steinfath M. Clinical Pharmakokinetics of Alfentanil, Fentanyl and Sufentanil. An Update. Clin. Pharmacokinetics. 1996; 31(4): Urch CE, Carr S, Minton O. A retrospective review of the use of alfentanil in a hospital palliative care setting. Palliat Med 2004; 18(6): US Food and Drug Administration [homepage on the internet]. Rockville MD: Details View: Safety Labelling Changes Approved by FDA Centre for Drug Evaluation and Research. [Updated 2006 Jan; accessed 2006 May 11]. Available from Produced January Review date January