Medication Tables
Medication tables
The medication tables that follow list medications commonly used in palliative medicine. They may serve as a reference tool for clinicians in the United States.
Several caveats should be noted:
• the dosage forms may not be limited–the ones listed and will likely change over time
• only the common adverse effects (AE) and drug interactions are listed
• the listed trade names either represent the only product available, or one that is commonly known
For a complete, up–to–date list of the products available, adverse effects, and drug interactions, refer to the current PDR.
Adverse effects
Adverse effects may be allergic, idiosyncratic, or dose–related extensions of known effects. They may increase with the number of different medications and the dosage. In the presence of liver or renal failure, adverse effects may emerge if dosage/frequency is not adjusted downward. If adverse effects occur, reduce or stop offending medications and provide appropriate antidotes.
As medications may have many effects, they may also produce many different adverse effects. In some instances, they occur frequently enough–be grouped as below:
|Adverse Effect Group |Possible Adverse Effects |
|anti–cholinergic AE |Dry mouth, decreased GI motility, constipation, tachycardia, urinary retention, mydriasis (=|
| |pupil dilatation), cycloplegia (= paralysis of ciliary muscle, of accommodation ( blurred |
| |vision). May lead–restlessness, confusion, hallucinations, memory impairment and delirium. |
| |May precipitate acute glaucoma |
|CNS excitation |Euphoria, restlessness, agitation, vivid dreams, nightmares, hallucination, myoclonus |
| |(jerks/twitches), focal motor or grand mal seizures |
|Extra pyramidal (EPS) |Early effects (usually dose related): |
| |acute dystonic reactions: torticollis (= cervical muscle spasm ( unnatural twisting of |
| |head), opisthotonos (= a tetanic spasm with head and heels bent backward, body bowed |
| |forward), tics, grimacing, dysarthria, oculogyric crisis. Rx diphenhydramine 25(50 mg PO: |
| |IM, IV q 4 h PRN |
| |parkinsonian reactions: tremor, bradykinesia, rigidity, abnormalities of gait and posture. |
| |Rx benztropine (Cogentin () 1(2 mg IV, IM acutely then 1(2 mg PO daily(bid |
| |akathisia: sense of constant motor restlessness. Rx benztropine 1(2 mg PO daily–bid |
| |Late effects: |
| |tardive dyskinesia: involuntary movements of lips, tongue, jaws, extremities. May persist |
| |indefinitely after medication is stopped. Antidopaminergic drugs may suppress these |
| |movements |
|Hypersensitivity |Rash, urticaria, bronchospasm, laryngeal or angioneurotic edema. In extreme cases, |
| |anaphylactic shock. |
|Signs of electrolyte imbalance, |Dry mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pain/cramps, muscle |
|dehydration |fatigue, hypotension (may be orthostatic), oliguria, tachycardia, nausea/vomiting |
|Upper gastrointestinal (GI) |Nausea, vomiting, dyspepsia. May include erosions, ulceration, bleeding. Rx misoprostol 200 |
| |(g PO q 6 h or histamine H2 receptor antagonists (see Antacids) |
Abbreviations, Symbols
|Routes of Administration |
|PO |per os, by mouth |
|PR |per rectum, by the rectum |
|IM |intramuscular |
|IV |intravenous |
|SC |subcutaneous |
|SL |sublingual |
|TD |transdermal |
|Others |
|COX–2 |Cyclooxygenase–2 selective inhibitor. may have less gastrointestinal, renal, and anti–platelet adverse effects |
|ER |Extended/sustained release (extended/sustained release tablets must be taken intact, never broken or crushed) |
|IR |Immediate release (tabs are IR unless noted) |
|ODT |Orally dissolving tabs |
|MAOI |Monoamine oxidase inhibitor |
|NA |Not available |
|NS |Normal saline |
|NSAID |Nonsteroidal anti–inflammatory drug |
|PDR |Physicians’ Desk Reference, Medical Economics Company, Inc., 1999 |
|SSRI |Selective serotonin reuptake inhibitor |
|TCA |Tricyclic antidepressant |
|( |Upper dose limited only by need and adverse effects |
|† |Fixed–dose combinations not recommended in young children |
|†† |Dose varies depending on condition being treated |
|ϑ |Insufficient experience in the pediatric population. If these drugs need–be used, consultation is appropriate |
|ϑϑ |Insufficient experience in the pediatric Population for this indication, although the drug may be used for other |
| |reasons. If these drugs need–be used, consultation is appropriate |
Medication information resources
Micromedex Healthcare Series, Thompson Healthcare, Inc. 2005
Goodman & Gilman's The Pharmacologic Basis of Therapeutics, Tenth Edition, McGraw-Hill Medical Publishing Division, 2001
American Hospital Formulary Service (AHFS) Drug Information 2005, American Society of Health-System Pharmacists, Bethesda, MD
Palliative Care Formulary, Second Edition, Radcliffe Medical Press, UK, 2002
Medication table – alphabetical index
This alphabetic index is included to assist in locating a specific medication in the tables that are sorted by Therapeutic Group Medications in the miscellaneous group appear at the end of the medication tables.
|Generic name |Therapeutic group|Generic name |Therapeutic group|Generic name |Therapeutic group|
|Acetaminophen |Analgesic |Flurbiprofen |Analgesic |Nortriptyline |Depression |
|Acetylsalicylic acid (ASA)|Analgesic |Fosphenytoin |Miscellaneous |Octreotide |Diarrhea |
|Albuterol |Dyspnea |Furosemide |Ascites |Olanzapine |Delirium |
|Alginic acid |Nausea |Gabapentin |Pain |Omeprazole |Nausea |
|Alprazolam |Anxiety |Glycerin |Constipation |Ondansetron |Nausea |
|Aluminum or magnesium |Constipation |Glycopyrrolate |Drying |Orphenadrine |Miscellaneous |
|hydroxide | | | | | |
|Amitriptyline |Depression |Haloperidol |Delirium |Oxandrolone |Anorexia |
|Atropine |Drying |Hesperidins |Analgesic |Oxazepam |Anxiety |
|Attapulgite |Diarrhea |Hyaluronidase |Miscellaneous |Oxybutynin |Miscellaneous |
|Baclofen |Miscellaneous |Hydrocodone |Cough |Oxycodone |Analgesic |
|Belladonna & opium |Miscellaneous |Hydrocodone + |Analgesic |Oxycodone + Acetaminophen |Analgesic |
| | |Acetaminophen | | | |
|Bethanechol |Miscellaneous |Hydrocodone + Ibuprofen|Analgesic |Oxycodone + Aspirin |Analgesic |
| | | | |combinations | |
|Bisacodyl |Constipation |Hydromorphone |Analgesic |Paroxetine |Depression |
|Bismuth subsalicylate |Diarrhea |Hydroxyzine |Miscellaneous |Pemoline |Depression |
|Bupropion |Depression |Hyoscyamine |Drying |Perphenazine |Delirium |
|Capsaicin |Pain |Ibuprofen |Analgesic |Phenazopyridine |Miscellaneous |
|Carbamazepine |Pain |Imipramine |Depression |Phenobarbital |Sedation |
|Celecoxib |Analgesic |Indomethacin |Analgesic |Phenytoin |Miscellaneous |
|Chlorpromazine |Delirium |Ketoprofen |Analgesic |Piroxicam |Analgesic |
|Choline magnesium |Analgesic |Ketorolac |Analgesic |Prednisone |Steroids |
|trisalicylate | | | | | |
|Cimetidine |Nausea |Lactulose |Constipation |Prochlorperazine |Nausea |
|Clomipramine |Depression |Lansoprazole |Nausea |Promethazine |Nausea |
|Clonazepam |Anxiety |Levorphanol |Analgesic |Protriptyline |Depression |
|Codeine |Analgesic |Lidocaine |Pain |Psyllium |Constipation |
|Codeine + acetaminophen |Analgesic |Lidocaine + prilocaine |Pain |Quetiapine |Delirium |
|Cyclobenzaprine |Miscellaneous |Loperamide |Diarrhea |Quinine sulfate |Miscellaneous |
|Cyproheptadine |Miscellaneous |Lorazepam |Anxiety |Ranitidine |Nausea |
|Dantrolene |Miscellaneous |Magnesium citrate |Constipation |Risperidone |Delirium |
|Desipramine |Depression |Magnesium hydroxide |Constipation |Salsalate |Analgesic |
|Dexamethasone |Steroids |Meclizine |Miscellaneous |Scopolamine |Drying |
|Dextroamphetamine |Depression |Megestrol acetate |Anorexia |Sennosides |Constipation |
|Dextromethorphan |Cough |Methadone |Analgesic |Sertraline |Depression |
|Diazepam |Anxiety |Methocarbamol |Miscellaneous |Silver sulfadiazine |Skin |
|Diclofenac |Analgesic |Methylphenidate |Depression |Simethicone |Miscellaneous |
|Dicyclomine |Miscellaneous |Metoclopramide |Nausea |Sodium phosphate |Constipation |
|Diflunisal |Analgesic |Metolazone |Ascites |Sorbitol |Constipation |
|Diphenhydramine |Delirium |Metronidazole |Skin |Spironolactone |Ascites |
|Diphenoxylate |Diarrhea |Mexiletine |Pain |Sucralfate |Nausea |
|Docusate sodium or calcium|Constipation |Midazolam |Anxiety |Sulindac |Analgesic |
|Doxepin |Depression |Mineral Oil |Constipation |Theophylline |Dyspnea |
|Dronabinol |Nausea |Mirtazapine |Depression |Tramadol |Analgesic |
|Droperidol |Nausea |Misoprostol |Nausea |Trazodone |Depression |
|Etodolac |Analgesic |Morphine, ER |Analgesic |Trimethobenzamide |Nausea |
|Famotidine |Nausea |Morphine, IR |Analgesic |Trimipramine |Depression |
|Fentanyl |Analgesic |Nabumetone |Analgesic |Valproic acid |Pain |
|Flavoxate |Miscellaneous |Nandrolone decanoate |Anorexia |Venlafaxine |Depression |
|Flecainide |Pain |Naproxen |Analgesic |Zolpidem |Insomnia |
|Fludrocortisone acetate |Steroids |Nefazodone |Depression | | |
|Fluoxetine |Depression |Nifedipine |Miscellaneous | | |
Common analgesics
|Generic name |Trade name(s) |Dosage forms available |Time Cmax |Elimination t½ |Route of elimination |Usual dosing |Recommended |
| | | | | | | |maximum dosing |
| |
|Acetaminophen |Various, Tylenol ® |tabs: 325, 500 mg |PO: 1–2 hr |2–4 hr in normal |Liver metabolism: 25% on |325–650 mg PO PR |650 mg PO PR q 4 h |
|(paracetamol) |Plain and Extra |elixir: 80 mg/0.8 ml, |PR: 107–288 minutes |individuals |first pass through the |q 4 h |(4 g/24h ) |
| |Strength are examples|160 mg/5 ml | | |liver |routinely or PRN | |
| | |supp: 120, 325, 650 mg, | | |Renal Excretion: | | |
| | |81 mg chew | | |1%–4% unchanged | | |
|NSAIDs and ASA |
|Acetylsalicylic |Various, Aspirin ® |caplets, tabs: 325, 500, |PO: buffered tablet: |4.7–9 hr (average 6 hr) |Liver metabolism |325–650 mg PO, PR |650 mg PO PR q 4 h |
|acid (ASA) |is an example |975 mg |20 minutes |The half-life is |Renal Excretion: |q 4 h routinely or PRN |(5 g/24h ) |
|(salicylic acid | |children's tab: 80 mg |PO: effervescent solution: |dose–related |5.6%–35.6% | | |
|derivative) | |EC tabs: 81, 325, 500 mg |15 minutes | | | | |
| | |elixir: 80 mg/ | | | | | |
| | |supp: 300, 600 mg | | | | | |
|Celecoxib |Celebrex ® |cap:100, 200, 400 mg |PO: ≈ 3 hr |11 hr |Liver metabolism: |100–200 mg PO bid |200 mg PO bid |
|(COX–2 selective) | | | | |extensive | | |
| | | | | |Renal Excretion: 27% | | |
| | | | | |Less than 3% of a dose is | | |
| | | | | |eliminated as unchanged | | |
| | | | | |drug | | |
| | | | | |Feces: 57% | | |
|Choline magnesium |Trilisate ® |tab: 500, 750, 1000 mg |PO: tab: 1.5–2 hr |2–12 hr |Hydrolysis in |1–1.5 g PO q 12 h or |1.5 g PO q 8 h |
|trisalicylate | |salicylate |Elixir:: 3.5 hr |Dose–dependent; higher |GI–salicylates |0.5–1.0 g PO q 8 h |(4.5 g/24h ) |
|(salicylic acid | |elixir: 500 mg/5 ml | |doses produce longer |Liver metabolism | | |
|derivative) | | | |half-life |Renal Excretion: | | |
| | | | | |5.6%–35.6% | | |
|Diclofenac |Various, |IR tabs: 50 mg |IR: (diclofenac potassium): |2 hr |Liver metabolism: |IR: 50–75 mg PO PR |50 mg IR PO q 6 h or |
|(acetic acid |Cataflam ®, Voltaren |ER tabs: 25, 50, 75, |1 hr (range 0.33–2 hr) | |extensive first–pass |q 6–8 h or |75 mg ER PO q 8 h |
|derivative) |® are examples |100 mg |ER: (diclofenac sodium): | |Renal Excretion: 65% |ER 75–100 mg PO |(225 mg/24h ) |
| | |(with 200 mcg misoprostol: |2 hr (range 1–4 hr) | |Bile: 35% |q 8–12 h | |
| | |Arthrotec ® 50, 75 mg) |PR: 30 minutes | | | | |
|Diflunisal |Various, Dolobid ® |tabs: 500 mg |PO: 2–3 hr |8–12 hr |Liver metabolism: |250–500 mg PO |500 mg PO q 8 h |
|(salicylic acid |is an example | | |Half-life is dependent on |extensive |q 8–12 h |(1.5 g/24h ) |
|derivative) | | | |the dose |Renal Excretion: | | |
| | | | | |80%–90% | | |
| | | | | |Feces: less than 5% | | |
|Etodolac |Various, Lodine ® |IR tabs: 200, 300, 400, 500|PO IR: 1–2 hr |6–7 hr |Liver metabolism: |200–500 mg PO |400 mg PO q 8 h |
|(acetic acid |is an example |mg |PO ER: 3–12 hr | |extensive |q 6–12 h |ER: 1,200 mg daily |
|derivative) | |ER tabs: 400, 500, | | |Renal Excretion: 72% | | |
| | |600 mg | | |Feces: 16% | | |
|Flurbiprofen |Various, Ansaid ® |tabs: 50, 100 mg |PO: 1.5–2 hr |5.7 hr |Liver metabolism: |50–100 mg PO q 12 h |200–300 mg/24h |
|(propionic acid |is an example | | | |extensive | | |
|derivative) | | | | |Renal Excretion: 95% | | |
|Ibuprofen |Various, Motrin ® |tabs: 200, 400, 600, |PO: 1.4–1.9 hr |1.8–2 hr |Liver metabolism: |200–800 mg PO q 6–8 h |800 mg PO q 6 h |
|(propionic acid |is an example |800 mg | | |extensive | |(3.2 g/24h ) |
|derivative) | |elixir: 40 mg/1 ml, | | |Renal Excretion: | | |
| | |100 mg/5 ml | | |Major route | | |
|Indomethacin |Various, Indocin ® |IR tabs: 25, 50 mg |PO: 2 hr |4.5 hr |Liver metabolism: |25–75 mg PO q 8–12 h or |50 mg PO q 6 h |
|(indole) |is an example |ER tabs: 75 mg | | |extensive |75 mg ER PO q 12–24 h |(200 mg/24h ) |
| | |supp: 25 mg/5 ml | | |Renal Excretion: 60% | | |
| | | | | |≈ 26% eliminated as | | |
| | | | | |unchanged drug | | |
| | | | | |Feces: 33% | | |
|Ketoprofen |Various, Orudis ® |cap: 12.5, 50, 75 mg |PO IR: 1.2–2 hr |2–4 hr |Liver metabolism |150–200 mg PO/24h |75 mg PO q 6 h |
|(propionic acid |is an example |ER tabs: 100, 200 mg |PO ER: 6.8–9.2 hr |ER is 5.4 +/– 2.2 hr |Renal Excretion: 80%; |IR: q 6–8 h |(300 mg/24h ) |
|derivative) | | | | |Bile: up to 40% |ER: q 12–24 h | |
|Ketorolac |Various, Toradol ® |tab: 10 mg |PO: 44 minutes |5.6 hr |Liver metabolism |10 mg PO qid or 60 mg IM, |40 mg PO/24h or |
|(acetic acid |is an example |inj: 15, 30 mg/ml |IM: 30–45 minutes | |Renal Excretion: 92% |IV loading dose, then |120 mg IM, IV /24h |
|derivative) | | |IV: 1–3 minutes | |excreted in the urine; |10–30 mg IM, IV q 6 h | |
| | | | | |(60.6%) as unchanged drug | | |
| | | | | |Feces: 5.9%–6.3% | | |
|Nabumetone |Various, Relafen ® |tab: 500, 750 mg |PO: 3–6 hr |Nabumetone (pro–drug): |Liver metabolism: |1–2 g PO q 12–24 h |1 g PO q 12 h |
| |is an example | | |unknown |extensive | |(2 g/24h ) |
| | | | |Active metabolite |Renal Excretion: 80% | | |
| | | | |(6–methoxy–2–naphthylaceti|Feces: 10% | | |
| | | | |c acid): 24 hr | | | |
|Naproxen |Various, |IR tabs: 220, 275, 250, |PO IR: naproxen: 2–4 hr, |12–15 hr |Liver metabolism: |250–500 mg PO |500 mg PO q 8 h |
|(propionic acid |Naprosyn ® is an |375, 500, 550 mg |naproxen sodium: 1–2 hr | |extensive |q 8–12 h |(1.5 g/24h ) |
|derivative) |example |ER tab: 375, 500 mg |PO ER: 3 hr | |Renal Excretion: 95% | | |
| | | |Topical, gel: 24 hr | | | | |
|Piroxicam |Various, Feldene ® |caps: 10, 20 mg |PO: 3–5 hr |50 hr; range:30–86 hr |Liver metabolism: |10–20 mg PO q 12–24 h |20 mg PO q 12 h |
|(oxicam) |is an example | | | |extensive | |(40 mg/24h ) |
| | | | | |Renal Excretion: moderate;| | |
| | | | | |5%–10% of a dose is | | |
| | | | | |eliminated as unchanged | | |
| | | | | |drug | | |
| | | | | |Feces: small | | |
|Salsalate |Various, Disalcid ® |tabs: 500, 750 mg |PO: 1.4 hr |1 hr |Liver metabolism: < 1% |1,000–1,500 mg PO bid |3,000 mg/day |
|(salicylic acid |is an example | | | |appears as unchanged | | |
|derivative) | | | | |salsalate. The remainder | | |
| | | | | |is excreted as salicylic | | |
| | | | | |acid or metabolites of | | |
| | | | | |salicylic acid. | | |
|Sulindac |Various, Clinoril ® |tabs: 150, 200 mg |PO: 1 hr |Sulindac: 7.8 hr |Liver metabolism: |150 mg PO q 12 h |200 mg PO q 12 h |
|(indole) |is an example | | |Active Metabolite: |extensive | |(400 mg/24h ) |
| | | | |16.4 hr |Sulindac has no | | |
| | | | | |pharmacologic activity and| | |
| | | | | |must be metabolized–the | | |
| | | | | |pharmacologically active | | |
| | | | | |metabolite | | |
| | | | | |Renal Excretion: 50% | | |
| | | | | |Feces: 25% | | |
|Opioids |
|Codeine (alone) |Various |IR tabs: 15, 30, 60 mg |PO: 1–2 hr | 2.5–3.5 hr |Liver metabolism: |15–60 mg PO, SC, IM |600 mg/24h |
|(methylmorphine, | |elixir: 15 mg/5 ml |IM: 30 minutes | |24–89% (metabolized to |q 4 h routinely or q 1 h | |
|naturally occurring| |inj: 15, 30 mg/ml |PR: 30 minutes | |morphine) |PRN | |
|opioid metabolized | | | | |Renal Excretion: | | |
|into morphine) | | | | |90% (3–16% of unchanged | | |
| | | | | |drug) | | |
| | | | | |Feces: about 5% | | |
|Codeine + |Various, Tylenol |tabs: 30, 60 mg codeine + |Codeine: PO: 1–2 hr |Acetaminophen: 4 hr |Codeine and Acetaminophen:|1–2 tabs PO q 4 h routinely|limited to 12 tabs/24h by |
|acetaminophen |# 3, 4 ® are examples|325 mg acetaminophen (may |Codeine PR: 30 min |Codeine: 2.5–3.5 hr |see above. |or PRN |acetaminophen |
|combinations | |include caffeine, |APAP: PO: 1–2 hr | | | | |
| | |butalbital) |APAP: PR: 107–288 min | | | | |
|Fentanyl |Various, Duragesic,® |patch: 25, 50, 75, |Epidural: 30 minutes |≈ 4 hr |Liver metabolism: to |patch: 25–( mcg/h q 72 h |limited only by need and adverse|
| |Actiq,® |100 mcg/hr |Transmucosal: |Transdermal patch: |inactive metabolites |lozenge: 200 (g q 1 h |effects |
| |Sublimaze ® are |lozenge: 200, 400, 600, |20–40 minutes |17 hr |Renal Excretion: 75% |titrate PRN | |
| |examples |800, 1200, 1600 mcg |Transdermal patch: 24–72 hr | |(metabolites); 10% | | |
| | |inj: 50 mcg/ml | | |(unchanged drug) | | |
| | | | | |Feces: 9% | | |
|Hydrocodone + |Various, Vicodin,® |tabs: 5/500, 5/325, |PO: 1.3 hr for hydrocodone |Hydrocodone: |Liver metabolism: |1–2 tabs PO q 4–6 h |limited to 4 g acetaminophen in |
|acetaminophen |Lortab,® Norco ® |7.5/325, 7.5/500, 7.5/750, | |3.8–4.5 hr |Acetaminophen: see above |routinely or PRN |24 h |
| |are examples |10/325, 10/500, 10/660 | |Acetaminophen: see above |Hydrocodone: extensive | | |
| | |elixir: 7.5/500 in 15 ml | | |active metabolites | | |
| | | | | |Renal excretion: 26% | | |
|Hydrocodone + |Vicoprofen® |tab: 7.5/200 |PO: within 2 hr (both |Hydrocodone |Liver metabolism: see |1–2 tabs PO q 4–6 h |limited–2,400 mg ibuprofen in 24|
|ibuprofen | | |components) |3.8–4.5 hr |above |routinely or PRN |h |
| | | | |Ibuprofen 1.8–2 hr |Renal excretion: see above| | |
|Hydromorphone |Various, Dilaudid,® |IR tabs: 2, 4, 8 mg |PO IR: 48–60 minutes |IR: ≈ 3-4 hr |Liver metabolism: |1–( mg: PO q 4 h routinely |limited only by need and adverse|
| |Palladone® are |ER capsules: 12, 16, 24, 32|PO ER: 12 – 16.5 hr | |extensive |or q 1 h PRN, |effects |
| |examples |mg |Epidural: 8 minutes | |Renal excretion: As |SC, IM q 3 h routinely or | |
| | |elixir: 1 mg/ml | | |hydromorphone |q 30 min PRN, | |
| | |inj: 1, 2, 4, 10 mg/ml | | |1.3%–13.2% |SC, IV q 1 h via infusion +| |
| | |powder: 250 mg/vial | | |Conjugates: 22%–51% |breakthrough | |
| | |supp: 3 mg | | | |q 30 min PRN | |
|Levorphanol |Levo–Dromoran® |tab: 2 mg |PO: 1 hr |11 hr; |Liver metabolism: |2–( mg PO q 6–8 h |limited only by need and adverse|
| | | | |With chronic PO dosing, |extensive | |effects |
| | | | |the half-life can be as |Renal excretion: extensive| | |
| | | | |long as |as conjugate | | |
| | | | |30 hr | | | |
|Meperidine |Various, |tabs: 50, 100 mg |PO: ≈ 1 hr |Meperidine 3.2–3.7 hr |Liver metabolism: 50% |50–150 mg PO IM, SC, IV q 4|150 mg q 3–4 h, |
|(pethidine) |Demerol ® is an |inj: 50, 75, 100 mg/ml |IM: 25 minutes |Active metabolite: |first pass through the |h PRN |900–1200 mg/24h |
|(synthetic opioid |example |syrup: 10mg/1ml, | |24–48 hr |liver |NOT RECOMMENDED FOR CHRONIC| |
|not | |25 mg/1 ml, 50 mg/5 ml | | |Renal Excretion: 0.5%–5.2%|DOSING as active | |
|related–morphine, | | | | |(average 2.2%) unchanged |metabolite, normeperidine | |
|Useful for rigors) | | | | |Active metabolite, |may produce adverse effects| |
| | | | | |normeperidine, excreted | | |
| | | | | |0.6%–21% (average 6.2%) | | |
| | | | | |unchanged in the urine | | |
|Methadone |Various, |tab: 5, 10, 40 mg |PO: 2–4 hr |Methadone: 23 hr |Liver metabolism: 4 times |5 mg PO q 8 h |limited only by need and adverse|
| |Dolophine ® is an |elixir: 1, 2, 10 mg/ml | |Metabolite: 39.8–48 hr |greater after PO |Titrate dose q 3–5 days |effects |
| |example | | |After a single PO dose, |administration than after |due–delayed clearance | |
| | | | |half-life is biphasic with|IM administration | | |
| | | | |an initial phase range of | | | |
| | | | |12–24 hr and a secondary | | | |
| | | | |phase of up to 55 hr | | | |
|Morphine, IR |Various |IR tabs: 10, 15, 30 mg |Buccal: 5 hr (range 1.5–12 hr) |4 hr |Liver metabolism: ≈ 90% of|1–( mg: PO PR q 4 h |limited only by need and adverse|
| | |elixir: 1, 2, 20 mg/ml |Colostomy, suppository: | |a given dose is |Routinely or q 1 h PRN, |effects |
| | |supps: 5, 10, 20, 30 mg |0.5–1 hr | |conjugated–morphine–3–gluc|SC, IM q 3h routinely or q | |
| | |inj: 1, 2, 8, 10, 15, 25, |Epidural/Intrathecal: | |uronide (M3G) and |30 min PRN, or | |
| | |50 mg/ml |5–10 minutes | |morphine–6–glucuronide |SC, IV q 1 h via infusion +| |
| | | |IV/IM: 10–60 minutes | |(M6G-active) |breakthrough | |
| | | |Inhalation (nebulized): | |Renal Excretion: 90% |q 30 min PRN | |
| | | |10–45 minutes | |(metabolites and free | | |
| | | |PO IR: 1 hr | |drug) within 24 hr | | |
| | | |PO ER: 8.4 hr | |The pharmacokinetics of | | |
| | | |PO ER: capsules (Avinza): | |morphine are altered in | | |
| | | |30 minutes | |renal failure. Clearance | | |
| | | |PR: using PO ER: | |is decreased. M3G and M6G | | |
| | | |5.4–6.7 hr | |accumulate several fold | | |
| | | |PR: supp IR: | |with associated risk of | | |
| | | |0.75–1 hr | |toxicity | | |
| | | |SC: 30 minutes | |Feces: 7–10% | | |
|Morphine, ER |capsule: Kadian ® |Kadian ® capsules: 20, 50, | | | |10–( mg: PO/PR |limited only by need and adverse|
| |tabs: Ora–Morph–ER,® |100 mg (q 12–24 h) | | | |q 8–24 h routinely only |effects |
| |MS– Contin ® |MS–Contin ® tabs: 15, 30, | | | |(depending on product). | |
| |Avinza® |60, 100, 200 mg | | | |Provide breakthrough doses | |
| | |(q 8–12 h) | | | |using IR morphine q 1 h | |
| | |Ora–Morph–ER ® tabs: 15, | | | |PRN. | |
| | |30, 60, 100 mg | | | | | |
| | |(q 8–12 h) | | | | | |
| | |(Kadian ® capsules may be | | | | | |
| | |opened and pellets mixed | | | | | |
| | |with fluids or soft food) | | | | | |
|Oxycodone |IR: various |IR tabs: 5, 10, 15, 30 mg |PO IR: 1.6 hr |PO IR: 4 hr |Liver metabolism: |5–( mg IR PO PR q 4 h |limited only by need and adverse|
|(alone) |ER: OxyContin ® |ER tabs: 10, 20, 40, |PO ER: 2.1–3.2 hr |PO ER: 4.5–8 hr |extensive |routinely, or q 1 h PRN or |effects |
| | |80 mg | | |Renal Excretion: extensive|10–( mg ER PO q 12 h | |
| | |elixir: 1, 20 mg/ml | | |with approximately 20% | | |
| | | | | |unchanged | | |
|Oxycodone + |Various, Percocet ® |5 mg oxycodone + |See above |4 hr for oxycodone |See above |1–2 tabs PO q 4 h routinely|limited to 12 tabs/24h by |
|Acetaminophen |is an example |325 mg acetaminophen | |2–4 hr for acetaminophen | |or PRN |acetaminophen |
|combinations | |5/500,7.5/325, 7.5/500, | | | | | |
| | |10/325, 10/650 (may include| | | | | |
| | |caffeine) | | | | | |
|Oxycodone + Aspirin|Various, Percodan® is|5 mg oxycodone + |See above |Oxycodone: 4 hr |Renal Excretion: |1–2 tabs PO q 4 h routinely|limited to 12 tabs/24h by ASA |
|combinations |an example |325 mg ASA (may include | |ASA: 4.7–9 |approximately 20% |or PRN | |
| | |caffeine) | | |unchanged | | |
| | | | | |See above | | |
|Tramadol |Ultram ® |tab: 50 mg |PO: 2 hr |Tramadol: 6.3 hr |Liver metabolism: |1–2 tabs PO q 6 h |2 tabs PO q 6 h |
| | | | |Metabolite: 7.4 hr |extensive | | |
| | | | | |Renal Excretion: 30% | | |
| | | | | |excreted in the urine as | | |
| | | | | |unchanged drug, 60% of the| | |
| | | | | |dose is excreted as | | |
| | | | | |metabolites | | |
|Extracted and updated from: |
|– Ferris FD, Flannery JS, McNeal HB et al, eds. Medication Table, in Module 4: Palliative Care, A Comprehensive Guide for the Care of Persons With HIV Disease. Toronto, Ontario: Mount Sinai Hospital and Casey House |
|Hospice; 1995:162–166. |
|– Physicians' Desk Reference. Montvale, NJ: Medical Economics Company, Inc; 1999. |
|Equianalgesic Doses of Opioid Analgesics |
|Oral/Rectal Dose (mg) |Analgesic |Parenteral Dose (mg) |
|150 |Codeine |50 |
|– |Fentanyl |0.050 |
|15 |Hydrocodone |– |
|3 |Hydromorphone |1 |
|2 |Levorphanol |1 |
|150 |Meperidine (pethidine) |50 |
|15 |Morphine |5 |
|10 |Oxycodone |– |
When converting–or from transdermal fentanyl patches, published data suggest that a
25–μg patch is equivalent to 45–135 mg of oral morphine/24h. However, clinical experience suggests that most patients will use the lower end of the range of morphine doses, ie, for most patients 25 μg is ≈ 50 mg of oral morphine/24h
Other medications used in palliative care
|Generic name |
|Megestrol acetate |
|Progestin for appetite stimulation |
|Alprazolam |
|Benzodiazepine |
|Furosemide |
|Loop diuretic |
|Aluminum or Magnesium Hydroxide |
|Antacids |
|Dextromethorphan |
|Antitussive |
|Chlorpromazine |
|Dopaminergic antiemetic, sedating neuroleptic, hiccups |
|Amitriptyline |
|Tricyclic antidepressant for neuropathic pain |
|Attapulgite |
|Antidiarrheal |
|Atropine |
|Antimuscarinic anticholinergic |
|Albuterol |
|Inhaled ß adrenergic agonist |
|Zolpidem |
|Nonbenzodiazepine hypnotic |
|Cimetidine |
|H2 receptor antagonist, antacid |
|Capsaicin |
|Topical for neuropathic pain |
|Phenobarbital |
|Barbiturate antiepileptic and sedative |
|Metronidazole |
|Topical and PO antibiotic particularly for malodorous skin ulcers |
|Dexamethasone |
|Glucocorticoid |
Baclofen
Muscle relaxant |Various, Lioresal ( is an example:
tabs: 10, 20 mg |PO: 2 hr |3–6.8 hr |Liver metabolism: limited
Renal Excretion: 69%–85%
Feces: 10 % |5–20 mg PO bid–tid (max 120 mg/24h) |☺ |nausea/vomiting
sedation
dizziness
weakness
neuropsychiatric disturbances
genitourinary effects |CNS depressants | |Belladonna & Opium
Anticholinergic + opioid
Relief of pain due–smooth muscle spasm |Various:
belladonna/opium: 16.2/30 mg
16.2/60 mg |NA |NA |Renal excretion:
Belladonna 33% |1 PR q 6 h PRN |☺ |anticholinergic AE
photophobia
constipation
difficulty urinating
somnolence |antacids, histamine H2 receptor antagonists may interfere with absorption
amantadine, quinidine
haloperidol
phenothiazines
MAOIs
TCAs | |Bethanechol
Cholinergic stimulant
|Various, Urecholine( is an example:
tabs: 5, 10, 25, 50 mg |NA |NA |Unknown |10–50 mg PO tid–qid, or
2.5–10 mg SC tid–qid |☺ |cholinergic stimulation, including sweating, salivation, flushing, decreased BP, nausea, abdominal pain, diarrhea, bronchospasm |anticholinergic drugs
atropine
quinidine
procainamide
sympathomimetics | |Cyclobenzaprine
Muscle relaxant |Various, Flexeril (is an example:
tab: 5, 10 mg |PO: 3.9 hr |18 hr |Liver metabolism: extensive
Renal Excretion: 1% |20–40 mg daily in divided doses
(max 60 mg/24h) |☺ |drowsiness
dry mouth
dizziness
fatigue
nausea/vomiting
confusion |TCAs
MAOIs
CNS depressants
anticholinergics | |Cyproheptadine
H1 receptor antagonist |Various, Periactin ( is an example:
tab: 4 mg
syrup: 2 mg/5 ml |PO: 6–9 hr |16 hr |Liver metabolism: 57%
Renal Excretion: 40%
Feces:
2%–20% |4–20 mg PO (
q 4–6 h
(max 32 mg/24h) |2–4 mg bid–tid depending on age and weight
(max 16 mg/24h) |sedation
dizziness
confusion
nausea/vomiting
arrhythmias
hypersensitivity |CNS depressants
ephedrine
MAOIs | |Dantrolene
Muscle relaxant |Dantrium (:
caps: 25, 50, 100 mg
inj: 20 mg/vial |PO: 4–8 hr |8.7 hr |Liver metabolism: 80% of the absorbed dose as metabolites |25–50 mg PO daily–qid |☺ |muscle weakness
slurred speech
drowsiness
dizziness
diarrhea
nausea/vomiting
malaise
hepatic effects |verapamil
CNS depressants | |Dicyclomine
Anticholinergic antispasmodic |Various, Bentyl (is an example:
tabs: 10, 20 mg
syrup: 10 mg/5 ml
inj: 10 mg/ml |PO: 60–90 minutes |1.8 hr |Renal Excretion: 79.5%
Feces: 8.4% |10–20 mg PO tid–qid |☺ |anticholinergic AE |antacids
slow K
levodopa
digoxin
phenothiazines
amantadine
antiparkinsonian agents
glutethimide | |Flavoxate
Smooth muscle relaxant |Urispas (:
tab: 100 mg |Initial response PO:
55 minutes–
2 hr |NA |Liver metabolism:
Renal Excretion: 57% |100–200 mg PO tid–qid |☺ |nausea/vomiting
dry mouth
headache
drowsiness
confusion |none significant | |Fosphenytoin
Antiepileptic injectable prodrug of phenytoin |Cerebyx (:
inj: dosed as phenytoin equivalents |IM: 30 minutes
IV: immediate (at end of infusion) |Conversion half-life of fosphenytoin to phenytoin is 15 minutes
Phenytoin:
12–28.9 hr |Liver metabolism: to phenytoin which is metabolized extensively (95%)
Bile excretion |IM, SC, IV
consult pharmacy for phenytoin equivalent determination |IM, SC, IV
consult pharmacy for phenytoin equivalent determination |ataxia, diplopia, dizziness, nystagmus
confusion, drowsiness, hallucinations
cardiovascular effects
constipation
depression
gingival hyperplasia
hematologic effects
hepatic dysfunction
hypotension
megaloblastic anemia
nausea/vomiting
hypersensitivity
avoid in pregnancy |amiodarone, mexiletine, quinidine
antihistamines
benzodiazepines
carbamazepine, valproic acid
cimetidine
chloramphenicol
corticosteroids, salicylates
cyclosPO:rine
disulfiram
doxycycline
folic acid
isoniazid, rifampin
methadone
phenobarbital
TCAs, trazodone
theophylline | |Hydroxyzine
Histamine H1 receptor antagonist |Various, Atarax,( Vistaril ( are examples:
caps: 10, 25, 50,
100 mg
inj: 25 mg/ml,
50 mg/ml
syrup: 10 mg/5 ml |PO: 2 hr |3–20 hr
Cetirizine: 25 hr |Liver metabolism: to Cetirizine, active |25 mg PO tid–qid PO/IV |2 mg/kg/24h PO ÷ tid–qid |drowsiness
dry mouth
dizziness
headache
nausea/vomiting
bitter taste in mouth |CNS depressants
anticholinergics
epinephrine | |Meclizine
Histamine H1 receptor antagonist |Various, Antivert,( Bonine ( are examples:
tab: 12.5, 25,
50 mg |Initial response: PO: 1 hr |6 hr |Liver metabolism: probable
Renal excretion: Metabolites
Fecal: unchanged drug |25–100 mg PO daily–qid |use ½ the adult dose |drowsiness
dry mouth
blurred vision |CNS depressants
anticholinergics
| |Methocarbamol
Muscle relaxant |Various, Robaxin ( is an example:
tabs: 500, 750 mg
inj: 100 mg/ml |PO: 1–2 hr |0.9–2 hr |Liver metabolism: extensive |500 mg PO tid–qid
(max 6000 mg/24h ) |☺ |drowsiness
dizziness
headache
blurred vision
nausea/vomiting
hypersensitivity |CNS depressants
anticholinergics
pyridostigmine | |Nifedipine
Calcium–channel blocker
Hiccups |Various, Adalat,( Procardia ( are examples:
IR tabs: 10, 20 mg
ER tabs: 30, 60,
90 mg |PO IR: 20–45 minutes
PO ER: 6 hr
SL: 60 minutes |2–2.5 hr
|Liver metabolism: extensive
Renal Excretion: 70%–80%
Bile/Feces: 20% |hiccups: 10–20 mg PO, SL
q 8 h or
30–60 mg PO daily ER |hypertension: 0.5 mg/kg/24h PO: ÷ q 8 h,
increase as needed up–1.5 mg/kg/24h |dizziness
lightheadedness
headache
insomnia
palpitations
nausea/vomiting |cimetidine
ranitidine
propranolol | |Orphenadrine
Muscle relaxant |Norflex (:
tab: 100 mg
inj: 30 mg/ml |PO: 2–4 hr
IM: 1 hr | 13.2–20.1 hr |Liver metabolism:
Renal Excretion: 60% |60 mg IM, IV q 12 h or
100 mg PO bid |☺ |anticholinergic AE
nausea/vomiting
headache
drowsiness |propoxyphene
CNS depressants | |Oxybutynin
For relief of urinary urgency, frequency, leakage, incontinence associated with a neurogenic bladder |Various, Ditropan ( is an example:
tab: 5 mg
syrup: 5 mg/5 ml
Oxytrol( Transdermal 3.9mg |PO: 1 hr
TD: NA |1.1–2.3 hr
|Liver metabolism: primary site
Renal excretion: less than 0.1% |5 mg PO bid–tid
(max dose 20 mg daily)
3.9 mg TD twice weekly |< 5rs: 0.5 mg/kg/24h PO ÷ qid
> 5 y: 10–15 mg/24h ÷
bid–tid |anticholinergic AE |none significant | |Phenazopyridine
Anesthetic–relieve dysuria |Pyridium (:
tabs: 100, 200 mg |NA |NA |Liver Metabolism:
Renal Excretion: 65% |200 mg PO tid |☺ |orange or red urine
mild upper GI upset
other AE are rare, including:
headache
transient acute renal failure
methemoglobinemia
hypersensitivity |none significant | |Phenytoin
Antiepileptic |Various, Dilantin ( is an example:
caps: 30, 100 mg
infatabs: 50 mg
suspension: 30 or 125 mg/5 ml
inj: 50 mg/ml |PO ER capsules:
4–12 hr
IV with loading dose:
20–25 minutes |PO: 7–42 hr; value is variable due–the saturation kinetics
IV: 10–15 hr |Liver metabolism: extent unknown
Renal excretion: 2%
Bile: most of the dose |seizures, hiccups: start with 100 mg PO/IV tid and adjust–achieve therapeutic blood levels
(monitor blood levels)
(if the person is unable–swallow and IV access is not possible, parenteral solutions may also be administered PR)
(see fosphenytoin) |6 mo–3 y: 7–9 mg/kg/24h ÷ bid–tid
4–6 y: 6.5 mg/kg/24h ÷ bid–tid
7–9 y: 6 mg/kg/24h ÷ bid–tid
10–16 y: 3–5 mg/kg/24h ÷ bid–tid |ataxia, diplopia, dizziness, nystagmus
confusion, drowsiness, hallucinations
cardiovascular effects
constipation
depression
gingival hyperplasia
hematologic effects
hepatic dysfunction
hypotension
megaloblastic anemia
nausea/vomiting
hypersensitivity
avoid in pregnancy |amiodarone, mexiletine, quinidine
antihistamines
benzodiazepines
carbamazepine, valproic acid
cimetidine
chloramphenicol
corticosteroids, salicylates
cyclosPO:rine
disulfiram
doxycycline
folic acid
isoniazid, rifampin
methadone
phenobarbital
TCAs, trazodone
theophylline | |Quinine sulfate
For nighttime leg cramps |Various:
tab:260, 325 mg |PO: 1–3.2 hr |4.1–11.1 hr |Renal Excretion: 12%–30% |200–300 mg PO nightly PRN |☺ |headache
nausea/vomiting
tinnitus
confusion
hypersensitivity |mefloquine
cardiac glycosides,
cimetidine | |Simethicone
Antiflatulent, particularly for gastric gas |Various combinations with antacids
tab: 80, 125 mg
susp: 40 mg/0.6ml |Inert: not absorbed |NA |Feces: unchanged |as per antacid directions
40–120 mg PO qid PRN pc + hs
(max daily dose = 500 mg) |see directions on bottle |none significant |none significant | |
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