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 (1.8-4.8 hr)|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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