Transdermal preparations of fentanyl and buprenorphine are available (section 4.7.2 ); they are not suitable for acute pain or in patients whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of the dose. Prescribers should ensure that they are familiar with the correct use of transdermal preparations, see under buprenorphine and fentanyl (inappropriate use has caused fatalities). Immediate-release morphine can be given for breakthrough pain.
The following 24-hour oral doses of morphine are considered to be approximately equivalent to the buprenorphine and fentanyl patches shown, however when switching due to possible opioid-induced hyperalgesia, reduce the calculated equivalent dose of the new opioid by one-quarter to one-half.
| Buprenorphine patches are approximately equivalent to the following 24-hour doses of oral morphine | |||
|---|---|---|---|
| morphine salt 12 mg daily | ≡ | BuTrans® ‘5’ patch | 7-day patches |
| morphine salt 24 mg daily | ≡ | BuTrans® ‘10’ patch | 7-day patches |
| morphine salt 48 mg daily | ≡ | BuTrans® ‘20’ patch | 7-day patches |
| morphine salt 84 mg daily | ≡ | Transtec® ‘35’ patch | 4-day patches |
| morphine salt 126 mg daily | ≡ | Transtec® ‘52.5’ patch | 4-day patches |
| morphine salt 168 mg daily | ≡ | Transtec® ‘70’ patch | 4-day patches |
| Note Conversion ratios vary and these figures are a guide only. Morphine equivalences for transdermal opioid preparations have been approximated to allow comparison with available preparations of oral morphine | |||
| 72-hour Fentanyl patches are approximately equivalent to the following 24-hour doses of oral morphine | ||
|---|---|---|
| morphine salt 30 mg daily | ≡ | fentanyl ‘12’ patch |
| morphine salt 60 mg daily | ≡ | fentanyl ‘25’ patch |
| morphine salt 120 mg daily | ≡ | fentanyl ‘50’ patch |
| morphine salt 180 mg daily | ≡ | fentanyl ‘75’ patch |
| morphine salt 240 mg daily | ≡ | fentanyl ‘100’ patch |
| Note Fentanyl equivalences in this table are for patients on well-tolerated opioid therapy for long periods; for patients who are opioid naive or who have been stable on oral morphine or other immediate release opioid for only several weeks, see Transdermal Route above, and section 4.7.2. Conversion ratios vary and these figures are a guide only. Morphine equivalences for transdermal opioid preparations have been approximated to allow comparison with available preparations of oral morphine | ||
Symptom control
Unlicensed indications or routes
Several recommendations in this section involve unlicensed indications or routes.
Anorexia Anorexia may be helped by prednisolone 15–30 mg daily or dexamethasone 2–4 mg daily.
Bowel colic and excessive respiratory secretions Bowel colic and excessive respiratory secretions may be reduced by a subcutaneous injection of hyoscine hydrobromide 400 micrograms, hyoscine butylbromide 20 mg, or glycopyrronium 200 micrograms. These antimuscarinics are generally given every 4 hours when required, but hourly use is occasionally necessary, particularly in excessive respiratory secretions. If symptoms persist, they can be given regularly via a continuous infusion device, see Bowel Colic and Excessive Respiratory Secretions. Care is required to avoid the discomfort of dry mouth.
Capillary bleeding Capillary bleeding can be treated with tranexamic acid (section 2.11) by mouth; treatment is usually discontinued one week after the bleeding has stopped, or, if necessary, it can be continued at a reduced dose. Alternatively, gauze soaked in tranexamic acid 100 mg/mL or adrenaline (epinephrine) solution 1 mg/mL (1 in 1000) can be applied to the affected area.
Vitamin K may be useful for the treatment and prevention of bleeding associated with prolonged clotting in liver disease. In severe chronic cholestasis, absorption of vitamin K may be impaired; either parenteral or water-soluble oral vitamin K should be considered (section 9.6.6).
Constipation Constipation is a common cause of distress and is almost invariable after administration of an opioid analgesic. It should be prevented if possible by the regular administration of laxatives; a faecal softener with a peristaltic stimulant (e.g. co-danthramer) or lactulose solution with a senna preparation should be used (section 1.6.2 and section 1.6.3). Methylnaltrexone (section 1.6.6) is licensed for the treatment of opioid-induced constipation.
Convulsions Patients with cerebral tumours or uraemia may be susceptible to convulsions. Prophylactic treatment with phenytoin or carbamazepine (section 4.8.1) should be considered. When oral medication is no longer possible, diazepam 10 mg given rectally (as a solution) (section 4.8.2), or phenobarbital 50–200 mg twice daily given by injection, can be continued as prophylaxis. For the use of midazolam by subcutaneous infusion using a continuous infusion device, see below.
Dry mouth Dry mouth may be relieved by good mouth care and measures such as chewing sugar-free gum, sucking ice or pineapple chunks, or the use of artificial saliva (section 12.3.5); dry mouth associated with candidiasis can be treated by oral preparations of nystatin or miconazole (section 12.3.2); alternatively, fluconazole can be given by mouth (section 5.2.1). Dry mouth may be caused by certain medications including opioids, antimuscarinic drugs (e.g. hyoscine), antidepressants and some antiemetics; if possible, an alternative preparation should be considered.
Dysphagia A corticosteroid such as dexamethasone 8 mg daily may help, temporarily, if there is an obstruction due to tumour. See also Dry Mouth above.
Dyspnoea Breathlessness at rest may be relieved by regular oral morphine in carefully titrated doses, starting at 5 mg every 4 hours. Diazepam 5–10 mg daily may be helpful for dyspnoea associated with anxiety. A corticosteroid, such as dexamethasone 4–8 mg daily, may also be helpful if there is bronchospasm or partial obstruction.
Fungating tumours Fungating tumours can be treated by regular dressing and antibacterial drugs; systemic treatment with metronidazole (section 5.1.11) is often required to reduce malodour but topical metronidazole (section 13.10.1.2) is also used.
Gastro-intestinal pain The pain of bowel colic may be reduced by loperamide 2–4 mg 4 times daily. Hyoscine hydrobromide (section 4.6) may also be helpful, given sublingually at a dose of 300 micrograms 3 times daily as Kwells® tablets. Subcutaneous injections of hyoscine butylbromide, hyoscine hydrobromide, and glycopyrronium can also be used to treat bowel colic (see above). For doses by continuous subcutaneous infusion, see Bowel Colic and Excessive Respiratory Secretions.
Gastric distension pain due to pressure on the stomach may be helped by a preparation incorporating an antacid with an antiflatulent (section 1.1.1) and a prokinetic such as domperidone 10 mg 3 times daily before meals.
Hiccup Hiccup due to gastric distension may be helped by a preparation incorporating an antacid with an antiflatulent (section 1.1.1). If this fails, metoclopramide 10 mg every 6 to 8 hours by mouth or by subcutaneous or intramuscular injection can be added; if this also fails, baclofen 5 mg twice daily, or nifedipine 10 mg three times daily, or chlorpromazine (section 4.2.1) can be tried.
Hypercalcaemia see section 9.5.1.2
Insomnia Patients with advanced cancer may not sleep because of discomfort, cramps, night sweats, joint stiffness, or fear. There should be appropriate treatment of these problems before hypnotics are used. Benzodiazepines, such as temazepam (section 4.1.1), may be useful.
Intractable cough Intractable cough may be relieved by moist inhalations or by regular administration of oral morphine in an initial dose of 5 mg every 4 hours. Methadone linctus should be avoided because it has a long duration of action and tends to accumulate.
Muscle spasm The pain of muscle spasm can be helped by a muscle relaxant such as diazepam 5–10 mg daily or baclofen 5–10 mg 3 times daily.
Nausea and vomiting Nausea and vomiting are common in patients with advanced cancer. Ideally, the cause should be determined before treatment with an antiemetic (section 4.6) is started. A prokinetic antiemetic may be a preferred choice for first-line therapy.
Nausea and vomiting may occur with opioid therapy particularly in the initial stages but can be prevented by giving an antiemetic such as haloperidol or metoclopramide. An antiemetic is usually necessary only for the first 4 or 5 days and therefore combined preparations containing an opioid with an antiemetic are not recommended because they lead to unnecessary antiemetic therapy (and associated side-effects when used long-term).
Metoclopramide has a prokinetic action and is used in a dose of 10 mg 3 times daily by mouth for nausea and vomiting associated with gastritis, gastric stasis, and functional bowel obstruction. Drugs with antimuscarinic effects antagonise prokinetic drugs and, if possible, should not be used concurrently.
Haloperidol is used by mouth in an initial dose of 1.5 mg once or twice daily (can be increased if necessary to 5–10 mg daily in divided doses) for most metabolic causes of vomiting (e.g. hypercalcaemia, renal failure).
Cyclizine is given in a dose of 50 mg up to 3 times daily by mouth. It is used for nausea and vomiting due to mechanical bowel obstruction, raised intracranial pressure, and motion sickness.
Levomepromazine is used as an antiemetic; it is given by mouth or by subcutaneous injection in an initial dose of 6 mg or 6.25 mg at bedtime, titrated if necessary to 12.5–25 mg twice daily (6-mg tablets available from ‘special-order’ manufacturers or specialist importing companies). For the dose by subcutaneous infusion, see Nausea and vomiting. Dexamethasone 8–16 mg daily by mouth can be used as an adjunct.
Antiemetic therapy should be reviewed every 24 hours; it may be necessary to substitute the antiemetic or to add another one.
For the administration of antiemetics by subcutaneous infusion using a continuous infusion device, see below.
For the treatment of nausea and vomiting associated with cancer chemotherapy, see section 8.1.
Pruritus Pruritus, even when associated with obstructive jaundice, often responds to simple measures such as application of emollients (section 13.2.1). In the case of obstructive jaundice, further measures include administration of colestyramine (section 1.9.2).
Raised intracranial pressure Headache due to raised intracranial pressure often responds to a high dose of a corticosteroid, such as dexamethasone 16 mg daily for 4 to 5 days, subsequently reduced to 4–6 mg daily if possible; dexamethasone should be given before 6 p.m. to reduce the risk of insomnia.
Restlessness and confusion Restlessness and confusion may require treatment with an antipsychotic, e.g. haloperidol 2 mg by mouth or 2.5 mg by subcutaneous injection, or levomepromazine 6 mg by mouth or 6.25 mg by subcutaneous injection, both repeated every 2 hours if required. The dose and frequency is adjusted according to the level of patient distress and the response. A regular maintenance dose should also be considered, given twice daily either by mouth or by subcutaneous injection; alternatively use a continuous infusion device, see Restlessness and Confusion.
Levomepromazine is licensed to treat pain in palliative care — this use is reserved for distressed patients with severe pain unresponsive to other measures (seek specialist advice).
Continuous subcutaneous infusions
Although drugs can usually be administered by mouth to control the symptoms of advanced cancer, the parenteral route may sometimes be necessary. Repeated administration of intramuscular injections can be difficult in a cachectic patient. This has led to the use of portable continuous infusion devices, such as syringe drivers, to give a continuous subcutaneous infusion, which can provide good control of symptoms with little discomfort or inconvenience to the patient.
Syringe driver rate settings
Staff using syringe drivers should be adequately trained and different rate settings should be clearly identified and differentiated; incorrect use of syringe drivers is a common cause of medication errors.
Indications for the parenteral route are:
the patient is unable to take medicines by mouth owing to nausea and vomiting, dysphagia, severe weakness, or coma;
there is malignant bowel obstruction in patients for whom further surgery is inappropriate (avoiding the need for an intravenous infusion or for insertion of a nasogastric tube);
occasionally when the patient does not wish to take regular medication by mouth.
Bowel colic and excessive respiratory secretions Hyoscine hydrobromide effectively reduces respiratory secretions and bowel colic and is sedative (but occasionally causes paradoxical agitation); it is given in a subcutaneous infusion dose of 1.2–2 mg/24 hours.
Hyoscine butylbromide is used for bowel colic and for excessive respiratory secretions, and is less sedative than hyoscine hydrobromide. Hyoscine butylbromide is given in a subcutaneous infusion dose of 60–300 mg/24 hours for bowel colic and 20–120 mg/24 hours for excessive respiratory secretions (important: these doses of hyoscine butylbromide must not be confused with the much lower dose of hyoscine hydrobromide, above).
Glycopyrronium 0.6–1.2 mg/24 hours by subcutaneous infusion may also be used to treat bowel colic or excessive respiratory secretions.
Confusion and restlessness Haloperidol has little sedative effect; it is given in a subcutaneous infusion dose of 5–15 mg/24 hours.
Levomepromazine has a sedative effect; it is given in an initial subcutaneous infusion dose of 12.5–50 mg/24 hours, titrated according to response (doses greater than 100 mg/24 hours should be given under specialist supervision).
Midazolam is a sedative and an antiepileptic that may be used in addition to an antipsychotic drug in a very restless patient; it is given in an initial subcutaneous infusion dose of 10–20 mg/24 hours, titrated according to response (usual dose 20–60 mg/24 hours). Midazolam is also used for myoclonus.
Convulsions If a patient has previously been receiving an antiepileptic drug or has a primary or secondary cerebral tumour or is at risk of convulsion (e.g. owing to uraemia) antiepileptic medication should not be stopped. Midazolam is the benzodiazepine antiepileptic of choice for continuous subcutaneous infusion, and it is given initially in a dose of 20–40 mg/24 hours.
Prescribing of midazolam in palliative care
The use of high-strength midazolam (5 mg/mL in 2 mL and 10 mL ampoules, or 2 mg/mL in 5 mL ampoules) should be considered in palliative care and other situations where a higher strength may be more appropriate to administer the prescribed dose, and where the risk of overdosage has been assessed. It is advised that flumazenil (section 15.1.7) is available when midazolam is used, to reverse the effects if necessary.
Nausea and vomiting Haloperidol is given in a subcutaneous infusion dose of 2.5–10 mg/24 hours.
Levomepromazine is given in a subcutaneous infusion dose of 5–25 mg/24 hours but sedation can limit the dose.
Cyclizine is particularly likely to precipitate if mixed with diamorphine or other drugs (see under Mixing and Compatibility, below); it is given in a subcutaneous infusion dose of 150 mg/24 hours.
Metoclopramide can cause skin reactions; it is given in a subcutaneous infusion dose of 30–100 mg/24 hours.
Octreotide (section 8.3.4.3), which stimulates water and electrolyte absorption and inhibits water secretion in the small bowel, can be used by subcutaneous infusion in a dose of 250–500 micrograms/24 hours to reduce intestinal secretions and to reduce vomiting due to bowel obstruction. Doses of 750 micrograms/24 hours, and occasionally higher, are sometimes required.
Pain control Diamorphine is the preferred opioid since its high solubility permits a large dose to be given in a small volume (see under Mixing and Compatibility, below). The table below shows approximate equivalent doses of morphine and diamorphine.
Mixing and compatibility The general principle that injections should be given into separate sites (and should not be mixed) does not apply to the use of syringe drivers in palliative care. Provided that there is evidence of compatibility, selected injections can be mixed in syringe drivers. Not all types of medication can be used in a subcutaneous infusion. In particular, chlorpromazine, prochlorperazine, and diazepam are contra-indicated as they cause skin reactions at the injection site; to a lesser extent cyclizine and levomepromazine also sometimes cause local irritation.
In theory injections dissolved in water for injections are more likely to be associated with pain (possibly owing to their hypotonicity). The use of physiological saline (sodium chloride 0.9%) however increases the likelihood of precipitation when more than one drug is used; moreover subcutaneous infusion rates are so slow (0.1–0.3 mL/hour) that pain is not usually a problem when water is used as a diluent.
Diamorphine can be given by subcutaneous infusion in a strength of up to 250 mg/mL; up to a strength of 40 mg/mL either water for injections or physiological saline (sodium chloride 0.9%) is a suitable diluent — above that strength only water for injections is used (to avoid precipitation).
The following can be mixed with diamorphine:
| Cyclizine17 | Hyoscine hydrobromide | |
| Dexamethasone18 | Levomepromazine | |
| Haloperidol19 | Metoclopramide20 | |
| Hyoscine butylbromide | Midazolam |
Subcutaneous infusion solution should be monitored regularly both to check for precipitation (and discoloration) and to ensure that the infusion is running at the correct rate.
Problems encountered with syringe drivers The following are problems that may be encountered with syringe drivers and the action that should be taken:
if the subcutaneous infusion runs too quickly check the rate setting and the calculation;
if the subcutaneous infusion runs too slowly check the start button, the battery, the syringe driver, the cannula, and make sure that the injection site is not inflamed;
if there is an injection site reaction make sure that the site does not need to be changed — firmness or swelling at the site of injection is not in itself an indication for change, but pain or obvious inflammation is.
| Equivalent doses of morphine sulfate and diamorphine hydrochloride given over 24 hours | ||
|---|---|---|
| These equivalences are approximate only and should be adjusted according to response | ||
| MORPHINE | PARENTERAL DIAMORPHINE | |
| Oral morphine sulfate | Subcutaneous infusion of morphine sulfate | Subcutaneous infusion of diamorphine hydrochloride |
| over 24 hours | over 24 hours | over 24 hours |
| 30 mg | 15 mg | 10 mg |
| 60 mg | 30 mg | 20 mg |
| 90 mg | 45 mg | 30 mg |
| 120 mg | 60 mg | 40 mg |
| 180 mg | 90 mg | 60 mg |
| 240 mg | 120 mg | 80 mg |
| 360 mg | 180 mg | 120 mg |
| 480 mg | 240 mg | 160 mg |
| 600 mg | 300 mg | 200 mg |
| 780 mg | 390 mg | 260 mg |
| 960 mg | 480 mg | 320 mg |
| 1200 mg | 600 mg | 400 mg |
| If breakthrough pain occurs give a subcutaneous (preferable) or intramuscular injection equivalent to one-tenth to one-sixth of the total 24-hour subcutaneous infusion dose. It is kinder to give an intermittent bolus injection subcutaneously — absorption is smoother so that the risk of adverse effects at peak absorption is avoided (an even better method is to use a subcutaneous butterfly needle). To minimise the risk of infection no individual subcutaneous infusion solution should be used for longer than 24 hours. | ||
Prescribing for the elderly
Old people, especially the very old, require special care and consideration from prescribers. Medicines for Older People, a component document of the National Service Framework for Older People,21 describes how to maximise the benefits of medicines and how to avoid excessive, inappropriate, or inadequate consumption of medicines by older people.
Appropriate prescribing Elderly patients often receive multiple drugs for their multiple diseases. This greatly increases the risk of drug interactions as well as adverse reactions, and may affect compliance (see Taking medicines to best effect under General guidance). The balance of benefit and harm of some medicines may be altered in the elderly. Therefore, elderly patients’ medicines should be reviewed regularly and medicines which are not of benefit should be stopped.
Non-pharmacological measures may be more appropriate for symptoms such as headache, sleeplessness, and lightheadedness when associated with social stress as in widowhood, loneliness, and family dispersal.
In some cases prophylactic drugs are inappropriate if they are likely to complicate existing treatment or introduce unnecessary side-effects, especially in elderly patients with poor prognosis or with poor overall health. However, elderly patients should not be denied medicines which may help them, such as anticoagulants or antiplatelet drugs for atrial fibrillation, antihypertensives, statins, and drugs for osteoporosis.
Form of medicine Frail elderly patients may have difficulty swallowing tablets; if left in the mouth, ulceration may develop. They should always be encouraged to take their tablets or capsules with enough fluid, and whilst in an upright position to avoid the possibility of oesophageal ulceration. It can be helpful to discuss with the patient the possibility of taking the drug as a liquid if available.
Manifestations of ageing In the very old, manifestations of normal ageing may be mistaken for disease and lead to inappropriate prescribing. In addition, age-related muscle weakness and difficulty in maintaining balance should not be confused with neurological disease. Disorders such as lightheadedness not associated with postural or postprandial hypotension are unlikely to be helped by drugs.
Sensitivity The nervous system of elderly patients is more sensitive to many commonly used drugs, such as opioid analgesics, benzodiazepines, antipsychotics, and antiparkinsonian drugs, all of which must be used with caution. Similarly, other organs may also be more susceptible to the effects of drugs such as antihypertensives and NSAIDs.
Pharmacokinetics
Pharmacokinetic changes can markedly increase the tissue concentration of a drug in the elderly, especially in debilitated patients.
The most important effect of age is reduced renal clearance. Many aged patients thus excrete drugs slowly, and are highly susceptible to nephrotoxic drugs. Acute illness can lead to rapid reduction in renal clearance, especially if accompanied by dehydration. Hence, a patient stabilised on a drug with a narrow margin between the therapeutic and the toxic dose (e.g. digoxin) can rapidly develop adverse effects in the aftermath of a myocardial infarction or a respiratory-tract infection. The hepatic metabolism of lipid soluble drugs is reduced in elderly patients because there is a reduction in liver volume. This is important for drugs with a narrow therapeutic window.
Adverse reactions
Adverse reactions often present in the elderly in a vague and non-specific fashion. Confusion is often the presenting symptom (caused by almost any of the commonly used drugs). Other common manifestations are constipation (with antimuscarinics and many tranquillisers) and postural hypotension and falls (with diuretics and many psychotropics).
Hypnotics Many hypnotics with long half-lives have serious hangover effects, including drowsiness, unsteady gait, slurred speech, and confusion. Hypnotics with short half-lives should be used but they too can present problems (section 4.1.1). Short courses of hypnotics are occasionally useful for helping a patient through an acute illness or some other crisis but every effort must be made to avoid dependence. Benzodiazepines impair balance, which can result in falls.
Diuretics Diuretics are overprescribed in old age and should not be used on a long-term basis to treat simple gravitational oedema which will usually respond to increased movement, raising the legs, and support stockings. A few days of diuretic treatment may speed the clearing of the oedema but it should rarely need continued drug therapy.
NSAIDs Bleeding associated with aspirin and other NSAIDs is more common in the elderly who are more likely to have a fatal or serious outcome. NSAIDs are also a special hazard in patients with cardiac disease or renal impairment which may again place older patients at particular risk.
Owing to the increased susceptibility of the elderly to the side-effects of NSAIDs the following recommendations are made:
for osteoarthritis, soft-tissue lesions, and back pain, first try measures such as weight reduction (if obese), warmth, exercise, and use of a walking stick;
for osteoarthritis, soft-tissue lesions, back pain, and pain in rheumatoid arthritis, paracetamol should be used first and can often provide adequate pain relief;
alternatively, a low-dose NSAID (e.g. ibuprofen up to 1.2 g daily) may be given;
for pain relief when either drug is inadequate, paracetamol in a full dose plus a low-dose NSAID may be given;
if necessary, the NSAID dose can be increased or an opioid analgesic given with paracetamol;
do not give two NSAIDs at the same time.
For advice on prophylaxis of NSAID-induced peptic ulcers if continued NSAID treatment is necessary, see section 1.3.
Other drugs Other drugs which commonly cause adverse reactions are antiparkinsonian drugs, antihypertensives, psychotropics, and digoxin. The usual maintenance dose of digoxin in very old patients is 125 micrograms daily (62.5 micrograms in those with renal disease); lower doses are often inadequate but toxicity is common in those given 250 micrograms daily.
Drug-induced blood disorders are much more common in the elderly. Therefore drugs with a tendency to cause bone marrow depression (e.g. co-trimoxazole, mianserin) should be avoided unless there is no acceptable alternative.
The elderly generally require a lower maintenance dose of warfarin than younger adults; once again, the outcome of bleeding tends to be more serious.
Guidelines
Always consider whether a drug is indicated at all.
Limit range It is a sensible policy to prescribe from a limited range of drugs and to be thoroughly familiar with their effects in the elderly.
Reduce dose Dosage should generally be substantially lower than for younger patients and it is common to start with about 50% of the adult dose. Some drugs (e.g. long-acting antidiabetic drugs such as glibenclamide) should be avoided altogether.
Review regularly Review repeat prescriptions regularly. In many patients it may be possible to stop some drugs, provided that clinical progress is monitored. It may be necessary to reduce the dose of some drugs as renal function declines.
Simplify regimens Elderly patients benefit from simple treatment regimens. Only drugs with a clear indication should be prescribed and whenever possible given once or twice daily. In particular, regimens which call for a confusing array of dosage intervals should be avoided.
Explain clearly Write full instructions on every prescription (including repeat prescriptions) so that containers can be properly labelled with full directions. Avoid imprecisions like ‘as directed’. Child-resistant containers may be unsuitable.
Repeats and disposal Instruct patients what to do when drugs run out, and also how to dispose of any that are no longer necessary. Try to prescribe matching quantities.
If these guidelines are followed most elderly people will cope adequately with their own medicines. If not then it is essential to enrol the help of a third party, usually a relative or a friend.
Prescribing in dental practice
The following is a list of topics of particular relevance to dentists.
Advice on the drug management of dental and oral conditions has been integrated into the BNF. For ease of access, guidance on such conditions is usually identified by means of a relevant heading (e.g. Dental and Orofacial Pain) in the appropriate sections of the BNF. For guidance on finding dental information in the BNF see How to Use the BNF.
General guidance
Prescribing by dentists, see Prescription Writing
Medical emergencies in dental practice
Medical problems in dental practice
Drug management of dental and oral conditions
Non-opioid analgesics and compound analgesic preparations
Non-steroidal anti-inflammatory drugs
Oral infections
Broad-spectrum penicillins (amoxicillin and ampicillin)
Cephalosporins (cefalexin and cefradine)
Macrolides (clarithromycin, erythromycin and azithromycin)
Viral infections
Herpetic gingivostomatitis, local treatment, see Oropharyngeal Viral Infections
Herpetic gingivostomatitis, systemic treatment, see Oropharyngeal Viral Infections and section 5.3.2.1
Anaesthetics, anxiolytics and hypnotics
Anaesthesia, sedation, and resuscitation in dental practice
Sedation for dental procedures
Oral ulceration and inflammation
Mouthwashes, gargles and dentifrices
Minerals
Dental Practitioners’ Formulary
Changes to Dental Practitioners’ Formulary
Medical emergencies in dental practice
This section provides guidelines on the management of the more common medical emergencies which may arise in dental practice. Dentists and their staff should be familiar with standard resuscitation procedures, but in all circumstances it is advisable to summon medical assistance as soon as possible. For an algorithm of the procedure for cardiopulmonary resuscitation, see section 2.7.3.
The drugs referred to in this section include:
Adrenaline Injection (Epinephrine Injection), adrenaline 1 in 1000, (adrenaline 1 mg/mL as acid tartrate), 1-mL amps
Aspirin Dispersible Tablets 300 mg
Glucagon Injection, glucagon (as hydrochloride), 1-unit vial (with solvent)
Glucose (for administration by mouth)
Glyceryl Trinitrate Spray
Midazolam Oromucosal Solution, midazolam 5 mg/mL
Oxygen
Salbutamol Aerosol Inhalation, salbutamol 100 micrograms/metered inhalation
Adrenal insufficiency
Adrenal insufficiency may follow prolonged therapy with corticosteroids and can persist for years after stopping. A patient with adrenal insufficiency may become hypotensive under the stress of a dental visit (important: see also Adrenal Suppression, section 6.3.2 for details of corticosteroid cover before dental surgical procedures under general anaesthesia).
Management
Lay the patient flat
Give oxygen (see section 3.6)
Transfer patient urgently to hospital
Anaphylaxis
A severe allergic reaction may follow oral or parenteral administration of a drug. Anaphylactic reactions in dentistry may follow the administration of a drug or contact with substances such as latex in surgical gloves. In general, the more rapid the onset of the reaction the more profound it tends to be. Symptoms may develop within minutes and rapid treatment is essential.
Anaphylactic reactions may also be associated with additives and excipients in foods and medicines (see Excipients). Refined arachis (peanut) oil, which may be present in some medicinal products, is unlikely to cause an allergic reaction — nevertheless it is wise to check the full formula of preparations which may contain allergens (including those for topical application, particularly if they are intended for use in the mouth or for application to the nasal mucosa).
Symptoms and signs
Paraesthesia, flushing, and swelling of face
Generalised itching, especially of hands and feet
Bronchospasm and laryngospasm (with wheezing and difficulty in breathing)
Rapid weak pulse together with fall in blood pressure and pallor; finally cardiac arrest
Management
First-line treatment includes securing the airway, restoration of blood pressure (laying the patient flat and raising the feet, or in the recovery position if unconscious or nauseous and at risk of vomiting), and administration of adrenaline (epinephrine) injection (section 3.4.3). This is given intramuscularly in a dose of 500 micrograms (0.5 mL adrenaline injection 1 in 1000); a dose of 300 micrograms (0.3 mL adrenaline injection 1 in 1000) may be appropriate for immediate self-administration. The dose is repeated if necessary at 5-minute intervals according to blood pressure, pulse, and respiratory function. Oxygen administration is also of primary importance (see section 3.6). Arrangements should be made to transfer the patient to hospital urgently.
For further details on the management of anaphylaxis including details of paediatric doses of adrenaline, see Anaphylaxis
Asthma
Patients with asthma may have an attack while at the dental surgery. Most attacks will respond to 2 puffs of the patient’s short-acting beta2 agonist inhaler such as salbutamol 100 micrograms/puff; further puffs are required if the patient does not respond rapidly. If the patient is unable to use the inhaler effectively, further puffs should be given through a large-volume spacer device (or, if not available, through a plastic or paper cup with a hole in the bottom for the inhaler mouthpiece). If the response remains unsatisfactory, or if further deterioration occurs, then the patient should be transferred urgently to hospital. Whilst awaiting transfer, oxygen (section 3.6) should be given with salbutamol 5 mg or terbutaline 10 mg by nebuliser; if a nebuliser is unavailable, then 2–10 puffs of salbutamol 100 micrograms/metered inhalation should be given (preferably by a large-volume spacer), and repeated every 10–20 minutes if necessary. If asthma is part of a more generalised anaphylactic reaction, an intramuscular injection of adrenaline (as detailed under Anaphylaxis above) should be given.
For a table describing the management of acute asthma, see Management of Acute Asthma.
Patients with severe chronic asthma or whose asthma has deteriorated previously during a dental procedure may require an increase in their prophylactic medication before a dental procedure. This should be discussed with the patient’s medical practitioner and may include increasing the dose of inhaled or oral corticosteroid.
Cardiac emergencies
If there is a history of angina the patient will probably carry glyceryl trinitrate spray or tablets (or isosorbide dinitrate tablets) and should be allowed to use them. Hospital admission is not necessary if symptoms are mild and resolve rapidly with the patient’s own medication. See also Coronary Artery Disease.
Arrhythmias may lead to a sudden reduction in cardiac output with loss of consciousness. Medical assistance should be summoned. For advice on pacemaker interference, see also Pacemakers.
The pain of myocardial infarction is similar to that of angina but generally more severe and more prolonged. For general advice see also Coronary Artery Disease
Symptoms and signs of myocardial infarction
Progressive onset of severe, crushing pain across front of chest; pain may radiate towards the shoulder and down arm, or into neck and jaw
Skin becomes pale and clammy
Nausea and vomiting are common
Pulse may be weak and blood pressure may fall
Breathlessness
Initial management of myocardial infarction
Call immediately for medical assistance and an ambulance, as appropriate.
Allow the patient to rest in the position that feels most comfortable; in the presence of breathlessness this is likely to be sitting position, whereas the syncopal patient should be laid flat; often an intermediate position (dictated by the patient) will be most appropriate. Oxygen may be administered (see section 3.6).
Sublingual glyceryl trinitrate may relieve pain. Intramuscular injection of drugs should be avoided because absorption may be too slow (particularly when cardiac output is reduced) and pain relief is inadequate. Intramuscular injection also increases the risk of local bleeding into the muscle if the patient is given a thrombolytic drug.
Reassure the patient as much as possible to relieve further anxiety. If available, aspirin in a single dose of 300 mg should be given. A note (to say that aspirin has been given) should be sent with the patient to the hospital. For further details on the initial management of myocardial infarction, see Management of ST-Segment Elevation Myocardial Infarction.
If the patient collapses and loses consciousness attempt standard resuscitation measures. For an algorithm of the procedure for cardiopulmonary resuscitation, see section 2.7.3.
Epileptic seizures
Patients with epilepsy must continue with their normal dosage of anticonvulsant drugs when attending for dental treatment. It is not uncommon for epileptic patients not to volunteer the information that they are epileptic but there should be little difficulty in recognising a tonic-clonic (grand mal) seizure.
Symptoms and signs
There may be a brief warning (but variable)
Sudden loss of consciousness, the patient becomes rigid, falls, may give a cry, and becomes cyanotic (tonic phase)
After 30 seconds, there are jerking movements of the limbs; the tongue may be bitten (clonic phase)
There may be frothing from mouth and urinary incontinence
The seizure typically lasts a few minutes; the patient may then become flaccid but remain unconscious. After a variable time the patient regains consciousness but may remain confused for a while
Management
During a convulsion try to ensure that the patient is not at risk from injury but make no attempt to put anything in the mouth or between the teeth (in mistaken belief that this will protect the tongue). Give oxygen (section 3.6) to support respiration if necessary.
Do not attempt to restrain convulsive movements.
After convulsive movements have subsided place the patient in the coma (recovery) position and check the airway.
After the convulsion the patient may be confused (‘post-ictal confusion’) and may need reassurance and sympathy. The patient should not be sent home until fully recovered. Seek medical attention or transfer the patient to hospital if it was the first episode of epilepsy, or if the convulsion was atypical, prolonged (or repeated), or if injury occurred.
Medication should only be given if convulsive seizures are prolonged (convulsive movements lasting 5 minutes or longer) or repeated rapidly.
Midazolam oromucosal solution can be given by the buccal route in adults as a single dose of 10 mg [unlicensed]. For further details on the management of status epilepticus, including details of paediatric doses of midazolam, see Drugs used in status epilepticus.
Focal seizures similarly need very little active management (in an automatism only a minimum amount of restraint should be applied to prevent injury). Again, the patient should be observed until post-ictal confusion has completely resolved.
Hypoglycaemia
Insulin-treated diabetic patients attending for dental treatment under local anaesthesia should inject insulin and eat meals as normal. If food is omitted the blood glucose will fall to an abnormally low level (hypoglycaemia). Patients can often recognise the symptoms themselves and this state responds to sugar in water or a few lumps of sugar. Children may not have such prominent changes but may appear unduly lethargic.
Symptoms and signs
Shaking and trembling
Sweating
‘Pins and needles’ in lips and tongue
Hunger
Palpitation
Headache (occasionally)
Double vision
Difficulty in concentration
Slurring of speech
Confusion
Change of behaviour; truculence
Convulsions
Unconsciousness
Management
Initially glucose 10–20 g is given by mouth either in liquid form or as granulated sugar or sugar lumps. Approximately 10 g of glucose is available from non-diet versions of Lucozade® Energy Original 55 mL, Coca-Cola® 100 mL, Ribena® Blackcurrant 19 mL (to be diluted), 2 teaspoons sugar, and also from 3 sugar lumps22. If necessary this may be repeated in 10–15 minutes.
If glucose cannot be given by mouth, if it is ineffective, or if the hypoglycaemia causes unconsciousness, glucagon 1 mg (1 unit) should be given by intramuscular (or subcutaneous) injection; a child under 8 years or of body-weight under 25 kg should be given 500 micrograms. Once the patient regains consciousness oral glucose should be administered as above. If glucagon is ineffective or contra-indicated, the patient should be transferred urgently to hospital. The patient must also be admitted to hospital if hypoglycaemia is caused by an oral antidiabetic drug.
Syncope
Insufficient blood supply to the brain results in loss of consciousness. The commonest cause is a vasovagal attack or simple faint (syncope) due to emotional stress.
Symptoms and signs
Patient feels faint
Low blood pressure
Pallor and sweating
Yawning and slow pulse
Nausea and vomiting
Dilated pupils
Muscular twitching
Management
Lay the patient as flat as is reasonably comfortable and, in the absence of associated breathlessness, raise the legs to improve cerebral circulation
Loosen any tight clothing around the neck
Once consciousness is regained, give sugar in water or a cup of sweet tea
Other possible causes
Postural hypotension can be a consequence of rising abruptly or of standing upright for too long; antihypertensive drugs predispose to this. When rising, susceptible patients should take their time. Management is as for a vasovagal attack.
Under stressful circumstances, some patients hyperventilate. This gives rise to feelings of faintness but does not usually result in syncope. In most cases reassurance is all that is necessary; rebreathing from cupped hands or a bag may be helpful but calls for careful supervision.
Adrenal insufficiency or arrhythmias are other possible causes of syncope
Medical problems in dental practice
Individuals presenting at the dental surgery may also suffer from an unrelated medical condition; this may require modification to the management of their dental condition. If the patient has systemic disease or is taking other medication, the matter may need to be discussed with the patient’s general practitioner or hospital consultant.
For advice on adrenal insufficiency, anaphylaxis, asthma, cardiac emergencies, epileptic seizures, hypoglycaemia and syncope see under Medical Emergencies in Dental Practice.
Allergy
Patients should be asked about any history of allergy; those with a history of atopic allergy (asthma, eczema, hay fever, etc.) are at special risk. Those with a history of a severe allergy or of anaphylactic reactions are at high risk — it is essential to confirm that they are not allergic to any medication, or to any dental materials or equipment (including latex gloves). See also Anaphylaxis.
Arrhythmias
Patients, especially those who suffer from heart failure or who have sustained a myocardial infarction, may have irregular cardiac rhythm. Atrial fibrillation is a common arrhythmia even in patients with normal hearts and is of little concern except that dentists should be aware that such patients may be receiving anticoagulant therapy. The patient’s medical practitioner should be asked whether any special precautions are necessary. Premedication (e.g. with temazepam) may be useful in some instances for very anxious patients.
See also Cardiac emergencies and Dental Anaesthesia.
Cardiac prostheses
For an account of the risk of infective endocarditis in patients with prosthetic heart valves, see Infective Endocarditis. For advice on patients receiving anticoagulants, see Thromboembolic disease.
Coronary artery disease
Patients are vulnerable for at least 4 weeks following a myocardial infarction or following any sudden increase in the symptoms of angina. It would be advisable to check with the patient’s medical practitioner before commencing treatment. See also Cardiac Emergencies.
Treatment with low-dose aspirin (75 mg daily), clopidogrel, or dipyridamole should not be stopped routinely nor should the dose be altered before dental procedures.
A Working Party of the British Society for Antimicrobial Chemotherapy has not recommended antibiotic prophylaxis for patients following coronary artery bypass surgery.
Cyanotic heart disease
Patients with cyanotic heart disease are at risk in the dental chair, particularly if they have pulmonary hypertension. In such patients a syncopal reaction increases the shunt away from the lungs, causing more hypoxia which worsens the syncopal reaction — a vicious circle that may prove fatal. The advice of the cardiologist should be sought on any patient with congenital cyanotic heart disease. Treatment in hospital is more appropriate for some patients with this condition.
Hypertension
Patients with hypertension are likely to be receiving antihypertensive drugs such as those described in section 2.5. Their blood pressure may fall dangerously low under general anaesthesia, see also under Dental Anaesthesia.
Infective endocarditis
While almost any dental procedure can cause bacteraemia, there is no clear association with the development of infective endocarditis. Routine daily activities such as tooth brushing also produce a bacteraemia and may present a greater risk of infective endocarditis than a single dental procedure.
Antibacterial prophylaxis and chlorhexidine mouthwash are not recommended for the prevention of endocarditis in patients undergoing dental procedures. Such prophylaxis may expose patients to the adverse effects of antimicrobials when the evidence of benefit has not been proven.
Reduction of oral bacteraemia Patients at risk of endocarditis23 should be advised to maintain the highest possible standards of oral hygiene in order to reduce the:
need for dental extractions or other surgery;
chances of severe bacteraemia if dental surgery is needed;
possibility of ‘spontaneous’ bacteraemia.
Postoperative care Patients at risk of endocarditis23 should be warned to report to the doctor or dentist any unexplained illness that develops after dental treatment. Any infection in patients at risk of endocarditis23 should be investigated promptly and treated appropriately to reduce the risk of endocarditis.
Patients on anticoagulant therapy For general advice on dental surgery in patients receiving oral anticoagulant therapy see Thromboembolic Disease.
Pacemakers
Pacemakers prevent asystole or severe bradycardia. Some ultrasonic scalers, electronic apex locators, electro-analgesic devices, and electrocautery devices interfere with the normal function of pacemakers (including shielded pacemakers) and should not be used. The manufacturer’s literature should be consulted whenever possible. If severe bradycardia occurs in a patient fitted with a pacemaker, electrical equipment should be switched off and the patient placed supine with the legs elevated. If the patient loses consciousness and the pulse remains slow or is absent, cardiopulmonary resuscitation (see section 2.7.3) may be needed. Call immediately for medical assistance and an ambulance, as appropriate.
A Working Party of the British Society for Antimicrobial Chemotherapy does not recommend antibacterial prophylaxis for patients with pacemakers.
Thromboembolic disease
Patients receiving a heparin or an oral anticoagulant such as warfarin, acenocoumarol (nicoumalone), phenindione, apixaban, dabigatran etexilate, or rivaroxaban may be liable to excessive bleeding after extraction of teeth or other dental surgery. Often dental surgery can be delayed until the anticoagulant therapy has been completed.
For a patient requiring long-term therapy with warfarin, the patient’s medical practitioner should be consulted and the International Normalised Ratio (INR) should be assessed 72 hours before the dental procedure. This allows sufficient time for dose modification if necessary. In those with an unstable INR (including those who require weekly monitoring of their INR, or those who have had some INR measurements greater than 4.0 in the last 2 months), the INR should be assessed within 24 hours of the dental procedure. Patients requiring minor dental procedures (including extractions) who have an INR below 4.0 may continue warfarin without dose adjustment. There is no need to check the INR for a patient requiring a non-invasive dental procedure.
If it is necessary to remove several teeth, a single extraction should be done first; if this goes well further teeth may be extracted at subsequent visits (two or three at a time). Measures should be taken to minimise bleeding during and after the procedure. This includes the use of sutures and a haemostatic such as oxidised cellulose, collagen sponge or resorbable gelatin sponge. Scaling and root planing should initially be restricted to a limited area to assess the potential for bleeding.
For a patient on long-term warfarin, the advice of the clinician responsible for the patient’s anticoagulation should be sought if:
the INR is unstable, or if the INR is greater than 4.0;
the patient has thrombocytopenia, haemophilia, or other disorders of haemostasis, or suffers from liver impairment, alcoholism, or renal failure;
the patient is receiving antiplatelet drugs, cytotoxic drugs or radiotherapy.
Intramuscular injections are contra-indicated in patients taking anticoagulants with an INR above the therapeutic range, and in those with any disorder of haemostasis. In patients taking anticoagulants who have a stable INR within the therapeutic range, intramuscular injections should be avoided if possible; if an intramuscular injection is necessary, the patient should be informed of the increased risk of localised bleeding and monitored carefully.
A local anaesthetic containing a vasoconstrictor should be given by infiltration, or by intraligamentary or mental nerve injection if possible. If regional nerve blocks cannot be avoided the local anaesthetic should be given cautiously using an aspirating syringe.
Drugs which have potentially serious interactions with anticoagulants include aspirin and other NSAIDs, carbamazepine, imidazole and triazole antifungals (including miconazole), erythromycin, clarithromycin, and metronidazole; for details of these and other interactions with anticoagulants, see Appendix 1 (dabigatran etexilate, heparins, phenindione, rivaroxaban, and coumarins). Although studies have failed to demonstrate an interaction, common experience in anticoagulant clinics is that the INR can be altered following a course of an oral broad-spectrum antibiotic, such as ampicillin or amoxicillin.
Information on the treatment of patients who take anticoagulants is available at www.npsa.nhs.uk/patientsafety/alerts-and-directives/alerts/anticoagulant.
Liver disease
Liver disease may alter the response to drugs and drug prescribing should be kept to a minimum in patients with severe liver disease. Problems are likely mainly in patients with jaundice, ascites, or evidence of encephalopathy.
For guidance on prescribing for patients with hepatic impairment, see Prescribing in hepatic impairment. Where care is needed when prescribing in hepatic impairment, this is indicated under the relevant drug in the BNF.
Renal impairment
The use of drugs in patients with reduced renal function can give rise to many problems. Many of these problems can be avoided by reducing the dose or by using alternative drugs.
Special care is required in renal transplantation and immunosuppressed patients; if necessary such patients should be referred to specialists.
For guidance on prescribing in patients with renal impairment, see Prescribing in renal impairment. Where care is needed when prescribing in renal impairment, this is indicated under the relevant drug in the BNF.
Pregnancy
Drugs taken during pregnancy can be harmful to the fetus and should be prescribed only if the expected benefit to the mother is thought to be greater than the risk to the fetus; all drugs should be avoided if possible during the first trimester.
For guidance on prescribing in pregnancy, see Prescribing in pregnancy. Where care is needed when prescribing in pregnancy, this is indicated under the relevant drug in the BNF.
Breast-feeding
Some drugs taken by the mother whilst breast-feeding can be transferred to the breast milk, and may affect the infant.
For guidance on prescribing in breast-feeding, see Prescribing in breast-feeding. Where care is needed when prescribing in breast-feeding, this is indicated under the relevant drug in the BNF.
Drugs and sport
UK Anti-Doping, the national body responsible for the UK’s anti-doping policy, advises that athletes are personally responsible should a prohibited substance be detected in their body. An advice card listing examples of permitted and prohibited substances is available from:
- UK Anti-Doping
- Oceanic House
- 1a Cockspur Street
- London
- SW1Y 5BG
- Tel: (020) 7766 7350
- Email: information@ukad.org.uk
- www.ukad.org.uk
General Medical Council’s advice
Doctors who prescribe or collude in the provision of drugs or treatment with the intention of improperly enhancing an individual’s performance in sport contravene the GMC’s guidance, and such actions would usually raise a question of a doctor’s continued registration. This does not preclude the provision of any care or treatment where the doctor’s intention is to protect or improve the patient’s health.
Emergency treatment of poisoning
These notes provide only an overview of the treatment of poisoning, and it is strongly recommended that either TOXBASE or the UK National Poisons Information Service (see below) be consulted when there is doubt about the degree of risk or about management.
Hospital admission Patients who have features of poisoning should generally be admitted to hospital. Patients who have taken poisons with delayed action should also be admitted, even if they appear well. Delayed-action poisons include aspirin, iron, paracetamol, tricyclic antidepressants, and co-phenotrope (diphenoxylate with atropine, Lomotil®); the effects of modified-release preparations are also delayed. A note of all relevant information, including what treatment has been given, should accompany the patient to hospital.
Further information and advice
TOXBASE, the primary clinical toxicology database of the National Poisons Information Service, is available on the internet to registered users at www.toxbase.org (a backup site is available at www.toxbasebackup.org if the main site cannot be accessed). It provides information about routine diagnosis, treatment, and management of patients exposed to drugs, household products, and industrial and agricultural chemicals.
Specialist information and advice on the treatment of poisoning is available day and night from the UK National Poisons Information Service on the following number:
- Tel: 0844 892 0111
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