Makindo Medical Notes

💡 Key point: Buprenorphine and Alfentanil are considered safe in patients with renal impairment. ✅ No dose adjustments are needed with transdermal buprenorphine. ⚠️ Morphine, diamorphine, and codeine derivatives produce toxic metabolites that accumulate in renal failure → avoid in stage 4/5 CKD.

📘 About

• Always check the BNF for up-to-date prescribing advice.

🤢 Nausea & Vomiting

• Common in renal impairment – may be due to uraemia, co-morbidities, or medication side effects.
• Haloperidol: 0.5–1 mg SC/IV/PO every 8 hours.
• Levomepromazine: 2.5–5 mg SC every 12 hours.

💉 Opioids for Pain & Breathlessness (Opioid-naïve)

Titrate to symptoms. Avoid morphine/codeine in advanced renal failure.

• Morphine (Oramorph): 5 mg PO every 4 hours as required.
• Morphine (modified release): 10 mg PO every 12 hours.
• Morphine SC: 2–5 mg every 4 hours, or 20 mg over 24 hours via syringe driver.
• Diamorphine SC: 1.25–2.5 mg every 4 hours, or 10 mg over 24 hours via syringe driver.
• Buprenorphine: Standard dosing, safe in renal failure.
• Alfentanil: 0.5–1 mg SC over 24 hours (syringe driver). Breakthrough: 0.1 mg SC PRN. Preferred in stage 4/5 renal failure.

💧 Anti-secretory (Respiratory Secretions)

• Repositioning first; avoid suction if possible (can worsen distress).
• Hyoscine butylbromide (Buscopan): 20 mg SC, repeat hourly PRN. Max 120 mg/24 hrs.
• Glycopyrronium: 100 micrograms SC every 6–8 hours as required (second-line).

😟 Anxiolytic Sedatives (Anxiety, Agitation, Breathlessness)

• Midazolam: 2 mg SC hourly PRN, or 5–10 mg/24 hrs via syringe driver.
• Lorazepam: 500 micrograms sublingual every 8 hours PRN.
• If worsening agitation: • Haloperidol 0.5–1 mg SC every 8 hours. • Levomepromazine 10–25 mg SC every 12 hours (use lower doses in frail elderly).

⚡ Myoclonus, Spasm, or Seizure

• Midazolam: 5–10 mg SC infusion over 24 hrs (can titrate up to 20 mg).
• Clonazepam: 500 micrograms PO or SC at night (specialist advice).
• Consider opioid toxicity → rotate to Alfentanil if not already used.

🔥 Terminal Agitation

• Seek specialist advice if delirium/agitation worsening.
• Step 1: Midazolam 10–20 mg SC/24 hrs via syringe driver + 5 mg SC hourly PRN.
• Step 2: Titrate Midazolam (up to 60 mg/24 hrs under specialist supervision).
• Levomepromazine: • Low dose: 2.5–5 mg SC every 2 hrs PRN if frail or naïve. • Higher dose: 10–25 mg SC every 2 hrs PRN for persistent delirium/distress. • May need hourly dosing initially until controlled.

📖 References

• Scottish Palliative Care Guidelines – Anticipatory Prescribing