💡 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

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Palliation prescribing