Alternatives to regular medication normally given via a syringe pump - condensed information

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Pain/breathlessness/cough/pyrexia
Medicine	Route	Dose	Administration/ Comments
Paracetamol suppositories 500mg and 1g	Rectal Short acting	500mg to 1g every 4 to 6 hours (max 4g/24hrs)	Use 500mg dose if: Weight <50kg, hepatic impairment, eGFR<30ml/min, history of alcohol excess.
Buprenorphine Patch – 5micrograms/hr 10micrograms/hr Larger doses available for converting from other opioids – 15, 20, 35, 52.5, 70 micrograms/hr	Transdermal Long acting	Opioid naïve – 5 micrograms/hr patch – equivalent to 12mg oral morphine/24 hr On regular opioid – 20micrograms/hr patch equivalent to 48mg oral morphine/24 hr	Note: some brands are 7 day patches and some 3 or 4 day patches.
Fentanyl matrix patch 12, 25, 50, 75, or 100micrograms/hr	Transdermal Long acting	Convert from current regular opioid. 12 micrograms/hr patch equivalent to 30mg to 60mg of oral morphine in 24 hours	Change every 3 days 12micrograms/hr patch can be halved (diagonally) to give a 6micrograms/hr dose†. 6micrograms/hr equivalent to 15mg to 30mg oral morphine in 24 hours.
MST Continus® tablets can be given rectally†.	Rectal Long acting	Convert from current oral opioid dose	MST tablets can be given rectally although the absorption is not as reliable as orally. Dose as per oral MST dose.
Diclofenac sodium suppositories 25mg, 50mg, 100mg	Rectal Long acting	75mg to 150mg daily in two divided doses	Avoid in renal impairment. Use with caution in Covid-19 patients.
Nausea and vomiting
QT †Prochlorperazine 3mg buccal tablets (Buccastem®)	Buccal Short acting	3mg to 6mg every 6 to 12hr	Maximum 12mg per day.
QT †Ondansetron 4mg orodispersible tablets	Oro-dispersible Short acting	4mg 6 to 8 hourly, up to maximum 16mg/24hrs.	Place on tongue and allow to dissolve. Mouth must be moist.
QT †Levomepromazine injection 25mg/ml	Sublingual or buccal Long acting	2.5mg every 4 to 6 hours as required	The injection solution can be used off label by the sublingual or the buccal route
†Hyoscine hydrobromide 1.5mg patches (1mg in 72 hr) (Scopoderm®)	Transdermal patch Long acting	1 to 4 patches every 72 hours	Apply behind ear. Watch for delirium.
QT †Olanzapine oro-dispersible tablets 5mg, 10mg	Sublingual Long acting	2.5mg stat dose and every 2 to 4 hours if required. Maximum dose 10mg daily	Place on or under tongue and allow to dissolve 5mg tablet can be halved and the other half discarded safely.
Respiratory secretions
Medicine	Route	Dose	Administration/ Comments
†Hyoscine hydrobromide 1.5mg patches (1mg in 72 hr)	Transdermal patch Long acting	1 to 4 patches every 72 hours	Apply behind ear. Watch for delirium.

†Hyoscine hydrobromide Kwells®)300microgram tablets	Sublingual or buccal Short acting	300 micrograms every 6 hours	Watch for delirium Maximum 1.2mg/24hrs
†Atropine 1% eye drops	Sublingual Short acting	2 to 4 drops every 4 hours	Watch for delirium. Caution in cardiac disease. Do not administer via eyes.
†Glycopyrronium bromide injection 200microgram/ml	Sublingual Short acting	200 microgram every hour as required	Maximum 1.2mg/24h. Higher doses can be used under specialist advice.
†Ipratropium 2 puffs via inhaler and spacer or 250micrograms via nebuliser	Inhaled Short acting	Every 4 to 6 hours
Anxiety and distress, for example associated with breathlessness
†Lorazepam 1mg tablets (blue, scored tablets)	Sublingual Short acting	500 micrograms every 4 hours as required	Put half a tablet under the tongue and leave to dissolve.
†Midazolam Buccal preparation or midazolam injection 10mg/2ml	Buccal Short acting	2.5mg every hour as required	Buccolam® or Epistatus® (NB. Buccolam® 5mg/ml as 2.5mg, 5mg, 7.5mg and 10mg or Epistatus® 10mg/ml)
Diazepam 2.5mg, 5mg or 10mg rectal tubes	Rectal Short acting	2.5mg to 5mg every 4 to 6 hours†
Delirium and agitation
QT †Levomepromazine injection 25mg/ml	Sublingual or buccal Long acting	5mg or 6mg every 2 to 4 hours as required	The injection solution can be used off label by the sublingual or the buccal route May be advised to give higher doses or more frequently on specialist advice.
QT †Olanzapine oro-dispersible tablets 5mg, 10mg	Sublingual Long acting	2.5mg at night and 2.5mg every 4 hours as required Up to maximum 10mg in 24 hours	Place under tongue and allow to dissolve. 5mg tablet can be halved and the other half discarded safely.
QT †Risperidone oro-dispersible tablets 500micrograms, 1mg, 2mg, 3mg, 4mg	Sublingual Long acting	Start with 500 micrograms every 12 hours	Place under tongue and allow to dissolve.
If antipsychotics are contraindicated, midazolam can be given via the buccal route, however benzodiazepines can worsen delirium so are not used first line. Benzodiazepines can be used first line for agitation.
†Midazolam Buccal preparation or midazolam injection 10mg/2ml	Buccal Short acting	2.5mg every hour as required	Buccolam® or Epistatus® (NB. Buccolam® 5mg/ml as 2.5mg, 5mg, 7.5mg and 10mg or Epistatus® 10mg/ml)
Seizures
Midazolam Buccal preparation or midazolam injection 10mg/2ml	Buccal Short acting	10mg as required for seizure. Can repeat after 15 minutes	Buccolam® or Epistatus® (NB. Buccolam® 5mg/ml as 2.5mg, 5mg, 7.5mg and 10mg or Epistatus® 10mg/ml)
Diazepam 5mg or 10mg rectal tubes	Rectal Short acting	10mg in event of seizure
Carbamazepine suppositories 125mg, 250mg	Rectal Long acting	Convert previous oral dose and give twice daily – not for use in new seizures	Administer rectally. 125mg suppository equivalent to 100mg orally.