Section 19
Supportive & Palliative Neurology
Opioids, antiemetics, secretion control, mood and bowel medications used in neurologic and palliative care
20 AGENTS
Morphine
MS Contin / Roxanol / genericOpioid agonist (CII)
- Forms
- IR tab: 15, 30mg | ER tab: 15, 30, 60, 100, 200mg | Soln: 10mg/5mL, 20mg/mL | Inj: 2, 4, 10mg/mL
- Dose
- Opioid-naive pain or dyspnea: 2.5-10mg PO every 4h as needed (start low in frail or renally impaired); IV/SC 1-5mg every 3-4h; titrate to effect
- MOA
- μ-opioid receptor agonism
Hydromorphone
DilaudidOpioid agonist (CII)
- Forms
- Tab: 2, 4, 8mg | Soln: 1mg/mL | Inj: 1, 2, 4mg/mL
- Dose
- Opioid-naive: 1-2mg PO every 4-6h as needed; IV 0.2-1mg every 2-3h; preferred over morphine in renal impairment
- MOA
- μ-opioid receptor agonism
Oxycodone
Roxicodone / OxaydoOpioid agonist (CII)
- Forms
- Tab: 5, 10, 15, 20, 30mg | Soln: 5mg/5mL, 100mg/5mL
- Dose
- Opioid-naive: 5mg PO every 4-6h as needed; titrate to effect
- MOA
- μ-opioid receptor agonism
Fentanyl
Duragesic / genericOpioid agonist (CII)
- Forms
- Patch: 12, 25, 50, 75, 100mcg/h | Inj: 50mcg/mL
- Dose
- Transdermal only in opioid-tolerant patients (at least 60mg oral morphine equivalents/day for 1 week): change every 72h; IV 25-100mcg boluses
- MOA
- Potent μ-opioid receptor agonism
Methadone
Dolophine / MethadoseOpioid agonist + NMDA antagonist (CII)
- Forms
- Tab: 5, 10mg | Soln: 5, 10mg/5mL, 10mg/mL
- Dose
- Neuropathic or refractory pain (specialist-guided): start 2.5mg every 8-12h; nonlinear opioid conversion; QTc monitoring
- MOA
- μ-opioid agonism with NMDA receptor antagonism and monoamine reuptake inhibition
Metoclopramide
ReglanD2 antagonist prokinetic
- Forms
- Tab: 5, 10mg | ODT: 5, 10mg | Soln: 5mg/5mL | Inj: 5mg/mL
- Dose
- Gastroparesis or nausea: 5-10mg 30 min before meals and at bedtime; avoid beyond 12 weeks; avoid in Parkinson's disease
- MOA
- D2 and 5-HT3 blockade, 5-HT4 agonism
Prochlorperazine
CompazinePhenothiazine antiemetic
- Forms
- Tab: 5, 10mg | Supp: 25mg | Inj: 5mg/mL
- Dose
- Nausea: 5-10mg PO every 6-8h, or 25mg PR every 12h; avoid in Parkinson's disease
- MOA
- D2 blockade at the chemoreceptor trigger zone
Olanzapine
ZyprexaAtypical antipsychotic
- Forms
- Tab: 2.5, 5, 7.5, 10, 15, 20mg | ODT | IM: 10mg
- Dose
- Delirium or refractory nausea (off-label): 2.5-5mg at bedtime or divided; titrate cautiously
- MOA
- D2, 5-HT2A, H1 and muscarinic antagonism
Atropine 1% (sublingual drops)
Isopto Atropine (ophthalmic, used SL)Anticholinergic
- Forms
- Ophthalmic solution: 1% (10mg/mL)
- Dose
- Sialorrhea or terminal secretions (off-label): 1-2 drops sublingually every 4h as needed
- MOA
- Muscarinic receptor antagonism
Hyoscyamine
Levsin / LevbidAnticholinergic
- Forms
- Tab: 0.125mg | SL tab: 0.125mg | ODT: 0.125mg | ER: 0.375mg | Soln: 0.125mg/mL | Inj: 0.5mg/mL
- Dose
- Sialorrhea or secretions: 0.125-0.25mg SL/PO every 4h as needed (max 1.5mg/day)
- MOA
- Muscarinic receptor antagonism
Sertraline
ZoloftSSRI
- Forms
- Tab: 25, 50, 100mg | Soln: 20mg/mL
- Dose
- Depression or anxiety: start 25-50mg daily, usual 50-200mg/day
- MOA
- Selective serotonin reuptake inhibition
Escitalopram
LexaproSSRI
- Forms
- Tab: 5, 10, 20mg | Soln: 1mg/mL
- Dose
- Depression or anxiety: start 5-10mg daily, max 20mg/day (10mg max in older adults and hepatic impairment)
- MOA
- Selective serotonin reuptake inhibition
Mirtazapine
RemeronNoradrenergic and specific serotonergic antidepressant
- Forms
- Tab: 7.5, 15, 30, 45mg | ODT: 15, 30, 45mg
- Dose
- Depression with insomnia, anorexia or nausea: start 7.5-15mg at bedtime, up to 45mg/day
- MOA
- α2 antagonism with 5-HT2 and 5-HT3 and H1 blockade
Buspirone
BuSparAnxiolytic (azapirone)
- Forms
- Tab: 5, 7.5, 10, 15, 30mg
- Dose
- Anxiety: start 5mg two to three times daily, usual 20-30mg/day, max 60mg/day
- MOA
- 5-HT1A partial agonism
Dronabinol
Marinol / SyndrosCannabinoid (CIII)
- Forms
- Cap: 2.5, 5, 10mg | Soln: 5mg/mL (Syndros)
- Dose
- Appetite or nausea: 2.5mg twice daily (before lunch and dinner), titrate; also used off-label for spasticity or pain
- MOA
- CB1/CB2 receptor agonism
Senna
SenokotStimulant laxative
- Forms
- Tab: 8.6, 17.2mg | Syrup: 8.8mg/5mL
- Dose
- Opioid-induced or neurogenic constipation: 8.6-17.2mg at bedtime, up to twice daily
- MOA
- Stimulates colonic motility and secretion
Polyethylene glycol 3350
MiraLAXOsmotic laxative
- Forms
- Powder: 17g per dose
- Dose
- Constipation: 17g in 120-240mL fluid once daily, titrate
- MOA
- Retains water in the stool through osmosis
Bisacodyl
DulcolaxStimulant laxative
- Forms
- Tab: 5mg | Supp: 10mg
- Dose
- Constipation: 5-15mg PO daily, or 10mg PR daily for neurogenic bowel programs
- MOA
- Stimulates enteric neurons and colonic secretion
Methylnaltrexone
RelistorPeripheral μ-opioid antagonist
- Forms
- SC: 8mg/0.4mL, 12mg/0.6mL | Tab: 150mg
- Dose
- Opioid-induced constipation: SC 8mg (38 to under 62kg) or 12mg (62-114kg) every other day; tablets 450mg once daily in chronic non-cancer pain
- MOA
- Blocks gut μ-opioid receptors without reversing central analgesia
Naloxone
Narcan / Evzio / ZimhiOpioid antagonist
- Forms
- Nasal: 4mg | Inj: 0.4mg/mL | Auto-injector: 5mg (Zimhi)
- Dose
- Opioid overdose: 4mg intranasal repeated every 2-3 min, or 0.4-2mg IV/IM/SC every 2-3 min; titrate small doses (0.04mg) for opioid-induced respiratory depression in palliative care
- MOA
- Competitive μ-opioid receptor antagonism