Prescribing

Key points

  • Issues related to safe use of medicines in palliative care are important to consider. They include:
    • Monitoring for effectiveness and adverse effects
    • Minimising burden on patients
    • Safety of opioid use and disposal  
    • Complexities of opioid prescribing
    • Polypharmacy
    • Deprescribing
  • Be aware that some medications have a specific palliative care listing or require an authority prescription.  
  • A palliative care listing allows larger quantities of medications to be prescribed, to reduce burden in terms of costs and need for repeat prescriptions
  • Palliative care listings are 'authority required' - an initial authority is requested for a 4 month supply for palliative care patients. Subsequent prescriptions require confirmation that a palliative care service has been consulted
  • For palliative care patients, it is best to use the palliative care listing and not the general benefits system if a drug is available in both lists
  • For long-term opioids, using authority scripts is extremely helpful for the patient as standard scripts provide very small quantities.
  • Be aware of non-PBS medications that are sometimes recommended for palliative care patients.
    • Sometimes non-PBS medications may be essential, with no suitable PBS alternatives - discussion with the prescriber is helpful to clarify this. If non-PBS listed medications are required, a plan for how the patient can access them will be needed as well
    • The commonest are cyclizine (an antihistamine for nausea), and levomepromazine (also called methotrimeprazine - an antipsychotic for nausea and/or agitated delirium). They are obtainable via the Special Access Scheme
    • Sometimes a hospital pharmacy or palliative care service will take responsibility for ongoing supply and management of such medications.
  • 'Off-label' medications are often prescribed for palliative care patients
    • These are medications prescribed for a different indication or route than the one for which they are approved by the TGA, for example:
      • Antipsychotics or antihistamines for nausea
      • Antidepressants or anticonvulsants for neuropathic pain
      • Administration of IV preparations by the subcutaneous route, and in combination
  • Evidence for off-label use of these medications may be available, but has sometimes not been used by the drug company to obtain a listing for their medication
  • Generally there is considerable clinical experience with the common off-label uses of medications in palliative care. Your local palliative care team can advise you on their own approach. 
  • Useful Tip

In general, injectable medications that do not require dilution or a separate diluent can safely be given subcutaneously, with the exception of prochlorperazine and diazepam.

Pharmaceutical benefits - Palliative care items

The PBS website lists preparations which may be prescribed specifically for patients receiving palliative care:  

Ref: The Pharmaceutial Benefits Scheme. Browse by Palliative Care [Internet]. Commonwealth of Australia; [cited 2015 Mar 6].

Special Access Scheme (SAS) - Accessing medications not on the PBS 

The SAS refers to arrangements which provide for the import and / or supply of an unapproved therapeutic good for a single patient, on a case by case basis.  Palliative care patients meet the criteria for category A. Category A patients are defined as 'persons who are seriously ill with a condition from which death is reasonably likely to occur within a matter of months, or from which premature death is reasonably likely to occur in the absence of early treatment'.

Ref: Thererapeutic Goods Administration. Special access scheme [Internet]. Commonwealth of Australia; 2015 [updated 2015 Jan 28; cited 2015 Mar 6].

Editorial - Off-label prescribing

Off-label prescribing
'Off-label prescribing means that the Therapeutic Goods Administration (TGA) has not approved the indication, route of administration or patient group. It does not mean that the TGA has rejected the indication. Commonly the TGA has not been asked to evaluate the indication.'

Ref: Day R. Off-label prescribing. Australian Prescriber. 2013 Dec;36(6):182-3.

Discussion paper - Use of 'off label' or drugs beyond licence in pain medicine

Use of 'off label' or drugs beyond licence in pain medicine (449kb pdf)
Discusses problems relating to off-label prescribing, which include 'a relative lack of readily available information for prescribers, nurses and consumers about the unapproved use of some medications and especially the higher risk of adverse drug reactions. Consumers should give fully informed consent to the use of off-label or unlicensed drug use'.
 
Clinicians may have conflicting ethical, legal and social responsibilities in regard to off-label prescribing. The discussion paper suggests a strategy to assist clinician decision making.

From: Faculty of Pain Medicine, Australian New Zealand College of Anaesthetists (2007)

Off Licence Prescribing in Palliative Care: A systematic review and narrative synthesis

Drug use beyond the licence in palliative care: A systematic review and narrative synthesis
Subscription or Institution access required

Ref: Hagemann V, Bausewein C, Remi C. Drug use beyond the licence in palliative care: A systematic review and narrative synthesis. Palliat Med. 2019 Jun;33(6):650-62.

Last updated 21 February 2017