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Orodispersible and transmucosal alternative medications for symptom control in adults
  1. Anna Elizabeth Sutherland1,
  2. Melinda Presland1,
  3. Emily Harrop2,3,
  4. Matthew Carey1,
  5. Mary Miller3,4 and
  6. Ian Chi Kei CK Wong5,6
  1. 1 Palliative Medicine, Sir Michael Sobell House Hospice, Oxford, UK
  2. 2 Paediatric Palliative Medicine, Helen and Douglas House, Oxford, UK
  3. 3 Palliative Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  4. 4 Palliative Care, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  5. 5 Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
  6. 6 Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong, China
  1. Correspondence to Dr Anna Elizabeth Sutherland, Palliative Medicine, Sir Michael Sobell House Hospice, Oxford OX3 7LE, UK; annasutherland{at}


Background Paediatric palliative care makes frequent use of orodispersible and transmucosal drug delivery routes. The limited published experience of this practice suggests that it enables the delivery of needle-free symptom relief, with the potential to train family carers to administer anticipatory medications without reliance on trained health professionals.

Aims To identify orodispersible and potential transmucosal alternatives that may be used in adults in the event of a patient having no oral or intravenous route and no access to subcutaneous injections.

Methods The author panel identified medications through review of multiple drug formularies, review of the published evidence and their experience. Where possible, licensed alternatives were identified and any ‘off label’ or unlicensed medications clearly highlighted.

Results A list of 27 medications is provided, which could be used either via the orodispersible or transmucosal alternative route for healthcare professionals delivering end of life care to consider when the licensed alternative routes are unavailable. All users of this guide are encouraged to use their professional judgement whenever selecting a medication for a patient, recognising that this review is neither a guideline nor a systematic review, and taking account of licensing considerations, adverse effects, potential unpredictability of time to effect and contraindications.

Conclusion Should it be necessary to use these orodispersible or transmucosal alternatives then any experience gained should be reported in the literature. Combined with further research, this experience offers the possibility of reducing injection frequency and inherent delays in medication administration, particularly in the community setting during the COVID-19 pandemic.

  • drug administration
  • home care
  • pharmacology
  • terminal care

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  • Contributors AES drafted the manuscript, undertaking the literature search and constructing the tables for each drug listed assisted by MP and EH. AES, MP, EH, MC, MM and ICKW jointly agree the drugs to include in the manuscript. MP, EH, MC, MM and ICKW had supervising input throughout the drafting the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests ICKW is the founder of Therakind Ltd (UCL spin-off company) which developed Buccolam (buccal midazolam) and Ayendi (intranasal diamorphine).

    ICKW and EH received funding from the NIHR in England to investigate transmucosal use of diamorphine in paediatric palliative care.

  • Provenance and peer review Not commissioned; internally peer reviewed.