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News and updates from
  1. Andrew Wilcock1 and
  2. Sarah Charlesworth2
  1. 1Palliative Medicine, University of Nottingham, Nottingham, UK
  2. 2Hayward House Study Centre, Nottingham University Hospitals,, Nottingham, UK
  1. Correspondence to Sarah Charlesworth, Hayward House Study Centre, Nottingham University Hospitals,, City Campus, Hucknall Road, Nottingham NG5 1PB, UK; s.charlesworth{at}

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The website http:\\ has provided essential independent information about drugs used in palliative and hospice care for over a decade, and has over 30 000 members from 169 countries. It contains the online Palliative Care Formulary (PCF) and provides free access to a Bulletin board to stimulate questions and share experiences, a Document library containing 475 items of useful information and a Syringe Driver Survey Database containing details of over 2350 different drug combinations. Territory-specific book versions (the UK Palliative Care Formulary 5th edition, Hospice and Palliative Care Formulary USA 2nd edition and Palliative Care Formulary Canadian edition), a PDF version of the PCF and subscription to the continually updated online PCF can also be purchased via the website. This feature provides a selection of items that have featured in the News and Latest additions sections in recent months; for additional information, please register for free on the website.

Safety updates

Enhanced warnings for opioids

US Food and Drug Administration (FDA) has announced class-wide enhanced labelling warnings for:

  • immediate-release opioid pain medications, in relation to risks of misuse, abuse, addiction, overdose and death similar to those added to modified-release formulations in 2013;

  • immediate-release and modified-release formulations, in relation to the undesirable effects on the endocrine system, and also the potential for interaction with other medicines resulting in serotonin toxicity.

The updated indication for immediate-release opioids states that they should be reserved for pain severe enough to require opioid treatment and for which alternative treatment options (eg, non-opioid analgesics or opioid combination products) are inadequate or not tolerated. The dosing information also provides clearer instructions regarding patient monitoring and drug administration, including initial dosage, dosage changes during therapy and a warning not to abruptly stop treatment in a physically dependent patient. In addition, a precaution that chronic maternal use of opioids during pregnancy can result in neonatal opioid withdrawal syndrome has been added.

Reminder of fire risk with paraffin-based emollients

UK Medicines and Healthcare products Regulatory Agency (MHRA) has reminded health professionals to warn patients using paraffin-based emollients, not to smoke or use naked flames (or be near people smoking or using naked flames) due to the risk of clothing or dressings catching fire. The risk is greatest when these preparations are applied to large areas of the body, or when dressings or clothing become soaked with emollient. Patients should also be advised to change clothing and bedding regularly.

Topical miconazole interaction with warfarin

MHRA has highlighted the risk of serious bleeding events in patients taking warfarin and using cream, ointment, powder or oral gel formulations of miconazole. The potential for a drug interaction between oral miconazole and warfarin is well documented due to miconazole inhibiting the CYP2C9 enzyme involved in the metabolism of warfarin. The MHRA are now receiving a large number of reports of potential drug interactions involving topical miconazole (particularly the oral gel formulation) and warfarin, and are now reviewing whether further measures are needed to minimise the risks to patients. In the mean time, their advice is to carefully monitor the anticoagulant effect and reduce the dose of warfarin if necessary. As some topical formulations of miconazole are available without prescription, patients taking warfarin should be warned not to use topical miconazole without consulting their doctor.

Hot topics

Guidance for the prescribers of specials

The Royal Pharmaceutical Society (RPS) has published guidance for the prescribers of specials. This was produced at the request of the National Institute for Health and Care Excellence (NICE) and can be downloaded from the RPS website. It complements the RPS professional guidance for the procurement and supply of specials published in December 2015.

Neuropathic pain: pregabalin and gabapentin prescribing

The latest PrescQIPP bulletin discusses dose optimisation of pregabalin and cost-effectiveness in line with authorised indications and guidance from National Health Service (NHS) England and NICE.

Fentanyl transdermal patient-controlled system

NICE has published an evidence summary for the new fentanyl transdermal system (IONSYS) that was launched earlier this year in the UK. It is authorised for the treatment of moderate–severe postoperative pain in adults (hospital use only).

NICE conclude that the fentanyl transdermal system has comparable efficacy to intravenous morphine patient-controlled analgesia (PCA). Its undesirable effect profile is as expected for an opioid used in postoperative pain, and is similar to that of intravenous morphine PCA. They report a better patient satisfaction than intravenous morphine PCA but a higher drug cost.

Sufentanil sublingual tablet patient-controlled system

NICE has published an evidence summary for a new sufentanil sublingual tablet system (Zalviso; Grunenthal) which is due to be launched in September 2016. The new tablet system is programmed to dispense a single 15 μg sufentanil tablet on a patient-controlled basis to manage moderate–severe postoperative pain. The tablets are contained within a cartridge which must be used with the Zalviso administration device. This controls the dispensing of the tablet in response to patient activation with a lockout period of 20 min. The cost of the system has not yet been released.

Safe use and management of controlled drugs: NICE guideline published

NICE has published the final guideline for the safe use and management of controlled drugs (NG46) that was available for consultation in October 2015. The guideline covers prescribing, obtaining, supply, administration, handling, recording and monitoring of controlled drugs in all NHS settings in England, except care homes. Managing and using controlled drugs in care homes is included in the separate NICE guideline (SC1).

Administration of medicines in care homes by care assistants

UK Department of Health has published evidence-based guidance for care home providers on the administration of medicines in care homes (with nursing) by care assistants.

Cochrane review: opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness

This new Cochrane review (CD011008) has been published in full online. The authors concluded that there was some low-quality evidence that showed a benefit of using oral or injectable opioid drugs for the treatment of the symptoms of breathlessness. There was no evidence for nebulised opioids.

Chronic heart failure patient information booklet

Scottish Intercollegiate Guidelines Network has published a patient booklet based on SIGN clinical guideline 147: management of chronic heart failure.

End-of-Life Care toolkit

The Royal College of General Practitioners has launched a Palliative and End-of-Life Care toolkit for health professionals, patients and carers in general practice. We are pleased to note that is listed as one of the clinical resources providing best practice guidance for the treatment of patients at the end of life.

Methadone for pain in palliative care

A 1-hour online course on the use of methadone for pain in palliative care has been launched by Canadian Virtual Hospice. It is accredited as a Royal College Accredited Group Learning Activity (free for those in Canada).

e-Learning Indian palliative care course

eCancer has launched a text only version of the palliative care e-learning course for health professionals in India.

Drug updates

New naproxen suspension available in UK

A new authorised naproxen oral suspension 125 mg/5 mL (Orion Pharma) is now available. The NHS indicative cost is £110 for 100 mL. This is significantly more expensive than the tablets or the effervescent tablets and the previously unauthorised special order product. The effervescent tablets are now accepted by the Scottish Medicines Consortium for use in NHS Scotland for patients with swallowing difficulties.

New buprenorphine transdermal patches available in UK

Lower strength

Qdem pharmaceuticals has launched a branded generic buprenorphine transdermal patch (Butec) in strengths of 5, 10 and 20 µg/hour.

Napp pharmaceuticals has launched an additional buprenorphine transdermal patch (BuTrans) of 15 µg/hour to add to its current range of 5, 10 and 20 µg/hour.

Higher strength

Two types of generic buprenorphine transdermal patches in the higher strengths of 35, 52.5 and 70 µg/hour are now available in addition to the branded generic (Hapoctasin; Actavis) and the original brand (Transtec; Napp).

Latest additions

Survey results

Results from our levomepromazine for antiemesis survey (April–May 2016) are available on the Latest additions section of the website.

Introducing Palliative Care 5th edition now available

We are pleased to announce that Introducing Palliative Care, 5th edition (IPC5) is now available to purchase from for £25 (including p&p in the UK).

IPC5 has moved from a single authorship to a collaborative project between editorial team and eight new contributors. Updates include:

  • Covering the Association for Palliative Medicine of Great Britain and Ireland recommended curriculum for medical undergraduates;

  • Expanded sections on ethics, law, children and symptom management;

  • The Essential Palliative Care Formulary, and a synoptic table of drug doses for common symptoms.

IPC5 has already received high praise and the University of Nottingham has adopted it as a core text and distributed a copy to each final year student. To purchase a copy and help support, please go to website store. For enquiries regarding multiple copies, contact

PCF updated monographs

The online PCF is being continually updated. Some of the website monographs now supersede those in the PCF 5th edition printed and PDF versions. The updated monographs can be accessed from the formulary section of the http:\\ website. A monthly summary and full list of all the monographs updated since the publication of PCF5 can be found on the Latest additions section of the http:\\ website. In addition, follow @palliativedrugs on twitter for the latest updates. Health on the Net code accreditation extended

We are delighted to report that has been reaccredited for the 15th year running by the Health on the Net (HON) foundation and complies with the HON code standard for trustworthy health information.

The HON certificate serves as a guarantee that our website, at the date of its certification, complies with and pledges to honour the eight principles of the HON Code of Conduct as drawn up by the HON foundation.

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  • Competing interests None declared.

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