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Prescribing for the syringe driver

Which medications should I prescribe?

Four groups of drugs are commonly prescribed:

Typical doses and indications are listed in the Brief guide to drugs for the syringe driver.

Prescriptions are generally written as dose/24 hours. Unless you are prescribing the maximum 24 hour dose in the syringe driver, an additional prescription for prn bolus doses through a separate butterfly (with frequency and maximum 24 hour dose) is helpful.

Additional prn bolus doses of analgesia should always be prescribed and available for administration by nursing staff as required.

What diluent is best to use?

Water is generally recommended unless there are problems with site irritation.

Can I mix medications in the same syringe?

Generally there are few compatibility problems with common two and three drug combinations containing:

Watch out for problems with:

Incompatibility problems can usually be resolved by changing the drugs, giving a drug as a single daily injections, or as a last resort, setting up two syringe drivers.

Drug Problem Solution
Cyclizine Precipitates with saline and with diamorphine doses exceeding 200mg/24 hours. Use water as diluent. At higher diamorphine doses, either put cyclizine in a second syringe driver or use levomepromazine as a single daily SC injection instead.
Ketorolac Incompatible with many drugs Use a separate syringe driver
Dexamethasone Inactivates glycopyrrollate. Common and unpredictable precipitation with other drugs. Use hyoscine hydrobromide instead of glycopyrrollate Give dexamethasone as separate once daily injection.
Hyoscine butyl bromide (Buscopan) Occasional incompatibility with cyclizine. Give levomepromazine as a single daily injection in place of cyclizine.

Table: Solutions to drug incompatibility problems

More detailed information is available from:

Key Points


The syringe driver: Continuous subcutaneous infusions in palliative care Andrew Dickman, Jennifer Schneider, James Varga (2nd edition) 2005 Oxford University Press

Department of Health, London Doing no harm The medical devices directorate 1994

Department of Health, London The report of the expert working group on alarms and clinical monitors The medical devices directorate 1995

MS16A and MS26 Instruction manual. SIMS Graseby 1998

Oliver DJ Syringe drivers in palliative care: a review Palliative Medicine 1988 2 21-26

Symptom management in advanced cancer Robert Twycross, Andrew Wilcock (3rd edition) Radcliffe Medical Press

A Guide to symptom relief in advanced cancer Claud Regnard, Sue Tempest (5th edition,) 2004 Radcliffe Medical Press

ABC of Palliative care Marie Fallon, Geoff Hanks (Eds) 2006 Blackwell

Palliative Care Formulary Robert Twycross, Andrew Wilcock (3rd edition) 2007 Ltd.

© Dr. Eileen Palmer, Dr John Howarth Palliative Care for the Primary Health Care Team (2009) Quay Books ISBN 1856422291
© Palliative care syringe driver pack 2 Dr Eileen Palmer 2009

Important News

Important Changes in Cumbria Palliative Care Prescribing Practice

Cumbria is changing practice, from 1st April 2011.

The Area Prescribing Committee has recommended the following changes:

  • All strong opioids are to be prescribed by brand name
  • "Just in Case" prescribing is to be encouraged and promoted
  • Morphine is to replace diamorphine as the subcutaneous injectable strong opioid of choice for palliative care patients in Cumbria


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North Cumbria Pallative Care website

The award winning North Cumbria Palliative Care website continues to receive around 30,000 page views a year. This is 82 page views every single day of the year, 2,500 hits every month, without any publicity or advertising program.


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