Sam and Vani explore the most common requests for after hours prescribing and how to safely and quickly approach prescribing of insulin, warfarin, analgesia, antiemetics, and sleeping tablets.
Insulin Generally treat any blood glucose of 20 or above.
Target range: Inpatient: 7 – 14 mmol/L
Outpatient: 4 – 10 mmol/L
Achieving target 60% of the time is quite good!
Neglecting high BSLs leads to irritating symptoms, opportunistic infections and delayed recovery.
Correct BSLs with a rapid acting insulin (Novorapid) Correction doses should be given at meals and no more frequently than 4 hourly.
If correction doses of insulin are required, consider increasing the person’s usual insulin / treatment.
Don’t recheck BSLs too early. Wait until the next scheduled check, unless there is concern of hypoglycaemia.
Don’t use ActRapid – it works slowly subcut so should only be used IV.
Waitemata DHB correction of hyperglycaemia guideline (August 2017) Diabetes in pregnancy requires frequent adjustment and tighter control – consult a senior.
Don’t withhold long acting insulin (Lantus and insulin degludec) if NBM, even if on a GIK.
Antiemetics Cyclizine (NZF) Antihistimine
Classic, old-school, and effective
Great for non-iatrogenic nausea and vomiting
Can give euphoria IV, so avoid in young patients specifically requesting it and in the elderly
25 – 50 mg PO/IV TDS PRN
Ondansetron (NZF) Serotonin antagonist
Newer, but not necessarily better antiemetic
Primarily indicated for PONV and chemotherapy-induced nausea
Can be constipating
Can reduce the effectiveness of tramadol, so avoid co-prescription
10 mg PO/IV TDS PRN
Metoclopramide (NZF) Dopamine antagonist
Gastric stimulant, avoid in suspected small bowl obstruction
Avoid co-prescribing with droperidol and prochlorperizine
Avoid in Parkinson’s disease
Avoid in under 20 year olds due to risk of oculogyric crisis
10 mg PO/IV TDS PRN
Domperidone (NZF) Somewhat interchangeable with metoclopramide, but no IV formulation
Does not cross BBB, so preferred in Parkinson’s disease
10 mg PO TDS PRN
Droperidol (NZF) Dopamine antagonist
Usually prescribed by anaesthetics for PONV
0.625–1.25 mg IV Q6H PRN
Scopoderm patch (NZF) Nonspecific antimuscarinic
Usually prescribed by anaesthetics for PONV
1 patch Q72H
Prochlorperazine (NZF) Oral: 20 mg initially then 10 mg after 2 hours; prevention 5–10 mg 2–3 times daily
Rectal: 25 mg when required followed if necessary after 6 hours by an oral dose, as above
Don’t confuse with chlorpromazine!
Analgesia Pain assessment Try to get some kind of assessment documented e.g. verbal pain score
Pain ladder Simple analgesia e.g. paracetamol +/- NSAID
“Weak” opioides e.g. tramadol or codeine
Titrate up opiates e.g. morphine or oxycodone
It may be necessary to “get on top” of the pain first with some IV boluses, then once the patient is comfortable, some low-dose long acting analgesia may be all that is required.
If possible, please avoid opiates in young patients (e.g. <25 years) as there is a strong link between opiate exposure in the young and subsequent drug and alcohol dependance and abuse. First do no harm!
Sleeping tablets Very common request on evening and ward calls
Balance benefit with risk Patients need sleep to recover from the illness, so don’t withhold unnecessarily
However don’t contribute to an avoidable fall
Zopiclone (NZF) 7.5 – 15 mg PO nocte
Generally first line unless the patient already uses an alternative
Quetiapine (NZF) Antipsychotic, not indicated for insomnia
However patient who have tried it tend to swear by it
Use as a sleeping tablet in low dose (e.g. 25 mg) is off-label, so generally avoid unless the patient already uses it.
Benzodiazepines Temazepam (NZF) 10 – 20 mg PO nocte
Generally avoid benzos unless you are experienced with their use, as they have many interactions and dependance is rapid.
Resources MCNZ Good prescribing practice (PDF)
MCNZ Statement on providing care to yourself and those close to you (PDF)
MCNZ Standards for doctors
New Zealand Formulary
onthewards podcast and blog
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