Syringe Driver Drug Compatibility

Compatibility of drugs mixed in a syringe driver.

Indications for use1,2

  • Persistent nausea and vomiting
  • Intestinal obstruction
  • Coma
  • Poor absorption of oral drugs (rare)
  • Weakness (unable to swallow oral drugs)
  • Patient preference

Infusion devices

The most frequently used type of syringe driver is the McKinley T34, which delivers drugs in ml per hour. Older devices with delivery rates based on length rather than volume of liquid should no longer be used.2 Syringe drivers should only be set up by healthcare professionals with adequate training in their use.

Choice of diluent

All drugs commonly used in palliative care are compatible with water for injection as a diluent, but 0.9% sodium chloride is recommended for diclofenac.1

Mixing drugs in syringe drivers

  • Check that drugs are compatible before mixing (including compatibility of diluent)
  • Combinations of two or three drugs in one syringe may require larger volumes of diluent1
  • Do not use solutions that are cloudy or have precipitated
  • Usually no more than three drugs are mixed in one syringe, although in some centres four drugs are used2
  • Drugs too irritant for subcutaneous administration via a syringe driver include chlorpromazine, diazepam and prochlorperazine1,2
  • A separate syringe driver should be used for diclofenac1,2 (some sources also recommend for dexamethasone, phenobarbital, ketamine and ketorolac1)
COMPATIBILITY INFORMATION FOR MIXING TWO DRUGS IN A SYRINGE DRIVER (DILUENT: WATER FOR INJECTION)
Drug Compatible with Caution with Incompatible with
Alfentanil Most drugs:1 clonazepam,2 glycopyrronium,2 haloperidol,2 hyoscine butylbromide,2 levomepromazine,2 metoclopramide,2 midazolam,2 octreotide,2 ondansetron2 Cyclizine (reported compatible up to alfentanil 0.24mg/ml + cyclizine 8.8mg/ml),2 dexamethasone2
Clonazepam Alfentanil,2 diamorphine,2 glycopyrronium,2 haloperidol,2 hyoscine butylbromide,2 hyoscine hydrobromide,2 morphine sulfate,2 oxycodone2 Cyclizine (reports of incompatibility),2 dexamethasone2
Cyclizine Haloperidol,2 hyoscine hydrobromide,2 morphine sulfate,2 morphine tartrate2 Clonazepam, octreotide (reports of incompatibility).2 Reported compatible up to certain concentrations with alfentanil,1,2 dexamethasone,2 diamorphine,2 hydromorphone,2 midazolam,2 oxycodone1,2 - see individual drugs Hyoscine butylbromide (one report of compatibility),2 ketorolac,2 sodium chloride 0.9%1,2
Dexamethasone (DSP = dexamethasone sodium phosphate) Alfentanil,2 clonazepam,2 diamorphine2, granisetron,2 hyoscine butylbromide,2 hyoscine hydrobromide,2 metoclopramide,2 octreotide (reports of incompatibility),1,2 oxycodone.2 Reported compatible up to certain concentrations with cyclizine (compatible up to DSP 0.33mg/ml + cyclizine 8.33mg/ml),2 haloperidol,2 hydromorphone,2 levomepromazine2 - see individual drugs Glycopyrronium,1,2 midazolam1,2
Diamorphine Most drugs:1** clonazepam,2 glycopyrronium,2 hyoscine butylbromide,2 hyoscine hydrobromide,2 ketorolac,2 levomepromazine,2 metoclopramide,2 octreotide,2 ondansetron2 Dexamethasone,2 midazolam (one report of incompatibility).2 Reported compatible up to certain concentrations with cyclizine (diamorphine 20mg/ml + cyclizine 20mg/ml, or diamorphine >20mg/ml + cyclizine 10mg/ml, or diamorphone 15mg/ml + cyclizine >20mg/ml),2 haloperidol (diamorphine 50mg/ml + haloperidol 4mg/ml, or diamorphine 50–100mg/ml + haloperidol 3mg/ml)2
Glycopyrronium bromide Most drugs:1 alfentanil,2 clonazepam,2 diamorphine,2 haloperidol,2 hydromorphone,2 levomepromazine,2 metoclopramide,2 midazolam,2 morphine sulfate,2 oxycodone2
Dexamethasone,2 ketorolac2
Drug Compatible with Caution with Incompatible with
Granisetron Dexamethasone2
Haloperidol Most drugs:1 alfentanil,2 clonazepam,2 cyclizine,2 glycopyrronium,2 hyoscine butylbromide,2 hyoscine hydrobromide,2 metoclopramide,2 midazolam,2 oxycodone2 Hydromorphone (incompatible at haloperidol 2mg/ml + hydromorphone 10mg/ml).2 Reported compatible up to certain concentrations with dexamethasone (haloperidol 0.38mg/ml + DSP 0.15mg/ml),2 diamorphine (haloperidol 4mg/ml + diamorphine 50mg/ml, or haloperidol 3mg/ml + diamorphine 50–100mg/ml),2 morphine sulfate (haloperidol <1mg/ml + morphine sulfate <10mg/ml)2 Ketorolac2
Hydromorphone Glycopyrronium,2 hyoscine butylbromide,2 hyoscine hydrobromide,2 ketamine,2 levomepromazine,2 metoclopramide,2 midazolam2 Haloperidol (incompatible at hydromorphone 10mg/ml + haloperidol 2mg/ml).2 Reported compatible up to certain concentrations with cyclizine (hydromorphone 5.8mg/ml + cyclizine 8.82mg/ml),2 dexamethasone (hydromorphone 20mg/ml + DSP 2mg/ml, or hydromorphone 10mg/ml + DSP >2mg/ml),2 ketorolac (hydromorphone 0.5mg/ml + ketorolac 15mg/ml)2
Hyoscine butylbromide Most drugs:1 alfentanil,2 clonazepam,2 diamorphine,2 haloperidol,2 hydromorphone,2 levomepromazine,2 midazolam,2 morphine sulfate,2 octreotide,2 oxycodone2 Dexamethasone2 Cyclizine (one report of compatibility)2
Ketamine Hydromorphone,2 metoclopramide,2 midazolam,2 morphine sulfate,2 morphine tartrate2
Ketorolac Diamorphine2 Hydromorphone (reported compatible up to ketorolac 15mg/ml + hydromorphone 0.5mg/ml)2 Cyclizine,2 glycopyrronium,2 haloperidol,2 levomepromazine,2 midazolam,2 morphine sulfate1,2
Drug Compatible with Caution with Incompatible with
Levomepromazine Alfentanil,2 diamorphine,2 glycopyrronium,2 hydromorphone,2 hyoscine butylbromide,2 hyoscine hydrobromide,2 midazolam,2 morphine sulfate,2 morphine tartrate,2 oxycodone2 Dexamethasone (reported compatible up to levomepromazine 2.78mg/ml + DSP 0.11mg/ml;2 some sources advise incompatible1), octreotide (reports of incompatibility)2 Ketorolac2
Metoclopramide Most drugs:1 Alfentanil,2 diamorphine,2 glycopyrronium,2 haloperidol,2 hydromorphone,2 ketamine,2 midazolam,2 morphine sulfate,2 octreotide,2 oxycodone2 Dexamethasone2
Midazolam Most drugs:1 Alfentanil,2 glycopyrronium,2 haloperidol,2 hydromorphone,2 hyoscine butylbromide,2 hyoscine hydrobromide,2 ketamine,2 levomepromazine,2 metoclopramide,2 octreotide,2 oxycodone2 Cyclizine (reported compatible up to midazolam 0.88mg/ml + cyclizine 8.82mg/ml),2 diamorphine (one report of incompatibility),2 morphine sulfate2 Dexamethasone,2 ketorolac2
Morphine sulfate Clonazepam,2 cyclizine,2 glycopyrronium,2 hyoscine butylbromide,2 hyoscine hydrobromide,2 ketamine,2 levomepromazine,2 metoclopramide,2 octreotide2 Haloperidol (reported compatible up to morphine sulfate >10mg/ml + haloperidol >1mg/ml),2 midazolam2 Ketorolac1,2
Morphine tartrate Cyclizine,2 ketamine,2 levomepromazine2
Octreotide Alfentanil,2 diamorphine,2 hyoscine butylbromide,2 metoclopramide,2 midazolam,2 morphine sulfate,2 ondansetron,2 oxycodone2 Reports of incompatibility with cyclizine,2 dexamethasone,1,2 levomepromazine2
Ondansetron Alfentanil,2 diamorphine,2 octreotide2

Oxycodone

 

Clonazepam,2 glycopyrronium,2 haloperidol,2 hyoscine butylbromide,2 hysocine hydrobromide,2 levomepromazine,2 metoclopramide,2 midazolam,2 octreotide2

Cyclizine (compatible up to oxycodone 9mg/ml + cyclizine 3mg/ml),2 dexamethasone2

**Compatible three-drug combinations include:2

  • Diamorphine plus haloperidol plus hyoscine hydrobromide/glycopyrronium
  • Diamorphine plus cyclizine plus hyoscine hydrobromide
  • Diamorphine plus midazolam plus hyoscine hydrobromide/hyoscine butylbromide/levomepromazine/glycopyrronium
  • Diamorphine plus levomepromazine plus hyoscine hydrobromide/hyoscine butylbromide/glycopyrronium

For further information on compatibility, including three- and four-drug combinations, contact your local hospital medicines information service or visit www.palliativedrugs.com. Healthcare professionals are urged to contact hq@palliativedrugs.com if their experience indicates that the guidance for a combination should be changed.

References

  1. Watson M, Lucas C, Hoy A, Wells J. Oxford Handbook of Palliative Care. 2nd ed. Oxford: Oxford University Press, 2009.
  2. Twycross R, Wilcock A, Howard P. Palliative Care Formulary. 5th ed. Nottingham: Palliativedrugs.com Ltd, 2014. www.palliativedrugs.com

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