Off-label drug use in palliative care – a narrative review

Off-label drug use is a routine part of symptom management in palliative care in Poland. A narrative review of the peer-reviewed articles, searched according to unauthorized routes of administration was performed. The following main types of unlicensed administration were distinguished: subcutaneous route (amikacine, hyoscine, ceftriaxone, dexamethasone, furosemide, levomepromazine, haloperidol, ketamine, midazolam, metoclopramide, ranitidine, magnesium, lidocaine, ketamine, sodium valporate and 0,9% saline), sublingual route (intravenous fentanyl, methadone, eye drops of atropine and pilocarpine), nebulized (gentamicin, furosemide, morphine), topical (tranexamic acid, morphine, ketamine), tablets decomposition (acceptable only when authorized drug forms are lacking and under specific conditions), and mixing up to two injectable drugs in a syringe (morphine, midazolam, metoclopramide, hyoscine butylbromide, haloperidol and levomepromazine, diluted in 0,9% saline). These procedures have predominantly weak evidence-based recommendations, however, may be performed when alternative licensed treatment modalities are unavailable. In such inevitable cases off-label use is acceptable after obtaining agreement, and with close monitoring.