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Palliative cancer care - dyspnoea - Management
What morphine dose regimen is recommended?

  • There is a wide variation in regimens used in clinical practice. CKS cannot be prescriptive here but can only offer a general guide based on assessment of the literature and on the professional opinion of expert reviewers. A morphine dose regimen should always be tailored to an individual's needs and requirements. If a clinician is still unsure how best to manage a person in this scenario, then seek specialist advice.
  • The initial starting dose depends on the person's previous exposure to opioids (as well as other factors such as age of the person, degree of frailty, associated morbidity such as chronic obstructive pulmonary disease or interstitial lung disease, and renal and liver function). In people with dyspnoea, morphine should be increased more cautiously than when used for palliative care pain relief.
  • In an opioid-naive person:
    • Start with oral morphine 2 mg or 2.5 mg.
    • Most people can take this dose every 4 hours and as required, although people with breathlessness may not need as frequent dosing (e.g. people with dyspnoea on exertion can just take the morphine dose when required as long as they plan their activity, and take the morphine dose about 30 minutes in advance).
  • In a person taking a weak opioid (e.g. codeine):
    • Start an oral morphine dosage of 2.5 to 10 mg every 4 hours and as required (only continue the weak opioid if appropriate).
    • As previously, if people with dyspnoea on exertion plan their activity, they may take the morphine dose just 'as required'.
  • If the person is already receiving regular (analgesic) morphine, increase the regular dose of morphine by in the region of 30% every 2 to 3 days until symptoms are controlled or adverse effects prevent further dose increases.
  • Reassess after 2 days. If, after a clinical assessment, the person has no adverse effects and the morphine is demonstrating some benefit, then reassess the morphine dose and increase if necessary, taking into account factors such as the age of the person, degree of frailty, associated morbidity, and renal and liver function.
  • Repeat this process every 2 days until breathlessness is controlled (also checking for any adverse effects). Once a stable dose has been reached, the new 4-hourly and 'as required' dose is one sixth of the new total daily dose (unless a person with dyspnoea on exertion is controlled on an 'as required' dose as explained previously). If the person needs regular morphine dosing throughout the day for dyspnoea then convert to once- or twice-daily administration of modified-release morphine. However, if only one or two doses are needed each day to control symptoms, then it may be fine to stick with 'as required' doses of standard release morphine.

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