Benefits of Intranasal Administration of Diamorphine and Midazolam in the Management of Patients Receiving Palliative Care in the Community: A Case Series.

Opioids and benzodiazepines are cornerstones of the pharmacological management of pain and agitation in palliative medicine. Oral drug delivery is the most popular route of administration, with the subcutaneous route typically utilized where oral medications are not tolerated or are ineffective. Intranasal drug delivery offers an important alternative administration route, with benefits including ease of administration, tolerability and avoidance of needle use, and is particularly useful in the community, where medications may be administered by lay carers or by patients themselves. Intranasal diamorphine and intranasal midazolam both have demonstrated efficacy and safety in adult and pediatric cohorts, however there is limited research into their use in managing pain and agitation in palliative care. We describe the management of three patients under the community palliative care team who received intranasal diamorphine, two of whom also received intranasal midazolam, to manage breakthrough symptoms of pain and agitation at home. In each case, the patient or their relative was taught how to prepare and administer the relevant intranasal medication. This case series demonstrates that for selected patients, diamorphine and midazolam administered intranasally by patients or lay carers at home is efficacious, acceptable and generally well tolerated.