Week 1 | | At end of week 1, if dyspnea score on Likert scale ≥ 4 (i.e., dyspnea is somewhat intolerable or completely intolerable), then: |
Day 1, 2 | Morphine sulfate 0.5 mg twice daily |
Day 3, 4 | Morphine sulfate 0.5 mg every 4 hours |
Day 5, 6, 7 | Morphine sulfate 1 mg every 4 hours |
Week 2 | Morphine sulfate 2 mg every 4 hours | At end of week, if dyspnea score ≥ 4 as above, then: |
Week 3 | Morphine sulfate 3 mg every 4 hours | At end of week, if dyspnea score ≥ 4 as above, then: |
Week 4 | Morphine sulfate 5 mg every 4 hours | At end of week, if dyspnea score ≥ 4 as above, then: |
Week 5+ | Ongoing titration weekly, with increase of 30%–50% in dose based on severity of dyspnea and adverse effects. If persistent intolerable adverse effects develop, revert to previous tolerated dose and re-evaluate in 48 hours. If adverse effects persist, rotate to hydromorphone or taper dose by 50% per day and stop over 72 hours. |
Week 6+ | Patients who remain on a stable dose of opioid (i.e., have not required titration in the preceding 2 weeks) can switch to a sustained-release preparation. |