1
|
Hamatani Y, Iguchi M, Moriuchi K, Anchi Y, Inuzuka Y, Nishikawa R, Shimamura K, Kondo H, Mima H, Yamashita Y, Takabayashi K, Takenaka K, Korai K, Kawase Y, Murai R, Yaku H, Nagao K, Kitano M, Aono Y, Kitai T, Sato Y, Kimura T, Akao M. Effectiveness and safety of morphine administration for refractory dyspnoea among hospitalised patients with advanced heart failure: the Morphine-HF study. BMJ Support Palliat Care 2024; 13:e1300-e1307. [PMID: 37169517 DOI: 10.1136/spcare-2023-004247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/12/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES Morphine is effective in alleviating dyspnoea in patients with cancer. We aimed to investigate the effectiveness and safety of morphine administration for refractory dyspnoea in patients with advanced heart failure (HF). METHODS We conducted a multicentre, prospective, observational study of hospitalised patients with advanced HF in whom morphine was administered for refractory dyspnoea. Morphine effectiveness was evaluated by dyspnoea intensity changes, assessed regularly by both a quantitative subjective scale (Visual Analogue Scale (VAS; graded from 0 to 100 mm)) and an objective scale (Support Team Assessment Schedule-Japanese (STAS-J; graded from 0 to 4 points)). Safety was assessed by vital sign changes and new-onset severe adverse events, including nausea, vomiting, constipation and delirium based on the Common Terminology Criteria for Adverse Events. RESULTS From 15 Japanese institutions between September 2020 and August 2022, we included 28 hospitalised patients with advanced HF in whom morphine was administered (mean age: 83.8±8.7 years, male: 15 (54%), New York Heart Association class IV: 26 (93%) and mean left ventricular ejection fraction: 38%±19%). Both VAS and STAS-J significantly improved from baseline to day 1 (VAS: 67±26 to 50±31 mm; p=0.02 and STAS-J: 3.3±0.8 to 2.6±1.1 points; p=0.006, respectively), and thereafter the improvements sustained through to day 7. After morphine administration, vital signs including blood pressure, pulse rate and oxygen saturation did not change, and no new-onset severe adverse events occurred through to day 7. CONCLUSIONS This study suggested acceptable effectiveness and safety for morphine administration in treating refractory dyspnoea in hospitalised patients with advanced HF.
Collapse
Affiliation(s)
- Yasuhiro Hamatani
- Cardiology, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Moritake Iguchi
- Cardiology, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| | - Kenji Moriuchi
- Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuta Anchi
- Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasutaka Inuzuka
- Cardiovascular Medicine, Shiga Medical Center for Adults, Moriyama, Japan
| | - Ryusuke Nishikawa
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | | | - Hibiki Mima
- Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yugo Yamashita
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | | | - Kengo Korai
- Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yuichi Kawase
- Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryosuke Murai
- Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | | | - Kazuya Nagao
- Cardiology, Osaka Red Cross Hospital, Osaka, Japan
| | - Mariko Kitano
- Cardiovascular Center, Kitano Hospital, Osaka, Japan
| | - Yuya Aono
- Cardiology, Kansai Electric Power Hospital, Osaka, Japan
| | - Takeshi Kitai
- Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yukihito Sato
- Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | | | - Masaharu Akao
- Cardiology, National Hospital Organisation Kyoto Medical Center, Kyoto, Japan
| |
Collapse
|
2
|
Kawaguchi J, Hamatani Y, Hirayama A, Nishimura K, Nakai E, Nakamura E, Miyata M, Kawano Y, Takada Y, Anchi Y, Funabashi S, Kuroda K, Azechi M, Takahama H, Anzai T, Yasuda S, Kitaoka H, Izumi C. Experience of morphine therapy for refractory dyspnea as palliative care in advanced heart failure patients. J Cardiol 2020; 75:682-688. [PMID: 32061472 DOI: 10.1016/j.jjcc.2019.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/05/2019] [Accepted: 12/21/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND In the field of palliative care, morphine is known to be effective for alleviating dyspnea in cancer patients. However, little is known regarding the safety and efficacy of morphine therapy for refractory dyspnea as palliative care in advanced heart failure (HF) patients. METHODS We retrospectively reviewed consecutive advanced HF patients who were referred to the Palliative Care Team at our institution and administered morphine for refractory dyspnea during hospitalization between September 2013 and December 2018. We investigated the details of morphine usage, vital signs, an 11-point quantitative symptom scale, and adverse events at baseline, 24 h, and 72 h after the start of treatment. RESULTS Morphine was administered for refractory dyspnea in 43 advanced HF patients [mean age: 73.5 years, male: 28 (65%), New York Heart Association functional class IV: 43 (100%), median left ventricular ejection fraction: 25%, median B-type natriuretic peptide level: 927 pg/ml, concurrent intravenous inotrope: 33 (77%)]. Median initial dose of morphine was 5 mg/day in both oral and intravenous administration and median duration of administration was 5 days. Significant decreases in an 11-point quantitative symptom scale [7 (5, 9) vs. 2 (1, 6); p < 0.01, (data available in 8 patients)] and respiratory rate (22.2 ± 6.1 vs. 19.7 ± 5.2 breaths per minute; p < 0.01) were observed 24 h after the start of morphine administration. Meanwhile, oxygen saturation, blood pressure, and heart rate were not significantly altered after treatment (NS). Common adverse events were delirium (18%) and constipation (8%); however, no lethal adverse event definitely related to morphine therapy occurred during treatment. CONCLUSIONS This single-center retrospective study revealed the clinical practice of morphine therapy and suggested that morphine therapy might be feasible for refractory dyspnea as palliative care in advanced HF patients.
Collapse
Affiliation(s)
- Juri Kawaguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan
| | - Yasuhiro Hamatani
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Atsushi Hirayama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Eri Nakai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Division of Cardiology, Department of Medicine II, Kansai Medical University, Osaka, Japan
| | - Emi Nakamura
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Michi Miyata
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yukie Kawano
- Department of Nursing, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yasuko Takada
- Department of Nursing, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yuta Anchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Sayaka Funabashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kensuke Kuroda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Michiyo Azechi
- Department of Psychiatry, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroyuki Takahama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.
| |
Collapse
|
3
|
|
4
|
Tanaka M, Maeba H, Senoo T, Iwasaka J, Ohkita A, Kita H, Uchitani K, Hirota Y. Efficacy of Oxycodone for Dyspnea in End-stage Heart Failure with Renal Insufficiency. Intern Med 2018; 57:53-57. [PMID: 29033442 PMCID: PMC5799057 DOI: 10.2169/internalmedicine.9216-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
A 67-year-old man with dilated cardiomyopathy and renal insufficiency was admitted to our hospital with dyspnea secondary to end-stage heart failure. We introduced oxycodone for medically refractory dyspnea instead of morphine because of the patient's renal insufficiency. After the administration of oxycodone, his dyspnea was alleviated without any adverse opioid effects, such as respiratory depression. After treating his heart failure, he was able to leave the intensive care unit. Oxycodone may therefore be a reliable agent for the treatment of dyspnea in patients with end-stage heart failure and renal insufficiency.
Collapse
Affiliation(s)
- Masayuki Tanaka
- Department of Pharmacy, Kansai Medical University Hospital, Japan
| | - Hirofumi Maeba
- Division of Cardiology, Department of Medicine II, Kansai Medical University, Japan
| | - Takeshi Senoo
- Division of Cardiology, Department of Medicine II, Kansai Medical University, Japan
| | - Junji Iwasaka
- Division of Cardiology, Department of Medicine II, Kansai Medical University, Japan
| | - Aki Ohkita
- Department of Nursing, Kansai Medical University Hospital, Japan
| | - Haruna Kita
- Department of Pharmacy, Kansai Medical University Hospital, Japan
| | - Kazuki Uchitani
- Department of Pharmacy, Kansai Medical University Hospital, Japan
| | - Yasuhiko Hirota
- Department of Pharmacy, Kansai Medical University Hospital, Japan
| |
Collapse
|
5
|
Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017; 33:1342-1433. [PMID: 29111106 DOI: 10.1016/j.cjca.2017.08.022] [Citation(s) in RCA: 433] [Impact Index Per Article: 61.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 02/06/2023] Open
Abstract
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
Collapse
Affiliation(s)
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | | | - Miroslaw Rajda
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Sean A Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | | | - Stephen Fremes
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Green
- University of Alberta, Edmonton, Alberta, Canada
| | - Haissam Haddad
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec, Canada
| | | | | | | | - Andre Roussin
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
| |
Collapse
|
6
|
Shearer FA, Struthers AD, Harbour R. Opioids for treating dyspnoea in patients with chronic heart failure. Hippokratia 2016. [DOI: 10.1002/14651858.cd010991.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Fiona A Shearer
- University of Dundee; Division of Cardiovascular and Diabetes Medicine; Ninewells Hospital and Medical School Dundee Scotland UK DD2 9SY
| | - Allan D Struthers
- University of Dundee; Division of Cardiovascular and Diabetes Medicine; Ninewells Hospital and Medical School Dundee Scotland UK DD2 9SY
| | | |
Collapse
|
7
|
Riesinger R, Iglseder B. [Tools for optimizing pharmacotherapy for geriatric patients with multimorbidity at the end of life: helpful oder just raising awareness?]. Wien Med Wochenschr 2014; 164:189-94. [PMID: 24715194 DOI: 10.1007/s10354-014-0274-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 03/13/2014] [Indexed: 01/08/2023]
Abstract
Pharmacotherapy for end-of-life patients with multimorbidity is a major challenge. Estimating prognosis can be much more difficult when compared to patients suffering from cancer alone.Nevertheless, it is crucial in order to prescribe in the context of the following determining factors: disease, co-morbidities, functional status, life expectancy and therapy goals.Since such patients are prone to adverse drug reactions, inappropriate prescriptions should be avoided, since evidence concerning the benefits or risks for various drugs used is as yet inadequate.Several tools can be of help to improve pharmacotherapy for this vulnerable group of patients.
Collapse
Affiliation(s)
- Renate Riesinger
- Palliativstation, Krankenhaus der Barmherzigen Schwestern, Schlossberg 1, 4910, Ried im Innkreis, Österreich,
| | | |
Collapse
|
8
|
Abstract
Older people reaching end-of-life status are particularly at risk of adverse effects of drug therapy. Polypharmacy, declining organ function, co-morbidity, malnutrition, cachexia and changes in body composition all sum up to increase the risk of many drug-related problems in individuals who receive end-of-life care. End of life is defined by a limited lifespan or advanced disability. Optimal prescribing for end-of-life patients with multimorbidity, especially in those dying from non-cancer conditions, remains mostly unexplored, despite the increasing recognition that the management goals for patients with chronic diseases should be redefined in the setting of reduced life expectancy. Most drugs used for symptom palliation in end-of-life care of older patients are used without solid evidence of their benefits and risks in this particularly frail population. Appropriate dosing or optimal administration routes are in most cases unknown. Avoiding or discontinuing drugs that aim to prolong life or prevent disability is usually common sense in end-of-life care, particularly when the time needed to obtain the expected benefits from the drug is longer than the life expectancy of a particular individual. However, discontinuation of drugs is not standard practice, and prescriptions are usually not adapted to changes in the course of advanced diseases. Careful consideration of remaining life expectancy, time until benefit, goals of care and treatment targets for each drug seems to be a sensible framework for decision making. In this article, some key issues on drug therapy at the end of life are discussed, including principles of decision making about drug treatments, specific aspects of drug therapy in some common geriatric conditions (heart failure and dementia), treatment of acute concurrent problems such as infections, evidence to guide the choice and use of drugs to treat symptoms in palliative care, and avoidance of some long-term therapies in end-of-life care. Solid evidence is lacking to guide optimal pharmacotherapy in most end-of-life settings, especially in non-cancer diseases and very old patients. Some open questions for research are suggested.
Collapse
|
9
|
|