Indications and patterns of use of benzodiazepines and opioids in severe interstitial lung disease: a population-based longitudinal study

Recent advances in understanding the role of antidepressants to manage breathlessness in supportive and palliative care

PURPOSE OF REVIEW

Breathlessness is a prevalent and distressing symptom in palliative and supportive care, with limited licensed pharmacological options once disease-directed therapies are no longer effective. Antidepressants have been proposed as a potential treatment, even in the absence of comorbid mood disorders, due to their modulation of neural circuits and serotonin pathways involved in breathlessness perception. Despite their off-label use in clinical practice for managing refractory or chronic breathlessness, robust evidence supporting their efficacy is needed. This review critically evaluates the latest evidence on their potential benefits and safety in breathlessness management.

RECENT FINDINGS

Breathlessness is influenced by at least three interrelated axes: lung-brain, behavioural-functional, and psycho-social-spiritual. These mechanisms operate across diseases, making them relevant in palliative and supportive care. Despite promise from early case reports and small trials, two recent large, randomised studies of mirtazapine and sertraline found no benefit in alleviating breathlessness or improving other outcomes. The mirtazapine trial also reported more adverse events than placebo. Earlier trials were small with design limitations, reducing reliability. A 2016 trial of sertraline found benefits for depression in stable COPD. Recent concerns over increased morbidity associated with antidepressant use in respiratory disease highlight the need for early detection of people at risk of worsening breathlessness or depression and a holistic, individualised approach.

SUMMARY

Current evidence does not support antidepressants for breathlessness in respiratory disease. Non-pharmacological approaches should be first line, given their proven benefits and low risk. Off-label medicine use requires caution and should ideally be offered within a trial or evaluation. Given the complex nature of breathlessness, future research should focus on innovating and then testing treatments and therapies in well-designed trials with appropriate outcome measures and reporting of adverse events, health care use and informal carer effects.

Should opioids be used for breathlessness and in whom? A PRO and CON debate of the evidence

Purpose of review

The net clinical benefit of opioids for chronic breathlessness has been challenged by recent randomized clinical trials. The purpose was to review and weigh the evidence for and against opioid treatment for chronic breathlessness in people with serious disease.

Recent findings

Evidence to date on the efficacy and safety of opioids for chronic breathlessness was reviewed. Findings supporting a benefit from opioids in meta-analyses of earlier, mostly smaller trials were not confirmed by recent larger trials. Evidence pertains mostly to people with chronic obstructive pulmonary disease but also to people with pulmonary fibrosis, heart failure, and advanced cancer. Taken together, there is no consistent evidence to generally recommend opioids for severe breathlessness or to identify people who are more likely to benefit. Opioid treatment may be tested in patients with intractable breathlessness and limited other treatment options, such as in end-of-life care. Knowledge gaps were identified and recommendations were made for future research.

Summary

Key Points Supportive findings of net benefit of opioids for chronic breathlessness in earlier trials have not been confirmed by recent larger randomized clinical trials. There is no evidence that the opioid treatment improves the person’s exercise capacity or quality of life, and it increases the risk of adverse events. Evidence to date does not support that opioids should generally be recommended for treating breathlessness. In people with intractable symptoms and short expected survival, with few or no treatment options, it may still be reasonable to try opioid treatment with the aim to alleviate severe breathlessness. Research is needed to explore the potential benefit of opioids in selected patient groups. Opioids cannot be generally recommended for treating breathlessness based on insufficient evidence for net clinical benefit.

Should Benzodiazepines be Used for Reducing Dyspnea in Patients with Advanced Illnesses?

Dyspnea is a common and highly distressing symptom in patients with advanced illnesses. Many patients continue to experience chronic dyspnea despite optimal management of underlying disease(s) and various non-pharmacologic interventions, necessitating the consideration of pharmacologic therapies for palliation of dyspnea. One commonly asked question by clinicians is whether benzodiazepines have a role in the palliation of dyspnea. In this "Controversies in Palliative Care" article, three groups of thought leaders independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. All three groups suggest that benzodiazepines alone do not confer a benefit for dyspnea in advanced illnesses based on existing data. They also expressed concerns about the potential adverse effects such as delirium and drowsiness and recommended against benzodiazepines as first line pharmacologic therapy. Some groups suggest that benzodiazepines may be used in highly selected patients with severe anxiety associated with dyspnea. Some investigators may also consider the adjunctive use of benzodiazepines in patients with severe dyspnea despite opioids, particularly if life expectancy is limited. Benzodiazepines also have a role in palliative sedation for refractory dyspnea in the last days of life. More research is needed to confirm the benefit of benzodiazepines in these populations.

A Retrospective, Descriptive Study of Dyspnea Management in a Multidisciplinary Interstitial Lung Disease Clinic

Background: Fibrotic interstitial lung diseases (F-ILDs) have a high symptom burden with progressive dyspnea as a primary feature. Breathlessness is underrecognized and undertreated primarily due to lack of consensus on how to best measure and manage it. Several nonpharmacologic and pharmacologic strategies are published in the literature, however there is a paucity of real-world data describing their systematic implementation. Objectives: We describe the types of breathlessness interventions and timing of implementation in our multidisciplinary collaborative care (MDC) ILD clinic and the impact of our approach on dyspnea trajectory and acute care use in ILD. Methods: A retrospective, observational study of deceased ILD patients seen in our clinic (2012-2018) was conducted. Patients were grouped by baseline medical research council (MRC) grade and dyspnea interventions from clinic enrolment until death were examined. Healthcare usage in the last 6 months of life was collected through Alberta's administrative database. Results: Eighty-one deceased ILD patients were identified. Self management advice was provided to 100% of patients. Pulmonary rehabilitation (PR) and home care (HC) referrals were made in 40% and 57% of patients, respectively. Eighty percent were treated with oxygen and 53% with opioids during the study. MDC-initiated referral to PR and HC, oxygen and opioid prescriptions were provided a median of 13, 9, 11, and 4 months prior to death, respectively. Stepwise implementation of interventions was observed more commonly in MRC 1-2 and concurrent implementation in MRC 4-5. Conclusions: Our clinic's approach allows early and systematic dyspnea management.

Real-world opioid prescription to patients with serious, non-malignant, respiratory illnesses and chronic breathlessness

BACKGROUND

Chronic breathlessness is a disabling symptom that is often under-recognised and challenging to treat despite optimal disease-directed therapy. Low-dose, oral opioids are recommended to relieve breathlessness, but little is known regarding long-term opioid prescription in this setting.

AIM

To investigate the long-term efficacy of, and side-effects from, opioids prescribed for chronic breathlessness to patients with advanced, non-malignant, respiratory diseases.

METHODS

A prospective cohort study of all patients managed by the advanced lung disease service, an integrated respiratory and palliative care service, at the Royal Melbourne Hospital from 1 April 2013 to 3 March 2020.

RESULTS

One hundred and nine patients were prescribed opioids for chronic breathlessness. The median length of opioid use was 9.8 (interquartile range (IQR) = 2.8-19.8) months. The most commonly prescribed initial regimen was an immediate-release preparation (i.e. Ordine) used as required (37; 33.9%). For long-term treatment, the most frequently prescribed regimen included an extended-release preparation with an as needed immediate-release (37; 33.9%). The median dose prescribed was 12 (IQR = 8-28) mg oral morphine equivalents/day. Seventy-one (65.1%) patients reported a subjective improvement in breathlessness. There was no significant change in the mean modified Medical Research Council dyspnoea score (P = 0.807) or lung function measurements (P = 0.086-0.727). There was no association between mortality and the median duration of opioid use (P = 0.201) or dose consumed (P = 0.130). No major adverse events were reported.

CONCLUSION

Within this integrated respiratory and palliative care service, patients with severe, non-malignant respiratory diseases safely used long-term, low-dose opioids for breathlessness with subjective benefits reported and no serious adverse events.