Drug interactions in palliative care

Potential Drug Interactions in Terminally-Ill Cancer Patients, a Report from the Middle East

This study aims to evaluate the epidemiology of potential drug interactions in terminally-ill cancer patients receiving exclusively supportive care. In this cross-sectional study, during a 6-month follow-up, we considered the medical record of terminally-ill cancer patients referred to palliative care at the cancer center in Isfahan, Iran. Potential drug-drug interactions (DDIs) were assessed by Lexi-Interact ver.1.1 online software. During the study period, 133 terminally-ill cancer patients were recruited. We detected 1678 DDIs with moderate or major severity levels. Among them, 330, 219, 32, 1075, and 51 interactions were categorized in B, C, D, and X drug interactions categories, respectively. One hundred and twenty-two patients (91.73%) encountered at least one potential drug-drug interaction during the end of life care. Mechanistically, most drug-drug interactions (64.5%) were pharmacodynamics. The most frequent pharmacological class of drugs responsible for DDIs were quetiapine (91 cases), oxycodone (87 cases), and sertraline (55 cases). Interaction between oxycodone and sertraline was found to be in the top 10 detected DDIs (13.7%). Our results showed that potentially moderate or major drug-drug interactions often occur among terminally-ill cancer patients and the clinical significance of DDIs should be considered meticulously in the palliative care cancer setting.

Identifying health outcomes of pharmaceutical clinical services in patients with cancer: A systematic review

BACKGROUND

Cancer is a major public health problem that imposes limitations on patients being treated. One of the strategies to improve health outcomes in cancer patients and promote the safety of their treatment is the provision of pharmaceutical clinical services (PCS). However, there is no evidence of health outcomes that are influenced by such services.

OBJECTIVE

Identify the health outcomes influenced by PCS in cancer patients.

METHODS

A systematic review was performed in the following databases: Cochrane Library, LILACS, PubMed, EMBASE, and Web of Science, and using the PRISMA Statement In addition to the search, we analyzed the references of systematic reviews and meta-analyses. The descriptors used were defined by the MeSH keywords "neoplasms," "pharmacists," and "pharmaceutical services". We analyzed the studies with an observational design published until March 2018 that used PCS and related them with the health outcomes. Two reviewers independently assessed titles, abstracts, and full texts according to the eligibility criteria, and then extracted data and assessed the methodological quality of the studies.

RESULTS

A total of 658 articles were found in the initial search, of which eight met the inclusion criteria. Six studies evaluated clinical outcomes: four assessed adverse reactions, one identified six barriers that prevented patients' adherence to medication and solved three of these barriers, and two evaluated PCS related to drug-related problems (DRP) in identification and resolution. Four studies identified a humanistic outcome: two evaluated the quality of life of patients on cancer treatment associated with improvement of symptoms, two investigated pain, and two performed a patient satisfaction survey on PCS. This systematic review identified only one study with an economic outcome, addressing the reduction of medical expenses related to the treatment of neutropenia that affects cancer patients. Most of the studies showed good methodological quality.

CONCLUSIONS

This systematic review identified health outcomes associated with PCS in cancer patients: clinical (adverse drug reaction, DRP resolution, adherence, and pain), humanistic (quality of life and satisfaction), and economic outcomes (reduction of treatment costs for cancer).

Risk of Opioid Overdose Associated With Concomitant Use of Oxycodone and Selective Serotonin Reuptake Inhibitors

Importance

Some selective serotonin reuptake inhibitors (SSRIs) inhibit the enzymes responsible for the metabolism of oxycodone, a potent prescription opioid. The clinical consequences of this interaction on the risk of opioid overdose have not been elucidated.

Objective

To compare opioid overdose rates in patients initiating oxycodone while taking SSRIs that are potent inhibitors of the cytochrome-P450 2D6 enzyme (CYP2D6) vs SSRIs that are not.

Design, Setting, and Participants

This cohort study included adults who initiated oxycodone while receiving SSRI therapy between 2000 and 2020 whose data were included in 3 US health insurance databases.

Exposures

Use of SSRIs that strongly inhibit CYP2D6 enzyme (fluoxetine or paroxetine) vs use of other SSRIs at the time of oxycodone initiation.

Main Outcomes and Measures

Opioid overdose hospitalization or emergency department visit. Outcomes were assessed within 365 days of oxycodone initiation; in primary analyses, patients were followed up until the discontinuation of either oxycodone or their index SSRI group. Propensity score matching weights were used to adjust for confounding. Crude and weighted (adjusted) incidence rates and hazard ratios were estimated using Cox regression models, separately within each database and overall, stratifying on database.

Results

A total of 2 037 490 initiated oxycodone while taking SSRIs (1 475 114 [72.4%] women; mean [SD] age, 50.1 [15.3] years). Most (1 418 712 [69.6%]) were receiving other SSRIs at the time of oxycodone initiation. In the primary analysis, we observed 1035 overdose events (0.05% of the study cohort). The adjusted incidence rate of opioid overdose in those using inhibiting SSRIs at the time of oxycodone initiation (9.47 per 1000 person-years) was higher than in those using other SSRIs (7.66 per 1000 person-years), indicating a greater risk of overdose among patients using CYP2D6-inhibiting SSRIs (adjusted hazard ratio, 1.23; 95% CI, 1.06-1.31). Results were consistent across multiple subgroup and sensitivity analyses.

Conclusions and Relevance

In this cohort study of US adults, initiating oxycodone in patients treated with paroxetine or fluoxetine was associated with a small increased risk of opioid overdose.

[Nutritional aspects of the palliative care of head and neck cancer patients]

Nutrition remains a relevant issue until the end of life, both for patients and their relatives. This is particularly true for palliative patients with advanced head and neck cancer. In addition to local problems caused by the disease and its treatment, patients suffer from social aspects such as isolation, decreasing strength, and reduced mobility. Effective nutritional counselling and therapy are necessary to retain quality of life and self-care for as long as possible. Dialogue between the palliative care team and ENT oncologists should serve as the basis for developing an individual plan for each patient in this difficult situation. A special section of this manuscript focuses on the value of traditional herbal medicine for different ENT symptoms in the context of nutrition. The aim of this review is to promote qualified discussion between patient, relatives, and professionals.

An Explorative Study of CYP2D6’s Polymorphism in a Sample of Chronic Pain Patients

Background

A proper antalgic treatment is based on the use of titrated drugs to provide adequate relief and a good tolerability profile. Therapies have a variable effectiveness among subjects depending on medical and genetic conditions. CYP2D6 variations determine a different clinical response to most analgesic drugs commonly used in daily clinical practice by influencing the drugs’ pharmacokinetics. This study was a monocentric clinical trial exploring the CYP2D6 variants in 100 patients with a diagnosis of chronic pain.

Methods

DNA was extracted to evaluate the genotype and to classify patients as normal-fast (gNMs-F), normal-slow (gNMs-S), ultrarapid (gUMs), intermediate (gIMs), and poor metabolizers (gPMs) using the Activity Score (AS). Information on therapies and general side effects experienced by patients was collected. Nongenetic co-factors were evaluated to examine the discrepancy between metabolic profile predicted from genotype (gPh) and metabolic profile (phenocopying).

Results

The distribution of our data underlined the prevalence of the gNMs-F (67%), whereas gNMs-S were 24%, gIMs 6%, gPMs 3%, and no gUMs were found, resulting in 33% of patients with reduced metabolic activity. In the analyzed population sample, 86% and 56% of patients, respectively, took at least one or two drugs inhibiting in vitro activity of the CYP2D6 enzyme.

Conclusions

Over one-third of the enrolled patients showed altered CYP2D6 enzymatic metabolic activity, with a risk of phenocopying potentially due to polypharmacology.

Trial registration

ClinicalTrials.gov ID: NCT03411759.

An In Vitro Study of Aromatic Stacking of Drug Molecules

In this paper, drug-drug chemical interactions between two different aromatic compounds were studied by mass spectrometry. Specifically, we examined non-covalent complexes (NCX) between paclitaxel, a chemotherapeutic compound, and medications widely used in palliative care for depression, psychosis, and anxiety. It is unknown whether psychotropic medications directly interact with paclitaxel. Here, we use a simple and rapid electrospray ionization mass spectrometry in vitro assay, which has been predictive in the case of neuropeptides, to measure the relative strength of non-covalent interactions. This chemical interaction is most likely due to the overlap of aromatic rings of π-orbitals between paclitaxel and five commonly used medications: diazepam, clonozepam, sertraline, fluoxetine, and haloperidol. Molecular modeling illustrates that differences in the stability of the NCXs are likely due to the distance between the aromatic rings present in both the paclitaxel and antidepressant medications. Graphical Abstract.

Metabolic Pathways and Potencies of New Fentanyl Analogs

Up to now, little is known about the metabolic pathways of new fentanyl analogs that have recently emerged on the drug markets worldwide with high potential for producing addiction and severe adverse effects including coma and death. For some of the compounds, limited information on the metabolism has been published, however, for others so far no information is available. Considering the well characterized metabolism of the pharmaceutically used opioid fentanyl and the so far available data, the metabolism of the new fentanyl analogs can be anticipated to generally involve reactions like hydrolysis, hydroxylation (and further oxidation steps), N- and O-dealkylation and O-methylation. Furthermore, phase II metabolic reactions can be expected comprising glucuronide or sulfate conjugate formation. When analyzing blood and urine samples of acute intoxication cases or fatalities, the presence of metabolites can be crucial for confirmation of the uptake of such compounds and further interpretation. Here we present a review on the metabolic profiles of new fentanyl analogs responsible for a growing number of severe and fatal intoxications in the United States, Europe, Canada, Australia, and Japan in the last years, as assessed by a systematic search of the scientific literature and official reports.

Might Massage Or Guided Meditation Provide “Means to A Better End”? Primary Outcomes from An Efficacy Trial with Patientsatthe end of Life

This article reports findings from a randomized controlled trial of massage and guided meditation with patients at the end of life. Using data from 167 randomized patients, the authors considered patient outcomes through 10 weeks post-enrolment, as well as next-of-kin ratings of the quality of the final week of life for 106 patients who died during study participation. Multiple regression models demonstrated no significant treatment effects of either massage or guided meditation, delivered up to twice a week, when compared with outcomes of an active control group that received visits from hospice-trained volunteers on a schedule similar to that of the active treatment arms. The authors discuss the implications of their findings for integration of these complementary and alternative medicine therapies into standard hospice care.

Interaction between CYP2D6 inhibitor antidepressants and codeine: is this relevant?

INTRODUCTION

Co-occurring pain impairs depression's prognosis. Selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) are first-line pharmacotherapies for depression and inhibit many cytochrome 2D6 enzymes. Codeine is a first-line treatment for pain and needs to be metabolized into morphine by cytochrome 2D6 to exert its analgesic effect. Concomitant prescription of both pharmacotherapies leads to inadequate analgesia. Areas covered: We performed a systematic review of the literature to amalgamate the current knowledge regarding the clinical effect of this association and quantified its prevalence in clinical practice in the French Pays de la Loire area using a retrospective observational cohort study design. Expert opinion: The literature review highlighted that antidepressants with moderate-to-strong inhibition of CYP2D6 should be avoided in patients receiving codeine. However, 0.44% of the 12,296 sampled patients received concomitant codeine and CYP2D6 inhibitor between January 2015 and June 2015. Switching drugs in both painful and depressive patients depends on the pain and depression subtypes. Promising drugs that both show an effect on pain and depression are currently being studied but are not usable in clinical practice. Until then, tailored communication reinforcement toward health-care professionals is needed to prevent these problematic occurrences of concomitant prescription administration.

Safe Opioid Use: Management of Opioid-Related Adverse Effects and Aberrant Behaviors

Opioids are highly effective for cancer pain but are associated with multiple adverse effects and risk of addiction. This article provides a synopsis on the management of various opioid-related adverse effects and strategies to minimize aberrant opioid use in patients who have cancer. Many adverse effects can be effectively managed. Some patients on chronic opioid therapy may demonstrate aberrant behaviors suggestive of opioid misuse or diversion. Through intensive education, longitudinal monitoring, early identification, and timely management, clinicians can optimize the risk to benefit ratio to support safe opioid use.

Burden and Management of Multidrug-Resistant Organisms in Palliative Care

Palliative care includes comprehensive strategies to optimize quality of life for patients and families confronting terminal illness. Infections are a common complication in terminal illness, and infections due to multidrug-resistant organisms (MDROs) are particularly challenging to manage in palliative care. Limited data suggest that palliative care patients often harbor MDRO. When MDROs are present, distinguishing colonization from infection is challenging due to cognitive impairment or metastatic disease limiting symptom assessment and the lack of common signs of infection. Multidrug-resistant organisms also add psychological burden through infection prevention measures including patient isolation and contact precautions which conflict with the goals of palliation. Moreover, if antimicrobial therapy is indicated per goals of care discussions, available treatment options are often limited, invasive, expensive, or associated with adverse effects that burden patients and families. These issues raise important ethical considerations for managing and containing MDROs in the palliative care setting.

Clinically significant drug-drug interactions involving opioid analgesics used for pain treatment in patients with cancer: a systematic review

BACKGROUND

Opioids are the most frequently used drugs to treat pain in cancer patients. In some patients, however, opioids can cause adverse effects and drug-drug interactions. No advice concerning the combination of opioids and other drugs is given in the current European guidelines.

OBJECTIVE

To identify studies that report clinically significant drug-drug interactions involving opioids used for pain treatment in adult cancer patients.

DESIGN AND DATA SOURCES

Systematic review with searches in Embase, MEDLINE, and Cochrane Central Register of Controlled Trials from the start of the databases (Embase from 1980) through January 2014. In addition, reference lists of relevant full-text papers were hand-searched.

RESULTS

Of 901 retrieved papers, 112 were considered as potentially eligible. After full-text reading, 17 were included in the final analysis, together with 15 papers identified through hand-searching of reference lists. All of the 32 included publications were case reports or case series. Clinical manifestations of drug-drug interactions involving opioids were grouped as follows: 1) sedation and respiratory depression, 2) other central nervous system symptoms, 3) impairment of pain control and/or opioid withdrawal, and 4) other symptoms. The most common mechanisms eliciting drug-drug interactions were alteration of opioid metabolism by inhibiting the activity of cytochrome P450 3A4 and pharmacodynamic interactions due to the combined effect on opioid, dopaminergic, cholinergic, and serotonergic activity in the central nervous system.

CONCLUSION

Evidence for drug-drug interactions associated with opioids used for pain treatment in cancer patients is very limited. Still, the cases identified in this systematic review give some important suggestions for clinical practice. Physicians prescribing opioids should recognize the risk of drug-drug interactions and if possible avoid polypharmacy.

Analysis of drug interactions at the end of life

BACKGROUND

As death approaches, patients are at their most frail, but an increasing symptom burden often necessitates an increase in medications, putting them at higher risk for drug-drug interactions.

OBJECTIVES

To assess the potential for drug-drug interactions in routine prescribing at the end of life.

METHODS

An Australian retrospective multicentre case-note review of 266 consecutive adult patients who were referred to specialist palliative care, with data available on 166. Medications used in the last 2 weeks of life were screened for potential interactions using the 'Stockley's Drug Interactions' software.

RESULTS

The mean number of medications prescribed was 10.8, median 9 (IQR 6-14); all patients received at least one medication. In this study, 72% of patients were at risk of 1 or more potential drug-drug interaction. The mean number of potential interactions was 4.4, with a median of 2.5 (IQR 0-7) per patient. There were only 4/166 (2.4%) prescribed medications with an associated clinical record of an adverse drug reaction.

CONCLUSIONS

Potential drug-drug interactions are common for this group of patients. Some interactions may be recognised as an acceptable risk when the prescription is written. Further research is necessary to determine the best way to improve recognition of potential drug-drug interactions and the rates of morbidity or accelerated mortality associated with this. It is likely that palliative care services will need to implement multiple strategies including greater use of computerised prescribing software, and greater closer liaison with clinical pharmacists.

Concomitant drugs with low risks of drug-drug interactions for use in oncology clinical trials

BACKGROUND

Drug-drug interactions (DDIs) may occur with investigational drugs and affect patient safety, trial outcomes, and drug development. A list of preferred drugs with minimal risks of DDIs for treatment of symptoms or comorbidities frequently encountered by cancer patients would be helpful.

METHODS

We reviewed the literature to assess DDIs reported for the main drugs available for treatment of symptoms/comorbidities frequently encountered by cancer patients. Reviews and relevant original articles cited were retrieved and analyzed, and the following data were collected and double-checked: pharmacological properties; effects, if any, of drugs on CYP enzymes, membrane transporters, and QT interval; and involvement in significant DDIs.

RESULTS

A list of preferred drugs with minimal risks of DDIs was compiled.

CONCLUSION

Acknowledging for heterogeneity in data sources, prevention of unexpected DDIs during clinical trials may be improved by using this list of preferred drugs for the management of study patient's symptoms.

Polypharmacy in patients with advanced cancer and pain: a European cross-sectional study of 2282 patients

CONTEXT

Patients with advanced cancer need multiple drugs to control symptoms and to treat cancer and concomitant diseases. At the same time, the goal of treatment changes as life expectancy becomes limited. This results in a risk for polypharmacy, maintained use of unneeded drugs, and drug-drug interactions (DDIs).

OBJECTIVES

The aim of the study was to analyze the use of medications and to identify unneeded drugs, and drugs and drug combinations with a risk for DDIs in a cohort of advanced cancer pain patients, defined by a need for a World Health Organization analgesic ladder Step III opioid.

METHODS

All drugs taken within a study day by cancer patients receiving opioids for moderate or severe pain (Step III opioids) were analyzed. Nonopioids and adjuvants were analyzed for their use across countries. Unneeded medications and drugs and drug combinations with a risk for pharmacodynamic and pharmacokinetic DDIs were identified on the basis of published literature and electronic resources.

RESULTS

In total, 2282 patients from 17 centers in 11 European countries were included. They received a mean of 7.8 drugs (range 1-20). Over one-quarter used 10 or more medications. The drugs and drug classes most frequently coadministered with opioids were proton pump inhibitors, laxatives, corticosteroids, paracetamol (acetaminophen), nonsteroidal anti-inflammatory drugs, metoclopramide, benzodiazepines, anticoagulants, antibiotics, anticonvulsants, diuretics, and antidepressants. The use of nonopioids and essential adjuvants varied across countries. Approximately 45% of patients received unnecessary or potentially unnecessary drugs, and about 7% were given duplicate or antagonizing agents. Exposures to DDIs were frequent and increased the risk of sedation, gastric ulcerations, bleedings, and neuropsychiatric and cardiac complications. Many patients were exposed to pharmacokinetic DDIs involving cytochrome P450, including about 58% who used a Step III opioid CYP3A4 (izoenzyme of cytochrome P450) substrate, and more than 10% who were given major CYP3A4 inhibitors or inducers.

CONCLUSION

Patients with cancer treated with a World Health Organization Step III opioid use a high number of drugs. Nonopioid analgesics and corticosteroids are frequently used, but different patterns of use between countries were found. Many patients receive unneeded drugs and are at risk of serious DDIs. These findings demonstrate that drug therapy in these patients needs to be evaluated continuously.

Frailty: a key indicator to minimize inappropriate medication in older people

Older populations are more likely to have multiple co-morbid diseases that require multiple treatments, which make them a large consumer of medications. As a person grows older, their ability to tolerate medications becomes less due to age-related changes in pharmacokinetics and pharmacodynamics often heading along a path that leads to frailty. Frail older persons often have multiple co-morbidities with signs of impairment in activities of daily living. Prescribing drugs for these vulnerable individuals is difficult and is a potentially unsafe activity. Inappropriate prescribing in older population can be detected using explicit (criterion-based) or implicit (judgment-based) criteria. Unfortunately, most current therapeutic guidelines are applicable only to healthy older adults and cannot be generalized to frail patients. These discrepancies should be addressed either by developing new criteria or by refining the existing tools for frail older people. The first and foremost step is to identify the frail patient in clinical practice by applying clinically validated tools. Once the frail patient has been identified, there is a need for specific measures or criteria to assess appropriateness of therapy that consider such factors as quality of life, functional status and remaining life expectancy and thus modified goals of care.

Drug therapy optimization at the end of life

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.

The role of corticosteroids in the treatment of pain in cancer patients

Pain is one of the most frequent and most distressing symptoms in the course of cancer. The management of pain in cancer patients is based on the concept of the World Health Organization (WHO) analgesic ladder and was recently updated with the EAPC (European Association for Palliative Care) recommendations. Cancer pain may be relieved effectively with opioids administered alone or in combination with adjuvant analgesics. Corticosteroids are commonly used adjuvant analgesics and play an important role in neuropathic and bone pain treatment. However, in spite of the common use of corticosteroids, there is limited scientific evidence demonstrating their efficacy in cancer patients with pain. The use of corticosteroids in spinal cord compression, superior vena cava obstruction, raised intracranial pressure, and bowel obstruction is better established than in other nonspecific indications. This review aims to present the role of steroids in pain and management of other symptoms in cancer patients according to the available data, and discusses practical aspects of steroid use.

The management of cancer pain

The experience of pain in cancer is widely accepted as a major threat to quality of life, and the relief of pain has emerged as a priority in oncology care. Pain is associated with both the disease as well as treatment, and management is essential from the onset of early disease through long-term survivorship or end-of-life care. Effective relief of pain is contingent upon a comprehensive assessment to identify physical, psychological, social, and spiritual aspects and as a foundation for multidisciplinary interventions. Fortunately, advances in pain treatment and in the field of palliative care have provided effective treatments encompassing pharmacological, cognitive-behavioral, and other approaches. The field of palliative care has emphasized that attention to symptoms such as pain is integral to quality cancer care.

Consensus-based evaluation of clinical significance and management of anticancer drug interactions

BACKGROUND

Anticancer drug interactions can affect the efficacy and toxicity of anticancer treatment and that of the interacting drugs. However, information on the significance, prevention, and management of these interactions is currently lacking.

OBJECTIVE

The purpose of this study was to assess the clinical significance of interaction among anticancer agents and comedications and to provide recommendations for the management of clinically significant interactions.

METHODS

Members of a multidisciplinary expert group of hospital and community pharmacists, medical oncologists, internists, and clinical pharmacologists were selected by their professional organizations, which participated in this consensus project. Literature was extensively searched for any drug interactions with anticancer agents using registration files, reference books, handbooks, and electronic databases. Interactions between anticancer agents were not considered. Interactions were classified by level of best available evidence for the interaction and by severity of the clinical effect, according to a structured assessment procedure. This assessment distinguished 5 levels for the amount and quality of evidence available and 6 severity levels for classification of potential drug-to-drug interactions.

RESULTS

A total of 88 drug interactions with anticancer agents were identified from 146 combinations of drugs with anticancer agents found in literature. For 58 combinations, there was insufficient evidence of an interaction. Of the identified interactions, 38 were classified as clinically significant, defined as necessitating an alert or intervention, such as dose adaptation, comedication, discontinuation of treatment, or additional monitoring of treatment. Recommendations were made for management of these interactions.

CONCLUSION

Numerous interactions with anticancer agents are clinically significant and should be considered by pharmacists and doctors in daily oncology practice.

Adverse events in hospice and palliative care: a pilot study to determine feasibility of collection and baseline rates

BACKGROUND

Continuous quality improvement is fundamental in all health care, including hospice and palliative care. Identifying and systematically reducing symptomatic adverse events is limited in hospice and palliative care because these events are mostly attributed to disease progression.

OBJECTIVES

The aim of this study was to assess the feasibility of symptomatic adverse events in hospice and palliative care and assessing their incidence.

METHODS

A retrospective, consecutive cohort of notes from a specialist palliative care inpatient service was surveyed by a clinical nurse consultant for symptomatic adverse events: falls, confusion, decreased consciousness, hypo- and hyperglycaemia, urinary retention, and hypotension. Demographic and clinical factors were explored for people at higher risk.

RESULTS

Data were available on the most recent admissions of 65 people, generating >900 inpatient days. Fifty people (78%) had events precipitating admission, of whom 31 (62%) had at least one further event during admission. Eleven of 15 people who were admitted without an event experienced at least one during their admissions. Only 4 did not have an adverse event. During their stay, there were 0.13 (standard deviation [SD] = 0.19) events per patient per day. No drug-drug or drug-host events were noted. No clinical or demographic factors predicted groups at higher risk.

CONCLUSIONS

This pilot highlights the feasibility of collecting, and ubiquity of, symptomatic adverse events, and forms a baseline against which future interventions to decrease the frequency or intensity can be measured. Given the frailty of hospice and palliative patients, any adverse event is likely to accelerate irreversibly their systemic decline.

Anticancer oral therapy: emerging related issues

The use of oral anticancer drugs has shown a steady increase. Most patients prefer anticancer oral therapy to intravenous treatment primarily for the convenience of a home-based therapy, although they require that the efficacy of oral therapy must be equivalent and toxicity not superior than those expected with the intravenous treatment. A better patient compliance, drug tolerability, convenience and possible better efficacy for oral therapy as compared to intravenous emerge as the major reasons to use oral anticancer agents among oncologists. Inter- and intra-individual pharmacokinetic variations in the bioavailability of oral anticancer drugs may be more relevant than for intravenous agents. Compliance is particularly important for oral therapy because it determines the dose-intensity of the treatment and ultimately treatment efficacy and toxicity. Patient stands as the most important determinant of compliance. Possible measures for an active and safe administration of oral therapy include a careful preliminary medical evaluation and selection of patients based on possible barriers to an adequate compliance, pharmacologic issues, patient-focused education, an improvement of the accessibility to healthcare service, as well as the development of home-care nursing symptom-focused interventions. Current evidences show similar quality of life profile between oral and intravenous treatments, although anticancer oral therapy seems to be more convenient in terms of administration and reduced time lost for work or other activities. Regarding cost-effectiveness, current evidences are in favor of oral therapy, mainly due to reduced need of visits and/or day in hospital for the administration of the drug and/or the management of adverse events.

Review: Pharmacogenetic aspects of the effect of cytochrome P450 polymorphisms on serotonergic drug metabolism, response, interactions, and adverse effects

The field of pharmacogenetics contains a wealth of potential for the enhancement of clinical practice by providing a more effective match between patient and drug, consequently reducing the probability of an adverse drug reaction. Although a relatively novel concept in the forensic context, pharmacogenetics has the capability to assist in the interpretation of drug related deaths, particularly in unintentional drug poisonings where the cause of death remains unclear. However, the complex pharmacology of the drugs when subjected to genetic variations in metabolism makes interpretation of the expected response and adverse events difficult. Many possess multiple metabolic pathways, narrow therapeutic indices and active metabolites or enantiomers which may be eliminated via different pathways to the parent drug. A number of these drugs, which are metabolised primarily by the CYP450 system, are also associated with serotonin syndrome, or serotonin toxicity, especially when used concomitantly with other serotonin active drugs which rely on the same metabolic pathways for drug elimination. A comprehensive understanding of polymorphic drug metabolism and its expected outcomes is therefore essential when interpreting the involvement of drugs in adverse reactions. This review examines the genetically variable CYP450-mediated metabolism of a number of serotonin-active drugs that are often implicated in cases of serotonin toxicity, to assess the impact of pharmacogenetics on drug metabolism, response, interactions and adverse effects.

Drug interactions in metastatic breast cancer

It is estimated that almost one-third of adverse reactions to pharmaceutical agents result from drug interactions. The potential for drug interactions in oncology complicates the pharmacist's role of finding a balance between efficacy and acceptable toxicity for all agents involved (anticancer agents, supportive therapies, and concomitant medications). In the realm of metastatic breast cancer, the heavily pretreated nature of many patients and the narrow therapeutic window associated with most therapies puts all patients at risk for drug interactions. In practice, co-administration of a pharmacological agent with the potential to alter the clinical profile of the patient's anticancer regimen may be unavoidable. Herein are discussed underlying molecular mechanisms that are usually responsible for drug interactions in the realm of breast oncology. Since more and more oral anticancer agents are emerging onto the market or are in late clinical development, special consideration is given to identification and management of potential interactions associated with oral anticancer therapeutics. In addition, recommendations are provided for dose reduction strategies, effective monitoring, management of drug interactions, and communication strategies with patients and other members of the clinical team.

Withholding, discontinuing and withdrawing medications in dementia patients at the end of life: a neglected problem in the disadvantaged dying?

Recent years have seen a growing recognition that dementia is a terminal illness and that patients with advanced dementia nearing the end of life do not currently receive adequate palliative care. However, research into palliative care for these patients has thus far been limited. Furthermore, there has been little discussion in the literature regarding medication use in patients with advanced dementia who are nearing the end of life, and discontinuation of medication has not been well studied despite its potential to reduce the burden on the patient and to improve quality of life. There is limited, and sometimes contradictory, evidence available in the literature to guide evidence-based discontinuation of drugs such as acetylcholinesterase inhibitors, antipsychotic agents, HMG-CoA reductase inhibitors (statins), antibacterials, antihypertensives, antihyperglycaemic drugs and anticoagulants. Furthermore, end-of-life care of patients with advanced dementia may be complicated by difficulties in accurately estimating life expectancy, ethical considerations regarding withholding or withdrawing treatment, and the wishes of the patient and/or their family. Significant research must be undertaken in the area of medication discontinuation in patients with advanced dementia nearing the end of life to determine how physicians currently decide whether medications should be discontinued, and also to develop the evidence base and provide guidance on systematic medication discontinuation.

Pediatric palliative care

Palliative care has always been a part of the care of children. It includes any intervention that focuses on relieving suffering, slowing the progression of disease, and improving quality of life at any stage of disease. In addition, for even the child with the most unpredictable disease, there are predictable times in this child's life when the child, family, and care team will be suffering in ways that can be mitigated by specific interventions. Rather than defining pediatric palliative care in terms of a patient base, severity of disease, or even a general philosophy of care, palliative care can best be understood as a specific set of tasks directed at mitigating suffering. By understanding these tasks; learning to identify predictable times and settings of suffering; and learning to collaborate with multidisciplinary specialists, use communication skills, and identify clinical resources, the pediatrician can more effectively support children with life-threatening illnesses and their families. In this article, we define palliative care as a focus of care integrated in all phases of life and as a set of interventions aimed at easing suffering associated with life-threatening conditions. We detail an approach to these interventions and discuss how they can be implemented by the pediatrician with the support of specialists in hospice and palliative medicine. We discuss common and predictable times of suffering when these interventions become effective ways to treat suffering and improve quality of life. Finally, we discuss those situations that pediatricians most commonly and intensely interface with palliative care-the care of the child with complex, chronic conditions and severe neurologic impairment (SNI).

Methylnaltrexone: the evidence for its use in the management of opioid-induced constipation

Introduction:

Constipation is a distressing side effect of opioid treatment, being so irksome in some cases that patients would rather suffer the pain than the side effect of opioid analgesics. Stool softeners or stimulating laxatives are often ineffective or even aggravate the situation. A new efficacious and safe drug is needed to limit the frequently observed side effects induced by effective opioid-based analgesic therapy and to improve the quality of life for patients, most of whom are impaired by a severe disease.

Aims:

The purpose of this article is to assess current evidence supporting the use of the peripherally acting μ-opioid receptor antagonist, methylnaltrexone, to restrict passage across the blood–brain barrier in patients with opioid-induced bowel dysfunction.

Evidence review:

There are now convincing data from phase II and multicenter phase III randomized, double-blind, placebo-controlled trials that methylnaltrexone induces laxation in patients with long-term opioid use without affecting central analgesia or precipitation of opioid withdrawal. Onset of the effect is rapid and improvement is maintained for at least 3 months during the drug treatment. The action of methylnaltrexone is dose dependent. Weight-related dosing appeared to be effective. There were no severe side effects or signs of opioid withdrawal. Adverse events, most frequently abdominal cramping or nausea, were usually mild to moderate. Methylnaltrexone is contraindicated in patients with known or suspected mechanical intestinal stenosis. Patients receiving methylnaltrexone must be monitored.

Place in therapy:

Methylnaltrexone applied subcutaneously every other day may be given to patients suffering from chronic constipation due to opioid therapy for whom laxatives do not provide adequate relief of their symptoms.

Cardiotoxicity of Oral Methadone as an Analgesic–-Recommendations for Safe Use

Once used only as third-line therapy in the management of chronic pain states, methadone is now being used as first- and second-line therapy. Most risks and the stigma associated with methadone use have been known for years. Only over the past decade or so have the unique pharmacokinetic-pharmacodynamic properties and methods for conversion from other opioids to methadone been established. Pertinent English-language literature was obtained from MEDLINE/PUBMED and EMBASE searches (1966-June 2009). This paper provides an overview of the cardiotoxicity of oral methadone, with an emphasis on its use as an analgesic. Cardiotoxicity during its use in the maintenance of opioid addiction has also been reviewed due to the wealth of epidemiologic, risk factor, and correlative analytic data contained therein. A series of recommendations are provided to improve the cardiac safety profile of oral methadone used for analgesia. In addition, there is a discussion of settings and patient types which may impact upon these recommendations.

Drug interactions in oncology: how common are they?

BACKGROUND

Drug-drug interactions (DDIs) comprise an important problem in medical oncology practice. We systematically reviewed the frequency of DDIs in oncology.

METHODS

We searched PubMed for eligible articles and on-line databases for abstracts of major oncology meetings.

RESULTS

Eight studies reported on the frequency of DDIs: six evaluated the frequency of potential DDIs, while two studies reported on real DDIs, i.e. interactions that had clinical consequences. Studies of potential DDIs found that approximately one-third of patients are exposed to dangerous drug doublets, with the most common ones involving warfarin and anticonvulsants. One study of real DDIs found that 2% of hospitalized cancer patients had a DDI as the cause of admission.

CONCLUSIONS

Drug interactions comprise an important issue in oncology, with approximately one-third of ambulatory cancer patients being at risk of DDIs. Data are limited on the clinical consequences of drug interactions among cancer patients.

An intravenous ketamine test as a predictive response tool in opioid-exposed patients with persistent pain

Chronic pain patients who are treated with opioid therapy represent a significant challenge to medical professionals. When pain recurs in the face of a previously effective opioid regimen, treatment options include dose escalation, opioid rotation, drug holidays, and the addition of adjuvants. Some experts advocate the use of N-methyl-D-aspartate receptor (NMDA-R) antagonists to combat tolerance. Recently, the use of an intravenous (i.v.) ketamine infusion to predict the response to a dextromethorphan (DX) treatment trial has been described. In this study, 56 opioid-exposed patients with recurrent pain were treated with a low-dose (0.1mg/kg) i.v. ketamine test followed by a DX treatment course. Using previously designated cutoff values for a positive response to ketamine (67% or more pain relief) and DX (50% or more pain relief), the sensitivity, specificity, positive predictive value, and negative predictive value for an i.v. ketamine infusion to predict subsequent response to DX treatment were 72%, 68%, 52%, and 85%, respectively. The observed agreement between analgesic responses was 78%, indicating a highly significant correlation (r=0.54, P=0.0001). Subgroup classification revealed no significant differences in the response to either ketamine or DX treatment based on pain classification (i.e., nociceptive, neuropathic, or mixed) or placebo response. In contrast, a weaker correlation between ketamine and DX response was found in subjects requiring high-dose rather than low-dose opioid therapy. A significant correlation also was noted between the development of side effects for the two NMDA-R antagonists. Based on these results, we conclude that an i.v. ketamine test may be a valuable tool in predicting subsequent response to DX treatment in opioid-exposed patients. with persistent pain.

Actual and potential drug interactions associated with methadone

OBJECTIVE

To identify and characterize methadone-related drug interactions, as well as factors accounting for the variability in manifesting these interactions clinically.

DESIGN

Systematic review of the primary literature.

METHODS

Over 200 articles, reports of clinical trials, and case reports were reviewed. Studies and case reports were included if they revealed either quantitative or qualitative methods to identify, evaluate severity of, or compare methadone-related drug interactions.

RESULTS OF DATA SYNTHESIS

The evidence base associated with methadone drug interactions is underdeveloped in general, as the majority of references found were case reports or case series. Most of the studies and reports focused on inpatients receiving methadone maintenance treatment (MMT) that were between 20 and 60 years of age, taking 200 mg/day of methadone or less. Evidence supporting the involvement of lesser known cytochrome P450 enzymes such as 2B6 is emerging, which may partially explain the inconsistencies previously found in studies looking specifically at 3A4 in vitro and in vivo. Genetic variability may play a role in the pharmacokinetics and pharmacodynamics of many medications, including methadone.

CONCLUSIONS

Drug interactions associated with methadone and their clinical significance are still poorly understood in general. Many tertiary drug information references and review articles report interactions associated with methadone in a general sense, much of which is theoretical and not verified by case reports, much less well-designed clinical trials. The majority of drug interaction reports that do exist were performed in the MMT population, which may differ significantly from chronic pain or cancer pain populations.

Variable response to opioid treatment: any genetic predictors within sight?

The aim of this literature review is to summarize and discuss the available evidence for a relationship between polymorphisms in human genes and variability in opioid analgesia and side effects among patients treated for moderate or severe pain. The evidence supporting a role of certain alleles, genotypes or haplotypes in modulation of opioid analgesia is derived from a limited number of studies, a limited number of genes and a limited number of opioids. Although several interesting candidates have emerged as potentially relevant factors, only for one polymorphism, the prevalent 118A>G of the micro-opioid receptor, the accumulated evidence is sufficient to suggest a clinically relevant effect for an opioid used for moderate or severe pain. Still the data are valid only at the group level and cannot be used to predict treatment outcome in individual patients. Only a few of the symptoms often seen as opioid adverse effects in palliative care, such as nausea, vomiting, constipation and sedation, have been associated with genetic variants in various genes, but the results have been based on case reports, healthy volunteers or post-operative patients. So far, there is no clear evidence that genetic markers can be used to predict opioid efficacy or adverse effects in palliative care patients. This reflects the general lack of studies performed in the context of palliative care, the lack of sufficiently scaled studies and the lack of international standards for the assessment of subjective symptoms.

Perspectives on pain and intellectual disability

Historically, individuals with intellectual disability (ID) have been excluded from pain research and assumed to be insensitive or indifferent to pain. The weight of the evidence suggests that individuals with ID have been subject to practices and procedures with little regard for their ability to experience or express pain. A number of issues central to improving understanding of pain in ID will be introduced and current research related to the definition of pain and its social context, underlying sensory and metabolic systems and factors influencing judgments about the ability to experience pain will be reviewed. Accumulating evidence from interdisciplinary research designed to improve assessment, understand individual differences, and evaluate bias and beliefs about pain suggests that new perspectives are emerging and beginning to shape an innovative frontier of research that will ultimately pay tremendous dividends for improving the quality of life of individuals with ID.

Prescribing in palliative care as death approaches

OBJECTIVES

To determine how prescribing for comorbid illnesses and symptom control changes during the palliative phase of a terminal illness.

DESIGN

This prospective cohort study explores the relative contribution to prescribing of symptom-specific medications (SSMs) and long-term medications for comorbid medical conditions.

SETTING

Regional consultative palliative care program, Adelaide, South Australia.

PARTICIPANTS

Two hundred sixty consecutive patients, 96% of whom had cancer, who enrolled and subsequently died in a larger randomized trial exploring palliative service delivery.

MEASUREMENTS

Medication and performance data were collected monthly from referral until death (mean 107 days, median 93 days, standard deviation (SD) 103 days, range 11-752 days). Prespecified subgroup analyses of age, performance status, and the baseline use of medications for comorbid medical conditions were performed.

RESULTS

At baseline, the mean total number of medications+/-SD was 4.9+/-2.8 (range 0-16), SSMs was 2.3+/-1.5 (range 0-7), and medications for comorbid medical conditions was 2.6+/-2.4 (range 0-13). As death approached, the total number of medications increased because of SSM prescribing (2.5 more medications, 95% confidence interval (CI)=2.2-2.9; P<.001) with a decrease in medications for comorbid medical conditions (1.1 fewer medications, 95% CI=0.8-1.3; P<.001). There was an increase in the number of medications meeting Beers' criteria for high-risk inappropriate medication use for SSMs (29% to 48%). More SSMs were prescribed in people with better performance status, and older participants took more medications for comorbid medical conditions.

CONCLUSION

Prescribing changes as life-limiting illnesses progress, with older people taking more medications. Medications for comorbid medical conditions should be reviewed in the context of their original therapeutic goals.