Welcome to the Delta Care Rx Blog

The contents of this blog contain topics relevant to end of life care written by our own hospice clinical pharmacists. Continue to check this site regularly for the newest post or subscribe to the RSS feed below.
Irene Petrides, PharmD

Oral Hygiene in End of Life Care

Oral mouth discomfort is often seen in advanced illness and this can strongly affect quality of life. It is therefore important to keep a close watch on a patient’s oral hygiene and make it a priority in the plan of care. Oral health issues can include but are not limited to dysphagia, nutrition and taste problems, thick mucus, difficulty speaking, denture related issues, nausea and vomiting, stomatitis, hypersalivation, mucositis, thrush, and xerostoma.1

Assessment of the patient’s self-care ability is the first step. This will help determine the level of support a patient a will require. Not all patients need full care, a simple reminder or assistance by a caretaker may provide a basic approach in order to stay on the right path of the daily oral regimen. Once a care plan is established, there are measures that can be taken in order to avoid complications which include using a soft toothbrush, avoid mouthwashes that contain alcohol, rinse with saline or soda water, or use moist gauze to wipe cheeks after each meal.2,7 In addition, it is imperative to review medications in order to rule out any undesired oral mucosa effects associated with medication therapy.1 The goal is to maintain optimal oral hygiene with minimal discomfort. Most of the time a proactive approach is desired however in hospice we are often using a palliative oral care approach in symptoms that already exist. Once preventative and standard oral hygiene procedures have been properly assessed and addressed, it may become necessary to treat common complications.

Mucositis is a painful condition that often presents as red or white lesions in the mucosal lining of mouth, pharynx and digestive tract. In the late stages it is associated with fibrosis of connective tissue and hypovascularity. It is most often seen in patients who have received toxic chemotherapy and radiotherapy in head and neck cancer.1,6 Palliative treatment includes viscous lidocaine 2%, combination oral rinse (lidocaine, diphenhydramine, sorbitol and Mylanta), and chlorhexidine gluconate.1

Oropharyngeal Candidiasis (oral thrush) is a condition where white patches can be located in the mouth, inner cheeks, throat, palate and tongue and also is associated with pain. The tissue under the white patches is often raw and sore. The patient may have bad breath, unpleasant taste in the mouth, or dry mouth. Medications that can cause thrush include corticosteroids, antibiotics, and chemotherapy. Patients who have a higher prevalence of candidiasis are those who have cancer, HIV, uncontrolled diabetes, and smokers.3,7 Treatment includes antifungal mouthwash (nsystatin) or lozenges (clotrimazole). Administration of systemic fluconazole or itraconazole may be necessary in the management of more severe cases.1 It is important to remember that if a patient wears dentures they must also be treated separately with antifungal mouth rinse.5

Xerostoma is a symptom referring to dry mouth. Nearly 75% of hospice patients are affected by xerostoma, which is the most common cause of malnutrition in palliative patients. It is often associated with difficulty chewing, altered taste burning sensation, and thick saliva.1,3 Causes of xerostoma may include dehydration, vomiting or diarrhea, medications with anticholinergic activity, benzodiazepines and opioids, radiation, HIV/ AIDS, diabetes, renal failure, and Sjogrens syndrome.1,3 Treatment includes oral hydration such as humidifiers, stimulating salivary reflexes with medications like xylitol, administration of the cholinergic agonist pilocarpine, or using saliva substitutes such Biotene®.

Hypersalivation also known as sialorrhea is an increase in salivary flow. Patients who have neurological conditions such as Parkinson’s disease or amyotrophic lateral sclerosis may find it difficult to manage hypersalivation. Often medications are contraindicated in the treatment due to the side effects associated with anticholinergic drugs. If the patient’s quality of life is affected, anticholinergic medications such as atropine, glycopyrrolate, or scopolamine can be used.1

Dysphagia, or difficulty swallowing effectively, is a common symptom seen in hospice care. Food debris and saliva accumulate in the oral cavity which can increase bacterial growth. Inadequate oral hygiene at this point in care may increase the patient’s risk of developing aspiration.4 Therefore dysphagia may not only have a negative impact on oral health but also on the systemic health of a hospice patient. Despite minimizing debris in the oral cavity with adequate oral hygiene other preventative measures are necessary in order to avoid undesired complications. The most common non-invasive approaches include pleasure feeding, pureed diet, and crushing medications.1,4

Awareness of oral hygiene in the hospice patient should be an extension of the palliative care plan. Identifying oral health barriers, preventing major complications and treating oral conditions is the mainstay of managing oral hygiene. In conclusion comfort care and palliative treatment are established in oral care if a patient can eat and drink adequately with minimal pain or discomfort.


References:

1. Mulk BS, Chintamaneni RL, Mpv P, Gummadapu S, Salvadhi SS. Palliative Dental Care- A Boon for Debilitating. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(6):ZE01-ZE06. doi:10.7860/JCDR/2014/8898.4427.

2. Chen X, Chen H, Douglas C, Preisser JS, Shuman SK. Dental treatment intensity in frail older adults in the last year of life. Journal of the American Dental Association (1939). 2013;144(11):1234-1242.

3. Alt-Epping B, Nejad RK, Jung K, Groß U, Nauck F. Symptoms of the oral cavity and their association with local microbiological and clinical findings—a prospective survey in palliative care. Supportive Care in Cancer. 2012;20(3):531-537. doi:10.1007/s00520-011-1114-z.

4. Gallagher R. Swallowing difficulties: A prognostic signpost. Canadian Family Physician. 2011;57(12):1407-1409.

5. Saini R, Marawar P, Shete S, Saini S, Mani A. Dental Expression and Role in Palliative Treatment. Indian Journal of Palliative Care. 2009;15(1):26-29. doi:10.4103/0973-1075.53508.

6. Davies, Andrew, and Ilora G. Finlay, eds. Oral care in advanced disease. Oxford University Press, 2005.

7. O’Reilly M. Oral care of the critically ill: a review of the literature and guidelines for practice. Australian Critical Care. 2003;16(3):101-110. doi:10.1016/s1036-7314(03)80007-3.

Continue reading
748 Hits
Michelle Mikus, PharmD

POEMS: Patient Oriented Evidence that Matters

We’ve entered a time where everything can be searched on the internet, and now patients have wanted to be more involved in their medical treatment than ever before. Talking to a patient and their families and caregivers is often quite different than talking to another healthcare professional and begs the question “What is important to both patient and medical provider?” That is where Patient Oriented Evidence that Matters (POEMs) comes into play.

Two practitioners introduced the POEMs concept into medicine: David Slawson and Allen Shaughnessy from the University of Virginia. They actually came up with the concept from a formula: U = R·V / W. The formula seeks to equate the information doctors find to its usefulness. In short, the more relevant (R) and valid (V) the information is and the less work (W) it takes to find correlates with higher usefulness (U). With the internet at everyone’s fingertips, practitioners are suffering from “the information paradox” as Muir Gray from the National Electronic Library of Health states, which is described as so much information that they may not be able to find what they need when they need it. This is where POEMs can be useful.

POEMs must meet three criteria: a) address a question that a doctor encounters, b) measure outcomes that doctors AND their patients care about (symptoms, morbidity, mortality, QOL), and c) have the potential to change the way doctors practice. Conventional journal articles outline in high detail specifics about clinical manifestations, however this is not language that the layperson can understand nor will it ultimately affect them. Often journal articles do not ultimately answer a question. The advantage of POEMs includes communication that is centered on what really matters to the patient in a way that is meaningful to the doctor also. A typical POEM report would pose the patient specific question and then provide a bottom line before going into detail. This summary format makes them quite user friendly.

Evidence-based medicine, by definition, integrates patient values and expectations as a core feature along with both individual clinical expertise and the best external evidence. It is a process that starts with the patient presentation/question and ends with the incorporation of findings into the patient’s care, but in the middle includes literature searches and evaluations. By focusing the search and evaluation steps on POEMs, the patient will remain at the center of the care. In addition, information discovered has the potential to be more relevant and valid while requiring less work.

Sample POEM with hospice focus Olanzapine for intractable nausea and vomiting:

Clinical Question: What can be used to treat intractable nausea that has been refractory to conventional nausea medications?

Bottom Line: Olanzapine (Zyprexa) has been found to very effectively control nausea due to its broad spectrum of activity at a dose of 5mg at bedtime.

Reference: Atkinson SR. Olanzapine for intractable nausea and vomiting in palliative care patients not receiving chemotherapy. J Palliat Med. 2014 May;17(5):503-4

Study Design: Retrospective review

Setting: Palliative care

Synopsis: Multiple studies have shown olanzapine to be effective for chemotherapy induced nausea and vomiting however none had previously studied the drug for non-chemotherapy receiving patients with intractable nausea. This type of nausea reduces the quality of life for patients and often results in multiple trials of different medications—sometimes in combination. Patients averaging 65 years in age that were not receiving chemotherapy were initiated scheduled olanzapine 5mg at bedtime. The need for other anti-emetics and rescue anti-emetics was significantly reduced and there were no extrapyramidal side effects reported. One patient required a reduction in dose to 2.5mg at bedtime due to somnolence. Overall, olanzapine has proven again to be effective in addition to being cost effective and its use in intractable nausea and vomiting will reduce drug interactions and polypharmacy.


References:

1. Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract. 1994;39:489-499.

2. Smith, Richard. A POEM a week for the BMJ. BMJ 2002;325:983 3. Smith, Richard. What clinical information do doctors need? BMJ 1996;313:1062-1068.

Continue reading
385 Hits
Delta Campus Pharmacy Student

Management of Pruritus from a Hepatic Etiology

Pruritus is a common symptom experienced by many patients in palliative and hospice care which can dramatically affect a patient’s comfort and quality of life even though it is not the most prevalent symptom such as pain or dyspnea. While the complete pathology of all causes of pruritus is not yet completely understood, the itching sensation is best relieved by properly treating the underlying etiology if it is known.1

Pruritus has been associated with both malignant disease as well as nonmalignant chronic diseases such as renal, thyroid, and hepatic disease. A Cochrane Review found that about one third of all patients with end stage renal disease not on hemodialysis and 70%-80% of patients receiving hemodialysis experience significant pruritus. The same review found that nearly 100% of patients with biliary cirrhosis had a cholestatic pruritus.1 According to the guidelines from the American Association for the Study of Liver Diseases, cholestatic pruritus is often times the initial symptom in half of the patients with biliary cirrhosis.1,2

There exist many therapies that could be used to treat pruritus in general such as antihistamines like hydroxyzine, opioid receptor antagonists similar to naloxone, direct serotonergic agents such as ondansetron, selective serotonin reuptake inhibitors (SSRI’s) such as paroxetine and sertraline, antiepileptics such as gabapentin, and the antibiotic rifampicin. Most of these agents have different mechanisms against pruritus which may be more or less effective given certain patient factors. The American Association for the Study of Liver Diseases guidelines for primary biliary cirrhosis recommend several agents for the treatment of cholestatic pruritus:1,2

Bile Acid Sequestrants: The first line therapy recommendation is to use a bile acid sequestrant agent. Bile acid sequestrants are approved for the treatment of dyslipidemias by functioning as a resin that traps cholesterol and other acids from bile in the GI tract which can allow passing of these substances out through the GI tract instead of being systemically reabsorbed. It is believed that forcing the elimination of these bile acids will also relieve cholestatic pruritus. The bile acid sequestrant of choice is cholestyramine dosed at 4 grams per dose with a maximum dose of 16 grams daily. [The other currently available bile acid sequestrants, colesevelam, and colestipol, have not been studied and currently contain no recommendations for the treatment of pruritis.2] Complications of bile acid sequestrant therapy include gastrointestinal disturbances (constipation, loose stool, cramping, excessive flatus, etc.) and the prevention of drug absorption in the GI tract since acidic drugs will also be trapped by the resin.1,2 It is recommended to separate the administration of a bile acid sequestrant from other medications by 2-4 hours.

Antidepressants: It is believed that serotoninergic activity contributes to signal transduction of pruritus. Several antidepressants have been tested including paroxetine, doxepin, and sertraline. Sertraline 75 mg to 100 mg is the preferred therapy for cholestatic pruritus according to the guidelines by the American Association for the Study of Liver Disease.2 General pruritus relief has been noticed with paroxetine 5 mg to 10 mg at night for multiple etiologies including hepatic and renal disease.1 Doxepin appears to be effective at doses of 25 mg daily, however tricyclic antidepressants tend to have anticholinergic activity which can cause adverse effects in older patients and should be avoided unless necessary.1,3 Relief of pruritus by antidepressants is usually seen in 24 to 48 hours, much sooner than the antidepressant effects of these agents.1 Ondansetron has been studied as a direct acting serotonergic agent, however it has only shown mild to no benefit in clinical trials.1,2

Rifampicin: Rifampicin is an antibiotic and hepatic enzyme inducer shown in several trials and meta-analyses to relieve hepatic pruritus. Recommended dose is 150-300 mg twice daily depending on serum bilirubin (300 mg for bilirubin less than 3 mg/dL and 150 mg for bilirubin 3 mg/dL or higher). Complications of therapy include drug induced hepatotoxicity or renal impairment and hepatic ennzyme induction which could decrease the efficacy of other medication therapies.1,2 Due to the risks for hepatotoxicity and nephrotoxicity, liver and renal function tests will need to be continually monitored suggesting that therapy with rifampicin should be held in reserve for when benefit outweighs risk in end-of-life care.

Opioid Antagonists: While there is strong evidence for the use of the opioid antagonists naloxone or naltrexone, these therapies are usually inappropriate in hospice care since these agents will counter the analgesic activity of other opioids used in the treatment of chronic pain and could also induce opiate withdrawal.1,2 In addition, naltrexone has a rare potential for causing hepatotoxicity which will require monitoring liver function. The recommended dose of naltrexone is 50 mg by mouth daily, however naltrexone is hepatically eliminated and will accumulate in decompensated and end-stage liver disease requiring that the dose of naltrexone be decreased.2 Due to the monitoring burden and the risk of counteracting chronic opiate activity, it is recommended only to use naltrexone when the patient is not taking opioid analgesics and benefit outweighs risk of decreasing liver function.

Antihistamines: The mechanism of antihistaminergic compounds is reliant on non-specific antipruritic effects with little treatment to the direct etiology of hepatic pruritus.2 Complications that occur are the risk of confusion, sedation, exacerbation of dementias, and increase in fall potential for patients that are still ambulatory from the anticholinergic activity of the antihistamine agents similar to diphenhydramine and hydroxyzine.3 It is recommended to use these only when other systemic therapies have failed or are inappropriate.

Phenobarbital: Phenobarbital was once utilized as a therapy for hepatic pruritus, however its use is limited in modern practice due to risks of severe sedation and hepatic enzyme induction.2,3

There is a large variety of medication therapies that can be used to treat pruritus from a hepatic etiology. Topical therapies such as the counter-irritants capsacin or menthol have some limited efficacy1 but the application area may become so large in advanced disease that their use becomes impractical. While conventional therapies of systemic antihistamines may be moderately effective, they have the potential for undesirable adverse events and may be less effective or efficient than an etiology specific agent. Cholestyramine or sertraline may not be the first agent that comes to mind when a patient complains of an itch, however these less conventional therapies have become a mainstay for the treatment of pruritus in advanced hepatic disease. In addition, the use of these alternate therapies broadens the spectrum of drugs that could be used for multiple pharmacological effects and can afford a patient specific drug selection.


Submitted by: James R. Thomas, PharmD., BS Hospice Clinical Pharmacist and Pharmacy Resident at Delta Care Rx


References:

1. Xander, C., Meerpohl, J. J., Galandi, D., Buroh, S., Schwarzer, G., Antes, G., & Becker, G. (2013). Pharmacological interventions for pruritus in adult palliative care patients. The Cochrane Database of Systematic Reviews, 6(6), CD008320. doi:10.1002/14651858.CD008320.pub2

2. Lindor, K. D., Gershwin, M. E., Poupon, R., Kaplan, M., Bergasa, N. V., & Heathcote, E. J. (2009). Primary biliary cirrhosis. Hepatology. doi:10.1002/hep.22906

Continue reading
441 Hits
Lori Osso-Connor, PharmD, CGP

Role of Warfarin in Hospice and Palliative Care

Patients who make the hospice choice have opted for comfort measures and are no longer seeking life sustaining treatment. However, as hospice professionals encounter daily, many patients are admitted on medications that are considered treatment and are used for curative measures and not palliative measures.

The risk for thromboembolism in hospice and palliative care patients increases due to advanced age and diagnoses such as cancer or cardiomyopathy. Warfarin (Coumadin®) is indicated as treatment to prevent clotting in atrial fibrillation, thromboembolic disease, and artificial heart valves. It is a medication that poses a clinical challenge on whether to continue or discontinue when the patient becomes hospice appropriate. Warfarin’s mechanism of action is to inhibit Vitamin K epoxide reductase which decreases the Vitamin K in the body and decreases clotting. While warfarin is typically indicated as treatment, it could be argued that it is used in hospice and palliative care to provide comfort by reducing the risk of pain and swelling in the extremities due to DVT, unilateral weakness, or paralysis related to stroke.

However, there are several arguments that can be made to support the discontinuation of warfarin in hospice and palliative care. Some issues to consider include:

• The use of warfarin requires PT/INR lab work to ensure therapeutic efficacy. Studies have shown that hospice and palliative care patients require more frequent INR monitoring. These blood draws may be undesirable to the patient and or caregivers at this point in care. Additionally, poor venous access may make obtaining the blood difficult.

• Warfarin is a medication that has many drug-drug interactions including many antibiotics and drug-dietary interactions which could pose unnecessary complications to the patient. Some examples of drug–drug interactions with warfarin in which the anticoagulant effect is increased include levofloxacin (Levaquin ®), sulfamethoxazole/ trimethoprim (Bactrim ®), prednisone, and NSAIDS. In addition, Vitamin K rich foods may decrease the effects of warfarin. Therefore, it is most important to keep a consistent type diet.

• As intake declines or is erratic, the dietary vitamin K may fluctuate which could increase the risk of a bleed or clot.

• Nausea and vomiting could impact the medication adherence which may alter INR due to drug interactions.

• When a dose is changed, it takes 5-6 days to take full effect. If the PT/INR is not carefully managed, it leads to additional increases or decreases in the dose and a myriad of additional blood draws.

• The risk of an intracranial hemorrhage in a debilitated ambulatory patient who may fall is greater than the benefit in preventing a stroke.3

• The risk of a GI hemorrhage is about 8%.1

• The 1-year risk of stroke in atrial fibrillation is 2% in patients treated with warfarin and 4% in those untreated.1

Do the benefits of continuing outweigh the risks? Some factors to consider when facing this decision include: indication, prognosis, bleeding risk, thrombosis risk, nutritional status, appropriate monitoring, medication adherence, medication changes, and patient/family preferences. It is also important to consider whether a new clot will impair the patient’s function or quality of life. As one can see, the choice to discontinue warfarin is a difficult one and is not always clear cut. The risks verse the benefits in each patient must be assessed in accordance with the family and patient’s goals. This individualized approach will help the hospice care professional determine whether the benefits outweigh the risks to the patient and make an appropriate choice.


References:

1. Allen, Richard. “10 Drugs to Reconsider When a Patient Enrolls in Hospice.” NHPCO Newsline(2014): 5.

2. Hill, Robin, Kerri Martinez, Thomas Delate, and Daniel Witt. “A Descriptive Evaluation of Warfarin Use in Patients Receiving Hospice or Palliative Care Services.” Journal of Thrombosis and Thrombolysis 27.3 (2008): 334-39.

3. Von Gunten, Charles, David Weissman, and Janet Abraham. “Fast Fact #278 Warfarin and Palliative Care.” #278 Warfarin And Palliative Care. Web. 26 Feb. 2015

Continue reading
1208 Hits
Char Cole, PharmD, CGP

Impact of Bariatric Surgery on End of Life Care Symptom Management

Obesity is a growing concern in the United States. There are three major types of bariatric surgery done in the United States to combat the obesity problem.

1. Vertical Banded (Stapled) Gastroplasty

2. Adjustable Gastric Banding

3. Roux-en-Y Gastric Bypass

Weight loss occurs by causing malabsorption or by restricting gastric volume or a combination of both. Banding procedures limit the amount of intake, whereas the Roux-en-Y procedure not only reduces the stomach size, it also changes the site of attachment of the small intestine. The Roux-en-Y procedure bypasses the lower portion of the stomach and a much smaller stomach pouch (15-30 mL capacity) is created, then the small intestine (the entire duodenum and part of the proximal jejunum) is removed from the lower stomach and attached to the newly formed stomach pouch. This procedure reduces the surface area that is available for absorption of nutrients and medications.

Different medications have different requirements for absorption and ultimately effectiveness. Medications in aqueous solution are more rapidly absorbed then those in oily solutions. Medications are soluble at different pH levels. Different medications that are more soluble at acidic pH are absorbed in the stomach, whereas medications that are more soluble at alkaline pH are absorbed in the small intestine. Intestinal enzymes are also necessary for the absorption of some medications. The Roux-en-Y Gastric Bypass can alter medication absorption.

Reducing the amount of time needed for absorption of the medication is essential for safe and effective use of medications. The formulation of the medication can be sufficient to reduce the amount of time needed in the stomach/small intestine for absorption. When possible the use of pills that can be crushed should be considered, as well as liquids, subcutaneous, intravenous, rectal, vaginal, intranasal and transdermal formulation and/or routes of administration should be considered. Avoid or use with caution any medication that has a long stomach absorptive phase.

Oral non-steroidal anti-inflammatory drugs (NSAIDs), salicylates and bisphosphonates should be avoided. These medications can cause or increase the potential of the patient to develop ulcers in the new much smaller stomach and/or reduced small intestines in all types of bariatric surgery. If the use of these medications are essential, then consider alternative routes of administration such as topical or injectable. Delayed release preparations of all medications such as CR, SR, XR, LA, EC, etc. should be avoided in Roux-en-Y Gastric Bypass.

Pain management in end of life care is essential. The use of MS Contin or morphine ER should be avoided in patients that have had a Roux-en-Y Gastric Bypass. Due to the reduced surface area of the gastrointestinal tract, the use of immediate release formulations would be a better alternative to extended release preparations. The use of immediate release formulations or non-extended release formulations may require a more frequent dosing schedule; however the Roux-en-Y bypass patient will be more apt to achieve more consistent pain management.

It is important to inform all healthcare providers of a patient’s bariatric surgical history if it exists as this will alter the medication therapy chosen for the patient. The length of time the patient is status post bariatric surgery has no impact to the medication therapy consideration. Once a patient has had bariatric surgery, medications will always need to be adjusted to take into account the changes made to the gastrointestinal tract through the bariatric surgery and how this will alter the absorption of medications. All medication therapies chosen for a bariatric surgery patient should be evaluated for effectiveness and for the increased potential for side effects if the proper monitoring is not done.


References:

1. Vanhoose K. Medication Absorption after Gastric Bypass. Advance Healthcare Network for NPs and PAs. www.ADVANCEforNPs\&Pas\_PrinterFriendly.htm

2. Rogula T, Schauer P. Medications after Bariatric Surgery. www.Medicationsafterbariatricsurgery.htm

3. Miller AD, Smith KM. Medication and Nutrient Administration Considerations after Bariatric Surgery. AM J Health Syst Pharm.2006;63(19):1852-1857.

4. Lawrecki T. How is drug absorption altered by bariatric surgery? University of Illinois Chicago College of Pharmacy

Continue reading
404 Hits