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BMJ Supportive & Palliative Care is an international peer review journal for clinicians, researchers and other healthcare workers in all clinical services where supportive and palliative care is practised. The journal aims to link many disciplines and specialties throughout the world, promoting an exchange of research evidence and innovative practice by presenting high quality scientific reports, reviews, comment, information and news of international importance.

BMJ Supportive & Palliative Care is owned by BMJ Group and is an official journal of the Association for Palliative Medicine and the Australian and New Zealand Society of Palliative Medicine.

Public Image Limited

13 Oct, 17 | by BMJSPCblog

 

Palliative Skateboard.

Brought to you by a few people, including:

 https://www.instagram.com/pmillustration/

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8 Sep, 17 | by James Smallbone, Publishing Assistant

Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data.

Bally M, Dendukuri N, Rich B, Nadeau L, Helin-Salmivaara A, Garbe E, Brophy JM.

BMJ. 2017 May 9;357:j1909.

A bayesian meta-analysis of individual patient data from Canadian and European healthcare databases (61460 cases of acute myocardial infarction and 385303 controls) compared non-steroidal anti-inflammatory drugs (NSAIDs) used in the general population. In the 1st week of NSAIDs use, there was a rapid increase in risk of acute myocardial infarction and there was a higher risk of myocardial infarction with higher doses of NSAIDs. With NSAID use for one to seven days, the odds ratios were 1.24 for celecoxib, 1.48 for ibuprofen, 1.50 for diclofenac, 1.53 for naproxen, and 1.58 for rofecoxib.

http://www.bmj.com/content/357/bmj.j1909

Composed by Elaine Boland.

That was the week that was – The @NHS account takeover!

8 Sep, 17 | by BMJSPCblog

by Dr Ollie Minton

Consultant in Palliative Medicine, London, UK

Yes, yes, I know I live in an echo chamber/social media bubble and the internet is full of fake news,but unless I imagined the whole experience I was given control of the @NHS twitter account (https://twitter.com/nhs?lang=en) for the week of the 28th August.

The premise: the account, each week,  is given to someone in the NHS – be that a professional or a patient. I was initially asked to run the account to coincide with Dying Matters week http://www.dyingmatters.org/AwarenessWeek but the 2017 General Election scuppered that plan. Blame Theresa May.

For those of you who don’t do “social media” the rest of this won’t necessarily make much sense, but I had 24,000 accounts (people / organisations / robots and the like) following my output. I have no idea who sees what, or perhaps more importantly does anything with it as a result. Although the interactions I had were 99% positive and those that weren’t, were simply ignored.

The remit is vague and that’s deliberate – YOU are in charge, you respond as you see fit and you yes YOU (like fighting fantasy books https://en.wikipedia.org/wiki/Fighting_Fantasy ) control your destiny. ‘Ah, ha, ha, haaaaa!’, I cried, channeling my inner Trump and started tweeting.

There are rules and guidelines but as a professional & more importantly a twitter aficionado I felt fairly comfortable with my outline plans.

So far so good: I had a notion of what I felt was important to me – namely communication, early referral and planning ahead. I wanted to raise 7 day services, research and money without getting too political. I was absolutely sure I was not going to send out a single paper or report or anything remotely “corporate”. However I did want it to be educational and informative and so I posted a few (more than a few) links to share.

I was taking my lead from previous weeks, the trust communication people & the team at NHS HQ (Jess).

We had an hour long teleconference: The only clear instructions I took away were
1) Quote tweet – so the chain of tweets can be seen underneath and so people can see what you’re replying too
2) Turn the phone horizontally when filming.

3) Don’t be like Donald Trump or Grumpy Skeletor

I remembered point 1 , forgot point 2 and 3, so the 1st of five films I made during the week which was promptly sent on to the masses by the official NHS England account was a bit tricky to view. I think the novelty of a geriatrician Jo  talking about a podcast she makes (http://thehearingaidpodcasts.org.uk/ ) obviously ticked all the necessary boxes.

Interestingly my “controversial” segment (not very, but was talking about weekend visiting & 24/7 cover and services) was taken up by the trust – perhaps as they are still promoting 24 hours in A&E (http://www.channel4.com/programmes/24-hours-in-ae).

The elements of my professional life I assumed would be most useful apart from all the Daily Mail headlines – those on syringe pumps, money, advance care planning, barely rippled in my notifications.

I’d like to think I did not compromise what I chose to share and mention. I was a LOT more conscious of everything I did than on my personal account and there were certainly less retweets of cat or dog pictures, and no Grumpy Skeletor regardless of my wish to have my tweets “go viral”.

If anyone has had any prompting from someone as a result of seeing or hearing about my week please do let me know in the comments section below or on Twitter.

The analytics are a dark art. The “impressions” came in at 865,000 for the week. The link clicks – (someone acted on a tweet) were 1,500 for the week. To my mind that feels like a success, a ripple in the chaotic pond of constant online information waterfall to mix all the metaphors.

I can only guess as to their impact, but I have a great selection of my hits for a permanent record for my CV and obviously everything on the internet lives forever – unlike us mere mortals.

Shortcuts

25 Aug, 17 | by James Smallbone, Publishing Assistant

C-reactive protein, symptoms and activity of daily living in patients with advanced cancer receiving palliative care.

Amano K, Maeda I, Morita T, et al

J Cachexia Sarcopenia Muscle. 2017 Jun;8(3):457-465.

A secondary data analysis of a cross-sectional study looked at the associations between C-reactive protein (CRP) level, manual muscle testing of limbs, symptoms and activities of daily living (ADL) in advanced cancer patients receiving palliative care in different settings. Data on 1702 patients were analysed and classified in groups depending on the CRP levels. As CRP levels increased, patients had more symptoms and ADL disabilities. In the very high CRP group (10 mg/dl = < CRP), (n = 394), weight loss (79%), anorexia (90%) and fatigue (81%) were common. Patients with severely weak muscle testing had higher CRP levels. Using an ordinal logistic regression model, symptoms were significantly higher (adjusted ORs) in the moderate, high, and very high CRP groups (1.6; P < 0.001; 2.5; P < 0.001; 3.5; P < 0.001, respectively).  This study shows that CRP is associated with ADL and symptoms and concludes that CRP might be a good biomarker in cancer patients receiving palliative care.

http://onlinelibrary.wiley.com/doi/10.1002/jcsm.12184/full

Composed by Elaine Boland.

Pejorative Words or ‘The bed blocker with acopia in bed 14 that passed away, having lost her fight’

16 Aug, 17 | by BMJSPCblog

By Dr Ollie Minton (Consultant in Palliative Medicine, somewhere in London town), Dr Erica Borgstrom (Medical Anthropologist, Open University), Dr Mark Taubert (Consultant in Palliative Medicine, somewhere in Wales)

 

 

 

 

 

 

 

 

When The Adventures of Huckleberry Finn was first published, readers were not much disturbed by Mark Twain’s use of the n-word, let alone ‘injun’, terms that have been replaced by slave and Indian in the latest versions. Back then, profanity and public morality were hotter issues and they would have found today’s scrutiny of those terms curious. We are all guilty of using a patois that we have acquired in our jobs, often handed on to us by our seniors and long-established colleagues. Indeed these turns of phrases are so commonplace that there is an ever growing list known to journalists far and wide; there are examples in book form, as well as frequently updated phrases, and an ever on-going debate on clichés and jargon on twitter ( for example: https://twitter.com/johnrentoul). This is – as you can imagine – not a new phenomenon and we all can quote examples of eye-rolling management speak.

But the term pejorative language refers to words and phrases that hurt, insult, or disparage someone or something. Also called a derogatory term or a term of abuse. The label pejorative (or derogatory) is sometimes used in dictionaries to identify expressions that offend or belittle a subject. Nonetheless, a word that’s regarded as pejorative in one context may have a non-pejorative function or effect in a different context.

Some see banned words and phrases as a sign of an ever-increasing political correctness society, others point out the offence that has been caused. Take the often used description ‘anti-ageing’ in cosmetics. You have heard it frequently, but did you ever think that perhaps older people may find it challenging and off-putting?

A list of verboten ‘bon mots’ listed on a whiteboard in a Welsh hospital circulated on Twitter recently, which had specific relevance to the specialty of palliative care. Whether we can agree on a definitive list remains to be seen – that’s for the comments section below. But it is a core set to get us started and a visual summary of ideas collated so far.

The themes that emerged were euphemisms for death or dying like “pass away” or “pass on”. Phrases like “nothing more can be done”, or “they lost the fight” were also scrutinized. Spelling errors like the extra ‘d’ that some people add at the end of ‘advance’ in Advance Care Plan were seen as minor irritations that distort the true meaning of a phrase.

The language we use day to day in medicine was put in more spotlight in a recent TEDX talk  by Dr Mark Taubert. We try to select our words carefully and sensitively – or at least should do within the specialty – which is to say we recognise the need for careful phrasing of uncertainty, prognostication, and deterioration, “while fostering hope”. Equally we cannot control the public perception or media interpretation of what we do; the word “pathway”, and all of its connotations, has stayed around to haunt us. We rarely use the term in our local settings and now have strong feelings about its use in any context in relation to dying and death. Words evoke emotions, whatever the logical side of our brain tells us about the dictionary definition.

Phrase that made the abovementioned list include: ”the patient is poorly”, “social admission”, “bed blocker”, and is “not coping” or the non-word “acopia”. These terms are judgment laden and do not necessarily add useful information to the user or the recipient. Even if they serve as a form of professional shorthand, they are usually woefully inaccurate and obscure a person’s experience. The lack of objective outcome measures perhaps compounds our ability to convey this.

In summary we should all expect “best supportive care” whatever the diagnosis or stage of illness, even when a full recovery can be expected. It should not require a room full of professionals at the MDT (multidisciplinary meeting) to decide on this, especially in the absence of the patient themselves. It should certainly not imply that “nothing more can be done”. What the ‘banned phrases’ list does is challenge how we articulate what palliative care does and how we talk about patients in perhaps a more respectful way, rather than describe them as “the ovarian in bed 14.”

End note: if you want to find out more about the visual summary of ‘banned phrases’ and how to create your own, see the Twitter discussion initiated by Dr Mark Taubert and the resulting blog and graphics by Dr Erica Borgstrom.

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11 Aug, 17 | by James Smallbone, Publishing Assistant

Retrospective review of serotonergic medication tolerability in patients with neuroendocrine tumors with biochemically proven carcinoid syndrome.

Shi DD, Yuppa DP, Dutton T, et al.

Cancer. 2017 Jul 15;123(14):2735-2742

A retrospective review of patients with metastatic carcinoid tumours and elevated serotonin levels who received serotonergic antidepressants was performed to evaluate the effect of serotonergic antidepressants on the carcinoid syndrome. 52 patients were identified who received a total of 73 courses of serotonergic antidepressants, most commonly citalopram, followed by trazodone and sertraline. The median duration of treatment with serotonergic drugs was 4.8 months, with 38% of patients taking them for more than 6 months. No apparent adverse interaction of the serotonergic antidepressants on the carcinoid syndrome was reported in 45 patients (62%); 7 (10%) were categorized as having an unlikely adverse interaction, and 6 (8%) as having a likely adverse interaction; common symptoms were flushing and diarrhoea. No patients developed a carcinoid crisis requiring emergency care or hospitalisation.

http://onlinelibrary.wiley.com/doi/10.1002/cncr.30633/abstract

Composed by Elaine Boland.

Shortcuts

28 Jul, 17 | by James Smallbone, Publishing Assistant

Prevalence and incidence of chronic pain with or without neuropathic characteristics in patients with cancer.

Bouhassira D, Luporsi E, Krakowski I.

Pain. 2017 Jun;158(6):1118-1125.

A prospective observational study in France recruited 1805 cancer patients attending out-patients for cancer treatment from 12 oncology units. A clinical examination, DN4 questionnaire and Brief Pain Inventory were used to detect and characterise the pain. Chronic pain characterised as due to the tumour, cancer treatment, or not related to cancer. The overall prevalence of chronic pain was reported as 28%, with 21% of these patients having characteristics neuropathic pain; an overall prevalence of 5%. Pain with neuropathic characteristics was more commonly reported by patients with lung, breast, or head and neck cancers. Patents with a neuropathic element to their pain reported a higher pain intensity and pain interference. This study also looked at the incidence of chronic pain in patients who had no chronic pain at first visit but subsequently developed pain. Three months after initial assessment, the incidence of chronic pain varied from 12% to 20% and at 6 months, from 20% to 28%.

https://www.ncbi.nlm.nih.gov/pubmed/28267066

Composed by Elaine Boland.

News and updates from www.palliativedrugs.com

28 Jul, 17 | by James Smallbone, Publishing Assistant

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website with over 30,000 members from 169 Countries.

Safety updates

Denosumab: reports of osteonecrosis of the external auditory canal

UK MHRA have highlighted that there have been reports of osteonecrosis of the external auditory canal with the use of denosumab (Prolia®, Xgeva®). In December 2015, there were similar reports with the use of bisphosphonates. Both denosumab and bisphosphonates are also known to be associated with osteonecrosis of the jaw. For more information, click here.

Hot topics

BTS guideline for oxygen use 2017

The British Thoracic Society (BTS) guideline for the use of oxygen in healthcare and emergency settings has been updated and published. For more information, click here.

Cochrane review: topical analgesics for acute and chronic pain in adults

This overview of Cochrane reviews has been published in full on-line.The authors conclude that there is reliable evidence that topical diclofenac and ketoprofen gel may be useful for strains and sprains, and to a lesser extent knee and hand osteoarthritis. Topical capsaicin (high-concentration) may be of limited use in some people with postherpetic neuralgia. Topical salicylate, capsaicin (low-concentration), clonidine, and lidocaine are not well supported by evidence, or much evidence of effect. However, there may be beneficial effects in a small number of people. For more information, click here.

Cochrane review: tramadol with or without paracetamol for cancer pain

This review has been published in full on-line. The authors conclude that there is no clear evidence to support the use of tramadol in mild−moderate, or severe cancer pain in adults. Tramadol may have a role if other opioids are not tolerated, providing the issues of dose titration and possible severe undesirable effects are considered. For more information, click here.

Cochrane review: morphine for chronic neuropathic pain in adults

This review has been published in full on-line. The authors conclude that there is no convincing evidence that oral morphine ≤180mg/24h is effective in relieving neuropathic pain (e.g. ≤50% pain reduction ≤12 weeks), but note the possibility that subgroups of people may get a good response. For more information, click here.

Cochrane review: methadone for neuropathic pain

This review has been published in full on-line. The authors conclude that methadone should not be considered a first-line opioid in the treatment of neuropathic pain mostly due to the possibility of increased risk of undesirable effects compared to other opioids. For more information, click here.

Drug updates

Pregabalin prescribing restrictions to be lifted

The patent for the use of pregabalin for neuropathic pain, held by Pfizer for its oral product Lyrica®, expires on 16 July 2017 in the UK. Thus, as of 17 July 2017, the prescribing restrictions imposed by NHS England in March 2015 on the use of generic pregabalin for neuropathic pain will no longer apply. New guidance from NHS England states that after this date, ‘when prescribing/dispensing pregabalin for the treatment of any condition, you should prescribe/dispense in accordance with your normal practice’. For more information, click here.

Magnesium glycerophosphate oral tablet authorized

An authorized, chewable, magnesium glycerophosphate tablet (magnesium 4mmol/tablet) is now available for the treatment of chronic hypomagnesaemia (Neomag; Neoceuticals). The cost of 28 days @ two tablets t.d.s. (24mmol/24h) = £77. For the SPC, click here.

Epistatus 10mg oromucosal solution now authorized

The Epistatus® brand of midazolam 10mg oromucosal solution for buccal administration has been authorized in the UK for the treatment of prolonged, acute seizures in children and adolescents <18 years. The NHS list price of one prefilled syringe is £60. This product was previously unauthorized but available as a special order product. The other strengths of Epistatus® oromucosal solutions remain unauthorized. For the SPC, click here.

Note. The Epistatus® oromucosal solution is 10mg/mL; this is double the concentration of the other authorized formulation of midazolam oromucosal solution (Buccolam®) in the UK which is 5mg/mL and available as 2.5mg, 5mg, 7.5mg and 10mg prefilled oral syringes.

Capsaicin patch risk minimization guide

Risk minimization material concerning the administration of capsaicin 8% patch (Qutenza®) has been produced by Grunenthal, for use by health professionals. For more information, click here.

Magnesium glycerophosphate oral tablet authorized

An authorized, chewable, magnesium glycerophosphate tablet (magnesium 4mmol/tablet) is now available for the treatment of chronic hypomagnesaemia in the UK (Neomag®; Neoceuticals). The approximate cost of 28 days @ two tablets t.d.s. (24mmol/24h) = £77. For the SPC, click here.

Latest additions

PCF updated monographs summary

The on-line Palliative Care Formulary is being continually updated. The following monographs have been updated during June 2017 and supersede those in the print publication of the 5th edition of the Palliative Care Formulary (PCF5) and PCF5+ 2016 PDF. They can be accessed from the formulary section of the website.

Chapter 01: Simeticone (minor change), QCG: Death rattle (noisy rattling breathing)

Chapter 10: Dantrolene, Tizanidine

Chapter 11; Pilocarpine

For a full list of all the monographs updated since the print publication of PCF5, click here. Follow us on twitter @palliativedrugs for the latest updates.

Website privacy policy updated

In order to comply with the requirements for our Health on the Net code standard for trustworthy health information annual accreditation, we are required to inform our website users of changes to our privacy policy. We have recently updated this to provide information on our use of google analytics. The updated privacy policy can be found via the link at the bottom of every page or click here.

 

Prepared by Sarah Charlesworth and Andrew Wilcock

Grief at Hay

27 Jun, 17 | by BMJSPCblog

by Carys Durie and Sioned Edwards
4th year Medical Students, Cardiff University

The 2017 Hay Festival of Literature and Arts set in the Welsh town of Hay-on-Wye, celebrated its 30th anniversary this year. Speakers included the likes of Tracey Emin, Bernie Sanders, Stephen Fry and Ed Balls. Pianist James Rhodes closed the first weekend with a Bach recital, dedicated to the people of Manchester after the terror attack that left many dead. These recent tragic news events gave particular poignancy and context to a discussion on grief, which formed a central theme of one particular literary event, which we have described below.

We attended a packed, sweltering Starlight tent, where an apparently disparate group of speakers took to the stage: Welshman George Brinley Evans, ex-miner and now recognized painter, sculptor and published author; Phil Steele, former Welsh rugby player and current BBC sports broadcaster; and Dr. Mark Taubert, Consultant Physician and Clinical Director for Palliative Care at Velindre Cancer Centre in Cardiff. The discussion entitled ‘Before the End – Telling Your Story In Time’ was chaired by Professor Hywel Francis, chair of Byw Nawr/Live Now, the coalition dedicated to raising awareness of dying, death and bereavement.

Left to right: Phil Steele, Mark Taubert, George Brinley Evans and Hywel Francis

Male grief remains a subject that is not talked about in our society. Bereavement and grief were the central themes of the day’s talk. Phil Steele and George Brinley Evans discussed how bereavement had encouraged them to tell their own stories, despite many setbacks. Steele’s autobiography Nerves of Steele, his writing debut, maps out his life from his beginning as an ‘Ely boy’ in Cardiff, to the successful and entertaining broadcaster he is today. Steele was a professional rugby player with Newport RFC, when he suffered his first bout of depression: aged just 23, he had sustained an injury that put paid to his promising career. Steele went on to endure the loss of four family members, including his wife, Liz, in 2009. Steele put it as having five losses in his life, four of them being bereavements, the fifth loss being his rugby playing career. He pointed out that grief or bereavement does not necessarily entail the death of a person or loved one, but can also be that of a bodily function or role. Thus grief can take many patterns and forms. He described how he did not find talking about it difficult, but that others avoided these conversations, and he sensed an awkwardness in discussing grief and depression in his wider circles.

Dr. Mark Taubert explained the different forms that grief can take. While most of us are aware of the stages of grief – denial, anger, bargaining, depression, acceptance – psychologists now also accept different types of grief, intuitive and instrumental, as two ends of a spectrum. Intuitive grief encompasses open expression and emotions, said Dr Taubert, describing it as a grief in which ‘expression mirrors feelings’. People veering more towards this form of grief, often talk about their feelings, and share their emotions and experiences with others. By contrast, in instrumental grief, grievers are less willing to share their thoughts and instead go through a period of quiet and inward processing, while they come to terms with their loss. Dr. Taubert described instrumental grief as being ‘action orientated’, with people finding comfort through channeling their energy into a project, and often immersing themselves in work. These two types of grief sometimes fit the perceived ‘gender stereotypes’; some people assume that women are more open (intuitive) grievers, and that men are more inward instrumental grievers, ‘disappearing to their sheds’ –some laughter and nods from the audience here-. Dr Taubert explained that these gender stereotypes are not always correct and he observed many female instrumental grievers and male intuitive grievers, sometimes oscillating between these two types of grief. Grief experiences are influenced by more than fourty distinct factors, making each grief experience, as Taubert put it, ‘as unique as a fingerprint’.

George Brinley Evans described growing up at a time when grief was simply not spoken about and “you certainly didn’t show it”. When he was a miner, three British coal miners were killed every day and children were dying of diphtheria; it was a time when men and women alike were expected to “carry on as normal”, as the iconic war time poster dictated. He described the way that, in times of grief, men would “go to work and busy themselves” rather than grieving with their family and talking about it. Men didn’t cry. He remembered the 1930’s when funerals were “gentlemen only”: women and children were kept at home to grieve in private, while the men in the community would attend the funeral on their behalf.

Evans’ most recent novel, ‘When I Came Home‘, recounts conversations from 60 years ago; these memories deal with births and deaths, struggles and triumphs, memories he has vividly captured. Reflecting on this latest work, George Brinley Evans stressed the importance of being able to get his story down on paper: “When you write, it’s just you and the page; there are no conflicts of characters”. For him, the best way to capture his story and relay it to loved ones was through writing it.

When talking about his experience of depression, Phil Steele – who described receiving comments such as “You of all people with depression Steeley!” and “How could it happen to you?!” – raised the question of the language we use when talking to a person facing a loss or struggling with mental health problems. There was too much ‘fighting talk’ and phrases such as “battling depression” or “you’re going to beat this”. This was seconded by Dr Taubert, who observes such war metaphors and battle language in everyday practice at the hospital, and who’s patients have told him it can be damaging and disempowering. He suggested that people actually feel let down by these expressions since, ultimately, we all ‘lose the battle’, if we chose to use this patois. The panel felt that it should not be about fighting depression or battling with grief, but learning to accept it. More on the language of grief and loss can be found in an article by Dr Taubert entitled “War and Peace in Cancer” in the Huffington Post. He has also made it the central theme in a recent Ted Talk.

There was discussion about the role of digital media in raising the issue of grief, but also offering new ways of collecting experiences and memories for future generations. This was not a session which finished with all answers tied up neatly at the end. By way of underlining the fact that this should be a constant and ongoing discussion for everyone, Professor Hywel Francis posed a further question for his speakers and audience. He simply asked a series of questions “What could you do, to help discussions about grief? What could you do to help a person come to terms with a loss or faced with a mental disorder? What could you do to change your perceptions of grief and how we grieve? What could you do to help a loved one share their feelings and experiences, and help them to tell their story before the end?” All salutary questions and hugely important in terms of raising consciousness of issues which inevitably affect us all.

As a society, we can at times be judgmental about the way people grieve and how we feel people ought to respond to loss. Discussions like this one at Hay focused attention on bringing death and grief into the everyday here and now and on the need to open people’s eyes to the complexity and uniqueness of bereavement. Bringing such things into the open creates the possibility of continuing bonds and encouraging resilience in those that are left behind.

The writers gather at Hay Festival Bookshop after the talk

News and updates from www.palliativedrugs.com

16 Jun, 17 | by bbutcher

June 2017

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website with over 30,000 members from 169 Countries.

Safety updates

FDA restricts codeine and tramadol in children and adolescents
As part of an on-going safety review, the FDA have further restricted the use of codeine and tramadol:

  • codeine is contra-indicated for the treatment of pain or cough in children <12 years
  • tramadol is contra-indicated for the treatment of pain in children <12 years
  • codeine and tramadol are contra-indicated in children <18 years to treat pain after surgery to remove the tonsils and/or adenoids
  • it is recommended that codeine and tramadol are not used in adolescents 12−18 years whoare obese, or have conditions such as obstructive sleep apnoea or severe lung disease, which may increase the risk of serious breathing problems
  • it is recommended that codeine and tramadol are not used by breastfeeding mothers.

For more information, click here.

Editor’s note: The restrictions for codeine reflect those issued in the UK by the MHRA in April 2015 (for cough) and July 2013 (for pain). The MHRA have not specifically highlighted any restrictions in
the UK for tramadol, which is unauthorized for use in children <12 years.

Drug updates
Acetylcysteine oral powder launched in UK
A new oral acetylcysteine powder is now available in the UK, authorized as a mucolytic adjuvant for respiratory disorders associated with thick, viscous, mucus hypersecretion. The dose is 200mg
(1 sachet, dissolved in a little water) three times a day. The cost for 28 days@ 1 sachet t.d.s. = £315. For more information, click here.

Nystatin dose changes in the BNF and SPC
The dose for oral candidosis in the BNF and all the SPCs for nystatin 100,000units/mL oral suspension, is now 1mL PO q.d.s.. There has been recent confusion over the authorized dose with generic and proprietary SPCs including differing dose schedules. The dose in the Nystan (Sqibb) SPC was increased in September 2016 from 1mL to 4−6mL q.d.s., but has now been changed back to 1mL q.d.s. This was after further discussion with the MHRA who re-assessed the evidence and did not find it robust enough to support the dose increase. For more information, click here.

Editor’s note: PCF has always recommended a higher dose of nystatin oral suspension 100,000units/mL of 5mL PO q.d.s. for oral candidosis. Nystatin is a topical treatment and few people have the oral dexterity to cover the relevant areas with just 1mL, i.e. it is an issue of volume and not the dose itself. The authorized dose in the USA is 4−6mL q.d.s.

Fentanyl lozenges (Actiq) risk minimization guides
As part of the terms of the Marketing Authorization for Actiq (fentanyl lozenges; Teva), the company have published the following educational guides to minimize risk of misuse/dependence, abuse, medication errors, drug diversion, accidental exposure, overdose, off-label use, respiratory depression and dental decay in patients on opioids.
Prescription guide
Patient guide
Patient treatment diary

Latest additions
Restructured and updated PCF Part 2 live on the website
We are delighted to announce the launch of the new format for Part 2 of PCF on the www.palliativedrugs.com website in anticipation of PCF6 print publication in late 2017. This work has been completed separately over the last 3 months. In addition, several updates to Part 1 monographs have also been completed. The changes include:

    • a more user-friendly order for the chapters and appendices; most chapters/appendices have been renumbered
    • splitting of long chapters, e.g. Chapter 14 into shorter more specific chapters, e.g. a new fully revised chapter on renal impairment
    • new chapters, in both Part 2 e.g. Transdermal patches and Part 1, e.g. Opioid antagonists (peripheral)
    • a total of 26 updated chapters/monographs (including 9 in Part 1 / Prelims)
    • a new Part 3 section for routes of administration.

For full details, see the link below. We will now be focusing on completing updates to Part 1 monographs which will be subsequently added to the website. Follow us on twitter@palliativedrugs for the latest updates.
List of changes and restructure Jan-April 2017

Survey results

Results are available from our latest survey, ‘SSRIs for pruritus – Do you use them?’. For more information, click here.

Prepared by Sarah Charlesworth and Andrew Wilcock.

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