Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

Safety updates

MHRA infusion device warning with 50mL syringes

The UK Medicines and Healthcare products Regulatory Agency (MHRA) has issued two separate warnings of the risk of false occlusion alarms occurring with certain 50mL syringes:

50mL Luer Lok Plastipak syringes made by BD Medical (MDA/2013/024)

A change in the design of the syringe plunger in April 2012 has led to false occlusion alarms. To avoid this, the syringe pump occlusion alarm settings need to be adjusted by biomedical engineering departments. BD medical is recalling syringes of the old design to avoid the converse risk of a delay to the occlusion alarm being triggered when used in pumps that have been adjusted. For further details, click here.[LINKhttp://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON266135].

50mL Luer Lok syringes made by Terumo (MDA/2013/030)

Three batches of syringes have been recalled as they have been found to require a greater force than usual to push the plunger. This can lead to false occlusion alarms being triggered when used in syringe pumps. For further details click here.[LINKhttp://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON272236

Drug updates

Sativex reclassified as schedule 4 part 1 Controlled Drug

Sativex (Cannabis sativa extract oromucosal spray; Bayer Heathcare and GW Pharmaceuticals) has been reclassified in England, Wales and Scotland as a Schedule 4 part 1 Controlled Drug (CD), with specific recording requirements applicable to possession and destruction. This has the following implications from the 10th April 2013:

• prescription writing requirements (as for schedule 2 and 3 CD) do not apply to Sativex
• safe custody requirements (as for schedule 2 and 3 CD) do not apply to Sativex
• the destruction of expired stocks of Sativex and patient returns by healthcare professionals does not need to be witnessed by an authorized witness
• standardized private prescription forms, i.e. FP10PCD, PPCD(1), WP10PCD and their requirements are not required when Sativex is prescribed privately
• a Home Office license “for research or other special purpose” for Sativex is no longer required.

Although record keeping requirements are not required for schedule 4 part1 CDs, records must be kept for 2 years for cannabis-based medicines (1961 UN Convention on Narcotic Drugs). This includes the amounts of Sativex possessed or destroyed by those authorized to do so (patients and their representatives are exempt). The Home Office strongly recommends the use of the CD register to do this.

A guide to the legislative changes has been produced by the Royal Pharmaceutical Society[LINK http://www.rpharms.com] (access via pharmacist members). Further information can be found on the UK Government website.[LINK https://www.gov.uk/government/publications/scheduling-of-the-cannabis-based-medicine-sativex]

Latest additions

Japanese translation of PCF now available!

A Japanese translation of the Palliative Care Formulary (PCF) is now available. It has been published by Igaku-Shoin and can be obtained from their website[LINK.http://www.igaku-shoin.co.jp/bookDetail.do?book=81351

Prepared by Sarah Charlesworth and Andrew Wilcock

Shortcuts May 2013

J Pain. 2013 Feb 26. [Epub ahead of print]

Lack of Correlation Between Opioid Dose Adjustment and Pain Score Change in a Group of Chronic Pain Patients.

Chen L, Vo T, Seefeld L, Malarick C, Houghton M, Ahmed S, Zhang Y, Cohen A, Retamozo C, St Hilaire K, Zhang V, Mao J.

In this retrospective chart review study, using data from the Research Patient Database Registry, a final set of 109 chronic pain patients over a 7-year period were evaluated for the impact of opioid dose adjustment on pain, gender and age differences in response to opioid therapy, and the influence of clinical pain conditions (neuropathic pain, nociceptive pain, mixed pain conditions and fibromyalgia) on the opioid analgesic efficacy. Changes in the opioid dose did not affect the pain score in patients on long term opioids (averaging nearly 2 years), irrespective of pain type, gender and age. Thus individualised opioid therapy based on the clinical effectiveness is needed to optimise treatment outcome.

BMC Palliat Care. 2013 Feb 18;12(1):9. [Epub ahead of print]

What is the extent of potentially avoidable admissions amongst hospital inpatients with palliative care needs?

Gott M, Gardiner C, Ingleton C, Cobb M, Noble B, Bennett MI, Seymour J.

Using a cross sectional survey of palliative care needs, this study assessed potentially avoidable hospital admissions in 580 inpatients with palliative care needs (from the standpoint of the admitting clinician and within the context of existing local health and social care services) as evaluated by two Palliative Medicine Consultants. The case note data collected included reasons for admission, diagnoses, cognitive impairment, age, living arrangements, time and route of admission, care plan, and specialist palliative care involvement. From the 208 patients meeting the criteria for needing palliative care, 6.7% were ‘potentially avoidable’ admissions, half of whom lived in a care homes and most of these could have received care in this setting. This study indicates that patients with palliative care needs have a relatively low level of potentially avoidable hospital admissions, but improvements could be made in the care home setting.

JAMA. 2013 Apr 3;309(13):1359-67.

Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial.

Smith EM, Pang H, Cirrincione C, Fleishman S, Paskett ED, Ahles T, Bressler LR, Fadul CE, Knox C, Le-Lindqwister N, Gilman PB, Shapiro CL; Alliance for Clinical Trials in Oncology.

This randomised, double-blind, placebo-controlled multi centre crossover trial of 231 patients evaluated the effect of duloxetine in painful chemotherapy-induced peripheral neuropathy.  The peripheral neuropathy was grade 1 or higher sensory neuropathy caused by taxane (mostly paclitaxel) or oxaliplatin causing pain of at least 4/10 from the Brief Pain Inventory-Short Form “average pain” item for at least three months. Patients were randomised (1:1 allocation ratio) to either duloxetine followed by placebo or placebo followed by duloxetine (30 mg per day for a week, then 60 mg daily for 4 weeks). In the patients receiving duloxetine first, they reported a mean decrease in average pain of 1.06 on an 11 point numeric rating scale (0.34 in the placebo group). Nearly 60% of patients initially receiving duloxetine had some reduction of pain (38% in the placebo group). A 30% and 50% pain reduction was 2 and 2.4 times more common with duloxetine than with placebo. Duloxetine also improved pain interfering with daily functioning, quality of life, numbness and tingling in the feet, and use of analgesics. Duloxetine was more effective in people treated with platinums than with taxanes. More people in the duloxetine first group dropped out because of side effects (11% v 1%), most commonly fatigue, insomnia and nausea, although none were serious.

Cochrane Database Syst Rev. 2013 Mar 28;3:CD004310.

Megestrol acetate for treatment of anorexia-cachexia syndrome.

Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, Gonzalvez Perales JL, Bort-Marti S.

This update of the 2005 Cochrane review evaluated the efficacy and safety of Megestrol acetate (MA) in anorexia-cachexia syndrome in patients with including cancer, AIDS and other underlying pathologies such as chronic obstructive pulmonary disease. This update included 35 randomised controlled trials (A total of 4234 patients were included with a total of 3963 patients for effectiveness and 3180 patients for safety) which compared MA to either placebo, another drug or another dose of MA in patients with anorexia-cachexia syndrome. Of the included studies, 16 trials were placebo controlled, 7 were compared with other drugs (including dronabinol, steroids and oxandrolone) and 10 compared different doses of MA; most of the trials had a follow-up of 56 to 84 days. Meta-analysis showed quality of life and appetite improvement as well as some weight gain with MA compared with placebo, in cancer and AIDS, with a mean follow-up of 4 to 12 weeks. There was no benefit of MA compared to other drugs with a mean follow-up of 8 to 15 weeks. Although higher doses (>800 mg/d) of MA were linked to greater increases in weight, there was not enough dose information to confirm this. There is limited long term safety data on MA, but reported side effects which could be related to the MA included oedema and thromboembolism; there were also an increased number of deaths with MA, which seemed more related to higher doses. In general the quality of the evidence was rated as very low.

by Jason Boland

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

Hot topics

NICE changes its name

The National Institute for Health and Clinical Excellence (NICE), has changed its name and is now known as the National Institute for Health and Care Excellence, still retaining the acronym NICE. This is to reflect recent changes to its role which include the integration of the National Prescribing Centre (NPC) and National Electronic Library for Medicines (NeLM) to form a joint new Medicines and Prescribing Centre. Information previously on the NeLM has been incorporated into the NHS Evidence services section which is now provided by NICE. For more information click here.

GMC publishes Good practice in prescribing and managing medicines and devices

The General Medical Council (GMC) has published Good practice in prescribing and managing medicines and devices (2013), which came into effect on the 25 February 2013. It replaces Good practice in prescribing medicines (2008) and incorporates Remote prescribing via telephone, video-link or online (2012). It is available to view or download from the GMC website.

Drug updates

Cyclizine 50mg/mL injection supply problem in UK

There is a national shortage of cyclizine 50mg/mL injection (Valoid; Amdipharm) which is expected to last into May 2013. There is no other authorized (licensed) cyclizine injection in the UK and the company does not have any stock for emergency supply. The supply of tablets is unaffected.

NICE evidence summary of oral desmopressin

NICE has published its evidence summary (ESUOM10)  for the unauthorized/off-label use of oral desmopressin for nocturia and nocturnal polyuria in men with lower urinary tract symptoms.

Aqueous cream may cause skin irritation

The UK Medicines and Healthcare products Regulatory Agency (MHRA) has warned that aqueous cream may cause skin irritation particularly in children with atopic eczema. The reactions may be due to the presence of sodium lauryl sulfate or other ingredients. Treatment should be discontinued and an emollient that does not contain sodium lauryl sulfate should be tried. For more information click here.

Latest additions

PCF updated monographs

The online Palliative Care Formulary (PCF) is being continually updated. The following monographs have been updated during April 2013 and supersede those in the publication of the 4^th edition of the Palliative Care formulary (PCF4). They can be accessed from the formulary section of the website:

Chapter 5: Morphine

Chapter 5: Oxycodone

Chapter 5: Naloxone

Chapter 6: Cellulitis in a lymphoedematous limb and Quick Prescribing Guide: Cellulitis in lymphoedema

Chapter 13: Ketamine

For a full list of all the monographs updated since the publication of PCF4, click here.

Prepared by Sarah Charlesworth and Andrew Wilcock

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

Hot topics

Free access to the on-line Palliative Care Formulary in Scotland

From April 2013, NHS Education for Scotland has subscribed to the on-line Palliative Care Formulary (PCF4+). The content is continually updated and represents the most current version. It is hosted on the Palliative Care Portal of the Knowledge Network website. It is available free of charge to those with an NHS Education Scotland ATHENS username and password.

Drug updates

Asilone discontinued in UK

Asilone^® oral suspension (Thornton & Ross) an antacid containing simeticone 135mg, aluminium hydroxide 420mg and magnesium oxide 70mg/5mL has been discontinued in the UK. Alternative simeticone-containing antacid preparations are:

Maalox Plus^® (Sanofi Aventis)
Oral suspension (sugar-free) simeticone 25mg, dried aluminium hydroxide 220mg, magnesium hydroxide 195mg/5mL, 28days @ 5mL q.d.s =.£3; low Na⁺.

Altacite plus^® (Peckforton)

Oral suspension (sugar-free) co-simalcite 125/500 (simeticone 125mg, hydrotalcite 500mg)/5mL 28days @ 10mL q.d.s =.£7.50; low Na⁺.

See PCF Simeticone monograph

Latest additions

 PCF updated monographs

The online Palliative Care Formulary (PCF) is being continually updated. The following monographs have been updated during March 2013 and supersede those in the publication of the 4^th edition of the Palliative Care formulary (PCF4). They can be accessed from the formulary section of the website:

Chapter 5: Fentanyl (transmucosal)

Chapter 7: Octreotide

For a full list of all the monographs updated since the publication of PCF4, click here.

The oral morphine equivalent of buprenorphine TD patches – What conversion ratio do you use?

Results from this www.palliativedrugs.com  survey (November 2012 – January 2013) can be downloaded from here.

Die Januar/Februar Ausgabe des APM Newsletter ist fertig

The January/February issue of the APM Newsletter for German-speaking users of www.palliativedrugs.com is available.

Der neue APM-Newsletter Jahrgang ist in der Ausgabe Januar/Februar erschienen. Über die aktuelle Ausgaben des Newsletters wird Sie das Bulletin Board informieren.

Prepared by Sarah Charlesworth and Andrew Wilcock

The Effect of Opioid Therapy on Endocrine Function.

Brennan MJ.

This review summarises the major effects of opioids on the endocrine system, outlining the long-term effects of their use, which can include reduced libido and sexual function, infertility, mood disorders and bone demineralisation. Although the effects of opioids on the endocrine system are relatively common they might not be detected as many patients do not report these symptoms, thus specific questioning regarding the endocrine effects needs to guide clinical monitoring. The patients most at risk of these toxicities are probably those taking over 100 mg of morphine equivalent daily in the long term. If the patient on opioids has hypogonadism, diagnosing it as opioid-related can be challenging as pain, comorbidities, other medications and age can also influence endocrine function. If it is the opioid causing the endocrine dysfunction, management options include optimisation of non-opioid analgesics which may enable reducing or cessation of the opioid, changing to a different opioid, and hormone supplementation.

A Nationwide Analysis of Antibiotic Use in Hospice Care in the Final Week of Life.

Albrecht JS, McGregor JC, Fromme EK, Bearden DT, Furuno JP.

This study from the USA used data from the 2007 National Home and Hospice Care Survey, to estimate the use of antibiotics in the last week of life in 3884 patients who died in hospice care. During this time 27% of hospice patients received at least one antibiotic and 85% of these patients had no documented infectious diagnosis. The authors suggest that further research is needed to elucidate the role of antibiotics in patient in the last week of life to reduce the use of unnecessary antibiotics while maintaining goals care at the end of life.

 Am J Med. 2013 Mar;126(3S1):S12-S18.

J Pain Symptom Manage. 2013 Jan. [Epub ahead of print]

Symptom burden, palliative care need and predictors of physical and psychological discomfort in two UK hospitals.

Ryan T, Ingleton C, Gardiner C, Parker C, Gott M, Noble B.

In this prospective study which had complete data sets on 514 hospital inpatients, the gold standards framework was used to identify the 185 patients who met palliative care criteria. This cohort had increased physical, psychological and social burden. The most prevalent physical symptoms were tiredness (35%), pain (31%) and weakness (29%) whereas low mood (20%) and anxiety (16%) were the most prevalent psychological symptoms. Only 8% had specialist palliative care input and these were mostly patients with cancer. Dementia was a predictor of physical (OR 3.94) and psychological burden (OR 2.88), and being female was a predictor of psychological burden (OR 2.00). This study indicates that a large proportion of patients with high symptom burden are not receiving specialist palliative care especially patients with non-malignant illnesses, including dementia, who may experience high levels of symptoms.

 BMC Palliat Care. 2013 Feb 26;12:11.

Prevalence and natural history of pain in adults with multiple sclerosis: Systematic review and meta-analysis.

Foley PL, Vesterinen HM, Laird BJ, Sena ES, Colvin LA, Chandran S, Macleod MR, Fallon MT.

This systematic review with a meta-analysis included 28 prospective articles (7101 subjects) which assessed the prevalence of pain syndromes in multiple sclerosis (MS) both cross-sectionally at key milestones, and longitudinally during the MS disease course. The pooled overall pain prevalence (17 studies, 5319 subjects) was 63%, although this estimate contained unexplained heterogeneity. Individual pains were also explored with 43% having headache, 26% neuropathic extremity, 20% back pain, 15% painful spasms, 16% Lhermitte sign, and 4% had trigeminal neuralgia. Cross-sectional prevalence of pain prior to the onset of MS, at onset, and at relapse, and longitudinally were poorly described. It was concluded that although pain and specific pain syndromes are common in MS, the clinical associations and natural history of pain in MS require clarification in future studies.

Pain. 2012 Dec. [Epub ahead of print]

By Jason Boland

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

Drug updates

Two strengths of insulin now available in UK

Insulin degludec (Tresiba^®; Novo Nordisk, Crawley, UK) has been launched in two strengths in the UK as 100 units/mL and 200 units/mL. This 200 units/mL is higher than any other strength in the UK. Both strengths are available as pre-filled pen devices with distinct labeling to differentiate between the two strengths.

The pre-filled pen devices both have a dose counter window and deliver the dose in units, regardless of the strength, therefore dose conversion is not required if swapping patients from one strength to another. For more information click here.

Dexamfetamine sulphate 5mg caution in use alert

The Medicines and Healthcare products Regulatory Agency (MHRA) have issued a caution in use alert for dexamfetamine sulphate 5mg (Auden McKenzie; pack size 28, batch number 12123/A) first distributed on 10-01-2013. A very small number of packs from the above batch may contain three blister strips instead of two. Contact Auden McKenzie (01895 627420) if packs with extra blister strips are found. For more information click here.

Oxymorphone new crush resistant strengths in USA

Oxymorphone modified release, crush resistant tablets (Opana^® ER; Endo pharmaceuticals, USA) are now available in 7.5mg and 15mg strengths joining the rest of the strength range (5mg, 10mg, 20mg, 30mg, and 40mg). For the SPC click here.

SMC accepts palonosetron capsules

The Scottish Medicines Consortium (SMC) has accepted palonosetron 500microgram soft capsules (Aloxi^®; Sinclair IS Pharma, Chester, UK) for use within NHS Scotland for the prevention of nausea and vomiting associated with moderately emetogenic cancer chemotherapy in adults.

The soft capsule formulation has been shown to be clinically non-inferior to the intravenous formulation and is cost neutral. SMC has previously accepted palonosetron intravenous injection for the prevention of nausea and vomiting associated with moderately emetogenic cancer chemotherapy. For more information click here. 

Prepared by Sarah Charlesworth and Andrew Wilcock

Rapid response teams, do not resuscitate orders, and potential opportunities to improve end-of-life care: a multicentre retrospective study.

Downar J, Rodin D, Barua R, Lejnieks B, Gudimella R, McCredie V, Hayes C, Steel A.

In this retrospective review from Canada, 300 in hospital Rapid response team (RRT) consultations were reviewed in the light that although RRTs were created to stabilise acutely ill inpatients a proportion of these will be patients in the last days of their life. The study showed that most consultation were for elderly patients with a chronic illness, with over 90% of patients being for resuscitation. After RRT review one third were admitted to the intensive care unit within 48 hours and 25% died. 9% had a patient/family meeting on the ward after the consultation, leading to nearly 90% changing their resuscitation status. Of these, less than 20% were referred to the palliative or spiritual care teams, or prescribed symptom control medications. Furthermore, 63% of these patients died before discharge. It was concluded that in the acute hospital setting RRT consultation is an important milestone for many patients approaching end-of-life.

J Crit Care. 2013 Jan. [Epub ahead of print]

Rehabilitation in Advanced, Progressive, Recurrent Cancer: A Randomized Controlled Trial.

Jones L, Fitzgerald G, Leurent B, Round J, Eades J, Davis S, Gishen F, Holman A, Hopkins K, Tookman A.

This two-arm, wait-list randomised controlled trial, assessed the clinical and cost-effectiveness of a rehabilitation intervention delivered by a hospice-based multidisciplinary team vs. usual care for patients with advanced, progressive, recurrent haematological and breast cancer, with a follow-up at three months. From the 41 enrolled participants, 36 completed the trial. There was improvement in the psychological subscale of the Supportive Care Needs Survey (primary outcome). There was also improvement in the physical and patient care subscales of the Supportive Care Needs Survey, and self-reported health state. The incremental cost-effectiveness ratio was calculated to be £19,390 per quality-adjusted life year. The authors recommend implementation alongside evaluation in wider clinical settings and patient populations.

J Pain Symptom Manage. 2012 Nov. [Epub ahead of print]

Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial.

Bruera E, Hui D, Dalal S, Torres-Vigil I, Trumble J, Roosth J, Krauter S, Strickland C, Unger K, Palmer JL, Allo J, Frisbee-Hume S, Tarleton K.

In a randomized, placebo-controlled, double-blind trial of 129 patients with cancer from six hospices, patients who were mildly to moderately dehydrated and in the last weeks of life either received subcutaneous hydration (1 L of normal saline) or placebo (100 mL of normal saline subcutaneously) over 4 hours every day until the they became unresponsive or died. The effect of hydration on symptoms associated with dehydration, quality of life, and survival in patients with advanced cancer was determined at baseline and day 4±2 days for the first week and then every 3 to 5 days (fatigue and biochemistry tests were performed at baseline and day 7). There were no differences between the two groups for change in the sum of the scores of dehydration symptoms (fatigue, myoclonus, sedation and hallucinations); Edmonton Symptom Assessment Scale; Dehydration, Delirium, Fatigue and Myoclonus Assessment scales; creatinine, urea, and overall survival.

J Clin Oncol. 2013 Jan 1;31(1):111-8.

by Jason Boland

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

Safety updates

Routine hepatic monitoring recommended for lenalidomide

The latest Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update recommends routine monitoring of hepatic function at baseline, every week for the first 8 weeks and then monthly, for patients being treated with lenalidomide (Revlimid^®; Celgene, Uxbridge, UK). This follows reports of elevations of hepatic enzymes occurring in up to 10% of patients treated with lenalidomide for multiple myeloma in clinical trials. This is mostly without serious consequence and resolves when lenalidomide is stopped, at which point reintroduction of lenalidomide at a lower dose can be considered. However, in <1% of treated patients, acute hepatic failure, toxic hepatitis, hepatocellular hepatitis and cholestatic hepatitis have been reported.

Because lenalidomide is excreted predominantly renally, the dose should be adjusted in patients with renal impairment to avoid high plasma levels which may increase the risk of severe hepatotoxicity, as well as haematological undesirable effects. For more information click here.

Denosumab rare cases of atypical femoral fracture with long-term use

The Medicines and Healthcare products Regulatory Agency (MHRA) have reported rare cases of atypical femoral fracture in patients receiving denosumab 60mg (Prolia^®; Amgen, Cambridge, UK) for post-menopausal osteoporosis for >2.5 years.

They advise during denosumab treatment:

• patients should report new or unusual thigh, hip, or groin pain which should be evaluated for an incomplete femoral fracture; these may occur with little/no trauma in the subtrochanteric and diaphyseal regions of the femur
• the contralateral femur should be examined carefully, as atypical femoral fractures are often bilateral
• consider discontinuing treatment while the patient is evaluated; benefits and risks should be assessed on an individual basis.

For more information click here.

Prepared by Sarah Charlesworth and Andrew Wilcock

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

Hot topics

Updated Controlled Drugs Regulations (Supervision of Management and Use) from 1^st April 2013

Controlled Drugs (Supervision of Management and Use) Regulations 2013 (SI2103/373) for England and Scotland will come into force on 1^st April 2013. These deal with governance arrangements, in particular the role and functions of Controlled Drugs Accountable Officers (CDAO), and also reflect the new architecture for the NHS in England from April 2013.

These regulations supersede the Controlled Drugs (Supervision of Management and Use) Regulations 2006 which came into force in 2007, and follow a consultation process by the Department of Health (DH) in September 2012 (see our article 28-09-2012).

The DH has published information about the 2013 Regulations, along with the official Regulations 2013 and the summary of consultation responses.

NPA resources on controlled drugs

The UK National Pharmacy Association (NPA) has produced resources for controlled drugs including Standard Operating Procedures (SOPs) and guidance sheets for its members. For more information click here.

Prepared by Sarah Charlesworth and Andrew Wilcock

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

Latest additions

PCF updated monographs

The online Palliative Care Formulary (PCF) is being continually updated. The following monographs have been updated during December 2012 and January 2013 and supersede those in the publication of the 4^th edition of the Palliative Care formulary (PCF4). They can be accessed from the formulary section of the website:

Chapter 1: PPI

Chapter 1: H₂-receptor antagonists

Chapter 5: Opioid antagonists

Chapter 5: Naltrexone

Chapter 7: Desmopressin

Chapter 11: Mouthwashes

For a full list of all the monographs updated click here.

Die November/Dezember Ausgabe des APM Newsletter ist fertig

The November/December issue of the APM Newsletter for German-speaking users of www.palliativedrugs.com is available.

Die November/Dezember Ausgabe des APM Newsletter ist fertig. Über die aktuelle Ausgaben des Newsletters wird Sie das Bulletin Board informieren.

Prepared by Sarah Charlesworth and Andrew Wilcock