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News and updates from

16 Jun, 14 | by James Smallbone, Publishing Assistant

9th June 2014

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


Hot topics

NICE Evidence Update: Opioids in palliative care
The UK National Institute for Health and Care Excellence has produced a summary of the selected new evidence relevant to the use of opioids in palliative care since the NICE clinical guideline: Opioids in palliative care (CG140) was published in 2012. The new evidence identified in this Evidence Update (58) is not expected to have any impact on the existing guidance. For more information, click here.


Drug updates

Tramadol to become Schedule 3 Controlled Drug
Tramadol, currently a Prescription Only Medicine (POM) will become a Schedule 3 Controlled Drug as from 10 June 2014 in England, Wales and Scotland. Controlled Drug prescription requirements will apply, but it will be exempt from safe custody requirements. This follows a consultation by the advisory Council on the Misuse of Drugs (see our news article 14 March 2014). For more information, click here.

Zopiclone and zaleplon to become Schedule 4 (Part 1) Controlled Drugs
Zopiclone and zaleplon currently both Prescription Only Medicines (POM) will become Schedule 4 (Part 1) Controlled Drugs as from 10 June 2014 in England, Wales and Scotland. This brings them under the same category as zolpidem and the benzodiazepines (except temazepam and midazolam). For more information, click here.

Ketamine injection supply problems
Pfizer UK has confirmed that it is currently out of stock of ketamine (Ketalar) 10mg/mL and 100mg/mL injection and that the 50mg/mL injection is very low. There have been supply problems with ketamine injection since November 2012 (see our news article 21-09-2012). The ketamine 10mg/mL and 100mg/mL are not expected to be back in stock until March 2015. There are currently no further details on the 50mg/mL injection. For enquiries please contact Pfizer customer services (01304 616161).


Latest additions

PCF updated monographs
The following monographs of the on-line Palliative Care Formulary (PCF) have been updated during April 2014 and supersede those in the publication of the 4th edition of the Palliative Care formulary (PCF4) and PCF4+2013 epdf. They can be accessed from the formulary section of the website:

Chapter 01: Loperamide
Chapter 02: Haemostatics (new merged monograph)
Chapter 04: Melatonin, Anti-epileptics (new merged monograph), Gabapentin and pregabalin (new merged monograph), Carbamazepine, Oxcarbazepine, Levetiracetam, Valproate
Chapter 05: Paracetamol, Nefopam, Celecoxib (minor update), Ibuprofen (minor update), Diamorphine, Alfentanil, Quick Prescribing Guide: Management of procedure-related pain
Chapter 06: Helicobacter pylori gastritis
Chapter 07: Progestogens
Chapter 09: Ferrous sulfate
Chapter 10: Rubefacients and other topical products
Chapter 20: Quick Clinical Guide: Setting up a CME McKinley T34 syringe pump for CSCI

For a full list of all the monographs updated since the publication of PCF4, click here. Follow us on twitter @palliativedrugs for the latest updates.

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from

11 Mar, 13 | by Assistant Editor

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


Drug updates


DTB Sativex in multiple sclerosis

The latest Drug and Therapeutics Bulletin (DTB) examines the place of the cannabinoid product, Sativex (GW Pharma, UK) in multiple sclerosis. For more information click here.


Glycopyrronium bromide inhaler launched in UK

A glycopyrronium bromide hard capsule powder inhaler (Seebri Breezhaler, Novartis) has been launched in the UK as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). The recommended dose is 50microgram once daily. The NHS cost of an inhaler plus 30 capsules = £28. The Scottish Medicines Consortium (SMC) has accepted Seebri Breezhaler for use within NHS Scotland. For the SPC, click here.

The National Institute for Health and Clinical Effectiveness (NICE) has produced a new medicine evidence summary for this product which can be accessed from the here.


Carbamazepine, oxcarbazepine and eslicarbazepine risk of serious skin reactions

The December Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update has highlighted the risk of serious skin reactions, including Stevens-Johnson syndrome, with carbamazepine, oxcarbazepine and eslicarbazepine in patients with European descent or Japanese origin who have the HLA-A*3101 genetic marker. The risk of serious skin reactions with these drugs is known to be associated with patients of Asian origin who have the genetic marker HLA-B*1502, and screening is recommended for patients of Han Chinese or Thai origin before treatment with these drugs.

There are currently insufficient data to support screening for the HLA-A*3101 genetic marker before treatment. Current advice is that patients of European descent or Japanese origin who are known to have the genetic marker HLA-A*3101 should only receive carbamazepine, oxcarbazepine or eslicarbazepine after careful consideration of the benefits and risks.


NICE evidence summary of oral magnesium glycerophosphate use

The National Institute for Health and Clinical Excellence (NICE) has published its evidence summary for the use of unauthorized (unlicensed) oral magnesium glycerophosphate for preventing recurrent hypomagnesaemia.


Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from

8 Mar, 13 | by Assistant Editor

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

Hot topics

Haloperidol for psychosis-induced aggression or agitation

A Cochrane review has been published on the use of haloperidol for rapid tranquilisation of psychosis-induced aggression or agitation. For more information click here.


BNF palliative care section updated

The online BNF (December 2012) palliative care section has been reorganised and now includes new tables for opioid conversions. The new pain management with opioids section has been organised to provide guidance on specific routes for pain management. The equivalent doses of opioid analgesics table has been expanded to include more drugs and routes; also included is a new buprenorphine table and updated fentanyl patch conversion table. For more information click here.


Guide on advance decisions to refuse treatment

The National Council for Palliative Care and the NHS National End of Life Care Programme have produced a guide for health professionals on Advance Decisions to Refuse Treatment (ADRT). This guide supersedes the 2008 version and can be downloaded from the NHS National End of Life Care website.


Prepared by Sarah Charlesworth and Andrew Wilcock

New study finds that UK breast cancer patients receive insufficient pain management and palliative care

22 Nov, 11 | by Assistant Editor

A study conducted by researchers at Breast Cancer Care and the University of Southampton indicates that over a third of female breast cancer patients are in unnecessary discomfort – despite recent advances in medical management of the disease.

The cross-sectional survey was carried out in two cancer centres in the UK and assessed a wide-range of quality of life indicators amongst 235 women with metastatic breast cancer. Over a quarter of the sample reported experiencing shortness of breath (27%) and nausea (26%). Additionally, 34% of participants reported high levels of pain or other uncontrolled symptoms.

Most notably, only 7% of respondents stated that they were being treated by local palliative care services and just 6% by their GP, indicating that there may be an unmet need in terms of access to palliative care amongst the study population.

The study highlights the fact that although palliative care services in the UK are amongst the most extensive in the world, their use is still generally confined to the very end of life and they are often not used alongside curative interventions.

Survey shows US doctors are strongly in favour of palliative care

17 Nov, 11 | by Assistant Editor

A poll released this week by The National Journal and Regence Foundation found that doctors in the US are overwhelmingly supportive of palliative care interventions for seriously ill patients.

Of the 500 doctors who completed the survey, 96% believed that enhancing the quality of life of seriously ill patients was more important than extending their lives for as long as possible. Another 96% of respondents agreed that making palliative care available to all patients who need it should be a higher priority for American healthcare providers.

When a similar survey was carried out on a random sample of adults earlier this year, only 71% said that quality of life was more important than length of life, indicating a difference of opinion between medical professionals and the general public.

The results also showed that whilst a large proportion of doctors believed that palliative care is important, a quarter stated that they were not sufficiently prepared to discuss options for end of life care with patients; highlighting a possible gap in expertise and training and perhaps also an unwillingness to tackle what is seen as a very sensitive subject.

Read an overview of the results here.

US project aims to integrate palliative care and emergency medicine

15 Nov, 11 | by Assistant Editor

A newly launched national initiative in the US entitled Improving Palliative Care in Emergency Medicine (IPAL-EM) will promote access to palliative medicine for seriously ill patients presenting at emergency departments.

The project, which was supported in part by the Centre to Advance Palliative Care, aims to increase referral rates for seriously ill patients from emergency wards to more appropriate care settings and also to improve control of physical symptoms.

It has become increasingly apparent over recent years that the fields of emergency medicine and palliative care are inter-linked in terms of patient experience. Many people suffering from serious and long-term illnesses will attend an emergency department at some point, often in need of pain relief. There is also more recognition of the general role which palliative care can play in the emergency room, where it can be used to decrease both physical pain and stress experienced by patients and their loved ones.

IPAL-EM aims to provide palliative and emergency physicians with the tools and evidence necessary to integrate the two therapeutic areas.

Tearfund to launch palliative care services in Zimbabwe

8 Nov, 11 | by Assistant Editor

The relief and development agency Tearfund is to launch a palliative care initiative in Manicaland, Zimbabwe. The project, funded by the Princess of Wales Memorial Fund, will focus on training palliative care professionals in the region, improving access to pain-relieving drugs and developing referral systems.

The population of Manicaland, which is located in the West of the country, has a high prevalence of HIV/AIDS and over 9000 deaths from cancer a year, only 1% of whom receive morphine.

Tearfund was awarded the grant after a pilot project in Tanzania was deemed successful.

The news is sure to be welcomed by advocates of palliative care provision in lower-income countries.

Does the legalisation of euthanasia affect palliative care?

2 Nov, 11 | by Assistant Editor

A new report by the European Association for Palliative Care (EAPC) may challenge the notion that the legalisation of euthanasia negatively affects the growth of palliative care services.

The study, which was originally requested by the Commission on Assisted Dying, compared palliative care indicators in countries with legalised euthanasia (Belgium, The Netherlands,  Switzerland and Luxembourg) and some without (Spain, Germany and France). This was supplemented by a review of the scientific literature on the subject.

The report concluded that there were well-developed palliative care services in countries with legalised euthanasia and that there was no detectable influence of euthanasia legislation upon the development of palliative care.

These results run contrary to the opinion that palliative care services in a country suffer as a result of assisted dying becoming legal.

However, the authors recommended that any country considering legalising euthanasia should also ensure that there is an equitable, accessible and affordable palliative care framework in place.

Read the full report here.


2 Nov, 11 | by Assistant Editor

Articles of interest in other scholarly journals

Click on the article headings to view abstracts

Antagonistic effects of ondansetron and tramadol? A randomised placebo and active drug controlled study.

Rauers NI, Stüber F, Lee EH, Musshoff F, Fimmers R, Barann M, Stamer UM.

This postoperative randomised, double-blinded study assessed if ondansetron and tramadol had opposing effects and if co-administration decreased their efficacy. It showed that using both drugs together did not increase tramadol use or emesis.

Undocumented alcoholism and its correlation with tobacco and illegal drug use in advanced cancer patients.

Dev R, Parsons HA, Palla S, Palmer JL, Del Fabbro E, Bruera E.

In this retrospective study of 665 patients, the frequency of undiagnosed alcoholism among patients with advanced cancer and its relationship to alcoholism, smoking and use of illegal drugs was assessed. 598 patients had completed the Cut Down, Annoyed, Guilty, Eye Opener (CAGE) questionnaire. The frequency of CAGE-positive results was 17%, of which only 13% had been identified before their palliative care consultation. These patients were more likely to have a current and past history of smoking, and illegal recreational drug use. Pain and dyspnea were worse in patients who had a history of nicotine use. Both CAGE-positive patients and patients who had a history of tobacco use more frequently were receiving strong opioids at the time of their palliative care consultation.

The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: A qualitative study.

Harris D, Finlay I, Flowers S, Noble S.

The practice of relieving patient distress through sedative doses of anxiolytics or opioids in terminal haemorrhage was evaluated through Semi-structured interviews with 11 specialist nurses. This showed that anxiolytics and opioids rarely benefit the patient who is having a terminal haemorrhage as it is so rapid that patients died before it could be administered. Furthermore, it may remove nurses from giving patient care, as staying with and supporting the patient, as well as using dark-coloured towels to camouflage blood was reported to be of more practical use. The focus on administering medications was often to the detriment of these non-pharmacological approaches.

Unidirectional Cross-Activation of GRPR by MOR1D Uncouples Itch and Analgesia Induced by Opioids.

Liu XY, Liu ZC, Sun YG, Ross M, Kim S, Tsai FF, Li QF, Jeffry J, Kim JY, Loh HH, Chen ZF.

Spinal opioids can cause itch, which has previously been thought to result from pain inhibition. This study separates the sensation of itch from analgesia, demonstrating that morphine directly induces itch in a subset of spinal neurons by signalling through a heterodimer of opioid (μ-opioid receptor isoform 1D) and gastrin-releasing peptide receptors. In addition, blocking MOR1D-GRPR association attenuates itch but not analgesia. This study also evaluated the downstream effectors of GRPRs and suggests potential pharmacological targets.

Non-steroidal anti-inflammatory drugs and risk of pulmonary embolism.

Biere-Rafi S, Di Nisio M, Gerdes V, Porreca E, Souverein P, Boer A, Büller H, Kamphuisen P.

In a case-control study (of 4433 cases and 16,802 controls) using a Dutch registry the population based effect of non-steroidal anti-inflammatory drugs (NSAIDs) on pulmonary embolism (PE) was assessed. Current use of NSAIDs was associated with PE, with the overall risk for NSAIDs being highest in the first 30 days of use. Use of acetaminophen and tramadol also increased the risk of PE with a similar time trend. Although NSAIDs are associated with an increased risk of PE, this might be due to the underlying medical condition for which they are prescribed, as suggested by a similarly increased thrombotic risk in patients receiving paracetamol and tramadol.

Comparative clinical effects of hydromorphone and morphine: a meta-analysis.

Felden L, Walter C, Harder S, Treede RD, Kayser H, Drover D, Geisslinger G, Lötsch J.

In this meta-analysis of eight studies the analgesic effects of morphine and hydromorphone were compared. It suggested that hydromorphone (494 patients) provides slightly better (P=0.012) clinical analgesia than morphine (510 patients). The effect-size was small although the advantage of hydromorphone was more evident in studies of better quality. Nausea, vomiting and itching were similar. This suggests some advantage of hydromorphone over morphine for analgesia. The authors suggest that hydromorphone’s safety in renal failure or during acute analgesia titration, are based on limited evidence and require substantiation by further studies.

Methadone toxicity due to smoking cessation–a case report on the drug-drug interaction involving cytochrome P450 isoenzyme 1A2.

Wahawisan J, Kolluru S, Nguyen T, Molina C, Speake J.

To report the potential clinically significant pharmacokinetic interaction that may result from smoking cessation in patients on methadone maintenance therapy.

This case report describes a 46-year-old man with decreased respirations and altered mental status related to methadone toxicity, despite being on a stable dose of methadone for chronic back pain. These toxicities resolved by withholding and then reducing the methadone dose. It was subsequently noted that he had recently stopped smoking, which was thought to be the precipitating factor. The explanation for this effect is that tobacco smoke contains polycyclic aromatic hydrocarbons which induce the cytochrome P450 CYP1A2 enzymes which partly metabolise methadone and decreased smoking can lead to a reduction in methadone metabolism, resulting in higher serum concentrations

By Jason Boland, Consultant in Palliative Medicine, Barnsley Hospice, United Kingdom

Department of Health in England launches end of life survey

27 Oct, 11 | by Assistant Editor

A new survey commissioned by the Department of Health aims to gauge the quality of end of life care in England. The project, which is being administered by the Office for National Statistics (ONS) will involve sending a postal survey to 49,000 individuals who registered the death of a loved one between November 2010 and June 2011.

Questions will relate both to the quality of care that the loved one received and also the support available to the respondents themselves. The results of the survey will inform the DoH End of Life Care Strategy which aims to improve the care available to people dying from long-term illness.

The results of the survey should be made available in March 2012.

Read the 2008 End of Life Care Strategy here.

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