You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Updates from www.palliativedrugs.com

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

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.

News and updates from www.palliativedrugs.com

12 May, 17 | by bbutcher

 

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
MHRA warning regarding hyoscine butylbromide
MHRA published a warning in February 2017 reminding health professionals about the risk of serious adverse effects with hyoscine butylbromide injection IV/IM in patients with underlying cardiac disease. This followed a recent fatality (myocardial infarction) and a subsequent recommendation from the coroner to clarify the cautions section in SPC. The MHRA stated that they had received 9 reports of patients who had died following receiving hyoscine butylbromide injection and published the following advice:

    • Hyoscine butylbromide injection can cause serious adverse effects including tachycardia,hypotension, and anaphylaxis,
    • These adverse effects can result in a fatal outcome in patients with underlying cardiac disease, such as those with heart failure, coronary heart disease, cardiac arrhythmia, or hypertension,
    • Hyoscine butylbromide injection should be used with caution in patients with cardiac disease,
    • Monitor these patients, and ensure that resuscitation equipment, and personnel who are trained how to use this equipment, are readily available,
    • Hyoscine butylbromide injection remains contra-indicated in patients with tachycardia.

Subsequently, the MHRA have reviewed their data and have corrected the total number of fatal outcomes attributable to hyoscine butylbromide to 8. However, the episodes lacked full data and it is difficult to interpret the specific relevance of the reports to use in a palliative care setting, where the CSCI route of administration is more likely than IV. PCF advises clinicians to remind themselves of the longstanding cautions relating to the use of any antimuscarinic in patients with cardiovascular disease, and to continue to balance the potential for benefit and harm on an individual patient basis. For more information, click here.

Hot topics
NICE: Care of dying adults in the last days of life quality standard
NICE has published a separate specific quality standard on care of dying adults in the last days of life (QS144). This replaces statement 11 in the quality standard for end of life care in adults (QS13), which has now been removed. For more information, click here.

Cochrane review: methadone for cancer pain
This is the second update to the initial review in 2004 and subsequent update in 2007. The authors conclude that although methadone has been used for many years to treat severe cancer pain, the evidence base is sparse. There is low quality evidence to suggest that methadone has similar analgesic benefits to morphine in the management of severe cancer pain in adults. However, issues such as titrating to an effective dose and adverse effects may limit its potential. Methadone may have a role if other opioids are not tolerated, providing the issues of dose titration and possible severe adverse effects are considered. For more information, click here.

Fentanyl nasal spray (Instanyl) SPC updated
The frequency of use for all strengths of Instanyl ® (fentanyl) nasal spray (Takeda) has been updated in the UK SPC. Patients are still advised to wait 4h before treating another breakthrough pain episode, however the following statement has now been added:
‘On exceptional occasions where a new episode of pain occurs earlier than 4h after the last dose, patients can use Instanyl to treat it, but they must wait least 2h before doing so. Dose adjustment of the background opioid therapy following pain reassessment should be considered if the patient frequently presents with breakthrough pain episodes that are less than 4 hours apart or with more than four breakthrough pain episodes per 24 hours.’ For more information, click here.

Latest additions
PCF updates
The on-line Palliative Care Formulary is being continually updated. For a full list of all the monographs updated since the print publication of PCF5, see the Latest additions section of the website or follow us on twitter @palliativedrugs for the latest updates. Over the next few months we will be working hard in the background on the technical side of the website in preparation for the publication of PCF6 print edition later this year. Part 2 of PCF (which contains the general topics) is being reorganised to make it more user-friendly. The new PCF format will be launched first on the website in April/May 2017 and will also contain multiple monographs that have been updated during the interim period.

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

7 Apr, 17 | by bbutcher

07/04/2017

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.

Hot topics

Cochrane review: pharmacological interventions for pruritus in adult palliative care
patients
In this update to the original review in 2013, the authors concluded that there were was
low–moderate quality evidence for gabapentin, nalfurafine and cromolyn sodium for itch
associated with chronic kidney disease, and rifampicin and flumecinol for itch associated with
cholestasis. Paroxetine may be useful for palliative care patients with itch of various aetiologies,
although evidence was only available from one study. For more information, click here.

Cochrane review: paracetamol with or without codeine or dihydrocodeine for neuropathic pain in adults
The authors concluded that there was insufficient evidence to support or refute the use of
paracetamol alone or with codeine or dihydrocodeine for neuropathic pain in adults. For more
information, click here.

Cochrane review: topical capsaicin (high concentration) for chronic neuropathic pain in
adults
In this update to the original review in 2013, the authors concluded that there is moderate quality
evidence that high-concentration (8%) capsaicin patches can give moderate pain relief, or better,
to a minority of people with post-herpetic neuralgia, and very low quality evidence that it benefits
those with HIV-neuropathy and peripheral diabetic neuropathy. For more information, click here.

Scottish Medicines Consortium: Butec patches for chronic non-malignant pain
The Scottish Medicines Consortium has accepted buprenorphine transdermal patches (Butec ® )
within NHS Scotland for chronic non-malignant pain of moderate intensity when an opioid is
necessary for adequate analgesia. It is restricted to use in patients >65 years. For more
information, click here.

NICE evidence summary: oral glycopyrronium bromide for severe sialorrhoea
NICE has produced an evidence summary for the use of oral glycopyrronium bromide in children
and young people with chronic neurological disorders. For more information, click here.

Drug updates
Glycopyrronium oral solution authorized for drooling now available in UK
Glycopyrronium 320microgram/mL oral solution (Sialanar ® ; equivalent to 400microgram/mL or
2mg/5mL glycopyrronium bromide), authorized for severe drooling in children and adolescents ≥3
years with chronic neurological disease, is now available. The NHS cost for 250mL bottle is £320.
It is authorized for use via EFT and doses must be reduced in renal impairment. Due to lack of
data the product is not authorized in adults or for long-term use. For the SPC, click here.
A glycopyrronium bromide 200microgram/mL (1mg/5mL; Colonis Pharmaceuticals) oral solution,
authorized for adults for the treatment of peptic ulceration is also available (see our news item
30th September 2016).

Glycopyrronium bromide
Tablets 1mg, 2mg, 28 days@ 1mg t.d.s. = £602.
Oral solution 1mg/5mL, 2mg/5mL 28 days @ 1mg t.d.s. = £255 or £269 respectively.
Injection 200microgram/mL, 1mL or 3mL amp = £1.20.

Note: other strengths of glycopyrronium bromide oral solution and oral suspension are also
available as unauthorized products via special order 200micorgram/5mL, 500micorgram/5mL,
2.5mg/5mL, 5mg/5mL.

FDA approves 2mg naloxone nasal spray
A 2mg naloxone nasal spray (Narcan ® ; Adapt Pharma) has been approved in the USA for use in
opioid-dependent patients, expected to be at risk for severe opioid withdrawal, in situations where
there is a low risk for accidental or intentional opioid exposure by household contacts.
A 4mg naloxone nasal spray (Narcan ® ; Adapt Pharma) has been available since February 2016
(see our news item 26-11- 2016).
The US Product Information for both the 2mg and 4mg naloxone nasal spray can be downloaded
from here. For more information, click here.

Thalidomide updated SPC
The UK SPC for thalidomide Celgene 50mg hard capsules now advises extra care when removing
capsules from the blister to avoid deformation/breakage and recommends to only press one end of
the capsule to remove from the blister. In addition, it highlights capsules should not be
opened/crushed. If powder makes contact with skin/mucous membranes, it should be washed or
flushed immediately/with water. For the SPC, click here.

Latest additions
Website satisfaction survey winners and results

Results are available from our satisfaction survey (October – December 2016). Congratulations to
the 5 members randomly selected to receive a free of copy of Introducing Palliative Care 5th
edition (IPC5).

PCF updates
The on-line Palliative Care Formulary is being continually updated. For a full list of all the
monographs updated since the print publication of PCF5, see the Latest additions section of the
website or follow us on twitter @palliativedrugs for the latest updates. Over the next few months
we will be working hard in the background on the technical side of the website in preparation for
the publication of PCF6 print edition later this year. Part 2 of PCF (which contains the general
topics) is being reorganised to make it more user-friendly. The new PCF format will be launched
first on the website in April 2017 and will also contain multiple monographs that have been
updated during the interim period.

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

3 Feb, 17 | by bbutcher

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.

Hot topics

Association for Paediatric Palliative Medicine (APPM) Master Formulary 2017

The 4th edition of the APPM Master Formulary is now available. It is available to download from the APPM website or from our Document library under the topic Paediatric (prescribing guidelines).

 

Cochrane review: fentanyl for neuropathic pain

The authors concluded that there is insufficient evidence to support or refute the suggestion that fentanyl has any efficacy in any neuropathic pain condition (CD011605). For more information, click here.

 

Cochrane review: hydromorphone for cancer pain

The authors found a lack of evidence to support a preference for hydromorphone over other opioid analgesics such as morphine and oxycodone. The treatment effect of hydromorphone appeared to be similar to that of the comparator drugs for adults with moderate to severe cancer pain, However, most of the outcome data were based on single randomised controlled trials with a small sample size (CD011108). For more information, click here.

 

Cochrane review: benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases

This updated review (CD007354) confirmed the previous conclusions:

  • there is no evidence for a beneficial effect of benzodiazepines in the relief of breathlessness in people with advanced cancer and COPD. There is a non-significant beneficial effect, but the overall effect size is small. Benzodiazepines caused more drowsiness as an adverse effect compared to placebo but less compared to morphine. These results justify considering benzodiazepines as second- or third-line treatment, when opioids and non-pharmacological measures have failed to control breathlessness
  • there is currently not enough evidence to support the use of benzodiazepines in the prevention of episodic breathlessness in people with cancer. There are no data from controlled trials for the treatment of episodic breathlessness with benzodiazepines
  • there are no differences regarding the type of benzodiazepine, dose, route and frequency of administration, and duration of treatment.

For more information, click here.

 

End of life care for infants, children and young people with life-limiting conditions: planning and management

This NICE guideline (NG61) has now been published in full on-line. For more information, click here.

Drug updates

Gabapentin oral solution and enteral feeding tubes

The UK Summary of Product Characteristics (SPC) for Gabapentin Rosemont 50mg/mL oral solution (Rosemont Pharmaceuticals) has been updated to include information about administration via nasogastric and percutaneous endoscopic gastrostomy feeding tubes. Section 6.6 of the SPC contains information on the specific type of tubes suitable for use (including the material, bore size, internal diameter and maximum length) and the procedure to be followed when administering the oral solution via these routes. For more information, click here.

Latest additions

The on-line Palliative Care Formulary is being continually updated. For a full list of all the monographs updated since the print publication of PCF5, see the Latest additions section of the website or follow us on twitter @palliativedrugs for the latest updates. Over the next few months we will be working hard in the background on the technical side of the website in preparation for the publication of PCF6 print edition later this year. Part 2 of PCF (which contains the general topics) is being reorganised to make it more user-friendly. The new PCF format will be launched first on the website in March/April 2017 and will also contain multiple monographs that have been updated during the interim period.

 

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

28 Dec, 16 | by James Smallbone, Publishing Assistant

22/12/16

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

Medical device alert: insulin delivery devices
UK MHRA have issued a Medical Device Alert (MDAS/2016/020) informing health professionals that they should warn patients not change their insulin delivery device without first checking with their diabetes specialist. This relates to disposable patch pumps, reusable ambulatory infusion pumps, handsets and insulin cartridges. Patients should contact their diabetes specialist if they are invited by a manufacturer or other organisation to try a new device, e.g. via social media, to avoid risk of hyperglycaemia, hypoglycaemia or diabetic ketoacidosis.

The action deadline for putting systems into place to inform diabetic patients of this is 21 December 2016. For more information, click here.

Hydrocortisone 100mg/mL injection batch recall
MHRA has issued a class 3 medicines recall for the specified batch of hydrocortisone 100mg/mL solution for injection (AmdiPharm UK Limited). The solution in some ampoules has a yellow appearance. The batch should be quarantined and returned to the original supplier. For more information, click here.

pH testing for nasogastric tube positioning
A National Institute for Health Research (NIHR) Signal has been published highlighting research which concluded that pH testing was the best initial approach for confirming the position of a nasogastric tube in adults. For more information, click here.

Patient Safety Alert: Risk of death and severe harm from error with injectable phenytoin
A warning alert NHS/PSA/W/2016/010 has been issued highlighting the risks associated with the prescribing, preparation, administration and monitoring of injectable phenytoin. It asks providers to consider if more can be done to strengthen local procedures to reduce the risks of error with this complex medicine. For more information, click here.

 

Drug updates

Hydromorphone injection now authorized in the UK
Hydromorphone solution for injection or infusion is now available as an authorized product (Palladone, Napp) in the UK as 2mg/mL, 10mg/mL, 20mg/mL and 50mg/mL. It is authorized for the relief of severe cancer pain in patients >12 years old by either intravenous injection/infusion or by subcutaneous injection/infusion.

When converting from oral hydromorphone to parenteral hydromorphone, the SPC recommends a 3:1 conversion ratio, i.e. dividing the total daily oral dose by 3 to give the total daily parenteral dose. (Note. This is a more conservative estimate than the traditional 2:1 dose conversion ratio as recommended in PCF).

The formulation can be diluted with WFI or 0.9% saline. The SPC states that no evidence of incompatibility was observed between Palladone injection and representative brands of the following drugs, when stored in high and low dose combinations in polypropylene syringes over a 24h period at ambient temperature:

  • dexamethasone sodium phosphate
  • glycopyrronium bromide
  • haloperidol
  • hyoscine butylbromide
  • hyoscine hydrobromide
  • ketamine hydrochloride
  • levomepromazine hydrochloride
  • metoclopramide hydrochloride
  • midazolam hydrochloride

(Note. Incompatibility has been observed with dexamethasone or haloperidol, at some higher concentrations, see PCF Appendix 3 compatibility charts and the SDSD for more details).

The NHS cost per 1mL ampoule of 2mg/mL, 10mg/mL, 20mg/mL and 50mg/mL is £1.60, £13.20, £26 and £34 respectively. (Note. Hydromorphone injection is ≤5 times more expensive than the equivalent dose of morphine injection). For more information, click here.

Hydrocortisone 100mg/mL injection batch recall
MHRA has issued a class 3 medicines recall for the specified batch below of hydrocortisone 100mg/mL solution for injection (AmdiPharm UK Limited). The solution in some ampoules has a yellow appearance. The batch should be quarantined and returned to the original supplier.

Batch: 039268 Expiry: Aug 2017 Size: 1 x 5 First issued: 27 May 2016. For more information, click here.

IV carbamazepine authorized in the US
The FDA has authorized a parenteral formulation of carbamazepine (Carnexiv; Lundbeck) for short-term replacement therapy for oral forms of the drug in adults with certain seizure types when oral administration is temporarily not feasible. The IV carbamazepine total daily dose is 70% of the PO carbamazepine total daily dose, and should be divided equally into four infusions to be administered q6h. Each dose should be diluted in 100mL of diluent and infused IV over 30 minutes. The company has not yet filed for a marketing authorization in Europe. For more information, click here.

 

Latest additions

PCF5+ 2016 PDF now available for only £25
We are pleased to announce that the September 2016 PDF version of the Palliative Care Formulary (PCF5+ 2016) is now available to purchase from our store and that we have been able to keep the cost at £25.

PCF5+ 2016 contains all the updates made to the on-line PCF over the last 12 months and reflects the content of the on-line PCF as of the 1 September 2016. It therefore supersedes both the printed version of PCF5 and the PCF5 September 2014 and 2015 PDF.

To purchase a licensed copy, and help support palliativedrugs.com, please go to our store. For enquiries regarding multiple copies please contact hq@palliativedrugs.com

PCF updated monographs summary (Nov 2016)
The on-line Palliative Care Formulary is being continually updated. The following monograph has been recently updated and supersedes that in the print publication of the 5th edition of the Palliative Care Formulary (PCF5) and PCF5+ 2016 PDF. It can be accessed from the formulary section of the website.

Chapter 02: Systemic local anaesthetics

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.

 

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

14 Oct, 16 | by Jenny Thomas

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.

Hot Topics

Updated Do Not Attempt Cardiopulmonary Resuscitation policy

The Scottish government has published an update to NHS Scotland’s Do Not Attempt Cardiopulmonary Resuscitation policy for adults. For more information, click here.

British guideline on management of asthma updated

The 2016 update to the BTS/SIGN British guideline on the management of asthma is now available. It includes a complete revision of the sections on diagnosis and pharmacological management of asthma, and updates to the sections on supported self-management, non-pharmacological management of asthma, acute asthma, difficult asthma, occupational asthma, and organisation and delivery of care.

A summary and the full guideline can be downloaded from both the BTS and the SIGN website. Additional supporting material are also available on the SIGN website

 NICE Consultation: Care of dying adults in the last days of life

NICE has published a draft quality standard for consultation on the care of dying adults in the last days of life. There are four quality statements listed:

  • adults who have signs and symptoms that suggest they may be in the last days of life are monitored for further changes to help determine if they are nearing death, stabilising or recovering
  • adults in the last days of life are given care that is in accordance with their stated preferences and responsive to their changing preferences
  • adults in the last days of life who are likely to need symptom control are prescribed anticipatory medicines with individualised indications for use and dosage
  • adults in the last days of life have their hydration status assessed daily, and a discussion about the risks and benefits of clinically assisted hydration.

The deadline for consultation responses is 27 October 2016. For more information, click here.

NICE guidance on multimorbidity

NICE guideline (NG56) multimorbidity: clinical assessment and management is now available.

Drug updates

Palladone (hydromorphone) SPC updated

Both immediate-release and modified-release Palladone (hydromorphone) capsules are now authorized to be opened and the granules sprinkled onto soft food for administration where necessary. However, the granules of the modified-release formulation must be swallowed whole and not crushed, broken or chewed as this can lead to a rapid release and absorption of a potentially fatal dose of hydromorphone. For more information, click here.

Authorized glycopyrronium oral solution now available in UK

A glycopyrronium 200microgram/mL (1mg/5mL; Colonis Pharmaceuticals) oral solution is now available, costing £91 for 150mL. It is authorized for the treatment of peptic ulceration, thus use in indications in palliative care, e.g. drooling would be off-label. However, a glycopyrronium 320microgram/mL oral solution, authorized for severe drooling, is expected to be launched soon (see our news item 28 July 2016). For more information, click here.

Glycopyrronium 200micorgram/ml (1mg/5mL) oral suspension, although cheaper (when comparing 28 days’ cost @ 1mg t.d.s.), remains an unauthorized product via special order.

SMC accepts diamorphine nasal spray

The Scottish Medicines Consortium has accepted diamorphine nasal spray (Ayendi; Wockhardt) for the treatment of acute severe nociceptive pain in children and adolescents in a hospital setting. It should be administered in the emergency setting by practitioners experienced in the administration of opioids in children and with appropriate monitoring. For more information, click here.

Latest additions

PCF5+ 2016 pdf available soon!

PCF5+ 2016 pdf version is anticipated to be available in November 2016. We are pleased to announce that we will be able to keep the cost of this version at £25.

This annual version of the PCF will contain the updates made to the on-line PCF over the last 12 months since the last pdf version (PCF5+ 2015 pdf), and will reflect the content of the website as of 1st September 2016.

The on-line formulary will still be continually updated, providing the most up to date version. The more members subscribe, the more we can reduce the cost of subscription. We would like to thank you for your support over the last 12 months. Please note if you require bulk purchases of the pdf format please contact hq@palliativedrugs.com to discuss your requirements.

Survey results: Withdrawal of ventilation at the request of a patient

Results from our survey (August-September 2016).

The Association of Palliative Medicine (APM) produced guidance for professionals on the withdrawal of assisted ventilation at the request of patients with motor neurone disease in 2015, and is now collating experiences for ventilator-dependent patients with a broader range of conditions who request that their assisted ventilation be stopped. It is hoped that this may inform guidance for other groups of patients in future editions of the guidelines. UK health professionals involved in supervising ventilator withdrawal are encouraged to complete the audit of process and outcomes which is available, alongside the current guidance, on the APM website.

 Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

8 Sep, 16 | by Jenny Thomas

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.

Hot topics

Cochrane review: codeine versus placebo for cough in children

In this review the authors conclude that codeine (or its derivatives) should not be used for cough in children <12 years, because:

  • there is no published RCT evidence of benefit in this age group
  • children may have a greater risk of undesirable effects
  • the high degree of variability in the metabolism of codeine to morphine in children, may negate a therapeutic effect or, conversely, risk opioid toxicity and respiratory depression
  • the underlying aetiology should be defined, rather than the cough empirically treated.

For more information, click here.

 Cochrane review: oxycodone for neuropathic pain

A previous Cochrane review on oxycodone for neuropathic pain and fibromyalgia has been split into separate reviews and the use of oxycodone for neuropathic pain has been updated (CD010692). The authors concluded that there was very limited evidence that oxycodone (as oxycodone m/r) provides moderate benefit (30% reduction in pain) in painful diabetic neuropathy or postherpetic neuralgia. There was no evidence for other neuropathic pain conditions. For more information, click here.

 NICE- Call for evidence for End of Life Care service delivery

NICE are requesting information for the guideline they are developing on End of Life Care for adults in the last year of life, specifically, on service delivery models to:

  • identify people who may be entering the last year of their life
  • support people to stay in their preferred place of care (e.g. out of hours services)
  • facilitate smooth transitions between care settings (e.g. discharge planning teams)
  • facilitate continuity and coordination of care (e.g. multidisciplinary team working)
  • reduce inappropriate/avoidable hospital admissions (e.g. community health services and telehealth)
  • facilitate discharge back to the community from other settings (e.g. rapid discharge pathways).

The deadline for submission is 19 September 2016. For more information, click here.

Latest additions

PCF updated monographs summary (August 2016)

The on-line Palliative Care Formulary is being continually updated. The following monographs have been updated during August 2016 and supersede those in the print publication of the 5th edition of the Palliative Care Formulary (PCF5) and PCF5+ 2015 pdf. They can be accessed from the formulary section of the website.

Chapter 01: Quick Clinical Guide: Death rattle (noisy rattling breathing), Quick Clinical Guide: Opioid-induced constipation, Laxatives (minor change), H2-receptor antagonists (minor change)

Chapter 02: Haemostatics

Chapter 04: Antihistaminic antimuscarinic anti-emetics (minor change)

Chapter 05: Paracetamol, Morphine (minor change)

Chapter 06: Helicobacter pylori gastritis monograph discontinued

Chapter 07: Corticosteroids (minor change), Danazol, Demeclocycline, Desmopressin

Chapter 10: Skeletal muscle relaxants (minor change)

Chapter 13: Propofol

For further details of minor changes, see the individual notifications in the Latest additions section of http://www.palliativedrugs.com/latest.html.

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.

Parenteral NSAIDs – Which one do you use?

Results from our survey (June-July 2016).

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

8 Aug, 16 | by Jenny Thomas

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 issues

Nasogastric tube misplacement: continuing risk of death and severe harm

A stage two (resource) patient safety alert (NHS/PSA/RE/2016/006) has been issued to help support implementation of the previous alerts on this issue (see our news item December 2013). This follows 95 incidents reported between September 2011 and March 2016, where fluids or medication were introduced into the respiratory tract or pleura, despite several patient safety alerts. A review highlighted problems with the organisational processes for implementing previous alerts. Thus this resource alert is directed at Trust boards (or equivalent) and the processes that support clinical governance. For more information, click here.

Citalopram suspected drug interaction with cocaine

MHRA has reminded prescribers to consider illicit drug use and the risk of drug interactions when prescribing. This follows a suspected fatal drug interaction between citalopram and cocaine. For more information, click here.

Thalidomide new risks

A letter has been sent to UK healthcare professionals about the risks of viral reactivation and pulmonary hypertension associated with thalidomide. For more information, click here.

Hot topics

NICE end of life care for infants, children and young people

NICE has published draft guidance for consultation on end of life care for infants, children and young people. The deadline for consultation responses is 12 August 2016. For more information, click here.

Cochrane review: oral morphine for cancer pain

The third updated version of this Cochrane review (CD003868) has been published. No new studies have been identified for inclusion in this update and the conclusions remain unchanged, i.e. oral morphine in either immediate-release or modified-release form remains the analgesic of choice for moderate or severe cancer pain. For more information, click here.

Cochrane review: hydromorphone for neuropathic pain

The previous Cochrane review on hydromorphone for acute and chronic pain has been updated and divided into more specific sub-sets. The authors have concluded that there is insufficient evidence to support or refute the suggestion that hydromorphone has any efficacy in any neuropathic pain condition (CD011604). For more information, click here.

Recognition of sepsis: NICE guideline published

NICE have published guidance (NG51) for the recognition, diagnosis and early management of sepsis in all areas. For more information, click here.

Choice in end of life care: government response

UK Department of Health has published a response to the independent review on choice in end of life care (February 2015). The government has made 6 commitments to the public to end variation in end of life care across the health system by 2020:

  • honest discussions between health professionals and dying people
  • dying people making informed choices about their care
  • personalised care plans for all
  • the discussion of personalised care plans with health professionals
  • the involvement of family and carers in dying people’s care
  • a main contact so dying people and their families know who to contact at any time.

For more information, click here.

CQC annual report: safer management of controlled drugs

The UK Care Quality Commission (CQC) has published their 2015 annual report on the safer management of controlled drugs. They make recommendations for controlled drugs accountable officers (CDAOs) and local authority public health and adult social care directors with regards to information collection and sharing in controlled drug local intelligence networks (CD LINs). For more information, click here.

Management of chronic pain in adult cancer survivors

The American society of clinical oncology has published guidelines on the management of chronic pain in survivors of adult cancer. For more information, click here.

RPS guide for pharmacists working in care homes

The UK Royal Pharmaceutical Society has developed guidance for pharmacists working in care homes. For more information, click here.

Drug updates

FDA authorizes dronabinol oral solution

A dronabinol oral solution (Syndros; Insys Therapeutics) has been authorized in the US for treating anorexia associated with weight loss in patients with AIDS, and nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional anti-emetic treatments. It is currently awaiting scheduling by the US Drug Enforcement Administration. For more information, click here.

Glycopyrronium oral solution authorized for severe drooling in the UK

European Medicines Agency has authorized a glycopyrronium 320microgram/mL oral solution (Sialanar; Proveca) for the treatment of severe drooling in children >3 years and adolescents, with neurological conditions. The Committee for medicinal products for human use had previously issued a negative opinion for wider use in patients with mild‒moderate drooling, however following re-application, authorization has been granted for severe drooling. For more information, click here.

Latest additions

PCF updated monographs summary (July 2016)

The on-line Palliative Care Formulary is being continually updated. The following monographs have been updated during July and supersede those in the print publication of the 5th edition of the Palliative Care Formulary (PCF5) and PCF5+ 2015 PDF. They can be accessed from the formulary section of the website.

Chapter 01: PPI (minor change)

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.

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

5 Jul, 16 | by Jenny Thomas

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 issues

Topical miconazole interaction with warfarin

MHRA has highlighted the risk of serious bleeding events in patients taking warfarin and using cream, ointment, powder or oral gel formulations of miconazole. The potential for a drug interaction between oral miconazole and warfarin is well documented due to miconazole inhibiting the CYP2C9 enzyme involved in the metabolism of warfarin. The MHRA are now receiving a large number of reports of potential drug interactions involving topical miconazole (particularly the oral gel formulation) and warfarin, and are now reviewing whether further measures are needed to minimise the risks to patients. In the meantime, their advice is to carefully monitor the anticoagulant effect and reduce the dose of warfarin if necessary. As some topical formulations of miconazole are available without prescription, patients taking warfarin should be warned not to use topical miconazole without consulting their doctor. For more information, click here.

Hot topics

RPS guidance for the prescribers of Specials

The Royal Pharmaceutical Society (RPS), has published guidance for the prescribers of specials. The document can be downloaded from the RPS website, or from here. This document was produced at the request of NICE and following consultation in 2015 (see our news item 10 November 2015). It complements the RPS professional guidance for the procurement and supply of specials which was published in December 2015.

Neuropathic pain: pregabalin and gabapentin prescribing

The latest PrescQIPP bulletin discusses dose optimisation of pregabalin and cost effectiveness in line with authorized indications and guidance from NHS England and NICE. For more information, click here.

 e-learning Indian palliative care course

eCancer has launched a text only version of the palliative care e-learning course for health professionals in India. For more information, click here.

Drug updates

Epistatus 10mg/mL oromucosal solution batch recall

MHRA has issued a class 2 medicines recall for a specified batch of Epistatus (midazolam) 10mg/mL oromucosal solution (unauthorized buccal liquid; Special products). The incorrect size of neck adaptor has been fitted and they are not compatible with oral syringes (Batch: 73234 Expiry: Oct 2017 Size: 1 x 5ml First issued: 24 Feb 2016). For more information, click here.

NICE evidence summary for fentanyl transdermal patient controlled system

NICE has published an evidence summary for the new fentanyl transdermal system (IONSYS) that was launched earlier this year in the UK (see our news item 28 March 2016). It is authorized for the treatment of moderate−severe post-operative pain in adults (hospital use only).

NICE conclude that the fentanyl transdermal system has comparable efficacy to IV morphine patient-controlled analgesia (PCA). Its undesirable effect profile is as expected for an opioid used in post‑operative pain, and is similar to that of IV morphine PCA. They report a better patient satisfaction than IV morphine PCA but a higher drug cost. For more information, click here.

New naproxen suspension available in UK

A new authorized naproxen oral suspension 125mg/5mL (Orion Pharma) is now available. The NHS indicative cost is £110 for 100mL. This is significantly more expensive than the tablets or the effervescent tablets and the previously unauthorized special order product. The effervescent tablets are now accepted by the Scottish Medicines Consortium (SMC) for use in NHS Scotland for patients with swallowing difficulties. For more information, click here.

Naproxen (generic)

Tablets 250mg, 500mg, 28 days @ 500mg b.d. = £2.75.

Tablets e/c 250mg, 375mg, 500mg, 28 days @ 500mg b.d. = £9.

Oral solution 125mg/5mL, 28 days @ 500mg b.d. = £1,232.

Stirlescent® (Stirling)

Tablets effervescent 250mg, 28 days @ 500mg b.d. = £44.

With esomeprazole

Tablets m/r naproxen 500mg e/c + esomeprazole 20mg, 28 days @ 1 tablet b.d. = £15. Note this product is cheaper than prescribing both drugs separately.

Latest additions

Levomepromazine for anti-emesis – How do you use it?

Results from our survey (April– May 2016).

 Introducing Palliative Care 5th edition (IPC5) now available.

We are pleased to announce that IPC5 is now available to purchase from our store for £25 (including p&p in the UK).

IPC5 has moved from a single authorship to a collaborative project between palliativedrugs.com editorial team and eight new contributors. Updates include:

  • covering the Association for Palliative Medicine of Great Britain and Ireland recommended curriculum for medical undergraduates
  • expanded sections on ethics, law, children, symptom management
  • the Essential Palliative Care Formulary, and a synoptic table of drug doses for common symptoms.

IPC5 has already received the following high praise:

We all need one book that we know, thumb often, trust and refer to. This palliative care book fills all these roles for staff at every grade. End of life care is everyone’s business; if used to the full, this book can and will improve patient care in all settings.’ Professor Ilora Baroness Finlay of Llandaff

This new collaborative edition is the best of the best. Its clear, concise, balance of theory and application is admirable and is replete with practical wisdom. This is required reading for anyone serious about caring for the dying well, for it is long enough to be useful and short enough to be digestible.’ Professor Rob George, President of the Association for Palliative Medicine

The holistic and multimodal approach of this book, which builds on the total pain model of Dame Cicely Saunders, is particularly to be commended.’ Professor Irene Higginson, Director of the Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London

This book is not just a symptom control handbook, it covers all aspects of holistic care in an easy to read and navigable format. It will become an old friend – get to know it!Dr Fiona Rawlinson, Programme Director, Palliative Care Education, Cardiff University.

To purchase a licensed copy, and help support palliativedrugs.com, please go to our store. For enquiries regarding multiple copies please contact hq@palliativedrugs.com

PCF updated monographs summary (May/June 2016)

The on-line Palliative Care Formulary is being continually updated. The following monographs have been updated during May/June and supersede those in the print publication of the 5th edition of the Palliative Care Formulary (PCF5) and PCF5+ 2015 PDF. They can be accessed from the formulary section of the website.

Chapter 02: Furosemide

Chapter 05: Opioid antagonists (minor change)

Chapter 24: Prolongation of the QT interval in palliative care (minor change)

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.

 

Prepared by Sarah Charlesworth and Andrew Wilcock

BMJ Supportive & Palliative Care blog

BMJ Supportive
& Palliative Care

BMJ Group's first dedicated supportive and palliative care journal.
Visit site



Creative Comms logo