Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.
Safety updates
Updated IV Ondansetron dosing for CINV
The UK MHRA has given new guidance for the administration of IV ondansetron based on further information on the risk of dose-dependent QT interval prolongation, (first reported in August 2012):
- for Chemotherapy Induced Nausea and Vomiting (CINV) in patients aged 65 years or older, all IV doses should be diluted in 50–100mL saline or other compatible fluid and infused over at least 15 minutes. The maximum single IV dose of ondansetron may be up to 16mg (maximum 8mg in patients aged 75 years or older).
- repeat IV doses of ondansetron should be given a minimum of 4 hours apart.
There are no changes to the recommended dosing or administration details for PO or PR ondansetron for CINV (including elderly patients), for IV or PO use in Postoperative Nausea and Vomiting (including elderly patients) or for IV or PO use in either indication in children (age >6 months and adolescents).
MHRA remind health professionals that ondansetron should be avoided in patients with congenital long QT syndrome, hypokalaemia and hypomagnesaemia should be corrected before ondansetron administration, and caution used in patients with risk factors for QT interval prolongation or cardiac arrhythmias. For more information, click here.
Hot topics
LCP independent report published
The independent report reviewing the Liverpool Care Pathway (LCP) for dying patients has been published. The recommendations include:
- phasing out the LCP and replacing it with an individual end of life care plan
- a general principle that a patient should only be placed on the LCP or a similar approach by a senior responsible clinician in consultation with the healthcare team
- unless there is a very good reason, a decision to withdraw or not to start a life-prolonging treatment should not be taken during any ‘out of hours’ period
- an urgent call for the Nursing and Midwifery Council to issue guidance on end of life care
- an end to incentive payments for use of the LCP and similar approaches
- a new system-wide approach to improving the quality of care for the dying
The full report, evidence and press release can be found here.
NHS England has published interim guidance to assist health professionals caring for people in the last days of life in light of the recommendations. A similar document is available from the Scottish Government, and the Palliative Care Implementation Board for Wales has issued a response document.
Driving under the influence of controlled drugs government consultation
The UK department for transport has issued a consultation seeking views on proposals for threshold drug driving limits to be specified in the new regulations regarding the offence of driving with a controlled drug in the body.
Views are sought on the government’s preferred policy option of making it an offence to drive if any of 16 controlled drugs are found in the blood over a specified limit.
They propose a zero tolerance approach to the threshold limits that are given for 8 drugs most associated with illegal use; cannabis and cannabinol, cocaine, ketamine, benzoylecgonine, Lysergic Acid Diethylamide (LSD), MDMA (Ecstasy), methamphetamine, 6-monoacetylmorphine (6-MAM; Heroin/diamorphine). A road safety risk approach to the threshold limits is proposed for a further 8 drugs most associated with medical uses; clonazepam, diazepam, flunitrazepam, lorazepam, methadone, morphine, oxazepam and temazepam. A limit for amphetamine will be subject to a further consultation. Two other policy options are also considered.
This consultation follows the report ‘Driving under the influence of drugs’ from the expert panel on drug driving which was published in March 2013. The report states that there was not enough evidence to set threshold limits for other opioids e.g. codeine, dihydrocodeine, oxycodone, hydrocodone, tramadol, however recommendations regarding the role of the health professionals in informing patients about the risks of driving under the influence of drugs are made.
The consultation which closes on 17 September 2013 and the full report from the expert panel which advised the department for transport can be downloaded below.
Drug driving expert panel report
Cochrane review: pharmacological interventions for pruritus in adult palliative care patients
A recent Cochrane review on the pharmacological interventions for pruritus in adult palliative care patients (CD008320) has been published.
WHO publishes a model list of essential medicines for palliative care
The World Health Organization (WHO) has published the new editions of the WHO Model List of Essential Medicines for Adults and for Children. The new editions of the model lists now include a list of medications used to treat the most common symptoms occurring in palliative care, and are located in a new separate section (section 2) called Medicines for Pain and Palliative Care. For access to the lists, click here.
Drug updates
Fentanyl updated SPC
The UK SPCs for fentanyl injection (Sublimaze; Janssen-Cilag) and fentanyl transdermal patches (Durogesic; Janssen-Cilag)have been updated to include a warning that if fentanyl is used in combination with other serotinergic drugs e.g. Selective Serotonin Re-uptake Inhibitors (SSRIs), Serotonin Norepinephrine Re-update Inhibitors (SNRIs) and Monoamine Oxidase Re-uptake Inhibitors (MAOIs) there is a possibility of serotonin syndrome occurring. This update comes following a review by Janssen- Cilag.
Fentanils have always been included in PCF as drugs with clinically relevant serotinergic potency (see Antidepressants, serotonin toxicity, Box 4.F) with a risk of serotonin toxicity in combination with MAOIs in particular (see Drug interactions in both the Fentanyl and Fentanyl (transmucosal) monographs). In addition, SPCs of some other fentanyl products have always stated that fentanyl should not be used within 14 days of discontinuation of an MAOI. For more information, click here.
Consultation on Controlled Drug Scheduling for tramadol
The UK government has issued a consultation document proposing that tramadol becomes controlled via Schedule 3 of the Misuse of Drugs Regulations 2001, following control under the Misuse of Drugs Act 1971 as a Class C drug.
The consultation also seeks views on the continued application of current exemptions for prescriptions for the Schedule 3 drug temazepam. The consultation closes on 11 October 2013.
NICE evidence summary of oral glycopyrronium bromide for hypersalivation
The National Institute for Health and Care Excellence (NICE) has published its evidence summary (ESUOM15) for the unauthorized (unlicensed)/off-label use of oral glycopyrronium bromide for hypersalivation.
NICE evidence summary of oral glycopyrronium bromide for hyperhidrosis
The National Institute for Health and Care Excellence (NICE) has published its evidence summary (ESUOM16) for the unauthorized (unlicensed)/off-label use of oral glycopyrronium bromide for hyperhidrosis.
Latest additions
PCF updated monographs
The online Palliative Care Formulary (PCF) is being continually updated. The following monographs have been updated during July 2013 and supersede those in the publication of the 4th edition of the Palliative Care formulary (PCF4). They can be accessed from the formulary section of the website:
Chapter 8: Oxybutynin
Chapter 4: Psychostimulants (combined monograph, replaces the separate methylphenidate, modafinil and Quick Practice Guide: Psychostimulants in depressed patients with a short prognosis, which are no longer available).
For a full list of all the monographs updated since the publication of PCF4, click here.
Die Mai/Juni Ausgabe des APM Newsletter ist fertig
The May/June issue of the APM Newsletter for German-speaking users of www.palliativedrugs.com is available.
Die Mai/Juni Ausgabe des APM-Newsletter Jahrgang ist erschienen. Über die aktuelle Ausgaben des Newsletters wird Sie das Bulletin Board informieren.
Prepared by Sarah Charlesworth and Andrew Wilcock