Speed Dating with a Palliative Care Pharmacist

Speed Dating with a Palliative Care Pharmacist Mary Lynn McPherson, PharmD, MA, MDE, BCPS Professor and Executive Program Director Online Master of Science, Graduate Certificates, and PhD* in Palliative Care Graduate.umaryland.edu/palliative | [email protected]

*pending MHEC approval Objectives

1. Discuss 3 pearls related to pharmacology of palliative medications. 2. Discuss 3 pearls related to appropriateness of maintenance medications in EOL care. 3. Discuss 3 pearls related to using palliative medications in a safe and effective manner. Equianalgesic Opioid Dosing 2010 Equianalgesic Doses (mg) 2018 Equianalgesic Doses (mg) Drug Parenteral Oral Drug Parenteral Oral Morphine 10 30 Morphine 10 25 Fentanyl 0.1 NA Fentanyl 0.15 NA Hydrocodone NA 30 Hydrocodone NA 25 Hydromorphone 1.5 7.5 Hydromorphone 2 5 Oxycodone 10* 20 Oxycodone 10* 20

*Not available in the US

Reprinted with permission from McPherson ML. Demystifying opioid conversion calculations: a guide for effective dosing, 2nd ed. Bethesda: ASHP; ©2018. NOTE: Learner is STRONGLY encouraged to access original work to review all caveats and explanations pertaining to this chart. Equianalgesic Opioid Dosing 2010 Equianalgesic Doses (mg) 2018 Equianalgesic Doses (mg) Drug Parenteral Oral Drug Parenteral Oral Morphine 10 30 Morphine 10 25 Fentanyl 0.1 NA Fentanyl 0.15 NA Hydrocodone NA 30 Hydrocodone NA 25 Hydromorphone 1.5 7.5 Hydromorphone 2 5 Oxycodone 10* 20 Oxycodone 10* 20

*Not available in the US

• Largely determined by oral bioavailability (of oral hydromorphone) • Parab - 50.7 +/- 29.8%; Ritschel – 51.35 +/- 29.3% • Do we need to evaluate conversion from oral to parenteral? • No, because conversion is determined primarily by BAB • Secondarily by pharmacogenetics • Clinical experience in large patient populations provide average guidance • Best data is 1:2.5 (IV:oral) McPherson Table Equianalgesic Doses (mg) Drug Parenteral Oral Hydromorphone 2 5

Biopharm & Drug Dispo, 1988;9(2):187-199. J Clin Pharm 1987;27(9):647-653. Conversion Ratio from IV Hydromorphone to Oral Opioids in Cancer Patients IV Hydromorphone → Oral Opioid 1 mg IV hydromorphone (< 30 mg/day) → Oral hydromorphone 2.5 mg 1 mg IV hydromorphone (> 30 mg/day) → Oral hydromorphone 2.1 mg 1 mg IV hydromorphone (< 30 mg/day) → Oral morphine 11.54 mg 1 mg IV hydromorphone (> 30 mg/day) → Oral morphine 9.86 mg 1 mg IV hydromorphone → Oral oxycodone 8.06

McPherson Table Equianalgesic Doses (mg) Reddy’s bottom line: Drug Parenteral Oral I:2.5 (IV hydromorphone to oral hydromorphone) Morphine 10 25 1:10 (IV hydromorphone to oral morphine) 1:8 (IV hydromorphone to oral oxycodone) Hydromorphone 2 5 Oxycodone 10* 20

Reddy A et al. J Pain Symptom Manage 2017;54(3):280-288. Morphine Hydromorphone

• Is it bidirectional? (IV HM to PO MS equal to PO MS to IV HM?) • Study by Lawlor – SQ to SQ HM/MS and PO to PO HM/MS • Going from morphine to hydromorphone (same route) was 5:1 (M:HM) • Going from hydromorphone to morphine (same route) was 3.7:1 (M:HM) • Limitations of Lawlor study: • Data highly skewed and variable, not normally distributed • Authors stated differences in direction were clinically insignificant and called for further research...in the meanme diﬀerences in M→HM and HM→M remain speculative

Pain 1997;72(1-2):79-85. How about oral MS to parenteral hydromorphone?

IV HM:PO MS - 1.5:30 IV HM:PO MS – 2:25 Coments Switching from 10 mg IV HM A. Calculate 200 mg PO MS B. Calculate 125 mg PO MS New conversion more per day to PO MS conservative, and it’s consistent with Reddy findings. Switching from 200 mg PO C. Calculate 10 mg IV HM D. Calculate 16 mg IV HM New conversion seems MS per day to IV HM more aggressive than older conversion ratio.

But wait! There’s more than one way to pluck a chicken! 2018 Equianalgesic Doses (mg) 200 mg oral morphine → 40 mg oral hydromorphone → Drug Parenteral Oral Morphine 10 25 16 mg IV hydromorphone Hydromorphone 2 5 Which is my seat?

Don’t know – I just got you in the ball park!

PRESENTED BY: What a pain in the butt! • Pain related to anal cancer – SO challenging to treat! • Reports of intrathecal opioid therapy, calcium channel blockers for perineal pressure-like pain and tenesmus • Opioids, steroids, lidocaine ointments • Case report from Nigeria – 34 yo man with anal cancer • Complained of extreme, nonradiating shapr pain within anal canal • Morphine 20 mg q4h plus acetaminophen 500 q6h plus meloxicam 15 qd • Radiation did not help pain • Rectal suppositories lidocaine 60 mg plus hydrocortisone 5 mg pr q12h

Ali SK, Abdulkarim S. JPSM 2018;56(1):e1-e2 What about topical compounds for pain management Ann Ann Intern Med 2019;170:309-318.

PRESENTED BY: Compounded Topical Pain Creams

• Military treatment facility • 399 patients with localized pain classified by their MD as neuropathic, nociceptive or mixed (back/butt; neck; limb; other location) Group Compounded Product 1 – Neuropathic pain Ketamine, gabapentin, clonidine, lidocaine 2 – Nociceptive pain Ketoprofen, baclofen, cyclobenzaprine, lidocaine 3 – Mixed Ketamine, gabapentin, diclofenac, baclofen, neuropathic/nociceptive cyclobenzaprine, lidocaine 4 –Placebo Placebo

Brutcher RE et al. Ann Int Med 2019;170:309-318. Concentrations of ingredients

• Ketamine 10% Apply to affected area 3 times per day. • Gabapentin 6% • Clonidine 0.2% Amount applied determined by size of the • Lidocaine 2% area (set by investigators – 4 rotations of • Ketoprofen 10% container for 5x5 area) • Baclofen 2% • Cyclobenzaprine 2% • Diclofenac 3% Magic Pain Cream • Lipophilic base carrier

Brutcher RE et al. Ann Int Med 2019;170:309-318. So WILL a little dab do ya?

• Primary outcome – average pain score 1 month after treatment • Positive categorical response was a reduction in pain score by > 2 points (0-10) WITH a satisfaction score of > 3 on a 5-point satisfaction scale • Data collected by phone by a trained, blinded investigator not involved in patient care • 1 month (24-40 days) • 3 months (75-110 days) • 399 started trial, 390 completed • 202 assigned to a study drug, 197 to placebo

Brutcher RE et al. Ann Int Med 2019;170:309-318. Drum roll please….

• No change in pain score at 1 month between drug and placebo for any group • Neuropathic pain – 0.1 point reduction in pain • Nociceptive pain – 0.3 point reduction in pain • Mixed pain – 0.3 point reduction in pain • SF-36 measures did not differ between the groups

Brutcher RE et al. Ann Int Med 2019;170:309-318. The ability to name 11 animals in one minute was the most useful indicator that an older adult could learn to self-inject insulin within one week.

J Diabetes Investig 2017 Metformin – New Cutoffs for Use

• Previously metformin was contraindicated with SCr > 1.4 mg/dl in women of SCr > 1.5 mg/dl in men • Using SCr tends to underestimate renal function in some populations (younger patients, African Americans, patients with greater muscle mass) • New recommendations are based on eGFR: • Contraindicated with eGFR < 30 ml/min/1.73m2 • Therapy not recommended with eGRF between 30 and 45 ml/min/1.73m2 • If eGFR falls below 45 ml/min/1.73m2 benefits and risks should be assessed • Do not administer metformin for 48 hours after an iodinated contrast imaging procedure in patients with eGFR < 60 ml/min/1.73m2 Hypoglycemia – How low can you go?

• About 25% of Americans die in a long-term care facility • Retrospective cohort study of patients > 65 years with T2DM admitted to a VA LTC. • Analysis included: • Cumulative incidence of hypoglycemia (BG < 70 mg/dl) • Cumulative incidence of severe hypoglycemia (BG < 50 mg/dl) • Cumulative incidence of hyperglycemia (BG > 400 mg/dl) • Competing risk of death among all hospice patients • Competing risk of death among patients treated with insulin vs. patients not treated with insulin

Petrillo et al. JAMA IM 2017. Hypoglycemia – How low can you go?

• 20,329 hospice patients • Despite guidelines that stress avoiding hypoglycemia in hospice PWD • Results showed:

• 1 in 9 LTC patients with T2DM experienced hypoglycemia • 1 in 20 experienced severe hypoglycemia • Risk highest among those receiving insulin (1/3 experienced hypoglycemia)

Petrillo et al. JAMA IM 2017. Give the dying diabetic a donut!

This here is a cheesecake stuffed baked donut

Recipe available at: https://www.handletheheat.c om/cheesecake-stuffed- baked-doughnuts/. Calories: 8 million STOP! Before you stop that medication!

Class Drug • ISMP reports on drug withdrawal Effects on serotonin Duloxetine symptoms Paroxetine • At least 10 reported cases of Venlafaxine withdrawal effect Effects on GABA Pregabalin Vigabatrin • Twice as many as expected given the Gabapentin total number of adverse events for Effects on opioid Buprenorphine/naloxone the drug receptors Oxcodone • 95% probability that withdrawal Gabapentin symptoms was not due to chance Effects on dopamine Quetiapine Olanzapine • Consider alternate delivery systems Methylphenidate • Taper doses down Other mechanisms Baclofen Cetirizine • Anticipate swallowing difficulties Ziconotide

Pharmacy Today October 2017 Just Say “NO” to Codeine

• American Academy of Pediatrics advises against giving codeine to children • FDA has now made pediatric use a black box warning • Children, especially those with sleep-disordered breathing, are at particular risk for opioid sensitivity • Codeine can be fatal due to variable metabolism • Majority of deaths occurred with: • Children of young age • Children were on codeine/acetaminophen post-operatively • Children had undergone adenotonsillectomy for sleep-disordered breathing

http://www.usatoday.com/story/news/nation-now/2016/09/22/dont-give-your-children-codeine-academy-pediatrics-says/90831620/ Codeine – World-Class Stinker! Tramadol too!

• FDA further restricted the use of codeine (and hydrocodone) in cough medicines in children under 18. • Risks of misuse, abuse, addiction, overdose, death and slowed or difficult breathing outweigh their benefit. • Single-ingredient codeine and tramadol are FDA approved only for use in adults • Codeine and tramadol should be avoided by breastfeeding mothers • Codeine, given post-stroke, is associated with poorer outcomes • OR for pneumonia 3.8 • OR for stroke worsening 2.7 • OR for death 2

Brain and Behavior 2017;7:e00869 Preventing Urinary Tract Infections

• Cranberry? • MOA – proanthrocyanidin disrupts adhesion of E. coli to the epithelium of the urinary tract, and may prevent infection • Cochrane review evaluated 24 trials comparing cranberry, placebo, no treatment, or water → no difference, and specifically no different in women or seniors • Consider sugar content for patients with diabetes Ok, how about some D-mannose?

• Other options include antibiotic or methenamin prophylaxis • Most common antibiotic regimens are TMP/SMX, trimethoprim, nitrofurantoin, cephalexin, fluoroquinolones at ¼ usual daily dose for 6 months • What about D-mannose? • MOA – inhibition of bacterial adherence to urothelial cells • D-mannose has been used to treat UTI’s in horses, cats and dogs • Been shown to reduce adherence of E. coli, Ps. Aeruginosa, S. zooepidemicus

Kranjcec et al. World J Urol 2014;32(1):79-84. Ok, how about some D-mannose?

• Study in 308 woman 18 years of age with acute UTI and h/o recurrence • Acute UTI treated with ciprofloxacin 500 mg bid for one week • Randomized to 2 g D-mannose powder daily (in 200 ml water), nitrofurantoin 50 mg once a day, or placebo • Placebo – 60% recurrence of UTI • Nitrofurantoin – 20% recurrence of UTI • D-mannose – 15% recurrence of UTI • Fewer adverse effects on D-mannose

Kranjcec et al. World J Urol 2014;32(1):79-84. Why Dex?

Name Eqivalent Glucocorticoid Mineralocorticoid Duration of Dose Potency Potency actions (mg) (anti-inflam) (Na retention) (T ½ hrs) Hydrocortisone 20 1 1 8 Prednisone 5 3.5-5 0.8 16-36 Prednisolone 5 4 0.8 16/36 Methylprednisolone 4 5-7.5 0.5 18-40 Dexamethasone 0.75 25-80 0 36-54 squattypotty.com The Disimpactor

http://disimpactor.centurionmp.com/ http://disimpactor.centurionmp.com/ • For relief of fecal impaction in patients > 18 years, clinically confirmed. Not for constipation. • Exclusion criteria: • Hemodynamic instability • Mental status changes • Renal failure • Hyperkalemia • Active anticoagulation • Rectal disease including neoplasma, active infection, active bleeding, inflammatory bowel disease, bowel obstruction, fissures, fistulres • Any GI or systemic condition that may pose a risk to the patient

1 – 2 – 3 (with enema) http://disimpactor.centurionmp.com/ Speaking of the rectum

• You CANNOT take any old tablet or capsule, insert it rectally, and happily assume it will be well-absorbed! • Patients don’t like it, it’s NOT pharmaceutically elegant • Chemical characteristics that allow an oral medication to be absorbed after oral ingestion, may prohibit rectal absorption! Pseudobulbar Affect – Who’s up for Nuedexta?

• Nuedexta – indicated for inappropriate laughing and crying – pseudobulbar affect • Dextromethorphan 20 mg and quinidine 10 mg/capsule • Sig: 1 capsule daily x 7 days, then 1 capsule twice daily • $1,000/month • I could laugh, I could cry! • Holy cow! Now what? Can we duplicate this and save some $$??

• Dextromethorphan - an uncompetitive NMDA receptor antagonist and sigma-1 receptor agonist, believed to modulate glutamate signaling • Dextromethorphan → dextrorphan • Phencyclidine-like behavioral eﬀects → exhibits anconvulsant and neuroprotective properties • Quinidine (a CYP2D6 inhibitor) increases dextromethorphan (DM) bioavailability ~20-fold and prolongs elimination half-life of DM from ~2 hours to 13 hours (29.5 hours in poor metabolizers) • Compounded quinidine 30 mg/5 ml (30 ml - $10) – about $1/day • Dextromethorphan – over the counter - < $1/day • AM I YOUR NEW BEST FRIEND OR WHAT??? Whoa – that’s intense. No, it’s an INTENSOL! • Mr. Jones is a 58-year-old man with • 54 mg/day IV morphine ~ 162 mg oral lung cancer, who was admitted to the morphine/day inpatient hospice unit for pain out of • ~ 16 mg a day oral methadone control. • Breakthrough oral morphine is 10-15% • His pain was eventually controlled on TDD, so 16-24 mg oral morphine an IV PCA infusion of morphine 2 mg/h with a 1 mg bolus every 15 • Order: minutes prn. • Methadone 10 mg/ml oral solution, 8 mg po q12h • He is very weak and has a hard time • Morphine 20 mgl/ml oral solution, swallowing, but he wants to go 20 mg po q2h prn additional pain HOME. • Do we have to send him home on the IV morphine? Intensols • Alprazolam 1 mg/ml • Dexamethasone 1 mg/ml • Diazepam 5 mg/ml • Lorazepam 2 mg/ml • Methadone 10 mg/ml • Morphine 20 mg/ml • Oxycodone 20 mg/ml • Prop upper body up 30 • Prednisone 5 mg/ml • Instill up to 1.5 ml in buccal cavity

Clin Pharmacol Ther 1988;44:335-342 “5 mL of Sugar” to Help the Medicine Go Down

• No more “teaspoon” measurement TSP: 1.5 – 10 mL on instructions  mL (+/- 4 mL ) • Use oral syringes instead of dosing cups Measurement

Tsp = 5 mL (100 mg morphine intensol)

Tbsp = 15 mL (300 mg morphine intensol)

J Am Pharm Assoc. 2016; 56: 369. Subcutaneous Levetiracetam

• The oral: parenteral conversion for levetiracetam is 1:1 • Per the (German) manufacturer, levetiracetam the concentrate for infusion should be diluted in at least 100 ml of dextrose 5%, lactated Ringer’s solution, or sodium chloride 0.9% and administered twice daily over 15 minutes • Von Hornstein - CSCI 100 mg/ml, dose ranged from 250-3200 with good effect1 • Wells - 2 grams diluted in 100 ml of 0.9% sodium chloride, administered over 24 hours2 • Lopez-Saca – 500 mg/ml, 1 grams every 12 hours diluted in 100 ml saline solution administered over 30 minutes3

1. http://conference.ncri.org.uk/abstracts/2014/abstracts/B031.html 2. 2. Wells GH et al. Age and Ageing 2016;45:321-322 3. Lopez-Saca JM et al. J Pain and Symptom Manage 2013;45(%):e7-8 SQ Methadone

• Dosing: use half of oral dose • Intermittent vs continuous • Reported risk of irritation limited, may be mitigated by: • Frequent change of infusion site • Flushing site with normal saline • Limiting dose (e.g. <30 mg) • Adding dexamethasone or hyaluronidase

J Pain Symptom Manage. 2007 Dec;34(6):573-5. SQ Lasix

• Intermittent vs continuous • Can be useful in patient refractory to oral loop diuretics • Concentration is 10 mg/mL so can be a challenge if large volume required

JPM. 2012; 30(8): 791-2; Palliat Med. 2011; 25(6): 658-663. Total vs Free Phenytoin

PhenytoinPhenytoin 90% 90% bound bound to to albumin albumin

Phenytoin Free Phenytoin Therapeutic Level: Albumin 15 mcg/ml 1.5 mcg/ml 1-2 ng/mL (free) 10-20 ng/mL (total)

Phenytoin Free Phenytoin Albumin 15.0 mcg/ml 3.0 mcg/ml mcg/ Total serum Total phenytoin concentration 15 mcg/ml Phenytoin 80% bound to albumin Why Dex?

• Take several deep breaths to relax neck and throat muscles. • Hold an ice cube or popsicle in your mouth to numb your throat and calm your gag reflex. • Take a drink of water before placing pills on your tongue. • Place the pill on the tip of your tongue. (Others recommend the middle of the tongue. Try both -- see what works for you.) • Don't psych yourself out by thinking "I'm taking a PILL". Think "FOOD." If you are thinking "PILL", you will feel your throat tightening. Oralflo Pill Swallowing Cup

https://www.oralflo.com/ Swish this…

• Nystatin swish-and-swallow for oral candidiasis • Prescribing information states patients should: • “Place half the dose in each side of the mouth and hold it there or swish it throughout the mouth for SEVERAL minutes before swallowing.” • In other words, it’s not just “swish-swish-swallow.” • Consider clotrimazole troches – place in mouth and allowed to dissolve slowly • Denture wearers? • Get 6 oz. of Nystatin swish and swallow, and soak in denture cup for 2 x 24 hours (denture cup holds 3 oz fluid) Fluconazole – Oropharyngeal Candidiasis

• Single dose fluconazole (Diflucan) in HIV pts • 150 mg fluconazole x 1 dose vs. 100 mg itraconazole once daily for a week • 75% of fluconazole patients cured on day 8 • 24% of itraconazole patients cured on day 8 • 220 HIV-infected patients • 750 mg oral fluconazole x 1 vs. 150 mg oral fluconazole daily for two weeks • Equivalent outcomes

J Int Med Res 1998;26(3):159-170; Clin Infect Dis 2008;47(10):1270-1276 Tramadol • 2013 – 43.8 million • Risk of hospitalization prescriptions for hypoglycemia in • MOA - mu-opioid patients with noncancer receptors agonist and a pain reuptake inhibitor of serotonin and norepinephrine. • Activity due to parent compound and the more active O- desmethylated metabolite • Metabolized by CYP 2D6 Eric Widera, MD, pallimed.org http://www.pallimed.org/2014/12/tramadol-induced-hypoglycemia-another.html JAMA Intern Med, doi: 10.1001/jamainternmed.2014/6512 Tramadol Worries

• Weak opioid • Serotonin syndrome • Seizures • Drug interactions • Hypoglycemia

• NOTE: I will only provide generic cookies on my hospice formulary Malignancy-Associated Perineal Pain and Tenesmus

• Common complaint with advanced cancer (colorectal, genitourinary, prostate) • Accounts for 8%of all cancer-associated pain syndromes • “Tight,” “aching,” “drilling,” “pressing” pain located deep within rectum or pelvis and associated with rectal tenesmus* and urgency • May be due to tumor recurrence, postsurgical resection or radiation injury • Pain and defecation issues can dramatically impact QOL

*Tenesmus is the feeling that you need to pass stools, even though your bowels are already empty. It may involve straining, pain, and cramping. (http://www.nlm.nih.gov/medlineplus/ency/article/003131.htm) Malignancy-Associated Perineal Pain and Tenesmus

• Case 1 • 70-year-old man with high-grade urothelial carcinoma. Pain described as “sitting on a football with radiation to the tip of his penis and into his groin. • Status-post three ganglion of impar blocks, OxyContin, hydromorphone, gabapentin. • Opioid escalated to point of neurotoxicity. • Started diltiazem 30 mg po q6h; within 72 hours pain rated 1-4/10; switched to diltiazem 120 mg ER qd Malignancy-Associated Perineal Pain and Tenesmus

• Case 2 • 64 yo woman with 3 year h/o rectal cancer • Describes constant pressure deep in rectum associated with tenesmus • On TDF 25 mcg/h, oxycodone 5 mg • Readmitted with rectal pain, rated as 9/10 • TDF increased, added hydromorphone PCA; switched to methadone and started diltiazem 30 mg po q6h • Within 48 hours pain much improved. Switched to diltiazem 120 mg po QD. Malignancy-Associated Perineal Pain and Tenesmus

• Diltiazem is a calcium channel blocker • Cardiovascular benefits, Raynaud’s, migraine, pulmonary hypertension, esophageal spasm • Blocks L-type calcium channel located in vascular and nonvascular smooth muscle • Dihydropyridines and nondihydropyridines • In GI tract, CCBs are potent inhibitors of intestinal smooth muscle contraction, decrease large bowel motility, reduce rectosigmoid intraluminal pressure and tone, diminish anal sphincter tone. Use of Pregabalin in the Management of Chronic Uremic Pruritus

• CKD patients with severe intractable pruritus • 12 patients; average dose 25 mg po qd

Time Point Pain Rating Baseline 9.7 +/-0.9 One week 3.7 +/-2.35 Four weeks 3.2 +/- 1.75 24 weeks 3 +/- 1.5

Shavit L et al. J Pain and Sx Manage 2013;45:776-781. Flavoring a bitter medication solution

• Opioid oral solutions are BITTER! • Many community pharmacists offer a flavoring system (FLAVORx) • Children may prefer: • Grape bubble gum • Banana-orange • Bitter solutions may be better mixed with: • Tutti-frutti • Crème de menthe • Raspberry • Chocolate Patient tells you “I’m allergic to sulfa drugs…”

• What does this mean? • Are they allergic to sulfa, sulfur, sulfites, or sulfates? • “Allergic to sulfa drugs” includes: • Sulfonamide antimicrobials • Sulfamethoxazole-trimethoprim (Bactrim) • Sulfisoxazole-erythromycin (Pediazole) • Sulfonamide non-antimicrobials such as • Celecoxib (Celebrex) • Furosemide (Lasix) • Glimepiride (Amaryl) • Hydrochlorothiazide (HCTZ) • Sumatriptan (Imitrex) What about the extended family?

• Sulfites – occur naturally in some foods during the fermentation process • May be in topical creams and ointments, cosmetic products, Chinese herbs • There is no evidence of cross-allergy between sulfites and sulfonamides • Sulfates – may occur in drugs (morphine sulfate, ferrous sulfate), dietary supplements, personal care products • Very rare for someone to be alleric to sulfates • No cross-allergy with sulfonamide drugs • Sulfur – a chemical element, third most abundant mineral in the human body! Also found in many foods • It would be impossible to be allergic to sulfur and still be alive • Obviously no cross-allergy with sulfonamide drugs! Drug-induced neuropsychiatric events

• Montelukast (Singulair) • Indicated to treat or prevent allergic rhinitis, asthma, bronchoconstriction • Often prescribed for COPD patients • Associated with increased risk of aggression, agitation, depression, suicidal ideation, sleep disturbances • Oseltamivir (Tamiflu) – abnormal ehavior and hallucinations • Varenicline (Chantix) – may cause neuropsychiatric events; BBB removed • Levetiracetam (Keppra) – behavior problems including anger, anxiety, depersonalization, neurosis, personality disorder, aggression Thin – Thick – Thin….ok which is it?

• Dysphagia is commonly seen in patients who have suffered a stroke, severe dementia, head and neck cancer, Parkinson’s disease and more. • Difficulty swallowing may lead to aspiration of food and beverages and pneumonia • Use of a thickening agents may be a useful strategy • Case report of adding polyethylene glycol (Miralax) to starch-thickened liquid. • RN mixed PEG with starch-thickened apple juice. • Adding the PEG rendered the apple juice back to its original consistency! • When administering PEG, consider using a gum-based thickener!

Carlisle BJ. JAMDA 2016;17:860-861. Question what you see