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Speed Dating with a Palliative Care Pharmacist

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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 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. Parenteral to Oral Hydromorphone • 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 Intern 2019;170:309-318.Med Intern Ann 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.
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