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Palliative Care World Health Organisation Essential Medicines List for Children (EMLc); Palliative Care CONSULTATION DOCUMENT Prepared by Anita Aindow Medicines Information Pharmacist Alder Hey Children’s Hospital, Liverpool, UK Dr Lynda Brook Macmillan Consultant in Paediatric Palliative Care Alder Hey Children’s Hospital, Liverpool, UK Acknowledgements Professor Tim Eden Professor of Paediatric Oncology, Royal Manchester Children’s Hospital, Manchester, UK Mr Anthony Nunn, Clinical Director of Pharmacy, Alder Hey Children’s Hospital, Liverpool, UK Dr Suzanne Hill Scientist, Policy, Access and Rational Use: Medicines Policy and Standards World health Authority, Geneva For their help and guidance in the preparation of this document Correspondence to Dr Lynda Brook, Macmillan Consultant in Paediatric Palliative Care Department of Paediatric Oncology, Royal Liverpool Children’s Hospital, Eaton Road, Liverpool, L12 2AP Tel: 0151 252 5187 Fax: 0151 252 5676 E-mail: [email protected] DECLARATION OF CONFLICT OF INTERESTS : None June 2008 WHO EMLc: Palliative Care – June 2008 CONTENTS Abstract 3 Summary of recommendations 5 Background 15 Methods 17 Identification of priorities for pharmacological management in palliative 17 care for children Pharmacological management of identified symptoms 17 Results 19 PRIORITIES FOR PHARMACOLOGICAL MANAGEMENT IN PALLIATIVE CARE FOR 19 CHILDREN ESSENTIAL MEDICINES FOR PHARMACOLOGICAL MANAGEMENT IN PALLIATIVE 23 CARE FOR CHILDREN Fatigue and weakness 24 Pain 29 Anorexia and weight loss 52 Delirium and agitation 55 Breathlessness 61 Nausea and vomiting 68 Constipation 89 Depression 95 Excess respiratory tract secretions 106 Anxiety 113 Appendix 116 2 WHO EMLc: Palliative Care – June 2008 ABSTRACT Background The World Health Organization (WHO) Essential Medicines List for Children (EMLc) aims to promote worldwide equity of access to essential medicines for children and is based on the criteria of safety, efficacy and cost effectiveness. The current EMLc does not include specific recommendations for paediatric palliative care. A review of the EMLc was proposed to ensure access to appropriate medicines for pharmacological management of the most prevalent and distressing symptoms in children with life threatening and life limiting (Life shortening) conditions worldwide. Objectives To identify the most important symptoms for paediatric palliative care taking into account prevalence and associated distress To identify appropriate pharmacological approaches for management of individual symptoms To determine effectiveness and safety of identified pharmacological approaches Methods Worldwide childhood mortality national data was identified through internet searching of relevant websites and databases: World Health Organisation Mortality Database, Demographic and Health Surveys and UNICEF. Representative data was then extracted to identify the most common causes of death from life threatening and life limiting conditions in infancy, childhood and adolescence. An electronic search of MEDLINE (1966 – May 2008) and EMBASE (1980 – May 2008) together with hand searching identified articles and target journals was used to identify incidence, prevalence and suffering from specific symptoms in children and young adults aged 0 – 24 years, with life threatening and life limiting conditions. A further literature search, using the same strategy supplemented by searching databases of evidence based review and evidence based guidelines was undertaken to identify evidence to support the pharmacological management of these symptoms. Meta- analyses, systematic reviews or good quality randomised controlled trials specific to the pharmacological management of the identified symptom in paediatric palliative care were sought Each symptom was presented in a monograph with supporting references and SIGN level of evidence Main results There was a lack of accurate data on childhood mortality from life threatening and life limiting conditions particularly in resource poor settings. However malignancy and HIV/AIDS were clearly identified as the most common worldwide causes of childhood mortality appropriate to palliative care. 3 WHO EMLc: Palliative Care – June 2008 No high quality prospective studies of symptoms and associated distress, using validated reporting tools, in children receiving palliative care were identified. Available evidence comprised almost exclusively retrospective case-note reviews, retrospective interviews from staff and studies of bereaved parents. One prospective study using reports from professionals was identified. Analysis of available evidence suggested 10 key symptoms and symptom clusters that should be considered a priority for EMLc palliative care. No high quality randomized controlled trials of symptom management in children receiving palliative care were identified. A number of systematic reviews of symptom management adult patients with malignancy receiving palliative care were identified. However, many of these reviews concluded that there was insufficient evidence to draw any firm conclusions. Several important medicines were identified that should be added to the EMLc in order to ensure access to appropriate pharmacological symptom control for children receiving palliative care. However research evidence to directly support these recommendations was generally weak. Conclusions Worldwide, malignancy and HIV/AIDS appear to be the most important diagnoses of children who require palliative care. Within these diagnostic groups there appear to be ten symptoms which are most important in terms of prevalence and suffering. Several important medicines were identified that should be added to the EMLc in order to ensure access to appropriate pharmacological symptom control for children receiving palliative care worldwide. However research evidence to directly support these recommendations was generally weak. 4 WHO EMLc: Palliative Care – June 2008 SUMMARY OF RECOMMENDATIONS Proposed priority symptom list for WHO EMLc Palliative Care Fatigue and weakness Pain Anorexia and weight loss Delirium and agitation Breathlessness Nausea and vomiting Constipation Depression Excess respiratory tract secretions Anxiety Fatigue and weakness NO PHARMACOLOGICAL AGENT RECOMMENDED There are relatively few studies conducted to evaluate the use of psychostimulants in the management of fatigue in adult palliative care although there are some positive results. No evidence has been identified to support the use of psychostimulants for this indication in children and inclusion in the EMLc is not recommended. Very few studies have been conducted to evaluate the effectiveness of corticosteroids in the management of fatigue in adult palliative care and available evidence for use is weak. No evidence of use in children for this indication was identified. Pain Recommendations for Inclusion: PARACETAMOL, IBUPROFEN, CODEINE, MORPHINE, AMITRIPTYLINE, CARBAMAZEPINE, and DEXAMETHASONE No new medicines for addition to EMLc as all of the above are currently included New formulations for addition to EMLc: Ibuprofen oral suspension 100mg/5ml Codeine oral syrup 25mg/5ml Morphine sulphate modified release granules 20mg, 30mg, 60mg, 100mg and 200mg Amitriptyline oral tablets 10mg Dexamethasone oral tablets 2mg There is good evidence and extensive experience of the use of paracetamol, ibuprofen, codeine and morphine in paediatric pain. These drugs are already included in the EMLc as analgesics. Morphine is the strong opioid of choice in moderate to severe pain and this is confirmed by a number of consensus guidelines. There is extensive clinical experience of its use in children and its use should be promoted to ensure adequate analgesia as necessary. The inclusion of both immediate release and sustained release oral 5 WHO EMLc: Palliative Care – June 2008 preparations is recommended to enable morphine to be successfully used in both acute and chronic pain. Although not specific to palliative care, good quality systematic reviews confirm the efficacy of adjunctive analgesic therapy with amitriptyline and carbamazepine in chronic neuropathic pain in adults. There is considerable experience of the use of these drugs in neuropathic pain and other indications in the paediatric population. Both these drugs are currently included in the EMLc for other indications and they are widely available worldwide with extensive safety data. Non-steroidal anti-inflammatory agents are considered the co-analgesic of choice for bony pain. There is insufficient evidence to support the use of one NSAID over another for this indication. Ibuprofen is already included in the EMLc and is an appropriate choice and there is evidence to support its safety and efficacy in children. Benzodiazepines are widely used as a co-analgesic to treat pain associated with skeletal muscle spasm. Diazepam has antispasticity action and is already included in EMLc for pre operative sedation and as an anticonvulsant for status epilepticus. Corticosteroids have demonstrable efficacy in the reduction of peritumour oedema. There is little good quality research evidence to support their use however consensus documents suggest they have a role in the reduction of pain due to raised intracranial pressure in central nervous system tumours and the treatment of neuropathic pain due to peripheral nerve compression. Dexamethasone is already included in EMLc for acute management of anaphylaxis and allergic reactions. Anorexia and weight loss NO PHARMACOLOGICAL AGENT RECOMMENDED A
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