Symptom Management Challenges at End-of-Life

Transcription

1 Symptom Management Challenges at End-of-Life Amanda Lovell, PharmD, BCGP Clinical Pharmacist- Inpatient Units Optum Hospice Pharmacy Services February 15, 2018 Hospice Pharmacy Services

2 Objectives Identify patient specific variables to select an appropriate route-ofadministration for administration of medications at end-of-life Recognize initial doses of symptom management medications when used via various routes-of-administration Select medications for symptoms management based on a comprehensive patient review 2

3 Disclosure This discussion will include the use of medications for off-label indications Medication use and monitoring parameters are intended for educational use only and is directed toward individuals receiving hospice care 3

4 Common Symptoms in Hospice Agitation Anorexia Anxiety Constipation Depression Dyspnea Edema Fatigue Fever GERD Hiccups Insomnia Nausea Pain Secretions Seizures 4

5 Goals of Symptom Management Improve quality of life Use medications efficiently Minimize side effects Use appropriate routes of administration Keep medication dosage schedules simple Anticipate disease progression Give patient and caregivers information and choices 5

6 Supporting the Patient s Goals Preferences - Give patient & caregivers information - Facilitate therapy choices & control History - Co-morbid conditions - Allergies - Anticipate disease progression QOL Medications - Use medications efficiently - Minimize side effects - Keep medication schedules simple 6

7 Routes of Administration Oral Feeding Tube Inhalation Rectal Rectal Administration Devices (Macy Catheter ) Sublingual Transdermal Intranasal Parenteral Intravenous Patient Controlled Analgesia Intramuscular Subcutaneous Epidural Intrathecal 7

8 Routes of Administration Oral Painless Convenient and safe route Most medications available in oral dosage forms Easy to titrate Difficult to tolerate in patients with nausea and vomiting Lack of available liquid options Limited use in patients with dysphagia Sublingual Typically painless Some burning or irritation possible May need to add water or wet tablets if patient has a dry mouth Limited volume can be administered comfortably Not all medications are absorbed sublingually Medication absorption can vary if patient holds tablets in mouth 8

9 Routes of Administration Rectal Must consider patient preference and privacy May be used for local and systemic effect Absorption may be variable Useful when unable to swallow or significant vomiting Some medications don t have literature to support rectal administration Transdermal Painless Difficult to titrate due to long titration intervals for many medications Most patches cannot be cut or folded Patients with multiple patches have an increased risk for medication errors Not all drugs will penetrate intact skin 9

10 Routes of Administration Intravenous Fastest and most reliable way of delivering a drug systemically Suitable for large volume infusions Easy to titrate and adjust doses Useful if severe vomiting, mucositis, bowel obstruction or questionable GI absorption Invasive May limit patient mobility Subcutaneous Bioavailability can be affected by body composition and hydration status Limited volume per single dose Potentially painful Not all injectable medications are safe for SQ injection 10

11 Choosing a Route Availability Patient Preference 11

12 Medication Route Options 12

13 Patient Case PW, 92yo male Hospice Diagnosis: Lung Cancer PMH: CHF PPS 20% PW is rapidly declining and having increased difficulty taking medications. Today he is unable to swallow any medications whole Presents with increased dyspnea and edema Medications Aspirin 81 mg PO daily Lisinopril 10 mg PO daily Furosemide 40 mg PO daily Oxycodone extended-release 60 mg PO q8h Oxycodone 15 mg PO q1h PRN for pain or shortness of breath Metoprolol tartrate 25 mg PO q12h Albuterol 90 mcg 2 puffs q4h PRN for shortness of breath 13

14 Common Medications for Symptom Management at Endof-Life

15 Shortages Many common parenteral medications have been in shortage during the last year Consider alternate routes of administration when medication is in shortage or alternate to another medication in same drug class Frequent medication shortages may lead to price increases Current list of medications available online through the American Society of Health System Pharmacists 15

16 Common Medication List Agitation Anorexia Anxiety Dyspnea Edema Fatigue Insomnia Muscle Spasms Haloperidol Chlorpromazine Nausea Pain Seizures Phenobarbital Lorazepam Furosemide Morphine Oxycodone Dexamethasone Prednisone 16

17 Notes on Common Medications Not all medications work for all patients Patient/family/caregiver preferences Medication allergies Drug-drug interactions Drug-disease interactions Always individualize medication choice to patient (and family/caregiver) parameters 17

18 Haloperidol Pharmacologic category: Typical antipsychotic Uses: Agitation, anxiety, nausea/vomiting Routes of administration: PO/SL/PR/SQ/IM/IV Starting dose: 0.5 mg PO/SL/PR/IV/SQ q4h PRN 18

19 Haloperidol Adverse effects EPS, QT prolongation, anticholinergic, insomnia, anxiety Monitoring parameters Vitals, hyperglycemia, abnormal involuntary movements Clinical pearls Assess for underlying causes of agitation/delirium Avoid in Parkinson s Disease or Lewy Body Dementia 19

20 Chlorpromazine Pharmacologic category: Typical antipsychotic Uses: Agitation, anxiety, nausea/vomiting, hiccups Routes of admin: PO/PR/IV/IM No evidence for SQ use, may cause tissue irritation Starting dose: 10 mg PO/PR/IV/IM q4h PRN Clinical pearls Injectable dose equal to oral and rectal dose Typically more sedating than low dose haloperidol Avoid in Parkinson s Disease or Lewy Body Dementia 20

21 Phenobarbital Pharmacologic category: Barbiturate anticonvulsant Uses: Agitation, insomnia, seizures Routes of admin: PO/PR/SQ/IM/IV Starting dose: 30 mg PO/PR/IV/SQ q4h PRN 21

22 Phenobarbital Adverse effects Somnolence, CNS excitation or depression, bradycardia Toxicity: drowsiness, ataxia, nystagmus Monitoring parameters CBC, Liver function tests (LFTs) Mental status, seizure activity Clinical Pearls Long half-life: allows for potential of once daily dosing May cause paradoxical stimulation in elderly patients 22

23 Lorazepam Pharmacologic category: Benzodiazepine Uses: Anxiety, dyspnea, insomnia, muscle spasms, seizures Routes of admin: PO/SL/PR/SQ/IM/IV Starting dose: 0.5 mg PO/PR/SQ/IV q4h PRN for anxiety/dyspnea 23

24 Lorazepam Adverse effects Sedation, dizziness, weakness, ataxia, agitation, amnesia Monitoring parameters Respiratory rate (reduced), hypotension Clinical pearls Conversion from oral/rectal to IV: 1:1 May cause paradoxical worsening of agitation May require higher doses for insomnia Approximate equivalence Lorazepam 1 mg= Alprazolam 0.5 mg PO= Diazepam 5 mg PO 24

25 Furosemide Pharmacologic category: Loop diuretic Uses: Dyspnea, edema Routes of admin: PO/SL/PR/SQ/IM/IV/neb Starting dose: 20 mg IV/SQ once daily or 40 mg PO/PR once daily 25

26 Furosemide Adverse effects Acute hypotension, dizziness, hyperglycemia, hyperuricemia, electrolyte abnormalities Monitoring parameters Weight, orthostatic hypotension Serum electrolytes (reduced calcium, potassium, chloride, sodium) Renal function Clinical pearls PO/PR to IV conversion: 40 mg PO = 20 mg IV Diuretic resistance Rotation to alternate loop diuretics Furosemide 40 mg PO= bumetanide 1 mg PO= torsemide 20 mg PO 26

27 Morphine Pharmacologic category: Opioid Uses: dyspnea, pain Routes of admin: PO/SL/PR/SQ/IV/IM Starting dose: 2 mg IV/SQ q1h PRN or 5 mg PO/PR q1h PRN 27

28 Morphine Adverse effects Somnolence, constipation, nausea, hypotension, vomiting, dry mouth, urinary retention, pruritus, respiratory depression Monitoring parameters CNS effects (sedation), vitals (cardiac, respiratory) Clinical pearls Multiple different concentrations help with SQ administration Use caution in renal impairment: metabolite accumulation Monitor for signs of opioid-induced neurotoxicity 28

29 Oxycodone Pharmacologic category: Opioid Uses: dyspnea, pain Routes of admin: PO/SL/PR Starting dose: 2.5 mg PO/PR q1h PRN for pain Clinical pearls Less risk of neurotoxicity than morphine and hydromorphone 29

30 Opioid Conversions Medication Name SC, IV Oral Rectal (IR) Morphine 10mg 30mg 30mg Hydromorphone 1.5mg H PO M PO use 1:4 M PO H PO use 7.5:1 H IV H PO use 1:3 7.5mg Oxycodone NA 20mg 20mg Hydrocodone NA 30mg 30mg 30

31 Dexamethasone Pharmacologic category: Corticosteroid Uses: Fatigue, inflammatory pain/dyspnea Routes of admin: PO/PR/SQ/IV/IM Starting dose: 4 mg PO/PR/SQ/IV once daily in the morning Clinical pearls Associated with less edema than prednisone and methylprednisolone Dexamethasone 1.5 mg= prednisone 10 mg 31

32 Prednisone Pharmacologic category: Corticosteroid Uses: Fatigue, inflammatory pain/dyspnea Routes of admin: PO Starting dose: 20 mg PO once daily in the morning 32

33 Patient Case PW, 92yo male Hospice Diagnosis: Lung Cancer PMH: CHF PPS 20% PW is rapidly declining and having increased difficulty taking medications. Today he is unable to swallow any medications whole Presents with increased dyspnea and edema Medications Aspirin 81 mg PO daily Lisinopril 10 mg PO daily Furosemide 40 mg PO daily Oxycodone extended-release 60 mg PO q8h Oxycodone 15 mg PO q1h PRN for pain or shortness of breath Metoprolol tartrate 25 mg PO q12h Albuterol 90 mcg 2 puffs q4h PRN for shortness of breath 33

34 Patient Case PW, 92yo male What medications are not necessary at this point? Patient is not able to swallow medications by mouth and has not taken these medications today Medications Aspirin 81 mg PO daily Lisinopril 10 mg PO daily Furosemide 40 mg PO daily Oxycodone extended-release 60 mg PO q8h Oxycodone 15 mg PO q1h PRN for pain or shortness of breath Metoprolol tartrate 25 mg PO q12h Albuterol 90 mcg 2 puffs q4h PRN for shortness of breath 34

35 Patient Case What symptoms do we need to address? Dyspnea, edema What medications can be used to manage these symptoms? 35

36 Patient Case Dyspnea Morphine/oxycodone Lorazepam Nebulized furosemide? Edema Furosemide 36

37 Patient Case Medication shortage Potential new medication regimen Oxycodone 30 mg PR q4h around-the-clock Oxycodone 15 mg PR q1h PRN for pain or shortness of breath Lorazepam 0.5 mg PR q4h PRN for anxiety or dyspnea Furosemide 40 mg PR once daily in the morning for treatment of edema Albuterol 0.083% nebulized solution 3 ml via nebulizer q4h PRN for shortness of breath 37

38 Key Points As patients decline, the oral route may no longer be an option for symptom management Consider patient-specific and medication-specific variables when choosing an alternate route Choose medications with potential for multi-symptom management when possible 38

39 Macy Catheter Information and Support Please visit: Clinical Support/Order Info:

40 Questions? Amanda Lovell, PharmD, BCGP Inpatient Unit- Clinical Pharmacist

41 References Compatibility of Parenteral Medications. Optum Hospice Pharmacy Services, LLC For more information contact Giving Meds by Alternate Routes. Pharmacist s Letter/Prescriber s Letter 2017; Resource Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Inten Med. 2006;166(6): Lexi-Comp Online [Internet]. Hudson, Ohio: Lexi-Comp Inc [cited 2017 Aug 8]. Available from: Protus BM, Kimbrel J, Grauer P. Palliative Care Consultant, 4 th edition. HospiScirpt, a Catamaran Company Symptom Management Medication Algorithm. Optum Hospice Pharmacy Services, LLC For more information contact druginformation@hospiscript.com 41