Download Symptom Management in End-of-Life Care

Jessica Richards Hosgood, PharmD, RPh
Clinical Pharmacist
HospiScript Services, LLC
A Catalyst Rx Company
[email protected]
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Identify the most common symptoms in end of life care
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List assessment parameters for symptoms
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Discuss rationales for drug choices to provide symptom control in hospice patients
Unapproved indications and routes of administration will be discussed
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 Anorexia  Anxiety
 Constipation
 Delirium
 Depression
 Dyspnea
 Fatigue
 Fever
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Fluid Overload
Infection
Insomnia
Muscle Spasms
Nausea and Vomiting
Pain
Seizures
Terminal Secretions
What medications would you chose?
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Acetaminophen
Albuterol
Atropine Oph Soln. Bisacodyl
Chlorpromazine
Ciprofloxacin
Citalopram
Dexamethasone
Diphenhydramine
Furosemide (KCL)
Haloperidol
Ibuprofen
Lorazepam
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Methadone
Methylphenidate
Metoclopramide
Morphine
Nortriptyline
Nystatin
Phenobarbital
Omeprazole OTC
Oxycodone
Senna/Docusate
Spironolactone
Trazodone
Unlabeled use
 Improve quality of life
 Use of medication efficiently  Minimize side effects
 Use appropriate routes of administration
 Keep medication dosage schedules simple
 Anticipate disease progression
 Give patient and care givers information and choices as appropriate
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Psychosocial/ emotional/spiritual issues
Depression
Anxiety
Delirium Bowel function
Bladder function
 Pain  Insomnia
 Nausea/vomiting
 Dyspnea
 Fever
 Terminal secretions  Loss of route of administration
 Corticosteroids
 Dexamethasone*  2‐4mg daily
 Prednisone (more cost effective)
 10mg daily
 Why not…
 Megesterol (Megace®)
 Dronabinol (Marinol®)
 Mirtazepine (Remeron®)
* Unlabeled use
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 Benzodiazepines
 Lorazepam (Ativan®)
 0.5‐2mg q4‐12 h
 Alternatives:
 Alprazolam (Xanax®)
 0.25‐1mg q4‐8 h
 Antipsychotics??
* Unlabeled use
 Stimulant laxatives
 Especially for opioid induced constipation
 Senna (Senokot‐S®)
 Use in combination with docusate sodium (stool softener)
 Bisacodyl (Dulcolax®)
 Alternatives:
 Osmotic laxatives
 Sorbitol 30mL BID
 Why not Lactulose?
 Polyethylene glycol (Miralax®) 17 grams daily
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 Hospice Patients
 30% occurrence on admission
 Cancer Patients
 87% during course of disease
Oxford Textbook of Palliative Medicine
 Reversible
 49% of palliative care patients
 Terminal Delirium
 88% of dying patients
Lawlor, Arch. Int. Med, 2000, 160: 786‐84.
 Urinary retention
 Fatigue, sleep deprivation,  Constipation
altered circadian rhythms
 Severe anemia
 Nutritional deficiencies
 Hypoxemia
 Infection
 Metabolic abnormalities
 ↑ or ↓ sodium
 ↑ calcium
 Altered blood glucose  Dehydration
 Thiamine, folate, B12
 Drug and alcohol withdrawal
 Pain (especially uncontrolled)
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 If appropriate, treat reversible causes
 Reduce, eliminate, or change drugs that may be contributing to delirium
 Use hypnotic medication to provide adequate sleep
 Use antipsychotic drugs to treat confusion
 Add benzodiazepines only if needed for anxiety and/or restlessness
 Pharmacologic interventions
 Antipsychotics
 Haloperidol* (Haldol®) 0.5‐5 mg q4 h SL/PO/PR/SQ
 AVOID BENZODIAZEPINES!  Unless in combination with neuroleptic (due to paradoxical worsening of delirium and anxiety)
* Unlabeled use
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 Psychostimulant  Methylphenidate* (Ritalin®) 5mg q am & q noon
 Selective Serotonin Reuptake Inhibitors (SSRIs)  Citalopram (Celexa®) 10‐40 mg daily  Generic  Alternatives:
 Fluoxetine (Prozac®) 20‐40 mg daily (Long t1/2)
 Sertraline (Zoloft®) 25‐100mg daily
* Unlabeled use
 Symptomatic management
 Opioids
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Low dose immediate release
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Nebulized opioids not necessarily effective
Anxiolytics
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Low dose ATC + Breakthrough
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Morphine* 2.5‐ 20 mg PO/SL q1 h prn Oxycodone* 2.5‐20 mg PO/SL q1 h prn
Lorazepam* (Ativan ®) 0.25‐2mg PO q6‐12 h ATC
Non‐pharmacologic interventions
Oxygen 
Only if hypoxic
* Unlabeled use
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 Bronchodilators
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Albuterol (Proventil®)  Corticosteroids  Oral better than inhaled in end‐stage disease
May not have adequate lung function to inhale corticosteroids
 Risk of oral thrush with inhaled corticosteroids
Dexamethasone
Prednisone
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Acetaminophen (Tylenol®) 
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Available as tablets, capsules, liquid, suppositories
325‐650mg PO/PR q4‐6 h
Caution use hepatic dysfunction
Ibuprofen (Motrin®) 
200‐400mg PO q4‐6 h
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 Diuretics
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Loop Diuretic
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Furosemide (Lasix®) 
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+ KCl if appropriate
Potassium Sparing Diuretic
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Spironolactone (Aldactone®)  Antibiotics
 Ciprofloxacin (Cipro®)
 Antifungals
 Nystatin (Mycostatin®)  Alternatives:
 Based on type of infection/patient
 C&S
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 Antidepressants
 Trazodone* (Desyrel®) 25‐50 mg q HS  Benzodiazepines
 Lorazepam (Ativan®) 0.5‐1mg q HS
 Barbiturate
 Phenobarbital 30‐120mg q HS
 Antihistamines
 Diphenhydramine (Benadryl®) 25‐50mg q HS  Not recommended in elderly
 Avoid  Zolpidem (Ambien/Ambien CR®)  Eszopiclone (Lunesta®)  Zaleplon (Sonata®)  Ramelteon (Rozerem®) * Unlabeled use
 Benzodiazepines  Lorazepam* (Ativan®)  0.25 ‐0.5mg q4‐12 h
 Alternatives:
 Baclofen (Lioresal®) 5‐10mg TID
 Tizanidine (Zanaflex®) 4mg q6‐8 h
 Cyclobenzaprine (Flexeril®) 10mg TID
* Unlabeled use
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Chemoreceptor
Trigger Zone (CTZ)
Cortex
Vestibular
Apparatus
Neurotransmitters
 Serotonin
 Dopamine
 Acetylcholine
 Histamine
GI Tract
EPEC Project 1999
 Mediated via
 Chemoreceptor Trigger Zone
 Gastric Stasis
 Vestibular Dysfunction
 Anxiety/Anticipation
 Increased Intracranial Pressure
 Gastric Irritants
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 Butyrophenones
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Promotility agents
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Haloperidol* (Haldol®) 0.5‐2mg BID & q4 h prn
Metoclopramide (Reglan®) 10mg AC & HS
What about Phenothiazines ? 
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Promethazine (Phenergan®) Prochlorperazine (Compazine®) Chlorpromazine * (Thorazine®) Trimethobenzamide (Tigan®)  Prokinetic agents
 Metoclopramide (Reglan®)
 5‐10mg AC & HS
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 Antihistamines
 Diphenhydramine* (Benadryl®)
 25mg q4‐6 h
 Alternative:
 Meclizine (Antivert®)  12.5‐25mg q6 h
* Unlabeled use
 Anticipatory/Anxiety
 Lorazepam (Ativan®)
 Haloperidol* (Haldol®)
 Increased intracranial pressure
 Dexamethasone (Decadron®)
* Unlabeled use
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 Proton Pump Inhibitors
 Omeprazole OTC (Prilosec OTC®) 20‐40mg daily
 Nociceptive
 Somatic
 Visceral
 Inflammatory
 Neuropathic
 Peripheral
 Central
 Functional
 Psycho/Social
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 Nociceptive
 Somatic
 Visceral
 Treatment options:
 Opioids
 Immediate‐release medications
 Morphine
 Oxycodone
 Extended‐release medications
 Morphine SR
 Oxycontin®
 Long‐acting medications
 Methadone
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 Morphine
 Gold Standard
 World Health Organization
 Mainly used to relieve pain and shortness of breath in palliative care/hospice  Metabolite accumulation with high doses and in renal insufficiency
 Other opioids available when patients are unable to tolerate morphine
 Hydrocodone
 Not available as a single agent
 Hydromorphone
 Less neurotoxicity than morphine
 Most potent injectable solution available
 Good for subcutaneous injections
 Oxycodone
 May be more appropriate than morphine in patients with renal failure
 Various formulations available
 Oxycodone oral concentrate 20 mg/mL
 Immediate release – 5 & 15mg tablets
 Extended release (OxyContin®)
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 Fentanyl (Duragesic®) Transdermal Patch
 Alternative route
 Difficult to dose correctly
 Slow onset/offset of action
 Difficult to respond to changing pain
 Dependent on physiological state of patient
 Cachexia
 Dehydration
 Fever
 Diaphoresis
 Safety issues
 Recommended to be prescribed by experienced clinician
 QT prolongation
 Drug interactions
 Indications for treatment
 Pain refractory to other opioids
 Neuropathic pain
 Opioid adverse effects
 Morphine (phenanthrene) allergy  Mechanism of action
 Mu receptor agonist
 Delta receptor agonist
 N‐methyl‐d‐aspartate (NMDA) receptor antagonist
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 Pharmacokinetics
 Steady state concentration occurs after 1 week
 Titrate slowly, monitor for accumulation
 Duration of action following steady state is 8‐12 hours
 No active metabolites
 Less sedation, no euphoria
 Inexpensive  May be associated with a stigma
 Opioid addiction treatment  Overdose and death
 Treatment options:
 Nonsteroidal anti‐inflammatory Drugs (NSAIDs)
 Steroids
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 Treatment Options
 Tricyclic antidepressants
 Nortriptyline (Pamelor®)
 10‐25mg qHS, titrate to 150mg
 Antiepileptic Drugs
 Gabapentin (Neurontin®)  100‐300mg TID (maximum 3600mg/day)
 NMDA Blockers
 Methadone
 Ketamine
 Sodium Channel Blockers
 Lidocaine
 Acute
 Lorazepam (Ativan®) 
2mg PO/SL/PR q15 min up to 8 mg/episode
 Maintenance
 Lorazepam 0.5‐1mg q6 h
 Phenobarbital 30‐120mg q8‐12h
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 Anticholinergic/Antimuscarinics
 Atropine 1% Ophthalmic Drops*
 2‐4 drops SL q2‐4 h  Titratable
 Alternatives:
 Hyoscyamine 0.25mg SL q4 h prn Why not Transderm Scop?
 Non‐pharmacologic Interventions
 Reposition patient first
 Suction is occasionally helpful
 Secretions re‐accumulate rapidly
* Unlabeled use
Jessica Richards Hosgood, PharmD, RPh
[email protected]
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