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    On Demand Clinical Newsletter May

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    A recent review has been published online in pain medicine, the official journal of the American Academy of Pain Medicine. Opioid rotation is essentially the switching from one opioid to another or from one route of administration to another. Available data suggests that 50-80% of patients with chronic pain who respond poorly to one opioid improve after being rotated to another opioid.

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    On Demand Clinical Newsletter May

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    A recent review has been published online in pain medicine, the official journal of the American Academy of Pain Medicine. Opioid rotation is essentially the switching from one opioid to another or from one route of administration to another. Available data suggests that 50-80% of patients with chronic pain who respond poorly to one opioid improve after being rotated to another opioid.

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    A recent review has been published online in pain medicine, the official journal of the American Academy of Pain Medicine. Opioid rotation is essentially the switching from one opioid to another or from one route of administration to another. Available data suggests that 50-80% of patients with chronic pain who respond poorly to one opioid improve after being rotated to another opioid.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    59 views2 pages

    On Demand Clinical Newsletter May

    Uploaded by

    OnDemandClinicalNews
    A recent review has been published online in pain medicine, the official journal of the American Academy of Pain Medicine. Opioid rotation is essentially the switching from one opioid to another or from one route of administration to another. Available data suggests that 50-80% of patients with chronic pain who respond poorly to one opioid improve after being rotated to another opioid.

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    ProCare HospiceCare

    Summer Edition 2012

    On-Demand Clinical News


    CLINICAL CORNER: Review of Opioid Rotation Practices
    A recent review has been published online in Pain Medicine, the official journal of the American Academy of Pain Medicine. The article was published March 28 and reviews the correlation between opioid-rotation and opioid-related deaths. Opioid rotation is essentially the switching from one opioid to another or from one route of administration to another route. The practice is common in pain management as well as the hospice setting when route of administration can change quickly. Available data suggests that 50-80% of patients with chronic pain who respond poorly to one opioid improve after being rotated to another opioid. Another study of patients with chronic non-cancer pain found that 81% of patients required a switch to another opioid with as many as five different extended-release opioids to establish an effective level of pain control with tolerable side-effects. To rotate from one opioid or route to another, clinicians rely in part on opioid equianalgesic tables. These are published tables describing equivalent strengths of one opioid to another (typically using oral morphine equivalents as a standard). As the authors of this recent study explain, there are numerous historical problems with published equivalency tables and for the most part they are lacking in validation. Further, some of the newer opioids may have confusing language in their package inserts. The authors of the study make one point very clear; there is a great deal of inter-patient variability in response to different opioids. Its important to understand the limitations of opioid equianalgesic tables and to consider patient-specific variables such as: age, renal function, prior opioid utilization, or tolerance, to name a few. There are a number of methods to ensure the safe rotation of opioids. In the same journal, the authors put forward a number of precautions clinicians can exercise when rotating opioids, such as tapering the first drug over 3 to 4 weeks while titrating upward on the second. Holding the next dose when a patient presents with sedation or lethargy is another common practice. The hospice setting frequently involves pain management and opioid rotation, and while there are many nuances that make end-of-life care unique, this study provides an excellent review for all clinicians. Also remember, your ProCare clinical pharmacists are always available to assist in interpreting past medical history and current pain management goals to determine the most appropriate opioid for your patients. This article can be found online at: http://onlinelibrary.wiley.com/doi/10.1111/j.15264637.2012.01357.x/abstract

    On-Demand Clinical News:

    Now Bi-Monthly and Digital!


    Thank you for reading this months OnDemand Clinical Newsletter. To improve the flow of information from our clinical team to you, we will now be releasing the newsletter on a bi-monthly basis. In this effort we hope to keep your team informed and up-to-date on all topics ranging from FDA communications to current trends in symptom management. As always, two-way communication is the best means for discussion, so please feel free to ask questions or request new topics as you see fit. We will strive to do our best in making a very useful, very informative, and very exciting newsletter. Aside from the frequency, there are new exciting ways to access the newsletter. Please feel free to visit the Education section of the ProCareHospiceCare.com website. Here you can find the most current On-Demand Clinical Newsletter, as well as previous newsletters from 2009 to present. You can access these newsletters after entering a request for a consult with a pharmacist. Again, please let us know if you have any questions, comments, concerns, or recommendationswe look forward to serving your needs.

    FDA Drug Safety Announcement


    Celexa (Citalopram) Alert [3-28-2012]
    The U.S. Food and Drug Administration (FDA) is clarifying dosing and warning recommendations for the antidepressant Celexa (citalopram hydrobromide; also available in generic form). In August 2011, FDA issued a Drug Safety Communication (DSC) stating that citalopram should no longer be used at doses greater than 40 mg per day because it could cause potentially dangerous abnormalities in the electrical activity of the heart. Citalopram use at any dose is discouraged in patients with certain conditions because of the risk of QT prolongation, but because it may be important for some of those patients to use citalopram, the drug label has been changed to describe the particular caution that needs to be taken when citalopram is used in such patients. The revised drug label also describes lower doses that should be used in patients over 60 years of age. FDA has received post-marketing reports of QT interval prolongation and Torsade de Pointes associated with Celexa and its generic equivalents. In addition, FDA has evaluated the results of a thorough QT study assessing the effects of 20-mg and 60-mg doses of citalopram on the QT interval in adults. The overall summary of findings is presented in Table below:

    Increase in the Corrected QT Interval for Citalopram (FDA Analysis) Citalopram Dose 20 mg/day 60 mg/day 40 mg/day Increase in QT Interval (ms) 8.5 18.5 12.6* 90% Confidence Interval (ms) (6.2, 10.8) (16.0, 21.0) (10.9, 14.3)*

    *Estimate based on the relationship between citalopram blood concentration and QT interval.

    Clinical Question: Rationale for Methadone 5-Day Methadone Checks


    By Joelle Potts, PharmD, CGP Q: Why do ProCare HospiceCare clinical pharmacists recommend daily methadone checks? A: We typically recommend doing daily methadone checks for 5 days after methadone is first initiated, and also after any methadone dose increases. The reason is that methadone has a potentially very long and variable half-life, and can take up to 7 days to reach steady state in the body; its peak effect of analgesia is typically seen 3-5 days after continuous PO dosing. In other words, methadone is "short-acting" with its initial dose, and becomes gradually longer-acting with each subsequent dose until steady state is achieved and this is true not only with the initiation of methadone, but with methadone dose increases as well (i.e. the dose increase will also take a few days to become long-acting and reach steady state). For these reasons, we also recommend to wait 5 days between methadone dose increases, so the effects of methadone can be more accurately assessed. The primary reason for daily methadone checks is to assess the patient's pain control (for example, to see if any adjustments need to be made in the breakthrough opioid being used). But they are also used to monitor for potential adverse effects due to methadone, including lethargy/sedation or respiratory depression, which could indicate that the dose of methadone is too high. Both aspects are important to monitor after a dose increase as well, and not just after methadone initiation.
    ProCare HospiceCare welcomes all suggestions and comments. If you would like additional information about our services, have ideas for articles, or wish to submit a comment, email us at resources@procarerx.com.

    The information provided within this newsletter is proprietary to ProCare Rx. Any reprint or reuse of this information must be approved via written consent.
    Copyright 2012, ProCare Rx

    3090 Premiere Pkwy., #100, Duluth GA 30097 Editor: Dr. Cody Midlam, PharmD Executive Editor: Dr. Raeanna Lewarne, PharmD

    ProCare HospiceCare

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