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News and updates from palliativedrugs.com
  1. Andrew Wilcock1 and
  2. Sarah Charlesworth2
  1. 1 Department of Palliative Medicine, University of Nottingham, Nottingham, UK
  2. 2 Hayward House Study Centre, Nottingham University Hospitals, Nottingham, UK
  1. Correspondence to Sarah Charlesworth, Hayward House Study Centre, Nottingham University Hospitals, City Campus, Hucknall Road, Nottingham NG5 1PB, UK; s.charlesworth{at}nhs.net

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The website www.palliativedrugs.com has provided essential independent information about drugs used in palliative and hospice care for over a decade and has over 30 000 members from 169 countries. It contains the online Palliative Care Formulary (PCF) and provides free access to a bulletin board to stimulate questions and share experiences, a document library containing 475 items of useful information and a Syringe Driver Survey Database containing details of over 2350 different drug combinations. The UK Palliative Care Formulary 5th edition (book, PDF and online versions) and Introducing Palliative Care 5th edition can also be purchased via the website. This feature provides a selection of items that have been featured in the News and Latest additions sections in recent months; for additional information, please register for free on the website.

Safety updates

MHRA warning regarding hyoscine butylbromide

The Medicines and Healthcare products Regulatory Agency (MHRA) published a warning in February 2017 reminding health professionals about the risk of serious adverse effects with hyoscine butylbromide injection intravenously/intramuscularly in patients with underlying cardiac disease. This followed a recent fatality (cardiac arrest) and a subsequent recommendation from the coroner to clarify the cautions section in Summary of Product Characteristics (SPC). The MHRA stated that they had received nine reports of patients who had died following receiving hyoscine butylbromide injection and published the following advice:

  • Hyoscine butylbromide injection can cause serious adverse effects, including tachycardia, hypotension and anaphylaxis.

  • These adverse effects can result in a fatal outcome in patients with underlying cardiac disease, such as those with heart failure, coronary heart disease, cardiac arrhythmia or hypertension.

  • Hyoscine butylbromide injection should be used with caution in patients with cardiac disease.

  • Monitor these patients, and ensure that resuscitation equipment and personnel who are trained how to use this equipment are readily available.

  • Hyoscine butylbromide injection remains contraindicated in patients with tachycardia.

Subsequently, the MHRA have reviewed their data and have corrected the total number of fatal outcomes attributable to hyoscine butylbromide to eight. However, the episodes lacked full data, and it is difficult to interpret the specific relevance of the reports to use in a palliative care setting, where the continuous subcutaneous infusion (CSCI) route of administration is more likely than intravenously. PCF advises clinicians to remind themselves of the long-standing cautions relating to the use of any antimuscarinic in patients with cardiovascular disease, and to continue to balance the potential for benefit and harm on an individual patient basis.

Hot topics

Cochrane reviews

The following Cochrane reviews have been published in full online:

  • Pharmacological interventions for pruritus in adult palliative care patients: In this update to the original review in 2013, the authors concluded that there was low-quality to moderate-quality evidence for gabapentin, nalfurafine and cromolyn sodium for pruritus associated with chronic kidney disease, and rifampicin and flumecinol for pruritus associated with cholestasis. Paroxetine may be useful for palliative care patients with pruritus of various aetiologies, although evidence was only available from one study.

  • Paracetamol with or without codeine or dihydrocodeine for neuropathic pain in adults: The authors concluded that there was insufficient evidence to support or refute the use of paracetamol alone or with codeine or dihydrocodeine for neuropathic pain in adults.

  • Topical capsaicin (high concentration) for chronic neuropathic pain in adults: In this update to the original review in 2013, the authors concluded that there is moderate-quality evidence that high-concentration (8%) capsaicin patches can give moderate pain relief, or better, to a minority of people with postherpetic neuralgia, and very low-quality evidence that it benefits those with HIV neuropathy and peripheral diabetic neuropathy.

  • Methadone for cancer pain: This is the second update to the initial review in 2004 and subsequent update in 2007. The authors conclude that although methadone has been used for many years to treat severe cancer pain, the evidence base is sparse. There is low-quality evidence to suggest that methadone has similar analgesic benefits to morphine in the management of severe cancer pain in adults. However, issues such as titrating to an effective dose and adverse effects may limit its potential. Methadone may have a role if other opioids are not tolerated, providing the issues of dose titration and possible severe adverse effects are considered.

National Institute for Health and Care Excellence publications

  • Care of dying adults in the last days of life: A separate specific quality standard on care of dying adults in the last days of life has been published (QS144). This replaces statement 11 in the quality standard for end-of-life care in adults (QS13), which has now been removed.

  • Oral glycopyrronium bromide for severe sialorrhoea: An evidence summary for the use of oral glycopyrronium bromide in children and young people with chronic neurological disorders has been published (ESUOM15).

Scottish Medicines Consortium: Butec patches for chronic non-malignant pain

The Scottish Medicines Consortium has accepted buprenorphine transdermal patches (Butec) within NHS Scotland for chronic non-malignant pain of moderate intensity when an opioid is necessary for adequate analgesia. It is restricted to use in patients >65 years.

Drug updates

Food and Drug Administration approves 2 mg naloxone nasal spray

A 2 mg naloxone nasal spray (Narcan; Adapt Pharma) has been approved in the USA for use in opioid-dependent patients, expected to be at risk for severe opioid withdrawal, in situations where there is a low risk for accidental or intentional opioid exposure by household contacts.

A 4 mg naloxone nasal spray (Narcan) has been available since February 2016.

Glycopyrronium oral solution authorised for drooling now available in UK

Glycopyrronium 320 μg/mL oral solution (Sialanar; equivalent to 400 μg/mL or 2 mg/5 mL glycopyrronium bromide), authorised for severe drooling in children and adolescents ≥3 years with chronic neurological disease, is now available. The NHS cost for 250 mL bottle is £320. It is authorised for use via enteral feeding tubes, and doses must be reduced in renal impairment. Due to lack of data, the product is not authorised in adults or for long-term use. A glycopyrronium bromide 200 μg/mL (1 mg/5 mL; Colonis Pharmaceuticals) oral solution, authorised for adults for the treatment of peptic ulceration, is also available.

Note: Other strengths of glycopyrronium bromide oral solution and oral suspension are also available as unauthorised products via special orders of 200 μg/5 mL, 500 μg/5 mL, 2.5 mg/5 mL and 5 mg/5 mL.

Thalidomide updated SPC

The UK SPC for thalidomide Celgene 50 mg hard capsules now advises extra care when removing capsules from the blister to avoid deformation/breakage and recommends to only press one end of the capsule to remove from the blister. In addition, it highlights that capsules should not be opened/crushed. If powder makes contact with skin/mucous membranes, it should be washed or flushed immediately with water.

Fentanyl nasal spray (Instanyl) SPC updated

The frequency of use for all strengths of Instanyl (fentanyl) nasal spray (Takeda) has been updated in the UK SPC. Patients are still advised to wait 4 hours before treating another breakthrough pain episode; however, the following statement has now been added:

‘On exceptional occasions where a new episode of pain occurs earlier than 4 hours after the last dose, patients can use Instanyl to treat it, but they must wait least 2 hours before doing so. Dose adjustment of the background opioid therapy following pain reassessment should be considered if the patient frequently presents with breakthrough pain episodes that are less than 4 hours apart or with more than four breakthrough pain episodes per 24 hours’.

Latest additions

Website satisfaction survey winners and results

Results are available from our satisfaction survey (October–December 2016). Congratulations to the five members randomly selected to receive a free copy of Introducing Palliative Care 5th edition.

PCF updates

The online PCF is being continually updated. For a full list of all the monographs updated since the print publication of PCF5, see the Latest additions section of the website or follow us on twitter @palliativedrugs for the latest updates. Over the past few months, we have been working hard in the background on the technical side of the website in preparation for the publication of PCF6 print edition later this year. Part 2 of PCF (which contains the general topics) is being reorganised to make it more user-friendly. The new PCF format will be launched first on the website in late Spring and will also contain multiple monographs that have been updated during the interim period.

Footnotes

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  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.