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Several of the palliative medications given subcutaneously are alkaline, including dexamethasone, esomeprazole, parecoxib, sodium valproate and tranexamic acid (alkaline, despite its name). Because pH affects ionisation and thus solubility, it is an important determinant of compatibility; alkaline medications often precipitate in acidic solutions and vice versa.1 Since most other palliative medications are weak acids, alkaline medications are often administered via separate pumps and cannulae.
Following the withdrawal of ranitidine, we selected subcutaneous esomeprazole as an alternative.2–4 We audited its introduction and found it to be well tolerated, but encountered circumstances where esomeprazole was required in parallel with other alkaline medicines. This became more common when two parecoxib-related gastrointestinal bleeds led us to use esomeprazole for gastroprotection more often. Thus, in some patients, multiple separate infusions presented practical challenges. After observing an absence of visible precipitation in alkaline admixtures kept for 24 hours, we discussed the risks and benefits of rationalising multiple infusions into single alkaline admixtures with selected patients. We went on to audit the use of subcutaneous alkaline admixtures.
Introduction of subcutaneous esomeprazole
Patients receiving subcutaneous esomeprazole alone in a single palliative care service were retrospectively audited between April 2020 and November 2021.
Introduction of alkaline admixtures
Esomeprazole-containing admixtures were prospectively audited from December 2021 until August 2022. Novel combinations of medications were observed for 24 hours to identify delayed precipitation before use. As is our normal practice, we used warning stickers to highlight the use of an admixture with limited supporting evidence and …
Contributors MW, PH and JC jointly conceived the audit. MW audited the use of subcutaneous esomeprazole. PH audited the use of combined admixtures. MW, PH and JC jointly wrote the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests PH is editorially associated with the palliativedrugs.com syringe driver database.
Provenance and peer review Not commissioned; internally peer reviewed.
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