The use of subcutaneous omeprazole in the treatment of dyspepsia in palliative care patients

Subcutaneous Drugs and Off-label Use in Hospice and Palliative Care: A Scoping Review

BACKGROUND

Subcutaneous drug administration is an interesting approach for symptom control in hospice and palliative care. However, most drugs have no marketing authorization for subcutaneous administration and are therefore used off-label. In order to meet the requirements of a safe and effective drug therapy, especially in highly vulnerable patients, it is essential to investigate the scope of evidence of these common practices.

OBJECTIVES

The purpose of this scoping review was to provide an overview of available data on the tolerability and/or effectiveness of subcutaneously administered and off-label used drugs.

METHOD

We performed a scoping review according to the PRISMA extension to identify data available on the tolerability and/or effectiveness of 17 predefined drugs that are commonly administered subcutaneously in Swiss hospices and hospice-like institutions and that have no marketing authorization (off-label use).

RESULTS

The scoping review identified 57 studies with most data available on their tolerability (68% local, 54% systemic), clinical effects (82%), details on dosage (96%) and routes of application (100%). Information on pharmacokinetic properties was mostly missing and only available for fentanyl, levetiracetam, midazolam, and ondansetron. For seven drugs, less than five articles were identified and no studies on codeine or clonazepam were available.

CONCLUSION

This work provides an overview of current evidence on subcutaneous and off-label used drugs in hospice and palliative care. Although both are common practices, evidence on tolerability and effectiveness, particularly pharmacokinetic data, is limited and the identified information gaps need to be closed. This work establishes a basis for further research in this area.

Administering esomeprazole subcutaneously via a syringe driver in the palliative demographic: A case series

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitors are potent suppressors of gastric acid secretion, and are commonly prescribed in palliative medicine. Despite multiple relevant indications in patients at the end-of-life, their use is often precluded as oral and intravenous administration is frequently inappropriate or not possible. Limited anecdotal evidence suggests proton pump inhibitors may be administered subcutaneously. Our objective was to investigate the tolerability and effectiveness of the administration of esomeprazole as a continuous subcutaneous infusion over 24 h via a syringe driver.

METHODS

Case series (n = 7) design assessing sequential patients admitted to a specialist inpatient centre for palliative care, who required parenteral proton pump inhibitor therapy.

RESULTS AND DISCUSSION

Four patients reported complete resolution of dyspeptic and reflux symptoms post commencement of esomeprazole. Two patients developed upper gastrointestinal bleeding, which via observation of vomitus and stools, resolved with the initiation of esomeprazole. A single patient, deemed high risk of gastrointestinal bleeding, was commenced on esomeprazole and no bleeding events occurred.

WHAT IS NEW AND CONCLUSION

Esomeprazole when administered via a syringe driver over 24 h appears well tolerated and effective for the symptomatic management of dyspepsia and treatment of gastrointestinal bleeding. Overall, this series adds to the limited evidence base for using subcutaneous proton pump inhibitors in the palliative demographic.

Omeprazole suppressed plasma magnesium level and duodenal magnesium absorption in male Sprague-Dawley rats

Hypomagnesemia is the most concerned side effect of proton pump inhibitors (PPIs) in chronic users. However, the mechanism of PPIs-induced systemic Mg²⁺ deficit is currently unclear. The present study aimed to elucidate the direct effect of short-term and long-term PPIs administrations on whole body Mg²⁺ homeostasis and duodenal Mg²⁺ absorption in rats. Mg²⁺ homeostasis was studied by determining the serum Mg²⁺ level, urine and fecal Mg²⁺ excretions, and bone and muscle Mg²⁺ contents. Duodenal Mg²⁺ absorption as well as paracellular charge selectivity were studied. Our result showed that gastric and duodenal pH markedly increased in omeprazole-treated rats. Omeprazole significantly suppressed plasma Mg²⁺ level, urinary Mg²⁺ excretion, and bone and muscle Mg²⁺ content. Thus, omeprazole induced systemic Mg²⁺ deficiency. By using Ussing chamber techniques, it was shown that omeprazole markedly suppressed duodenal Mg²⁺ channel-driven and Mg²⁺ channel-independent Mg²⁺ absorptions and cation selectivity. Inhibitors of mucosal HCO₃^- secretion significantly increased duodenal Mg²⁺ absorption in omeprazole-treated rats. We therefore hypothesized that secreted HCO₃^- in duodenum decreased luminal proton, this impeded duodenal Mg²⁺ absorption. Higher plasma total 25-OH vitamin D, diuresis, and urine PO₄^3- were also demonstrated in hypomagnesemic rats. As a compensatory mechanism for systemic Mg²⁺ deficiency, the expressions of duodenal transient receptor potential melastatin 6 (TRPM6), cyclin M4 (CNNM4), claudin (Cldn)-2, Cldn-7, Cldn-12, and Cldn-15 proteins were enhanced in omeprazole-treated rats. Our findings support the potential role of duodenum on the regulation of Mg²⁺ homeostasis.

Subcutaneous fluid and drug delivery: safe, efficient and inexpensive

Patients with difficult venous access or oral intolerance and clinical situations with inadequate response to oral therapy have generated the need for alternative routes of delivery for drugs and fluids.

The purpose of this study was to conduct a systematic review examining the evidence for subcutaneous (SC) administration of drugs and/or fluids.

We used a broad search strategy using electronic databases CINAHL, EMBASE, PubMed and Cochrane library, key terms and ‘Medical Subject Headings’ (MeSH) such as ‘subcutaneous route’, ‘hypodermoclysis’ and the name/group of the most used drugs via this route (e.g. ‘ketorolac, morphine, ceftriaxone’, ‘analgesics, opioids, antibiotics’).

We conclude that the SC route is an effective alternative for rehydration in patients with mild–moderate dehydration and offers a number of potential advantages in appropriately selected scenarios. Experience of administering drugs by this route suggests that it is well tolerated and is associated with minimal side-effects.

Recommendations for bowel obstruction with peritoneal carcinomatosis

This article reports on the clinical practice guidelines developed by a multidisciplinary group working on the indications and uses of the various available treatment options for relieving intestinal obstruction or its symptoms in patients with peritoneal carcinomatosis. These guidelines are based on a literature review and expert opinion. The recommended strategy involves a clinical and radiological evaluation, of which CT of the abdomen is a crucial component. The results, together with an analysis of the prognostic criteria, are used to determine whether surgery or stenting is the best option. In most patients, however, neither option is feasible, and the main emphasis, therefore, is on the role and administration of various symptomatic medications such as glucocorticoids, antiemetic agents, analgesics, and antisecretory agents (anticholinergic drugs, somatostatin analogues, and proton-pump inhibitors). Nasogastric tube feeding is no longer used routinely and should instead be discussed on a case-by-case basis. Recent studies have confirmed the efficacy of somatostatin analogues in relieving obstruction-related symptoms such as nausea, vomiting, and pain. However, the absence of a marketing license and the high cost of these drugs limit their use as the first-line treatment, except in highly selected patients (early recurrence). When these medications fail to alleviate the symptoms of obstruction, venting gastrostomy should be considered promptly. Rehydration is needed for virtually every patient. Parenteral nutrition and pain management should be adjusted according to the patient needs and guidelines.

Treatment of nausea and vomiting in terminally ill cancer patients

Nausea and vomiting is a common and distressing symptom complex in patients with far-advanced cancer, affecting up to 60% of individuals at some stage of their illness. The current approach to the palliative care of patients with nausea and vomiting is based on identifying the cause, understanding its pathophysiology and knowing the pharmacology of the drugs available for its amelioration. The following six main syndromes are identified: gastric stasis, biochemical, raised intracranial pressure, vestibular, mechanical bowel obstruction and ileus. A careful history, focused physical examination and appropriate investigations are needed to elucidate the syndrome and its cause, so that therapy is rational. Drugs are the mainstay of treatment in terminal cancer, and the main classes of antiemetic agents are prokinetics, dopamine antagonists, antihistamines, anticholinergics and serotonin antagonists. Dexamethasone and octreotide are also used, especially in bowel obstruction. Non-drug measures are important in relieving the associated distress. Patients should be able to die comfortably, without tubes. Despite decades of practice affirming this approach, the evidence base is weak and well designed studies are urgently needed.

Reducing gastric secretions--a role for histamine 2 antagonists or proton pump inhibitors in malignant bowel obstruction?

GOALS OF WORK

Inoperable bowel obstructions are not uncommon in advanced cancer and are associated with a very poor prognosis. Symptom control includes reducing the frequency of vomiting by prescription of antisecretory medications. The most commonly used agents for this are either hyoscine butylbromide or octreotide. Either histamine 2 antagonists or proton pump inhibitors are sometimes recommended as adjuvants to reduce gastric secretions. The aim of this study was to examine the effects of histamine 2 antagonists and proton pump inhibitors and to objectively compare the effects of one agent over another.

MATERIALS AND METHODS

Previously, electronic databases were searched for trials that compared ranitidine versus proton pump inhibitors in their effect on volume of gastric aspirates.

RESULTS

Seven trials were included in a meta-analysis. Pooled outcomes suggest that both proton pump inhibitors and ranitidine reduce gastric volumes, but the most superior agent is ranitidine, which reduces the volume of gastric secretions by an average of 0.22 ml.kg(-1); 95% confidence interval 0.04 to 0.41.

CONCLUSIONS

Based on well-conducted studies, objective evidence exists that confirms ranitidine will decrease the volume of gastric aspirates. This forms a sound basis from which to develop further research aimed at improving the care of people with malignant bowel obstructions.

A Review of Short Bowel Syndrome and Palliation: A Case Report and Medication Guideline

While patients with short bowel syndrome are not common in palliative care, they can present challenges for palliative care professionals. The case presented highlights a specific difficulty encountered. Many medications are poorly absorbed from a short bowel and alternative routes of administration need to be considered. A search was conducted to identify reviews, reports, and other articles from January 1960 to February 2004. MEDLINE, Cochrane Library, and CINAHL (Cumulative Index of Nursing and Allied Health Library) and MIMs (Medimedia Australia) databases were searched. A review of major textbooks was also conducted. Information on the site of absorption, time to peak plasma concentration, alternate routes, and pharmacokinetic information is summarized and presented in table form. This case report and review should assist practitioners with the palliative management of patients with short bowel syndrome.