Off-Label Medication Use in the Inpatient Palliative Care Unit

Mirtazapine to alleviate severe breathlessness in patients with COPD or interstitial lung diseases (BETTER-B): an international, multicentre, double-blind, randomised, placebo-controlled, phase 3 mixed-method trial

BACKGROUND

Breathlessness frequently becomes severe among people with respiratory disease. Mirtazapine, a widely used antidepressant, has shown promise in the modulation of respiratory sensation and the response to it, as well as reducing feelings of panic, which often accompanies breathlessness. We aimed to determine the effectiveness of mirtazapine to alleviate severe persisting breathlessness.

METHODS

This international, multicentre, phase 3, parallel-group, double-blind, randomised, placebo-controlled trial across 16 centres in seven countries (Australia, Germany, Ireland, Italy, New Zealand, Poland, and the UK), recruited adults with chronic obstructive pulmonary disease (COPD), interstitial lung diseases, or both, and grade 3 or 4 of the modified Medical Research Council breathlessness scale. Consenting participants were randomly assigned (1:1) to receive oral mirtazapine or matching placebo for 56 days. Randomisation was by minimisation. The initial mirtazapine dose was 15 mg, escalating to a maximum of 45 mg per day, tapered at treatment end. Participants, caregivers, assessors, and investigators were masked to group assignment. The primary outcome was worst breathlessness in the preceding 24 h measured on a 0-10 numerical rating scale (NRS), at 56 days post-treatment start, with follow-up to 180 days. The primary analysis was performed in the modified intention-to-treat population using multivariable multi-level repeated measures model. This trial was registered with ISRCTN (ISRCTN10487976 and ISRCTN15751764 [Australia and New Zealand]) and EudraCT (2019-002001-21) and is complete.

FINDINGS

Between Feb 4, 2021 and March 28, 2023, we enrolled 225 eligible participants (148 men and 77 women, 113 to the mirtazapine group and 112 to the placebo group). The median age was 74 years (IQR 67-78). No evidence of a difference was found in worst breathlessness at day 56 between mirtazapine and placebo (difference in adjusted mean NRS score was 0·105 [95% CI -0·407 to 0·618]; p=0·69). Although the study was underpowered, the primary endpoint effect did not reach the pre-specified treatment effect of 0·55 for worst breathlessness score reduction that the study was powered to detect for the primary analysis. There were 215 adverse reactions in 72 (64%) of 113 participants in the mirtazapine group versus 116 in 44 (40%) of 110 participants in the placebo group; 11 serious adverse events in six (5%) participants in the mirtazapine group versus eight in seven (6%) participants in the placebo group; and one (1%) suspected unexpected serious adverse reaction in the mirtazapine group. At day 56, there were three deaths in the mirtazapine group and two deaths in the placebo group. At day 180, there were seven deaths in the mirtazapine group and 11 deaths in the placebo group.

INTERPRETATION

Our findings suggested that mirtazapine of doses 15 to 45 mg daily over 56 days does not improve severe breathlessness among patients with COPD or interstitial lung diseases and might cause adverse reactions. Based on these findings, we do not recommend mirtazapine as a treatment to alleviate severe breathlessness.

FUNDING

EU Horizon 2020 (grant agreement No. 825319); Cicely Saunders International Breathlessness Programme; National Institute for Health and Care Research Applied Research Collaboration South London; Australian National Health and Medical Research Council-EU (application ID: APP1170731).

Polypharmacy in Children with Medical Complexity: A Cross-Sectional Study in a Pediatric Palliative Care Center

BACKGROUND

Children with medical complexity (CMC) often require multiple medications, leading to polypharmacy, which seems to be linked to adverse effects, administration errors, and increased caregiver burden. This study aimed to describe the prevalence of polypharmacy, medication burden, off-label drug use, and associated costs.

METHODS

Conducted at the Pediatric Palliative Care Center of Padua, Italy, from August to October 2021, this cross-sectional observational study included patients up to 23 years old with at least one prescribed drug. Data were collected from medical records and caregiver interviews. Drug costs were collected from the Italian Medicine Agency. Descriptive statistical analysis was performed. For comparisons among categorical variables, the Chi-square test was used, and for those among continuous variables, the ANOVA test was used.

RESULTS

This study analyzed treatment regimens of 169 patients with a median age of 12.5 years (0.3-23). Polypharmacy was present in 52.7% of patients, and medication burden was observed in 44.4%, both varying significantly by primary diagnosis (p < 0.001). The median daily cost per patient was EUR 2.2 (IQR 0.9-7.1), with significant variation among subgroups. Only 34.6% of prescriptions were off-label.

CONCLUSIONS

polypharmacy and medication burden are frequent among our CMC population, with some differences according to primary diagnosis.

Tongue edema as an adverse drug reaction to low-dose olanzapine in a cancer patient receiving palliative care

OBJECTIVES

Olanzapine is an atypical neuroleptic indicated for treatment of various psychiatric disorders, but it has also several indications in palliative care (PC) patients: opioids misuse, nausea not related to chemotherapy, anorexia-cachexia syndrome, and sleep and mood disorders. Peripheral and facial edema are a rare side effect of the treatment with olanzapine. I report a case of an advanced cancer patient cared receiving PC who developed moderate tongue edema on day 1 of a low dose of olanzapine.

METHODS

A patient with advance and metastatic colon cancer presented moderate tongue edema on day 1 of a low dose (2.5 mg) of olanzapine for the treatment of his nausea, anorexia-cachexia syndrome, and mood disorder (mainly anxiety).

RESULTS

The patient discontinued the drug with resolution of the edema. The day after he called our outpatients' service, a prompt physical examination, together with blood tests, excluded other differential diagnosis.

SIGNIFICANCE OF RESULTS

To the best of our knowledge, this is the second case reporting head and neck localized edema due to olanzapine treatment in a patient with advanced cancer receiving PC. Considering the increasing use of olanzapine as off-label treatment in these patients (often for cluster symptoms), our report could help clinicians in daily practice and researchers on put a deeper focus on indications for olanzapine in PC.

Palliative Care in Drug Resistance Tuberculosis: An Overlooked Component in Management

Palliative care should be an important component in the management of drug resistant tuberculosis (DRTB); however, it is not given much importance. Even in the current scenario, many patients and their caregivers consider multidrug-resistant and extensively drug-resistant tuberculosis (TB) as a terminal illness and considering it almost as a death sentence, this group of patients also require palliative care. There is a misconception about considering palliative care as a treatment component in the terminal stage of an illness where curative treatment has no role in improving the survival of the patient. However, the real meaning of palliative care is to relieve suffering in all stages of the disease and is not limited to end-of-life care only. Palliative care in DRTB aims to improve the quality of life, intractable symptoms and physical, psychosocial and spiritual suffering of patients as well as their caregivers. There is an imminent need to train all TB healthcare workers regarding basic palliative care and integrate palliative care into the TB healthcare system.

Hospice agency characteristics associated with benzodiazepine and antipsychotic prescribing

BACKGROUND

Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing.

METHODS

Cross-sectional analysis of hospice-enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics.

RESULTS

In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest-prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest-prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine- and antipsychotic- prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non-Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6-0.7, Hispanic RR 0.4, 95% CI 0.3-0.5; antipsychotic: non-Hispanic Black RR 0.7, 95% CI 0.6-0.8, Hispanic RR 0.4, 95% CI 0.3-0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine-prescribing quintile (RR 1.3, 95% CI 1.2-1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over-represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5-2.7) and antipsychotics (RR 2.7, 95% CI 2.6-2.8), as were for-profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3-2.4; antipsychotic: RR 2.3, 95% CI 2.2-2.4). Prescribing rates varied widely across Census regions.

CONCLUSIONS

Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients.

Off-label use in adult palliative care - more common than expected. A retrospective chart review

OBJECTIVE

Off-label drug use seems to be integral to adult palliative care pharmacotherapy. Balancing potential risks and benefits in the context of limited therapeutic options is challenging. To provide specific support for clinicians in dealing with off-label use, it is essential to understand off-label use in everyday clinical practice. The aim of this pilot study was to quantify and describe off-label use in an adult palliative care unit.

METHODS

Retrospective chart review of all adult patients treated on a palliative care unit in October 2017. All data on drug use (eg, indication, dose, route of administration) were extracted and matched with the prescribing information. Identified off-label use was subsequently compared with recommendations in the relevant literature. The main outcome measure was frequency and type of off-label drug use.

RESULTS

Some 2352 drug application days and 93 drugs were identified for 28 patients. Of all drugs, 47 (51%) were used off-label at least once. Most off-label uses concerned indication (57%) followed by mode of administration. In drugs highly relevant to palliative care the rate of off-label use was as high as 67%. The extent to which off-label therapy was supported by literature was very variable and ranged from 0% to 88%.

CONCLUSIONS

These data from a single unit confirm the high prevalence of off-label use in palliative medicine and demonstrate that off-label use in adult palliative care is multifaceted. The data presented allow for a more precise characterisation of various aspects of off-label use in order to derive concrete further measures for research and clinical practice.

Variation in Benzodiazepine and Antipsychotic Prescribing Among Hospice Agencies

BACKGROUND

Benzodiazepines and antipsychotics are routinely prescribed for symptom management in hospice. There is minimal evidence to guide prescribing in this population, and little is known about how prescribing varies across hospice agencies.

OBJECTIVE

Examine patient- and hospice agency-level characteristics associated with incident prescribing of benzodiazepines and antipsychotics in hospice.

DESIGN

Retrospective cohort study of a 20% sample of Medicare beneficiaries newly enrolled in hospice.

PARTICIPANTS

Medicare hospice beneficiaries ≥ 65 years old between 2014 and 2016, restricted to those without benzodiazepine (N = 169,688) or antipsychotic (N = 190,441) prescription fills in the 6 months before hospice enrollment.

MAIN MEASURES

The primary outcome was incident (i.e., new) prescribing of a benzodiazepine or antipsychotic. A series of multilevel Cox regression models with random intercepts for hospice agency were fit to examine the association of incident benzodiazepine and antipsychotic prescribing with patient and hospice agency characteristics.

KEY RESULTS

A total of 91,728 (54.1%) and 58,175 (30.5%) hospice beneficiaries were newly prescribed an incident benzodiazepine or antipsychotic. The prescribing rate of the hospice agency was the strongest predictor of incident prescribing: Compared to patients in bottom-quartile benzodiazepine-prescribing agencies, those in top-quartile agencies were 10.7 times more likely to be prescribed an incident benzodiazepine (adjusted hazard ratio [AHR] 10.7, 95% CI 10.1-11.3). For incident antipsychotic prescribing, patients in top-quartile agencies were 51.7 times more likely to receive an antipsychotic (AHR 51.7, 95% CI 44.3-60.4) compared to those in the bottom quartile. Results remained consistent accounting for comfort kit prescribing.

CONCLUSIONS

The pattern of benzodiazepine or antipsychotic prescribing of a hospice agency strongly predicts whether a hospice enrollee is prescribed these medications, exceeding every other patient-level factor. While the appropriate level of prescribing in hospice is unclear, this variation may reflect a strong local prescribing culture across individual hospice agencies.

Off-label use of inhaled bronchodilators in hospitalised patients in Spain: a multicentre observational study

BACKGROUND

Off-label prescription of inhaled bronchodilators (IB) is frequent, despite the fact that they can be ineffective and increase avoidable healthcare costs.

OBJECTIVE

To analyse the frequency of off-label prescription of IB in hospitalised patients. Indications and level of evidence, involved drugs, medical specialties prescribing off-label IB and patients' adherence to IBs were also evaluated.

METHOD

A descriptive, observational, cross-sectional study was performed in four tertiary hospitals in Spain. The main outcome measure was the number of patients prescribed off-label IBs. Prescriptions were checked against the European Medicines Agency-approved indications. The level of evidence supporting off-label prescription of IBs (according to MICROMEDEX 2.0) was also analysed. Patients were interviewed to test differences (off-label vs on-label) in adherence and knowledge about their inhaled therapy.

RESULTS

217 patients were prescribed IBs, 92 of whom were givend off-label IBs (54.7% men, mean age 73.9±12.9 years). The most common off-label prescriptions for IBs were: unspecified dyspnoea (not related to COPD or asthma) (27.2%), respiratory infections (23.9%) and heart failure (22.8%). 76.8% of patients did not have evidence supporting them. Beta2-agonist+corticosteroids and anticholinergics were most commonly prescribed off-label. Internal Medicine was the main medical specialty involved. There were no differences between off-label and on-label users in terms of patients' knowledge about treatment and adherence.

CONCLUSION

Off-label indications for IBs are common in hospitalised patients and are generally indicated without scientific support. Dyspnoea not related to COPD or asthma, respiratory infections and heart failure were the main off-label indications, most frequently treated with anticholinergics and beta2-agonists+corticosteroids, for which their efficacy and safety has not been proved. Our results show that prescribing needs to be improved to follow the evidence that exists. Moreover, further research focused on off-label indications is needed to clarify whether they are effective, safe and cost-effective.

Prescribing practices, patterns, and potential harms in patients receiving palliative care: A systematic scoping review

Background

Patients receiving palliative care often have existing comorbidities necessitating the prescribing of multiple medications. To maximize quality of life in this patient cohort, it is important to tailor prescribing of medication for preventing and treating existing illnesses and those for controlling symptoms, such as pain, according to individual specific needs.

Objective(s)

To provide an overview of peer-reviewed observational research on prescribing practices, patterns, and potential harms in patients receiving palliative care.

Methods

A systematic scoping review was conducted using four electronic databases (PubMed, EMBASE, CINAHL, Web of Science). Each database was searched from inception to May 2020. Search terms included ‘palliative care,’ ‘end of life,’ and ‘prescribing.’ Eligible studies had to examine prescribing for adults (≥18 years) receiving palliative care in any setting as a study aim or outcome. Studies focusing on single medication types (e.g., opioids), medication classes (e.g., chemotherapy), or clinical indications (e.g., pain) were excluded. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, and the findings were described using narrative synthesis.

Results

Following deduplication, 16,565 unique citations were reviewed, and 56 studies met inclusion criteria. The average number of prescribed medications per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in preventative medications and increases in symptom-specific medications closer to the time of death. Twenty-one studies assessed the appropriateness of prescribing using various tools. The prevalence of patients with ≥1 potentially inappropriate prescription ranged from 15 to 92%. Three studies reported on adverse drug events.

Conclusions

This scoping review provides a broad overview of existing research and shows that many patients receiving palliative care receive multiple medications closer to the time of death. Future research should focus in greater detail on prescribing appropriateness using tools specifically developed to guide prescribing in palliative care and the potential for harm.

Pharmacological and non-pharmacological treatment of delirium in an oncological hospital service: an integrative review

OBJECTIVES

to analyze the production of scientific articles about the pharmacological and non-pharmacological management of delirium in adult hospitalized cancer patients.

METHODS

integrative review whose sample was obtained from the databases Scopus, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Web of Science, and from the portals Biblioteca Virtual em Saúde, and PubMed.

RESULTS

among the ten studies analyzed, 80% described exclusively the pharmacological management, especially with regard to the use of haloperidol; 20% mentioned, superficially, non-pharmacological interventions/actions (educational actions) associated to pharmacological management, and adjusting them could result in the diminution and control of psychomotor agitation, contributing for the safety and comfort of the patient.

CONCLUSIONS

there are few studies addressing pharmacological and non-pharmacological interventions/actions to manage delirium. As a result, it is essential to develop studies focused on increasing and advancing scientific knowledge with regard to the theme, especially in the national context.

Prevalence of psychotropic and opioid prescribing among hospice beneficiaries in the United States, 2014-2016

BACKGROUND/OBJECTIVES

Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes.

DESIGN

Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016.

SETTING

Beneficiaries enrolled in the Medicare hospice benefit.

PARTICIPANTS

Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022).

MAIN OUTCOME

Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing.

RESULTS

70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics.

CONCLUSIONS

Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.

Off-Label and Unlicensed Drugs in Pediatric Palliative Care: A Prospective Observational Study

CONTEXT

Off-label and unlicensed use of drugs is a widespread practice in pediatric care because of the lack of specific efficacy and safety data and the absence of formulations adapted to the needs of these individuals. Pediatric patients with a life-limiting illness frequently receive drugs under these conditions, although no studies have established the prevalence of this practice.

OBJECTIVES

To describe the prevalence, indications, and most common uses of off-label and unlicensed drugs in a pediatric palliative care unit (PPCU).

METHODS

A prospective cross-sectional observational study carried out between January and October 2019.

RESULTS

About 85 patients involving 1198 prescriptions were analyzed. A total of 39.6% were off label, and 12.9% were unlicensed. All received at least one off-label drug, with a median of five per patient (interquartile range 3-7), and 81.2% received at least one unlicensed drug. A total of 36.1% of the prescriptions were considered off label because of indication, 33.8% because of dosage, and 26.6% because of age. The main drugs used off label were oral morphine, oral levetiracetam, inhaled albuterol, sublingual ondansetron, oral tizanidine, sublingual fentanyl, and oral diazepam. The main symptoms treated with off-label drugs were dyspnea, pain, and nausea/vomiting.

CONCLUSION

More than half of the prescriptions in this PPCU were off label or unlicensed. Treatment indication was one of the main reasons for off-label use. Administration of compounded preparations was common in patients with a life-limiting illness.

Retrospective analysis of off-label medication use at a plastic surgery hospital in China and evidence-based evaluation

To retrospectively analyze the off-label prescriptions at a plastic surgery hospital in China and conduct a literature review. The prescriptions in outpatient department from January 1, 2018 to December 31, 2018 were collected and compared with the related drug instructions in indications, dosage, frequency and route of administration to identify the off-label prescriptions. According to related literatures, guidelines, and MICROMEDEX, the rationality of off-label drug uses was evaluated. A total of 39 836 prescriptions were screened and 3395 (8.52%) off-label prescriptions were identified. It involved 23 items off-label medication uses. 20 items were off-label used in indication and three items were in indication and administration route. These off-label prescriptions involved 19 medicines and 12 indications and the dermatology related drug usage accounted for the largest proportion (91.3%). Additionally, five items (21.7%) were Chinese patent medicine related. Of the 23 items, seven (30.4%) have been recommended by guidelines and two (8.7%) by Thomson Grading System of Micromedex. All of them have been proved by literature evidence of level 1 to 4, in which 19 (82.6%) by Level 1 evidence, 21 (91.3%) by Level 1 to 2 evidence and 2 (8.7%) only by level 3 to 4 evidence. This can provide a theoretical basis to clinicians in prescribing. Our next work is to perfect some details about evidence assessment to improve the reliability.

[Clinical pharmacists in palliative care: effects on drug therapy and drug expenses]

BACKGROUND

The effect of integrating clinical pharmacists in German palliative care units with regard to the quality of drug therapy and drug costs has yet not been evaluated.

OBJECTIVES

This work aims to assess the number of pharmaceutical interventions (PI) and the cost-benefit ratio of a clinical pharmacist taking part in the interprofessional patient care team on an inpatient palliative care unit in Germany.

METHODS

The number of and underlying reasons for the pharmacist-led recommendations were recorded and analyzed over a 1-year period. In addition, the respective drugs and the acceptance rate of recommendations were assessed. To evaluate the cost-benefit ratio, the financial savings in the provision of drugs were recorded and compared with the expenses for the clinical pharmacy service.

RESULTS

A total of 245 PI were performed. Most frequently, the pharmacist advised physicians on drug choices and drug dosages. The acceptance rate was 93%. The cost savings in the provision of drugs covered 83% of the expenses for the clinical pharmacy service.

CONCLUSION

The results indicate that the integration of a clinical pharmacist is well suited to optimizing the interprofessional treatment of distressing symptoms with a beneficial economic outcome in palliative care. Consequently, the permanent integration of a clinical pharmacist on an inpatient palliative care unit seems to be beneficial and advisable.

Drug use beyond the licence in palliative care: A systematic review and narrative synthesis

BACKGROUND

Drug use beyond the licence (off-label use, off-label drug use) is a common practice in palliative care and respective recommendations can often be identified in the literature. It is both risky and offers opportunities at the same time and, therefore, requires special attention in clinical practice.

AIM

To determine the prevalence of off-label drug use in palliative care and to identify, evaluate and critically appraise studies describing the clinical practice, healthcare professionals' awareness, knowledge and attitudes towards off-label-use and management strategies.

DESIGN

Systematic literature review following the guidance of the Centre for Reviews and Dissemination.

DATA SOURCES

Medline, Embase, Web of Science and Current Contents Connect were searched in July 2018 as well as hand searches. The reference lists of pertinent studies were screened for further relevant publications, and citation tracking was performed.

RESULTS

Eight studies met the inclusion criteria. Due to the variety in study designs and settings, no meta-analysis or meaningful statistical analysis was possible and a narrative synthesis of the data was performed. Frequency of off-label drug use ranged from 14.5% to 35%. Up to 97% of palliative care units did not have any policy or guidance on handling off-label drug use. About 20% of prescribers never obtain consent in the context of off-label use.

CONCLUSION

Off-label use is common in palliative care with up to one-third of prescriptions affected. Challenges are often related to obtaining informed consent. Little is known about the decision-making process. More information and guidance for the prescribers are needed to enable safe handling of drugs outside their licence in palliative care.

Off-label drugs use in pediatric palliative care

Background

Paediatric palliative care (PPC) aim to ensure the control of symptoms and the best possible quality of life for patients whose underlying disease, characterized by an unstoppable evolution and negative prognosis, no longer responds to specific treatments. The scientific evidence in this context are very deficient and, in order to obtain welfare objectives consistent with the situation, in the overwhelming majority of cases the prescription of drugs is off-label for indication of use and/or for age and/or for way of administration and/or formulation.

The Agenzia Italiana del Farmaco - AIFA and the Italian Society of Palliative Care (Società Italiana di Cure Palliative - SICP), under a dedicated working group, wrote a document that collects the scientific evidence available to support the off-label use of medicines more frequently used in PPC. The goal is to certify the consolidated off-label use of these drugs and propose their use under the Law 648/96, in the absence of data from its pivotal clinical trials.

Aim of the commentary is to report the conditions for this important work and to present the 10 drugs, usually used off-label in PPC and in pain therapy, now included in Law 648/96.

Conclusion

This work is deemed essential to resolve, at least in part, the lack of availability of medicines researched and approved.

Intravenous Chlorpromazine for the Short-Term Treatment of Insomnia in End-Stage Cancer Patients With Difficulty in Oral Administration

The objective of the study was to evaluate effectiveness and safety of intravenous chlorpromazine for the short-term treatment of insomnia in end-stage cancer patients. Insomnia occurs as one of distressing symptoms in 70% of end-stage cancer patients. End-stage cancer patients often have difficulty in oral administration because of disease progress. We retrospectively evaluated 30 end-stage cancer patients with difficulty in oral administration who received intravenous chlorpromazine for the short-term treatment of insomnia. A primary end point was sleep quality based on St. Mary's Hospital Sleep Questionnaire 3 days after the treatment. Improved sleep quality was observed on the day after the treatment and later (P < .001), and the effective rate mean was 0.63 (95% confidential interval: 0.45-0.81) 3 days after the treatment. Increased total sleep time and decreased sleep latency time were observed 3 days after the treatment (P < .001); however, no improvement in depth of sleep was achieved (P = .231). There was no adverse event except for two delirium cases. The study indicated that intravenous chlorpromazine can be applied safely and effectively for the short-term treatment of insomnia in end-stage cancer patients with difficulty in oral administration.

Factors Associated with the Effectiveness of Intravenous Administration of Chlorpromazine for Delirium in Patients with Terminal Cancer

BACKGROUND

Delirium in patients with terminal cancer is irreversible and increases treatment resistance, which leads to a deterioration in quality of life.

OBJECTIVE

To investigate factors affecting the effectiveness and safety of intravenous chlorpromazine for irreversible delirium in patients with terminal cancer.

DESIGN/MEASUREMENTS

Multiple regression analysis for factors affecting treatment effectiveness was carried out based on a retrospective comparison between responders and nonresponders to intravenous chlorpromazine.

SETTING/SUBJECTS

Ninety-seven patients with terminal cancer who were treated with intravenous chlorpromazine for irreversible delirium were included.

RESULTS

The rate of patients with ≥50% improvement in mean Nursing Delirium Screening Scale score from pretreatment to day three of chlorpromazine treatment was 0.48 (95% confidence interval [CI]: 0.38-0.58). Factors affecting chlorpromazine treatment effectiveness were hyperactive delirium (odds ratio [OR]: 6.25, 95% CI: 1.14-34.5) and longer survival (OR: 1.096, 95% CI: 1.05-1.14). The mean chlorpromazine dose was low, at 17.9 mg/day. Adverse events were reported in 11 patients (11.3%) by day three of chlorpromazine treatment, and all were observed in patients who survived less than two weeks after chlorpromazine treatment. Patients who died, who had decreased blood pressure during chlorpromazine administration, and who showed acute akathisia all displayed shock index ≥1.

CONCLUSIONS

Intravenous administration of low-dose chlorpromazine may be an effective and safe treatment option for delirium in patients with terminal cancer who have hyperactive delirium, longer predictive prognosis, and shock index <1.

Physician-pharmacist agreement about off-label use of medications in private clinical settings in Baghdad, Iraq

Objective:

1) To evaluate the relationship between physician-pharmacist agreement about the off-label drug use and 2) and to identify the most common off-label medication category/indications and prescriber clinical disciplines in private settings in Baghdad area, Iraq

Methods:

This study evaluated 980 off-label use requests in the private clinical settings within Baghdad area, Iraq from October 2013 to September 2015. The efficacy, safety, and convenience of each drug request and its alternative options were evaluated according to the patient health and demographic characteristics and standard guidelines.

Results:

Of the 980 physician off-label requests, only 22.7% were approved by the pharmacists. Rheumatology and Nephrology accounted for the highest ratio of off-label use requests for adults (30.3% and 26.3%). The pharmacist rejection ratio of off-label use was comparable between the two groups (p>0.05). Most of the issued requests were attributed either to unapproved indication or to combination of more than one drug (38% and 35.3%). A low acceptance rate was reported in the requests issued for treatment in different clinical lines to the authorized one (11.9%). The lowest rate of acceptance was reported in the requests that had very low evidence level (9.1%). The mostly prescribed medications were musculoskeletal agents (28.9%). Finally, 78.2% of the requests came from clinical branches for adults. Although the agreement rate for requests in adults was higher than that in pediatrics, the two rates were not significantly different.

Conclusion:

Community pharmacists should effectively take responsibility for assessing off-label drug requests in Iraqi private settings. The quality of evidence does not represent the major factor influencing the approval rate of off-label drug use. The availability of safer and/or affordable alternatives and prescribing for a different patient age category highly impacted the pharmacists’ approval rate.