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Howard P, Clawson S, Curtin J. Short subcutaneous infusions for symptom control in palliative medicine. BMJ Support Palliat Care 2024; 14:183-186. [PMID: 37798082 DOI: 10.1136/spcare-2023-004593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/21/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVES To investigate the efficacy and safety of short subcutaneous infusions (SSCIs) for refractory symptoms in the palliative setting. METHODS A retrospective chart review of SSCIs in a single palliative care centre over an 18-month period. All clinical notes, medication administration records and infusion monitoring documentation were examined to ascertain therapeutic aim, efficacy and tolerability. RESULTS 111 patients received one or more SSCIs, 28 in the community and 83 in the inpatient hospice (21% of all admissions). SSCIs were used for a wide variety of reasons including loading doses (to achieve steady state and, thus, symptom relief, sooner), as required doses (for medications too irritant to give as bolus SC injections) and regular maintenance doses (where continuous subcutaneous infusion (CSCI), were unnecessary). 84 single drug SSCIs types and 51 admixtures SSCIs types (2 or more medications) were given. One infusion was poorly absorbed, but SSCIs were otherwise well tolerated. CONCLUSIONS SSCIs appear to be a promising additional option for administering medicines that are too irritant or large in volume for SC bolus injection. For medications with longer half-lives (eg, phenobarbital, valproate, levetiracetam), SSCI loading doses would be expected to achieve steady state and, thus, symptom relief, sooner than CSCIs alone.
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Affiliation(s)
- Paul Howard
- Earl Mountbatten Hospice, Newport, Isle of Wight, UK
- Palliative Care Team, Isle of Wight NHS Trust, Newport, UK
| | - Sandra Clawson
- Pharmacy, Earl Mountbatten Hospice, Newport, UK
- Pharmacy, Isle of Wight NHS Trust, Newport, Isle of Wight, UK
| | - John Curtin
- Earl Mountbatten Hospice, Newport, Isle of Wight, UK
- Palliative Care Team, Isle of Wight NHS Trust, Newport, UK
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Thomas B. Malignant bowel obstruction symptoms: subcutaneous bolus esomeprazole-retrospective case series. BMJ Support Palliat Care 2024; 13:e733-e734. [PMID: 35022187 DOI: 10.1136/bmjspcare-2021-003510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/01/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Benjamin Thomas
- Palliative Care, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
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Woodman M, Curtin J, Howard P. Esomeprazole for subcutaneous infusion: compatibility with other alkaline medications. BMJ Support Palliat Care 2024; 13:e751-e753. [PMID: 36100432 DOI: 10.1136/spcare-2022-003936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Myles Woodman
- General Medicine, Isle of Wight NHS Trust, Newport, UK
| | - John Curtin
- Mountbatten Hospice, Newport, UK
- Palliative Care Team, Isle of Wight NHS Trust, Newport, UK
| | - Paul Howard
- Mountbatten Hospice, Newport, UK
- Palliative Care Team, Isle of Wight NHS Trust, Newport, UK
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Jones S, Tomas J. Subcutaneous proton pump inhibitors (PPIs) in palliative medicine. BMJ Support Palliat Care 2024; 13:e772-e773. [PMID: 37336633 DOI: 10.1136/spcare-2023-004359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/24/2023] [Indexed: 06/21/2023]
Affiliation(s)
- Sophie Jones
- Medical School, Aston University, Birmingham, UK
- Palliative Care, Russells Hall Hospital, Dudley, UK
| | - Jon Tomas
- Palliative Care, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Wernli U, Dürr F, Jean-Petit-Matile S, Kobleder A, Meyer-Massetti C. Subcutaneous Drugs and Off-label Use in Hospice and Palliative Care: A Scoping Review. J Pain Symptom Manage 2022; 64:e250-e259. [PMID: 35870656 DOI: 10.1016/j.jpainsymman.2022.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Ursina Wernli
- Clinical Pharmacology and Toxicology (U.W., C.M.M.), Inselspital Bern, Switzerland; Graduate School for Health Sciences (U.W.), University of Bern, Switzerland.
| | - Fabienne Dürr
- Institute of Primary Health Care BIHAM (F.D., C.M.M.), University of Bern, Switzerland
| | | | - Andrea Kobleder
- Institute of Applied Nursing Science (A.K.), Eastern Switzerland University of Applied Sciences OST, St Gallen, Switzerland
| | - Carla Meyer-Massetti
- Clinical Pharmacology and Toxicology (U.W., C.M.M.), Inselspital Bern, Switzerland; Institute of Primary Health Care BIHAM (F.D., C.M.M.), University of Bern, Switzerland
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Hindmarsh J, Adelaja M, Abd Latif S, Lee M, Pickard J. Administering esomeprazole subcutaneously via a syringe driver in the palliative demographic: A case series. J Clin Pharm Ther 2021; 47:694-698. [PMID: 34961946 DOI: 10.1111/jcpt.13582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/05/2021] [Accepted: 11/23/2021] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Jonathan Hindmarsh
- Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, UK.,Department of Pharmacy, Sunderland Royal Hospital, Sunderland, UK
| | - Mercy Adelaja
- Department of Pharmacy, Sunderland Royal Hospital, Sunderland, UK
| | - Saiful Abd Latif
- Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, UK
| | - Mark Lee
- Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, UK
| | - Jonathan Pickard
- Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, UK
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Hwang JH, Jeong JW, Song GH, Koo TS, Seo KW. Pharmacokinetics and Acid Suppressant Efficacy of Esomeprazole after Intravenous, Oral, and Subcutaneous Administration to Healthy Beagle Dogs. J Vet Intern Med 2017; 31:743-750. [PMID: 28407418 PMCID: PMC5435062 DOI: 10.1111/jvim.14713] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/24/2017] [Accepted: 03/09/2017] [Indexed: 12/16/2022] Open
Abstract
Background Esomeprazole is an S‐enantiomer of omeprazole that has favorable pharmacokinetics and efficacious acid suppressant properties in humans. However, the pharmacokinetics and effects on intragastric pH of esomeprazole in dogs have not been reported. Objective To determine the pharmacokinetics of esomeprazole administered via various routes (PK study) and to investigate the effect of esomeprazole on intragastric pH with a Bravo pH monitoring system (PD study). Animals Seven adult male Beagle dogs and 5 adult male Beagle dogs were used for PK and PD study, respectively. Methods Both studies used an open, randomized, and crossover design. In the PK study, 7 dogs received intravenous (IV), subcutaneous (SC), and oral doses (PO) of esomeprazole (1 mg/kg). Each treatment period was separated by a washout period of at least 10 days. Esomeprazole plasma concentrations were measured by HPLC/MS/MS. In the efficacy study, intragastric pH was recorded without medication (baseline pH) and following IV, SC, and PO esomeprazole dosing regimens (1 mg/kg) in 5 dogs. Results The bioavailability of esomeprazole administered as PO enteric‐coated granules and as SC injections was 71.4 and 106%, respectively. The half‐life was approximately 1 hour. Mean ± SD percent time intragastric pH was ≥3 and ≥4 was 58.9 ± 21.1% and 40.9 ± 17.3% for IV group, 75.8 ± 16.4% and 62.7 ± 17.7% for SC group, 88.2 ± 8.9% and 82.5 ± 7.7% for PO group, and 12.5 ± 3.6% and 3.7 ± 1.8% for baseline. The mean percent time with intragastric pH was ≥3 or ≥4 was significantly increased regardless of the dosing route (P < .05). Conclusion The PK parameters for PO and SC esomeprazole administration were favorable, and esomeprazole significantly increased intragastric pH after IV, PO, and SC administration. IV and SC administration of esomeprazole might be useful when PO administration is not possible. No significant adverse effects were observed.
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Affiliation(s)
- J-H Hwang
- College of Veterinary Medicine, Chungnam National University, Yuseong-gu, Daejeon, Korea
| | - J-W Jeong
- Graduate School of New Drug Discovery and Development, Chungnam National University, Yuseong-gu, Daejeon, Korea
| | - G-H Song
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine, Chungnam National University, Yuseong-gu, Daejeon, Korea
| | - T-S Koo
- Graduate School of New Drug Discovery and Development, Chungnam National University, Yuseong-gu, Daejeon, Korea
| | - K-W Seo
- College of Veterinary Medicine, Chungnam National University, Yuseong-gu, Daejeon, Korea
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Abstract
SummaryPatients 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.
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Abstract
SummarySubcutaneous hydration, or hypodermoclysis (HDC), is a very simple technique that should be practised more often by doctors and nurses who care for older patients. It involves less discomfort, generates less cost and has fewer adverse effects than the intravenous route and may reduce the need for admission to the emergency department. The main indication is the management of mild to moderate dehydration, and prevention of dehydration in patients who are intolerant of oral intake. It should not be administered in situations of severe dehydration, in emergency situations, or in patients with fluid overload. Isotonic or hypotonic solutions must be used with appropriate electrolytes. Certain medicines can be given simultaneously by HDC and this may be especially valuable in palliative care settings. In most cases there is no need to add hyaluronidase.
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