Expert Sizes Up Palliative Care Medications

AUSTIN, TEX. — Many new medications relevant to palliative care have come on the market recently or are about to, hospital pharmacist Mary Lynn McPherson, Pharm.D., said at the American Academy of Hospice and Palliative Medicine annual meeting.

Dr. McPherson described several new prescription drugs and over-the-counter therapies that may often be given to patients at the end of life.

Dr. McPherson commented on the following products:

▸ Dexlansoprazole (Kapidex) delayed-release capsules were approved in late January for the treatment of heartburn associated with gastroesophageal reflux disease. This R-isomer of lansoprazole (Prevacid) comes to market just as Prevacid is expected to go generic. Dexlansoprazole is the first proton pump inhibitor (PPI) with a dual delayed-release formulation, allowing doses of 30–60 mg a day, versus 15–30 mg a day for Prevacid. Costs per month are $150 for dexlansoprazole and $168 for Prevacid.

“We get the patient frequently in my practice in a hospice on a PPI they don't even need that's been advertised to death,” said Dr. McPherson, a professor of pharmacy at the University of Maryland, Baltimore. “You know, the purple pill, [but] it doesn't work any better than the 80 cents a day over-the-counter omeprazole [Prilosec]. We only provide a PPI if the patient is on a steroid or nonsteroidal that we are also providing.”

▸ Sancuso is a transdermal patch designed to deliver 3.1 mg of granisetron over 24 hours to prevent emesis caused by moderate- and high-risk emetogenic drugs. Approved by the Food and Drug Administration last fall, the patch is applied to the upper arm at least 24 hours before the first chemotherapy session and can be worn for up to 7 days. In clinical trials, it has been shown to have equal efficacy to 2 mg oral granisetron per day, Dr. McPherson said. Cost is $287 per patch.

The patch may be a better option for inpatient palliative care than for home-based hospice, where Haldol (haloperidol) is the mainstay for nausea, she said.

▸ Zolpidem (ZolpiMist) 5-mg and 10-mg oral spray was approved in late December 2008 for the short-term treatment of difficulties getting to sleep. The spray acts quickly, reaching therapeutic levels within the body in 15 minutes. Patients should be prepared to spend 7–8 hours in bed after receiving the drug.

▸ Metoclopramide products, which include Reglan (metoclopramide) tablets and injections, received a black box warning in February because chronic use has been linked to tardive dyskinesia. Patients at the end of life typically are treated with up to 40 mg a day of metoclopramide for less than 3 months, but caution should be used in elderly patients, especially women, and in those receiving both Reglan and Haldol because the combination doubles the risk of tardive dyskinesia, Dr. McPherson said.

▸ Tapentadol, a centrally acting analgesic with potency between those of morphine and tramadol, was approved at the end of 2008 for relief of moderate to severe acute pain in adults. Although not approved for chronic pain, it may be of use in hospice and palliative care, Dr. McPherson said. Tapentadol is under review by the Drug Enforcement Administration and is expected to be a scheduled drug.

P Tramadol is not a controlled substance at the federal level, but it may be heading that way, Dr. McPherson said. Arkansas and Kentucky have made it a schedule IV drug, and authorities in North Dakota, Ohio, and Wyoming are tracking tramadol usage through their prescription drug monitoring program as if it were controlled.

▸ Propoxyphene may be on the chopping block after two FDA advisory committees narrowly voted on Jan. 30 to recommend discontinued marketing of Darvon and Darvocet for mild to moderate pain. Propoxyphene is banned in the United Kingdom and is rarely used in Canada, but it is among the top 25 most prescribed drugs in the United States, Dr. McPherson said. She added that physicians like it because it causes less stomach upset than other opioids and can be taken by patients allergic to morphine and hydrocodone.

Propoxyphene is far from benign, Dr. McPherson said, noting that both the drug and its metabolite are cardiotoxic. Propoxyphene was a factor in 5.6% of drug-related deaths in the United States from 1981 to 1999, she said.

▸ OTC products. Emuprofen is a topically administered analgesic that contains ibuprofen and oil from the fat of the emu. It's being marketed as an anti-inflammatory and an alternative to systemic NSAID therapy for various painful conditions. Cost is about $35 for a small jar. The cream is about 10% ibuprofen. Rash and itching at the application site have been reported in up to 15% of patients.

Rain Dry Mouth Spray may be another therapeutic option for xerostomia, which affects 20% of the U.S. population and is common in people with head and neck cancer. The active ingredient is xylitol, a sugar alcohol, which can raise blood glucose if overused. Cost is about $14 for 4.5 ounces.

Tums QuickPak is a calcium carbonate powder that dissolves instantly on the tongue without the need for water and is the equivalent of two regular-strength Tums. It can be used as a daily calcium source, and for patients who can no longer swallow, she said.

Dr. McPherson disclosed that she is a consultant for Alpharma Inc.

AUSTIN, TEX. — Many new medications relevant to palliative care have come on the market recently or are about to, hospital pharmacist Mary Lynn McPherson, Pharm.D., said at the American Academy of Hospice and Palliative Medicine annual meeting.

Dr. McPherson described several new prescription drugs and over-the-counter therapies that may often be given to patients at the end of life.

Dr. McPherson commented on the following products:

▸ Dexlansoprazole (Kapidex) delayed-release capsules were approved in late January for the treatment of heartburn associated with gastroesophageal reflux disease. This R-isomer of lansoprazole (Prevacid) comes to market just as Prevacid is expected to go generic. Dexlansoprazole is the first proton pump inhibitor (PPI) with a dual delayed-release formulation, allowing doses of 30–60 mg a day, versus 15–30 mg a day for Prevacid. Costs per month are $150 for dexlansoprazole and $168 for Prevacid.

“We get the patient frequently in my practice in a hospice on a PPI they don't even need that's been advertised to death,” said Dr. McPherson, a professor of pharmacy at the University of Maryland, Baltimore. “You know, the purple pill, [but] it doesn't work any better than the 80 cents a day over-the-counter omeprazole [Prilosec]. We only provide a PPI if the patient is on a steroid or nonsteroidal that we are also providing.”

▸ Sancuso is a transdermal patch designed to deliver 3.1 mg of granisetron over 24 hours to prevent emesis caused by moderate- and high-risk emetogenic drugs. Approved by the Food and Drug Administration last fall, the patch is applied to the upper arm at least 24 hours before the first chemotherapy session and can be worn for up to 7 days. In clinical trials, it has been shown to have equal efficacy to 2 mg oral granisetron per day, Dr. McPherson said. Cost is $287 per patch.

The patch may be a better option for inpatient palliative care than for home-based hospice, where Haldol (haloperidol) is the mainstay for nausea, she said.

▸ Zolpidem (ZolpiMist) 5-mg and 10-mg oral spray was approved in late December 2008 for the short-term treatment of difficulties getting to sleep. The spray acts quickly, reaching therapeutic levels within the body in 15 minutes. Patients should be prepared to spend 7–8 hours in bed after receiving the drug.

▸ Metoclopramide products, which include Reglan (metoclopramide) tablets and injections, received a black box warning in February because chronic use has been linked to tardive dyskinesia. Patients at the end of life typically are treated with up to 40 mg a day of metoclopramide for less than 3 months, but caution should be used in elderly patients, especially women, and in those receiving both Reglan and Haldol because the combination doubles the risk of tardive dyskinesia, Dr. McPherson said.

▸ Tapentadol, a centrally acting analgesic with potency between those of morphine and tramadol, was approved at the end of 2008 for relief of moderate to severe acute pain in adults. Although not approved for chronic pain, it may be of use in hospice and palliative care, Dr. McPherson said. Tapentadol is under review by the Drug Enforcement Administration and is expected to be a scheduled drug.

P Tramadol is not a controlled substance at the federal level, but it may be heading that way, Dr. McPherson said. Arkansas and Kentucky have made it a schedule IV drug, and authorities in North Dakota, Ohio, and Wyoming are tracking tramadol usage through their prescription drug monitoring program as if it were controlled.

▸ Propoxyphene may be on the chopping block after two FDA advisory committees narrowly voted on Jan. 30 to recommend discontinued marketing of Darvon and Darvocet for mild to moderate pain. Propoxyphene is banned in the United Kingdom and is rarely used in Canada, but it is among the top 25 most prescribed drugs in the United States, Dr. McPherson said. She added that physicians like it because it causes less stomach upset than other opioids and can be taken by patients allergic to morphine and hydrocodone.

Propoxyphene is far from benign, Dr. McPherson said, noting that both the drug and its metabolite are cardiotoxic. Propoxyphene was a factor in 5.6% of drug-related deaths in the United States from 1981 to 1999, she said.

▸ OTC products. Emuprofen is a topically administered analgesic that contains ibuprofen and oil from the fat of the emu. It's being marketed as an anti-inflammatory and an alternative to systemic NSAID therapy for various painful conditions. Cost is about $35 for a small jar. The cream is about 10% ibuprofen. Rash and itching at the application site have been reported in up to 15% of patients.

Rain Dry Mouth Spray may be another therapeutic option for xerostomia, which affects 20% of the U.S. population and is common in people with head and neck cancer. The active ingredient is xylitol, a sugar alcohol, which can raise blood glucose if overused. Cost is about $14 for 4.5 ounces.

Tums QuickPak is a calcium carbonate powder that dissolves instantly on the tongue without the need for water and is the equivalent of two regular-strength Tums. It can be used as a daily calcium source, and for patients who can no longer swallow, she said.

Dr. McPherson disclosed that she is a consultant for Alpharma Inc.

AUSTIN, TEX. — Many new medications relevant to palliative care have come on the market recently or are about to, hospital pharmacist Mary Lynn McPherson, Pharm.D., said at the American Academy of Hospice and Palliative Medicine annual meeting.

Dr. McPherson described several new prescription drugs and over-the-counter therapies that may often be given to patients at the end of life.

Dr. McPherson commented on the following products:

▸ Dexlansoprazole (Kapidex) delayed-release capsules were approved in late January for the treatment of heartburn associated with gastroesophageal reflux disease. This R-isomer of lansoprazole (Prevacid) comes to market just as Prevacid is expected to go generic. Dexlansoprazole is the first proton pump inhibitor (PPI) with a dual delayed-release formulation, allowing doses of 30–60 mg a day, versus 15–30 mg a day for Prevacid. Costs per month are $150 for dexlansoprazole and $168 for Prevacid.

“We get the patient frequently in my practice in a hospice on a PPI they don't even need that's been advertised to death,” said Dr. McPherson, a professor of pharmacy at the University of Maryland, Baltimore. “You know, the purple pill, [but] it doesn't work any better than the 80 cents a day over-the-counter omeprazole [Prilosec]. We only provide a PPI if the patient is on a steroid or nonsteroidal that we are also providing.”

▸ Sancuso is a transdermal patch designed to deliver 3.1 mg of granisetron over 24 hours to prevent emesis caused by moderate- and high-risk emetogenic drugs. Approved by the Food and Drug Administration last fall, the patch is applied to the upper arm at least 24 hours before the first chemotherapy session and can be worn for up to 7 days. In clinical trials, it has been shown to have equal efficacy to 2 mg oral granisetron per day, Dr. McPherson said. Cost is $287 per patch.

The patch may be a better option for inpatient palliative care than for home-based hospice, where Haldol (haloperidol) is the mainstay for nausea, she said.

▸ Zolpidem (ZolpiMist) 5-mg and 10-mg oral spray was approved in late December 2008 for the short-term treatment of difficulties getting to sleep. The spray acts quickly, reaching therapeutic levels within the body in 15 minutes. Patients should be prepared to spend 7–8 hours in bed after receiving the drug.

▸ Metoclopramide products, which include Reglan (metoclopramide) tablets and injections, received a black box warning in February because chronic use has been linked to tardive dyskinesia. Patients at the end of life typically are treated with up to 40 mg a day of metoclopramide for less than 3 months, but caution should be used in elderly patients, especially women, and in those receiving both Reglan and Haldol because the combination doubles the risk of tardive dyskinesia, Dr. McPherson said.

▸ Tapentadol, a centrally acting analgesic with potency between those of morphine and tramadol, was approved at the end of 2008 for relief of moderate to severe acute pain in adults. Although not approved for chronic pain, it may be of use in hospice and palliative care, Dr. McPherson said. Tapentadol is under review by the Drug Enforcement Administration and is expected to be a scheduled drug.

P Tramadol is not a controlled substance at the federal level, but it may be heading that way, Dr. McPherson said. Arkansas and Kentucky have made it a schedule IV drug, and authorities in North Dakota, Ohio, and Wyoming are tracking tramadol usage through their prescription drug monitoring program as if it were controlled.

▸ Propoxyphene may be on the chopping block after two FDA advisory committees narrowly voted on Jan. 30 to recommend discontinued marketing of Darvon and Darvocet for mild to moderate pain. Propoxyphene is banned in the United Kingdom and is rarely used in Canada, but it is among the top 25 most prescribed drugs in the United States, Dr. McPherson said. She added that physicians like it because it causes less stomach upset than other opioids and can be taken by patients allergic to morphine and hydrocodone.

Propoxyphene is far from benign, Dr. McPherson said, noting that both the drug and its metabolite are cardiotoxic. Propoxyphene was a factor in 5.6% of drug-related deaths in the United States from 1981 to 1999, she said.

▸ OTC products. Emuprofen is a topically administered analgesic that contains ibuprofen and oil from the fat of the emu. It's being marketed as an anti-inflammatory and an alternative to systemic NSAID therapy for various painful conditions. Cost is about $35 for a small jar. The cream is about 10% ibuprofen. Rash and itching at the application site have been reported in up to 15% of patients.

Rain Dry Mouth Spray may be another therapeutic option for xerostomia, which affects 20% of the U.S. population and is common in people with head and neck cancer. The active ingredient is xylitol, a sugar alcohol, which can raise blood glucose if overused. Cost is about $14 for 4.5 ounces.

Tums QuickPak is a calcium carbonate powder that dissolves instantly on the tongue without the need for water and is the equivalent of two regular-strength Tums. It can be used as a daily calcium source, and for patients who can no longer swallow, she said.

Dr. McPherson disclosed that she is a consultant for Alpharma Inc.