Tag - Hospice

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Statin Discontinuation in Hospice Patients
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Medication Discontinuation in Dementia Patients
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Options for Switching Antipsychotics
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Medication Discontinuation in Dementia Patients By Corina Reyna, PharmD, BCGP
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Morphine: What Caregivers Need to Understand

Statin Discontinuation in Hospice Patients

Hospice prescribers and pharmacists have long approached statins as appropriate for discontinuation in their patients who have no active cardiovascular disease since preventative or prophylaxis medications, as well as medications with long-term therapeutic outcomes, are not considered part of palliative care.  With the benefits of statin discontinuation ranging from decreasing pill burden to preventing myopathy, from cost-savings to fewer drug-drug interactions, it has become a common practice.  However, many hospice prescribers still overlook the potential benefits of statin discontinuation such that they do not always consider it in a timely manner after admission to hospice.

When the hospice team admits a patient with no known cardiovascular disease who is on a statin, it is helpful to remind new hospice prescribers of research demonstrating that the discontinuation of statins in this population does not alter mortality rates within 60 days of discontinuation or alter the median time to death.  Similarly, discontinuation does not appear to affect rates of cardiovascular events but may actually provide improvements in quality of life.  Research findings also imply that it is possible that statin deprescribing may lead to a reduction in the number of non-statin prescriptions required, perhaps due to fewer adverse effects requiring treatment for patient comfort.  It is prudent to consider the risks of continuation of any medication that no longer provides benefit, especially when dysphagia is present.

Of course, discussions about discontinuing any therapy should occur in the context of shared decision making, especially in the case of statins as research indicates that neither continuation nor discontinuation is clearly superior.  Furthermore, the data surrounding the topic of stopping statins in late-stage terminal patients serves as a reminder of the importance of utilizing patient-centered ongoing medication therapy reviews as an opportunity to continually assess the risk versus benefit of all components of a hospice patient’s medication regimen.

 

References:

Kutner, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA. 2015 May;175(5):691-700  https://www.ncbi.nlm.nih.gov/pubmed/25798575

Holmes H. & Todd A. Evidence-based deprescribing of statins in patients with advanced illness. JAMA. 2015 May;175(5):701-702  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420700/

Voelker R. Statin use may stop when illness is terminal, study says. JAMA. 2014 Jul 16;312(3):221

Medication Discontinuation in Dementia Patients

Understanding the progressive nature of dementia can help in the decision to continue or discontinue dementia medications in patients on hospice care for end-stage dementia.  Goals change as patients progress from mild to severe dementia.  In mild to moderate dementia, the primary goal is to slow the progression of the disease.  As dementia nears its end stages, the goal of care generally shifts to the control of dementia symptoms, especially when patients qualify for hospice care.

Neither the cholinesterase inhibitors nor the NMDA receptor antagonists have been proven beneficial in end-stage dementia.  Both classes of medications have the potential to cause significant adverse effects in declining patients whose bodies are less able to efficiently metabolize these medications.  Diarrhea, loss of appetite, nausea, symptomatic slow heart rate, and fainting are all potential side effects of cholinesterase inhibitors; memantine puts patients at greater risk for dizziness, headache, confusion and constipation.  When such medications are added to others commonly prescribed for patients admitted to hospice for dementia, the rates of these and other adverse effects often increase.  Though some patients gain a small benefit from the continuation of dementia medications, the potential dangers of continuing dementia medications must be considered.

The decision to continue or discontinue dementia medications can at first appear difficult, but a simple discontinuation plan can guide therapy options and ease caregiver concerns.  A prudent plan often includes a gradual discontinuation of dementia medications, monitoring patients for any new or worsening symptoms.  Some symptoms are better managed with other medications commonly used to manage dementia symptoms at end of life.  More often than not, patients do well with the discontinuation, have less risk of adverse effects from their remaining medications, and are well managed with conventional symptom management.

References:

Buckley JS, Salpeter SR. A risk-benefit assessment of dementia medications: systematic review of the evidence. Drugs Aging. 2015; 32(6):453-467.

Yang Z, Zhou X, Shand Q. Effectiveness and safety of memantine treatment for Alzheimer’s disease. J Alzheimers Dis. 2013; 36(3):445-458.

Minett TS, Thomas A, Wilkinson LM, Daniel SL, Sanders J. Richardson J, Littlewood E, Myint P, Newby J, McKeith IG. What happens when donepezil is suddenly withdrawn? An open label trial in dementia with Lewy bodies and Parkinson’s disease with dementia. Int J Geriatr Psychiatry. 2003; 18(11):988-93.

Options for Switching Antipsychotics

Medication cost, adverse effects, and poor therapeutic response often necessitate switching a hospice patient from one antipsychotic to another.  Prescribers can choose among several options when a switch is necessary.

Abrupt switch:

Often preferred by hospice prescribers, one antipsychotic can be abruptly discontinued with the immediate start of a new antipsychotic at a therapeutic dose.

Gradual tapering:

The initial antipsychotic dosage can be decreased by 25 to 50% of the total daily dose every 4 or 5 half-lives with concurrent up-titration of the new antipsychotic.  Refer to the chart of half-lives of common antipsychotics.

Overlap:

When overlapping products, the initial antipsychotic is continued at full dose while titrating the patient’s new antipsychotic.  When the new antipsychotic is at a therapeutic dose, the initial antipsychotic is tapered for discontinuation.

Since no one option is universally superior to another, prescribers must select the best switch method on a patient-by-patient basis.  Patient prognosis, patient stability, clinical status, efficacy of current medication(s), type of side effect(s) present, potential side effects of the new antipsychotic, and caregiver limitations are important factors that must be considered.

Problems occurring early after a switch can include psychotic symptoms, insomnia, anxiety, agitation, and extrapyramidal effects.  Since these effects can be either a response to the new medication or a result of withdrawal of the previous medication, they can be managed in various ways.  Watchful waiting is often preferred when symptoms are mild.  A slow restart of the initial antipsychotic may be necessary if severe rebound effects or withdrawal symptoms are present.  When the switch results in anxiety and restlessness, the addition of a benzodiazepine can provide temporary benefit of withdrawal effects, allowing clinicians to wait to see how the patient tolerates the switch once withdrawal dissipates.

Half-Lives of Common Antipsychotic Medications

Haloperidol 15-37 hours
Olanzapine 21-54 hours
Quetiapine 6 hours
Risperidone 3 hours in extensive metabolizers;20 hours in poor metabolizers
Ziprasidone 7 hours

 

References:

Martin, C. Reducing antipsychotic medications: developing a systematic process. Consult Pharm 2015;30:378-84.

Bobo, W. (2013, Mar 13). Switching anitpsychotics: why, when, and how? Psychiatric Times. Retrieved from http://www.psychiatrictimes.com

Medication Discontinuation in Dementia Patients By Corina Reyna, PharmD, BCGP

Understanding the progressive nature of dementia can help in the decision to continue or discontinue dementia medications in patients on hospice care for end-stage dementia.  Goals change as patient’s progress from mild to severe dementia.  In mild to moderate dementia, the primary goal is to slow the progression of the disease.  As dementia nears its end stages, the goal of care generally shifts to the control of dementia symptoms.

Neither the cholinesterase inhibitors nor the NMDA receptor antagonists have been proven helpful in end-stage dementia.  Both classes of dementia medications have the potential to cause significant adverse effects in declining patients whose bodies are less able to efficiently metabolize these medications.  Diarrhea, loss of appetite, nausea, symptomatic slow heart rate, and fainting are all potential side effects of cholinesterase inhibitors.  Interactions with other medications increase the risk for symptoms such as worsening of mental status, urinary retention, constipation, and dry mouth.  Though some patients gain a small benefit from the continuation of dementia medications, the potential dangers of continuing dementia medications must be considered.

The decision to continue or discontinue dementia medications can seem difficult until it is realized that a simple discontinuation plan can guide therapy options and ease caregiver concerns.  A prudent plan is to gradually discontinue dementia medications, monitoring patients for any new or worsening symptoms.  Some symptoms are better managed with other medications commonly used to manage dementia symptoms at end of life.  More often than not, patients do well with the discontinuation of medications, have less risk of adverse effects from their remaining medications, and are well managed with conventional symptom management.

Morphine: What Caregivers Need to Understand

For decades, patients, caregivers, and sometimes even hospice staff have erroneously believed that morphine use hastens death.  However, these same people have continued to use morphine believing that the provision of a pain-free death is more important than extending the dying process.  After the death of a loved one who was treated with morphine or other opioids at the end of life, too many caregivers are left with feelings of unrest regarding having allowed the opioids to be used.  In order to prevent caregivers from carrying around guilt years after the death of their loved one and to eradicate these long-standing, widespread myths, education regarding the erroneous nature of these ideas should be provided to all hospice staff, patients, and caregivers, regardless of whether they verbalize belief in such myths or not.

Several common myths can be easily countered by the facts surrounding morphine and its appropriate use.

Myth:  Caregivers are at high risk of expediting death if administering morphine as needed to control the patient’s pain.

Truth:  Morphine would have to be administered at doses that would cause bothersome toxic effects such as distressing agitation and/or myoclonic twitching before causing death.  Morphine has a wide therapeutic range, making actual overdose rare.  Even when high doses of morphine (greater than 300 mg/day) are necessary for pain control, patient survival is not affected.

Myth:  Morphine will make patients comatose.

Truth:  Morphine can cause some sedation initially, but this effect decreases within a few days.  Due to its actions to decrease pain and ease shortness of breath,  hospice staff often observe that morphine enables patients to catch up on sleep that has been lost as a result of these distressing symptoms.  Thus, patients will likely sleep more once morphine is initiated but not because the drug is inducing a comatose state.

Myth:  Morphine will cause respiratory depression along with pain control, expediting death.

Truth:  Studies show that if opioids are titrated against symptoms, they do not hasten death.  Also, patients develop a tolerance to the potential respiratory depression effects of morphine at oral doses of 60 mg per day or greater, such that respiratory depression rarely occurs in patients who have been on morphine for more than seven days.

References:

  • Bercovitch MWaller AAdunsky A. High dose morphine use in the hospice setting. A database survey of patient characteristics and effect on life expectancy. Cancer. 1999 Sep 1;86(5):871-7.
  • Bercovitch M, Adunsky A. Patterns of high-dose morphine use in a home-care hospice service: should we be afraid of it? Cancer. 2004 Sep 15;101(6):1473-7.
  • Stokowski, L. (2010, Dec 6). Adult cancer pain: part 2. Medscape Multispecialty. Retrieved from http://www.medscape.com

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