Lessons from the Literature

2021; Volume 22, No 10, October

IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

Under My Microscope

Dr. Tania Pastrana. Used with permission.

By Dr. Tania Pastrana
IAHPC Research Advisor

MASCC Antiemetics in Advanced Cancer Updated Guideline

Davis M, Hui D, Davies A, Ripamonti C, Capela A, DeFeo G, Del Fabbro E, Bruera E. Support Care Cancer 2021. DOI: 10.1007/s00520-021-06437-w

Last month, I presented a guideline on management of malignant bowel obstruction developed by the palliative care study group of the Multinational Association of Supportive Care in Cancer (MASCC). This month, I return to the MASCC group for its guidance on the treatment of nausea and vomiting in patients with advanced cancer.

Without a doubt, chronic nausea and vomiting are frequent and burdensome symptoms in palliative care. The team identified four randomized controlled trials (RTCs) and one systematic review to be included in the update of the 2015 MASCC antiemetic guidelines for advanced cancer.

Although opioid-induced nausea and vomiting is a daily problem in opioid pain therapy (8.5-18.5% and 23-40%, respectively), no new RCTs have been published in the last few years.

The inexpensive and essential medicines metoclopramide and haloperidol1 continue as first-line treatments. Methotrimeprazine (levomepromazine) and olanzapine were recommended as second-line treatments.

Interestingly, antiemetic choices based on the etiology, or specific cause, of nausea do not alleviate nausea any better than haloperidol. Furthermore, dexamethasone was ineffective as adjuvant, but was suggested for managing nausea from brain metastases or malignant bowel obstruction.

  1. 1. World Health Organization. Model List of Essential Medicines. Accessed online on October 1, 2021, at https://list.essentialmeds.org/?section=323&indication=&year=&age=&sex=

Background: Nausea and vomiting are a common clinical symptom in the advanced cancer patient. Pharmacologic management is important. Evidence for drug choices and guidelines are needed to help clinicians manage nausea and vomiting in this population

Methods: Evidence from a systematic review published in 2010, initial MASCC guidelines developed from a systematic review of literature to 2015, and a new systematic review of randomized trials published between 2015 and February 2, 2021, was combined to establish a new guideline.

Results: A search of the literature between 2015 and February 2, 2021, revealed 257 abstracts of which there was one systematic review and 4 randomized trials which were used to modify the guideline. The new guideline is as follows: First Line: Metoclopramide (II) multiple small RCTs including a placebo-controlled trial, haloperidol (II) multiple non-placebo-controlled RCTs, high consensus. Second line: Methotrimeprazine (II) 1 well-powered non-placebo-controlled RCT, olanzapine (II) 1 placebo-controlled pilot RCT, high consensus. Third line: Tropisetron (II) large unblinded lower quality non-placebo-controlled RCT, levosulpiride (II) 1 blinded non-placebo-controlled pilot RCT, high consensus.

Discussion: Haloperidol, metoclopramide, methotrimeprazine, olanzapine tropisetron, and levosulpiride have been antiemetics used in randomized trials with antiemetic activity demonstrated. There are only three placebo-controlled randomized trials we could find in our literature review. Placebo responses varied significantly between two randomized trials. More randomized placebo-controlled trials with either metoclopramide or haloperidol rescue are needed to clarify antiemetic choices in advanced cancer.

Conclusion: First-line antiemetics for nausea and vomiting in advanced cancer are metoclopramide and haloperidol, and second-line medications are methotrimeprazine and olanzapine.

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Media Watch: End-of-Life Medications

The articles below are selected from recent issues of Barry R. Ashpole’s weekly report Media Watch.

Prescribing Practices, Patterns, and Potential Harms in Patients Receiving Palliative Care: A systematic scoping review

EXPLORATORY RESEARCH IN CLINICAL & SOCIAL PHARMACY | Online – 23 July 2021 – This scoping review provides a broad overview of observational studies examining prescribing in palliative care (PC) A key finding was that the average number of prescribed medications per patient ranged from 3 to 23. The review shows that many patients with PC needs receive considerable numbers of medications, including preventative medications that may provide limited or no therapeutic benefit closer to death. A limited number of studies examined the appropriateness of prescribing or the potential for harm. Future research should look to include assessments of prescribing appropriateness using tools that have been developed specifically to guide prescribing in PC. This should also include assessments of the appropriateness of medications to relieve common symptoms experienced by PC populations towards the end of life. DOI: 10.1016/j.rcsop.2021.100050

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Unwelcome Memento Mori or Best Clinical Practice? Community End-of-Life Anticipatory Medication Prescribing Practice: A mixed methods observational study

PALLIATIVE MEDICINE | Online – 8 September 2021 – Anticipatory medications (AMs) are injectable drugs prescribed ahead of possible need for administration if distressing symptoms arise in the final days of life. This study provides valuable insights into an important area of community end-of-life care (EoLC) practice. Standardised anticipatory medication prescribing patterns suggest undue reliance on electronic EoLC templates and a lack of individualised prescribing as advocated in international policy. Marked variability in the timing of prescriptions, at times many months before death, underscores the challenge of prognostication and highlights the risks involved in putting medication in place too far in advance of possible need. The presence of AMs for long periods of time, or when situations are uncertain, may compromise patient safety unless robust systems are in place to review their continued appropriateness and safe use. DOI: 10.1177/02692163211043382

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Family and Health-Care Professionals Managing Medicines for Patients with Serious and Terminal Illness at Home: A qualitative study

HEALTH SERVICES DELIVERY & RESEARCH | Online – Accessed 24 August 2021 – As patients’ health deteriorated, family caregivers assumed the role of a care coordinator, undertaking the everyday work of organising and collecting prescriptions and storing and administering medicines around other care tasks and daily routines. Participants described the difficulties of navigating a complex and fragmented system and the need to remain vigilant about medicines prescribed, especially when changes were made by different professionals... Healthcare professionals often lacked understanding of the practical and emotional challenges involved. DOI: 10.33K10/hsdr09140

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Opioid Safety Recommendations in Adult Palliative Medicine: A North American Delphi expert consensus

BMJ SUPPORTIVE & PALLIATIVE CARE | Online – 13 August 2021 – U.S. and Canadian panellists in palliative care, addiction, and pain medicine developed a total of 130 recommendations covering: 1) General principles; 2) Measures for healthcare institution and palliative care training and clinical programmes; 3) Patient and caregiver assessments; 4) Prescribing practices; 5) Monitoring; and, 6) Patients and caregiver education. DOI: 10.1136/bmjspcare-2021-003178

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Assessment Tools for Problematic Opioid Use in Palliative Care: A scoping review

PALLIATIVE MEDICINE | Online – 17 May 2021 – Palliative care (PC) experts and organizations are recommending the use of tools developed for chronic pain populations in response to increasing concerns about harms associated with opioids. These recommendations are premature. Patients receiving PC may be at risk of opioid-related harms that differ from those of chronic pain populations, and that may vary according to country, PC setting, and stage of illness. DOI: 10.1177/02692163211015567

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Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.

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