ProCare HospiceCare

July Edition 2012

On-Demand Clinical News

CLINICAL CORNER:
Palliative Care offered at Time of Diagnosis: a Review of Recent American Society of Clinical Oncology Findings.
By Cody Midlam, PharmD, CGP [S]ubstantial evidence demonstrates that palliative care when combined with standard cancer care or as the main focus of care leads to better patient and caregiver outcomes." American Society of Clinical Oncology, 2011. In a new report published in the Journal of Clinical Oncology, the American Society of Clinical Oncology has put forward a provisional clinical opinion that extends early palliative care to all patients with metastatic cancer, although the evidence so far shows a survival benefit only in patients with metastatic non-small cell lung cancer. The expert panel concedes that while the phase III clinical trial only focuses on NSCLC, the consensus is that combined standard oncology care and palliative care should be considered early in the course of illness for patients with metastatic disease and/or for those patients with high symptom burden. As most palliative care is associated with end-of-life symptom management, this consensus opinion marks a major change in the provision of care for patients with advanced cancer. Of note, nearly half of all patients with metastatic cancer cannot be cured with currently available treatments. They can, however, survive for years after diagnosis. In the current healthcare climate, it is difficult to meet the needs of many patients with advanced cancer both from a quality and a cost perspective. As it is our primary goal as health care providers to ensure patients with advanced cancer maintain or improve survival and quality of life, it is of significant importance to note that the expert panel found that most studies demonstrate early palliative care improves outcomes at lower cost than standard oncologic care alone. The panel writes that the focus of palliative care emphasizes medically appropriate goal setting, honest and open communication with patients and families, and meticulous symptom assessment control. Further studies are necessary to evaluate the implications of early palliative care, but the focus and direction are a nod to the services we provide each day as hospice care providers. To review the Report in its entirety please see the ASCO website at: http://jco.ascopubs.org/content/30/8/880

FDA Alerts and the New ProCare HospiceCare Facebook Page!

Please see the new Drug Shortage News section of the ProCare HospiceCare website. To the left of the ProCare HospiceCare website you can find a scrolling marque that highlights the most recent FDA reported drug shortages. Each shortage is listed by the date of most recent update and includes specific information on the product, where appropriate, such as specific formulations affected, and dates of resolution. Select Click for Detail Drug Info! to re-direct to the FDA website for further details such as manufacturer phone numbers and productspecific NDC numbers. Additional FDA alerts and other great hospicespecific resources can be found on the new ProCare HospiceCare Facebook page! Stop by to see whats going on at ProCare HospiceCare. Topics on the Facebook page range from clinical questions to help physicians prepare for hospice and palliative medicine boards, to current ProCare HospiceCare events, and more. Feel free to Like the page or Friend us to receive timely updates! Input is always welcome, so feel free to leave a comment or send us a message! http://www.facebook.com/ProCareHospiceCare

Use our QR Code to go directly to ProCare HospiceCares Website!

Spotlight on Rilutek
By Brett Gillis, PharmD Lou Gehrig, the son of German immigrants, was born in 1903 in New York City. His mother worked tirelessly to make ends meet, and his father, in poor health, struggled to find work. Gehrigs mother sent him to Columbia University for a good education where he began to play baseball seriously. Scouts quickly discovered his talent, and Gehrig became a Yankee for good in 1925. His strength and endurance earned him the nickname Iron Horse. However, in 1938 Gehrig began to lack his usual strength, and his batting average suffered. Doctors initially suspected a gall bladder problem and prescribed a bland diet. This only made him weaker. One day, a teammate noticed that he was sliding his feet along the ground as he walked. The medical team at the Mayo Clinic diagnosed him with a very rare degenerative disease, amyotrophic lateral sclerosis (ALS). Amyotrophy is the wasting of muscles, (and sclerosis is pathological hardening) of tissue. In 1941, Gehrig succumbed to the effects of ALS and passed away. ALS, also called Lou Gehrigs Disease (LGD), is a serious neurological disease that causes muscle weakness, disability, and eventual death. ALS occurs in 1 to 3 people in 100,000. Patients with ALS often present with muscle twitching or weakness in an arm or leg or slurred speech. The disease eventually diminishes the patients ability to control muscles. Patients initially struggle to perform activities of daily living and, sadly, eventually become unable to move, speak, eat, and breathe. Despite extensive research and several hypotheses, the etiology and pathogenesis of ALS are unknown. One hypothesis proposes that motor neurons, vulnerable because of genetic predisposition and/or environmental factors, are injured by glutamate, one of the amino acid transmitters in nerve cells. Researchers suggest that glutamate is not cleared from nerve cell junctions swiftly enough in patients with ALS. A mutation that affects the transportation of glutamate away from the nerve junction may contribute or be responsible for excess glutamate. This results in prolonged excitation and toxicity in nerve cells. 40% of patients with sporadic cases of ALS present with elevated glutamate levels in cerebrospinal fluid. Abundant evidence points to glutamate as a destructive factor in ALS. The first, and only FDA approved specific pharmacologic treatment for ALS to date, is Rilutek (riluzole). Riluzole is a benzothiazole drug that modulates glutamate. The exact mechanism of action that ameliorates ALS symptoms is currently unknown. The following pharmacological properties may contribute to Riluzoles effect on ALS: inhibition of glutamate release, inactivation of sodium channels, and interference with transmitter binding at excitatory amino acid receptors. Riluzole researchers performed two small randomized clinical trials to study patients with early stage disease (less than 5 years and baseline Forced Vital Capacity (FVC) of at least 60%). The studies followed these patients for at least 12 months but no longer than 18 months. Survival curves were not statistically significant when analyzed by the method called for in the clinical trial protocol. Although both studies revealed an early increase in survival (extending life by 60 to 90 days for those patients in the Riluzole group), Riluzole failed to decrease mortality by the end of the trials (maximum 18 months).

Continued on page 3

Clinical Question: The Importance of PMH (Past Medical History) and Why We Ask
By Joelle Potts, PharmD, CGP During our new admission consults, ProCare Clinical Pharmacists will ask for the patients past medical history (PMH), or whether the patient has any other conditions or comorbidities. These other conditions may be from recent or remote history and may or may not be directly related to the patients primary/terminal diagnosis. However, even if these other conditions are not directly related to the terminal diagnosis, this information is still important for us to obtain for several reasons: allows for a more complete picture of the patients health and medical history, which can impact the patients status and symptoms as the patient declines allows us to more thoroughly assign coverage of medications as hospice-provided vs. patient-provided, both during the new admission consult and during future consults or medication updates provides valuable information for future consults, grouped in one place in the patients profile, when the information is often most readily available. This allows ProCare Clinical Pharmacists to quickly and easily see valuable information during future consults, when the complete information may not be available to the nurse calling in allows us to better assess whether a certain medication is related to the patients primary/terminal diagnosis or to a pre-existing/unrelated condition

Clinical examples of conditions/history that may be especially relevant to future medication choices while a patient is in hospice include: diabetes; cardiac arrhythmia or presence of a pacemaker; is the patient a current smoker; kidney or liver impairment; and psychiatric history, to name just a few. For example, certain antipsychotics and anti-emetics are either contraindicated or not recommended in patients with Parkinsons disease, and we would not recommend methadone (or certain other medications) as first-line options in patients with a pacemaker due to the potential for QTc interval prolongation. A coverage example is omeprazole, which could be patient-provided due to an unrelated history of GERD, or could be hospice-provided if it is more directly related to the patients terminal diagnosis or end of life comfort (e.g. due to other related medications such as steroids, or dyspepsia-induced nausea, etc.). We realize that sometimes PMH is just not available during the new admission consult. However, we hope that this explains why your ProCare Clinical Pharmacist asks for this information, and why it is important. In general, it allows us to make better recommendations for the patient while avoiding potential drug-disease interactions and adverse effects.

Continued from page 2

Riluzole is appropriate as part of the therapeutic management of early stage ALS to prolong survival and slow deterioration of muscle strength. Current guidelines for the clinical management of ALS recommend Riluzole therapy as soon as possible after a diagnosis of ALS is made. Riluzole is no longer indicated after switching from the active ALS treatment phase to end of life symptom management. References: Clarke, K. and Levine, T. Clinical Recognition and Management of Amyotrophic Lateral Sclerosis: The Nurses Role. Journal of Neuroscience Nurses 2011 Aug; 43 (4): 205-14 Rilutek [Package Insert]. Bridgewater, NJ: Sanofi-Aventis; 2009.

ProCare HospiceCare welcomes all suggestions and comments. If you would like additional information about our services, have ideas for articles, or wish to submit a comment, email us at resources@procarerx.com.

ProCare HospiceCare

The information provided within this newsletter is proprietary to ProCare Rx. Any reprint or reuse of this information must be approved via written consent.
Copyright 2012, ProCare Rx

1267 Professional Parkway, Gainesville, GA 30507

www.ProCareHospiceCare.com
Editor: Dr. Cody Midlam, PharmD Executive Editor: Dr. Raeanna Lewarne, PharmD