Monday, April 16, 2007

Alvimopan; End stage heart failure; Other things

Medscape is reporting that alvimopan (an investigational drug for opioid-induced constipation) caused a small increase in heart attacks in one of its phase III trials ( 1.1% of patients with placebo vs. 2.6% with alvimopan had cardiovascular events). The FDA is apparently reviewing things. Alvimopan, along with methylnaltrexone, has been one of the much hoped for up & coming agents for opioid constipation (and potentially other side effects), so we'll see where this leads. That magnitude of increase in CV events is similar to many other drugs which have remained on the market (newer antipsychotics come to mind)--the FDA will have to decide if the added benefit of this new drug will be worth the risks....

(Medscape articles are available free if you sign-up.)

Heart has a review of the management of 'end-stage' heart failure patients. It's noteworthy for a couple of reasons. First, it's a well-written overview of the subject and addresses some of the newer trends: devices (ICD's, biventricular pacing), ventricular assist devices, etc. Second, it gives a nod towards palliative-oriented approaches to care and advance care planning in this population (for those of you who've read this blog for a long time you'll remember I use to track major review articles of highly mortal diseases such as mesothelioma and if they mentioned palliative/terminal care). It has a section, 'Palliative Approaches,' which gets just about as much column space as 'Experimental Approaches' which mentions advance care planning, supportive care, treatment limitations, hospice, etc. Included in this is a mention of continuous infusions of inotropes (i.e. dobutamine), a practice many in our field will balk at, although they definitely fit a palliative model (they don't make people live longer...if anything they shorten peoples' lives...but they can make people feel better). I'm curious if anyone has used these or seen them used in 'terminal' settings with palliative-only goals--I haven't yet.

An update on an earlier post:
Marachne alerted me to a provision in the Oregon Death with Dignity Act which explicitly addresses insurance:

127.875 s.3.13. Insurance or annuity policies. The sale, procurement, or issuance of any life, health, or accident insurance or annuity policy or the rate charged for any policy shall not be conditioned upon or affected by the making or rescinding of a request, by a person, for medication to end his or her life in a humane and dignified manner. Neither shall a qualified patient's act of ingesting medication to end his or her life in a humane and dignified manner have an effect upon a life, health, or accident insurance or annuity policy. [1995 c.3 s.3.13]

And to continue in the vein of Christian' s recent media postings, American Radioworks has a radio documentary available online on the hospice movement (you can stream it for free). It's a couple years old, but I just recently discovered it because, despite its age, it's the most recently posted documentary on their podcast list in iTunes (for those of you who use iTunes go to the Podcast directory>American Public Media under 'Featured Providers'>American Radioworks). Worth listening to, particularly if you're a public radio junkie.

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