Wednesday, August 5, 2009
Pall-Pourri: Vertebroplasty & the QTc
1)
European Journal of Cancer has a small case series about vertebroplasty for vertebral metastases from solid malignancies. The study involves all consecutive vertebroplasties (n=19, mostly breast and prostate cancer, mean age 70 years, 47% received multiple level interventions at the same time) performed at a single UK center. In a relatively loose fashion, pain relief was assessed afterwards and at at least 3 month followup. They report that 84% (16) patients reported 'immediate benefit' in pain and ability to ambulate, and that all 16 of those continued to report some benefit (although unclear how much) at 3 months. 15 reported decreased use of analgesics although how much etc. is not described. We talked recently about the large, randomized, unblinded trial of a similar procedure (balloon kyphoplasty) which included a handful of cancer patients. This study confirms the general clinical impression that these procedures are helpful for most patients but doesn't unfortunately add much to that (how helpful, how long, how much more than medical management, etc.).
Late entry 8/5- I'm adding this after I originally posted this earlier today so it will at least be up to date for those who read this on email: two people have already emailed me about tomorrow's NEJM which presents two randomized, sham-procedure controlled trials of vertebroplasty for osteoporotic fractures and found no benefit over a sham procedure (here & here). I've only read these in abstract at this point; but will blog in-depth soon. Exciting stuff. Thanks to Drs. David Weissman & Bob Arnold who let me know.
2)
Annals of Internal Medicine has published a series of highly critical letters about the recently published consensus guidelines on QTc prolongation and methadone (our original blog post here; letters here, here, here, here; authors' reply here; original article here). The major themes of the letters are that QT monitoring as suggested in the guidelines is impractical, actual rates of harmful events from QT prolongation in methadone are very low, for patients on methadone maintenance therapy there is often no effective alternative to help maintain abstinence, and the evidence one way or the other is crap. This latter point is the real one; there can be such widely-divergent, well-informed opinion about this because there is really very little practical data to guide us.
4 Responses to “Pall-Pourri: Vertebroplasty & the QTc”
August 05, 2009
I updated the post about the NEJM vertebroplaty trials just published.
August 06, 2009
I use methadone quite a bit in my practice. I can't speak for methadone maintenance programs or pain management programs, they may have a very different population than we see in palliative care. My patients are unstable, have many co-morbidies and are on lots of medications. I often consult a pharmacist, since multiple meds can increase QTc cumulatively or interact in other ways. I always get a baseline ECG (or take a look at a recent one), and again with dose changes. I think the guidelines are very helpful-- MUCH better than having no guidance at all.
August 06, 2009
R - thanks for that. I don't find them too onerous myself however I only apply them to certain of my patients (with extended prognoses) I think the methadone maintenance question is much more challenging.
August 07, 2009
I'm of the camp that routine ECG monitoring of patients on methadone is burdensome, costly, impractical, and given the underwhelming evidence of harm, unnecessary. For patients that are actively dying, on hospice with prognosis less than two weeks, who may benefit from methadone because they were on higher doses of opioids or for ease of administration (SL route), I never get an ECG. In the hospital setting, chances are at some point they have had one anyway. For patients who are more walkie/talkie, maybe older with a good functional status, I only recently started getting a baseline ECG if I start them on methadone. Again, many of the patients we see in our practice have so many co-morbidities that concern over prolonged QT seems almost trivial.
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