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Tuesday, January 10, 2006

Propofol & octreotide

There are two more articles from December's Journal of Pain & Symptom Management that I wanted to highlight.

First, there's a brief piece about using propofol as an anti-emetic and sedative in palliative care. It's essentially a case series of 35 patients in a palliative care unit who received propofol over 10 years in Stockholm. I'm not going to make much of its use in palliative sedation--it seems to work, the authors show their dosing data, it's probably no more or less dangerous that palliative sedation with benzodiazepines or barbituates. What is more interesting is their use of it to treat refractory nausea/vomiting. They present experience from 13 patients whose nausea persisted despite most typical antiemetics being thrown at them. In only 3/13 was treatement limited by excessive sedation, and most of the rest had good control of nausea with propofol without dose-limiting sedation. Doses were generally less than 1mg/kg/hour, and the authors recommended starting at 0.5mg/kg/hour and titrating to effect. (Be warned: data was not collected prospectively or in an organized/standardized fashion for this case series--my overall take on this data is that it's proof of principle for propofol as an antiemetic but not much more).

Second, long acting octreotide is examined for malignant bowel obstruction for ovarian cancer. The findings aren't promising, but this study is so small and preliminary that really no conclusions can be drawn. This was a pilot trial on 13 people with advanced ovarian cancer and bowel obstruction (however, 5 of them didn't evidence of bowel obstruction when imaged!) who were ineligible for surgery. They received the "depo" form of octreotide. Results were a complete wash--over half had no evidence of response. 3 patients did remain on it for more than 8 months leading the authors to remark about its "safety and tolerability," which is swell, but "efficacy" is important also. The study is so small, and the patient population probably poorly chosen, that by no means can long acting octreotide be written off, although its use currently can't be endorsed outside of a trial either, especially when there's at least some decent, positive data for short acting octreotide.

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