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Sunday, April 17, 2011

A few pearls from ACP

Earlier this month the 2011 ACP annual meeting was held in San Diego.  In addition to escaping New England to Southern Cal in early April, I got to see old friends at San Diego Hospice, meet the fellows, and catch some pearls at the ACP meeting.  I wish there were more of us there tweeting and blogging, because I could not catch all the talks I wanted to.  Here are some of the articles highlighted in talks I attended that may be pertinent to our field:

Updates of Ethics, Dr. Sha reviewed key articles/events in palliative care and ethics:
Top Ten Medication Errors in IM - Douglas Paauw speaks of common drug side effects/reactions and drug-drug interactions.  The key drugs talked about that most apply to palliative care include:
  • PPIs are loosing favor.  Why? Due to increased risk of osteoporotic fractures (from the Arch Intern Med 2010; 170(9):765-771) and *c. diff (Arch Intern Med 2010; 170:772-778, W J Gastroenterology 2010:16(28):3573-3577 Open Access PDF). For us in palliative care, the latter is more critical - especially in the hospice setting. PPIs carry a much higher risk for recurrent c. diff.  
  • Triptans and SSRIs may not play well together. Beware of prescribing triptans for migraines in patients on SSRIs due to increased risk of serotonin syndrome.
  • Bisphosphonates may cause severe musculoskeletal pain.  Patients taking oral bisphosphonates for osteoporosis had 5.6% incidence of severe musculoskeletal pain, but for those taking it weekly, the incidence increased to 20-25%. This higher incidence is also noted in monthly dosing. - This to me was of note, given the number of our patients on bisphosphonates as co-analgesics for metastatic bone pain.  J Muscoloskeletal Neuronal Interact 2007; 7(2):144-148 612 Open Access PDF) -
  • SSRIs may cause increased risk of UGI bleeds. - especially when given in conjunction with NSAIDs.  The risk is higher in older patients.  (Clin Gastroenterol Hepatol 2009;7(12):1314-1321. Aliment Pharmacol Ther 2008;27:31-40 (meta-analysis))
Dr. Scott Goldstein presented some bread and butter information about managing Common Anorectal Disorders. Some key points for palliative care:
  • Anal fissures: symptomatic relief - use Sitz baths, stool softeners and pain management.  Other options include topical nitroglycerine, Botox injection, surgery.
Dr. Douglas Paauw out-did himself on this one: Evaluation and Treatment of Common Symptoms.
  • Cough associated with acute bronchitis: beta-agonists had little effect (although they did help wheezing); cough suppressants including codeine did little; placebo did wonders, as did honey. (Ann Intern Med 2000;133:981-991 Open Access PDF. Psychosomatic Medicine 2005;67:314-317 Open Access PDF. Arch Pediatr Adolesc Med 2007;161(12):1140-1146. Open Access PDF)
  • Migraine headaches are actually often the true etiology of what many patients call sinus headaches. (Tips include - no fever, no nasal discharge, no cobble-stoning).  Metoclopramide in combination with acetaminophen is as effective as triptans if patient has nausea. Otherwise, metoclopramide may potentiate effectiveness of triptans.  Metoclopramide may be more effective than hydromorphone in treating severe migraine headache pain. J Pain 2008;9(1):88-94.
  • Flatulence that is malodorous - the two best EBM ways to treat stinky flatulence - after stopping any drugs or food that might be the culprit (lactulose, Psyllium, PPIs) include rifaximin (Am J Gastroenterology 2006;101:326-333) and charcoal cushions (Gut 1998; 43:100-104).  For over the counter remedies - there is a question as to whether bismuth subsalicylate may decrease the smell. Simethicone has no effect.
If anyone is interested in writing up any one of these great articles for Pallimed, please let us know.  They deserve some more discussion individually.

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