1 Reviewer No. 2: IAHPC List of Essential Medicines for Palliative ...
1 Reviewer No. 2: IAHPC List of Essential Medicines for Palliative ...
1 Reviewer No. 2: IAHPC List of Essential Medicines for Palliative ...
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<strong>Reviewer</strong> <strong>No</strong>. 2: <strong>IAHPC</strong> <strong>List</strong> <strong>of</strong> <strong>Essential</strong> <strong>Medicines</strong> <strong>for</strong> <strong>Palliative</strong> Care<br />
The underlying list <strong>of</strong> medicines recommended from palliative care experts, takes into account only those not included in the precedent Model<br />
<strong>List</strong> and signalized in the propose <strong>of</strong> <strong>IAHPC</strong> as “not included”. These medicines are considered as new applications by the author <strong>of</strong> the present<br />
study and submitted to evidence based review <strong>for</strong> comments and recommendations.<br />
17 “not included” medicines distributed throughout 10 symptoms are exposed in the following table with our comments and recommendations:<br />
• Benzodiazepines : 4<br />
• Opioid analgesics : 3<br />
• <strong>No</strong>n opioid analgesic : 1<br />
• Neuropathic pain : 1<br />
• Antidepressants : 2<br />
• Antihistaminic : 1<br />
• Hormone antagonist 1<br />
• Antipsychotic : 1<br />
• Laxative : 1<br />
• Anorexia : 1<br />
• Control <strong>of</strong> respiratory secretion : 1<br />
Benzodiazepines (BZ) are the most important part in the <strong>IAHPC</strong> list, and there is increasing concern about the excessive use <strong>of</strong> this group <strong>of</strong><br />
medicines. This remark supposes a BZ policy <strong>for</strong> doctors, nurses, pharmacists and patients in the future WHO Model <strong>List</strong>. The main rules <strong>of</strong> the<br />
policy must be written:<br />
- Be<strong>for</strong>e prescribing a BZ consider alternative therapy/management.<br />
- BZ should not be given as hypnotic or anxiolytic to: children, the elderly, pregnant or lactating women, alcoholic patients.<br />
- Advice against use <strong>of</strong> lorazepam as an anxiolytic (high abuse potential).
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Table 1 : Review <strong>of</strong> the recommended medicines in relation to the symptoms<br />
Symptoms <strong>Medicines</strong> WHO essential <strong>Medicines</strong> Model <strong>List</strong><br />
Section, subsection and therapy. class<br />
1. Pain<br />
Mild to moderate Dicl<strong>of</strong>enac<br />
<strong>No</strong>n Opioid analgesic and NSAIMs<br />
Comments<br />
Adjunct to opioid <strong>for</strong> relief <strong>of</strong> post operative pain, better antiinflammatory<br />
comparatively to ibupr<strong>of</strong>en<br />
Decision<br />
ACL<br />
Tramadol<br />
Opioid analgesic<br />
Advantage in acute surgical pain not in chronic pain.<br />
ACL<br />
Moderate to severe<br />
Fentanyl<br />
Opioid analgesic<br />
Useful <strong>for</strong> procedural sedation, as injectable <strong>for</strong>m not patch<br />
AL<br />
Oxycodone<br />
Opioid analgesic<br />
Alternative to morphine<br />
Del<br />
Neuropathic<br />
Gabapentin<br />
Neuropathic pain<br />
Equal to tricyclic antidepressant, more effective when<br />
associated with morphine<br />
Del<br />
Visceral<br />
Hyoscine butylbromide<br />
Antimuscarinic<br />
Quaternary ammonium, less lipid soluble and less crossing<br />
the blood barrier than atropine. Only injectable <strong>for</strong>m<br />
AL<br />
2. Insomnia Diphenhydramine<br />
Sedative antihistaminic<br />
Prolonged sedation not recommended in children<br />
ACL<br />
Lorazepam<br />
Zolpidem<br />
Benzodiazepine<br />
<strong>No</strong>n benzodiazepine hypnotic<br />
Short acting carrying the risk <strong>of</strong> withdrawal in the treatment<br />
<strong>of</strong> insomnia, better indication in status epilepticus<br />
The magnitude <strong>of</strong> the effect is small in comparison to risk<br />
Del<br />
Del<br />
Trazodone<br />
3. Anxiety Midazolam<br />
Mono-amine-oxydase inhibitor<br />
Benzodiazepine<br />
Equivalent to imipramine<br />
Better efficacy when associated with anesthetics, analgesics<br />
Del<br />
ACL<br />
Lorazepam<br />
4. Depression Mirtazapine<br />
Benzodiazepine<br />
Presynaptic α2 antagonist<br />
Useful only as amnesic agent in premedication <strong>for</strong><br />
bronchoscopy or bone marrow biopsy, facilitates the<br />
investigations. Nevermore used as anxiolytic.<br />
<strong>No</strong>t different from the old antidepressant<br />
ACL<br />
Del<br />
Citalopram<br />
SSRI<br />
As a tricyclic antidepressant but useful in panic attack<br />
ACL
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Symptoms <strong>Medicines</strong> WHO essential <strong>Medicines</strong> Model <strong>List</strong><br />
Section, subsection and therapy. class<br />
5. Nausea, vomiting, Diphenhydramine Sedating antihistamin<br />
diarrhea<br />
Octreotide<br />
Hormone antagonist<br />
Comments<br />
<strong>No</strong>t useful <strong>for</strong> the proposed indication<br />
Evidence in the management <strong>of</strong> acute pancreatitis crisis when<br />
associated with gabexalate, mesylate<br />
Decision<br />
Del<br />
ACL<br />
6. Delirium Levomepromazine Antipsychotic <strong>No</strong>t better than haloperidol or chlorpromazine Del<br />
7. Terminal<br />
Levomepromazine Antipsychotic<br />
Occasionally<br />
Del<br />
restlessness<br />
Midazolam<br />
Benzodiazepine<br />
Suitable <strong>for</strong> restlessness patient<br />
AL<br />
8. Constipation Bisacodyl Laxative, stimulant Some benefit over senna : useful <strong>for</strong> breastfeeding mother ACL<br />
9. Anorexia Megestrol acetate Progestagen Weight gain but mainly by fat, without improving muscular<br />
mass<br />
10. Control <strong>of</strong> Hyoscine butylbromide Antimuscarinic Class <strong>of</strong> quaternary ammonium presents advantage over<br />
respiratory secretion<br />
atropine in the indication (only parenteral presentation)<br />
Del<br />
AL<br />
AL : proposed to add in the core list<br />
ACL : proposed to add in the complementary list<br />
Del : proposed to delete from the Model <strong>List</strong>.
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