Arthur G. Lipman

Anxiety in Palliative Care Patients

SUMMARY Anxiety is a common response to life limiting disease, but it can be pathological. Several different disorders are classified as anxiety and therapy for them varies. Potential underlying etiologies and presentations anxiety are discussed. Non-pharmacological therapies and drug therapy for anxiety in palliative care are described. Evaluation instruments that have been used for this symptom are described. Some open research questions are listed. Evidence tables and drug therapy tables which include drug costs are presented.

Evidence-Based Palliative Care

SUMMARY Palliative care and evidence-based medicine are defined and a brief history of modern hospice care is provided. Much palliative care provided today is based on anecdote, not evidence. While there are limited systematic reviews done in palliative care patients, there are sufficient small randomized controlled trials, n of 1 studies, and case reports to define clinical practice guidelines for common symptoms. The necessity for initiating palliative care as soon as possible after diagnosis of a life limiting disease is discussed. Symptom prevalence in palliative care patients is described. The process by which these guidelines were developed and the 5 levels of evidence are presented in a manner similar to that defined for the Agency for Health Care Policy and Research (AHCPR) clinical practice guideline on the management of cancer pain. Uses and limitations of the guidelines are described.

Report from the American Society of Health System Pharmacists 35th Annual Mid year Clinical Meeting

The Amer i can So ci ety of Health-Sys tem Phar ma cists (ASHP) Mid year Clin i cal meet ing is con sis tently the larg est and best at tended pro fes sional meet ing of phar ma cists in the world. The year 2000 meet ing, which was held in Las Ve gas, Ne vada last De cem ber 3 to 7, was the larg est and most suc cess ful mid year meet ing ever. Nearly 20,000 at ten dees par tic i pated in a broad range of sym po sia, short courses, re search re ports, clin i cal net work ing ses sions, case stud ies and poster pre sen ta tions. In ad di tion to prac ti tio ners from all 50 states, col leagues from 33 other coun tries also par tic i pated. The open ing gen eral ses sion set a theme of avoid ing ad verse drug events. Five half-day sym po sia on pain-re lated top ics were pre sented. A meet ing of the pain man age ment fo cus group and a nu mer ous post ers re lat ing to pain and symp tom con trol also were in cluded in the meet ing. Other sym po sia ad dressed top ics of di rect rel e vance to pain prac ti tio ners in clud ing eth ics, laws, genomics and im prov ing med i ca tion safety. ASHP Pres i dent Max L. Hunt ad dressed the open ing gen eral ses sion of the meet ing and touched upon a range of top ics im por tant to all health pro fes sion als. Hunt noted that in for ma tion tech nol ogy ad vances are bring ing about im mense changes in the way health pro fes sion als and con sum ers ac cess and use drug in for ma tion, now and into the fu ture.

Drug Interactions and Symptom Control

Interactions of medications with other drugs, diet, and co-morbidities with the disorder for which the medication was intended, often produce adverse events or decrease efficacy of the therapy. Many clinicians have become more aware of drug-drug interactions and most pharmacists use computer screening programs to help identify potential drug-drug interactions assistance today. Drug-diet interactions are often more subtle and are not as commonly detected. But such interactions can profoundly impact therapy. In this issue of the Journal, an extensive discussion of clinically important drug interactions with grapefruit juice is presented. The first drug interaction with this common fruit juice and constituent of many prepared foods was reported in 1989. Since then, potentially significant interactions between grapefruit juice and many drugs have been identified. Because first pass metabolism involving the cytochrome P3A isoenzymes is a property of many drugs and of grapefruit juice, interactions are common, and drugs that undergo significant first-pass

Foreword: Format of the Clinical Practice Guidelines

Evidence-Based Symptom Control in Palliative Care includes systematic reviews of the literature and validated clinical practice guidelines for 15 common problems in care of patients with advanced, irreversible disease. Systematically developed text, tables, and algorithms are presented in a consistent order for each symptom or symptom set. Evidence tables and drug therapy tables are provided. Additional tables are included for some symptoms when addition evidence was identified that was conducive to presentation as such. These guidelines are designed to provide clinicians with clinical recommendations based on published evidence which have been validated through reviews and field testing by experienced palliative care clinicians. Because the literature describes some symptoms in pairs, six of the symptoms in this publication are discussed in sets, i.e., nausea and vomiting, anorexia and cachexia, nutrition and hydration problems. Each symptom control guideline is formatted to include the following elements.