Sunday, August 3, 2014

Palliative Care: Better Early Than Late

The much referred to NEJM Temel article highlighted the positive impact of early palliative care in terms of symptom management and even extending life. The Pallium group summarize this nicely:


Monday, May 5, 2014

Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Clinical Practice Guideline

ASCO has recently published guidelines for the prevention and management of CIPN. Unfortunately, but not surprisingly even after a robust medical literature search, there are no revolutionary breakthroughs for the treatment or prevention of chemotherapy-induced neuropathy (CIPN). Here is a summary of the publication:

[You will also find this web page linked on the left hand side permanently under "Useful Links"]
"Recommendations: On the basis of the paucity of high-quality, consistent evidence, there are no agents recommended for the prevention of CIPN. With regard to the treatment of existing CIPN, the best available data support a moderate recommendation for treatment with duloxetine. Although the CIPN trials are inconclusive regarding tricyclic antidepressants (such as nortriptyline), gabapentin, and a compounded topical gel containing baclofen, amitriptyline HCL, and ketamine, these agents may be offered on the basis of data supporting their utility in other neuropathic pain conditions given the limited other CIPN treatment options. Further research on these agents is warranted."
Link to the guidelines, summary, slide deck, etc. at ASCO website: click here

Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline |
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Sunday, April 13, 2014

"Cancer: The Emperor of All Maladies" Preview at AACR Annual Meeting 2014

"The American Association for Cancer Research (AACR), the world's oldest and largest professional organization dedicated to advancing cancer research and its mission to prevent and cure cancer, is proud to be an outreach partner for "CANCER: The Emperor of All Maladies," a film documentary presented by Ken Burns. Based on the book "The Emperor of All Maladies: A Biography of Cancer" by Siddhartha Mukherjee, M.D., the film will air on PBS in spring 2015. The AACR is an outreach partner for the documentary, along with Stand Up To Cancer (SU2C), a program of the Entertainment Industry Foundation (EIF) that works to accelerate innovative cancer research and to increase awareness about progress being made in the fight against the disease."
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Saturday, March 22, 2014

Video: Healthcare Professionals on Twitter: Worldwide Growth Mapped 2006-2014

"Video maps growth in doctors, nurses and healthcare professionals using Twitter since its launch in 2006 to 2014. Data sourced using Creation Pinpoint, the world's largest research tool for learning from healthcare professionals in public social media."

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Wednesday, March 19, 2014

Valproic Acid Linked with Reduced Risk of Developing Head and Neck Cancer

Sodium valproate is a common mood stabilizer
Sodium valproate is a common mood stabilizer (Photo credit: Wikipedia)
I was surprised to read this press release this morning concerning valproic acid, an antiepileptic, mood stabilizing medication that has also been used traditionally in the management of neuropathic pain.

I am interesting in seeing the doses most commonly encountered and the relevant toxicities. As PCF-4 ( notes, no single mode of action accounts for its anti-seizure activity. It is a:
  • sodium and T-type calcium channel blocker
  • an NMDA receptor-channel blocker (?helpful in hyperalgesia)
  • alters GABA (distinctively selective for midbrain), dopamine and serotonin transmission
T-type calcium channels have been implicated in thalamic burst firing (absence seizures), neuropathic pain and possibly in regulating pain excitation thresholds in a 'T-rich' subset of peripheral nociceptors. 

Beneficial effects have been reports in cancer-related neuropathic pain in Europe and Australia, but mixed results in other pain scenarios. Onset of action can often be within 24 hours for neuropathic pain.

But I digress - on to the news of the day:

Excerpt of Press Release via Wiley:

"A new study indicates that a commonly used mood stabilizing drug may help prevent head and neck cancer. The study is published early online in CANCER, a peer-reviewed journal of the American Cancer Society.

Valproic acid (VPA) is currently prescribed as an anti-seizure medication and mood stabilizer, but it is also being studied as an anticancer agent because it inhibits histone acetyl transferases, which help control gene expression by changing DNA structure.

Johann Christoph Brandes MD, PhD, of the Atlanta Veterans Affairs Medical Center and Emory University in Atlanta, led a team that assessed the anticancer effects of VPA in a study of 439,628 veterans, of whom 26,911 were taking the medication for bipolar disorder, post-traumatic stress disorder, migraines, and seizures.

Veterans who took VPA for at least one year had a 34 percent lower risk of developing head and neck cancer compared with those who did not take the medication. Higher doses and longer duration of VPA use seemed to provide additional benefits. No significant differences were observed for lung, bladder, colon, and prostate cancer incidences.

“A 34 percent risk reduction for the development of head and neck cancer with VPA use could result in the prevention of up to approximately 16,000 new cases and 3,000 to 4,000 annual deaths in the US alone,” said Dr. Brandes. “Head and neck cancer is an important global health crisis, and low cost and low toxicity prevention strategies like VPA use have a high potential impact on pain, suffering, costs, and mortality associated with this disease.”

Article: “Long-term use of valproic acid in United States Veterans associates with reduced risk of smoking related head-and neck cancer.” Hyunseok Kang, Theresa Gillespie, Michael Goodman, Seth Brodie, Mina Brandes, Maria Ribeiro, Suresh Ramalingam, Dong Shin, Fadlo Khuri, and Johann Christoph Brandes. CANCER; Published Online: March 24, 2014 (DOI: 10.1002/cncr.28479).
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Tuesday, March 18, 2014

Treating ‘phantom limb pain’ with mirror therapy - Mirror Box Therapy

A mirror box used for treating phantom limbs, ...
A mirror box used for treating phantom limbs, developed by V.S. Ramachandran. (Photo credit: Wikipedia)
Treating ‘phantom limb pain’ with mirror therapy | mirror box therapy:

"Whether the phantom is in the hand or the foot the principle of mirror box therapy is still the same. In this video soldier Bryan Wagner talk us through his phantom and how mirror box therapy help him cope with the pain."

Link to full article and video
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Monday, March 3, 2014

The WPCA - Global Atlas of Palliative Care

The WPCA - Global Atlas of Palliative Care

"Published jointly by the World Health Organization and the Worldwide Palliative Care Alliance, the Atlas is the first document to map the need for and availability of palliative care globally.

Using maps, graphs and case studies, and drawing on a wealth of resources, the Atlas addresses the following questions:

  • What is palliative care?
  • What are the main diseases requiring palliative care?
  • What is the need for palliative care?
  • What are the barriers to palliative care?
  • Where is palliative care currently available?
  • What are the models of palliative care worldwide?
  • What resources are devoted to palliative care?
  • What is the way forward"

Read the full article here
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Tuesday, February 25, 2014

VTE Treatment and Secondary Prevention in Cancer Patients :: Treatment and Secondary Prevention

"The American Society of Clinical Oncology guideline: Recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer
Key recommendations for secondary prevention of recurrent VTE19"

  • LMWH is the preferred approach for the initial 5 to 10 days of anticoagulant treatment of the cancer patient with established VTE
  • LMWH given for 6 months is also the preferred approach for long-term anticoagulant therapy. Vitamin K antagonists with a targeted INR of 2 to 3 are acceptable for long-term therapy when LMWH is not available
  • After 6 months, indefinite anticoagulant therapy should be considered for selected patients with active cancer, such as those with metastatic disease and those receiving chemotherapy
  • The insertion of a vena cava filter is only indicated for patients with contraindications to anticoagulant therapy and in those with recurrent VTE despite adequate long-term therapy with LMWH
  • For patients with CNS malignancies, anticoagulation is recommended for established VTE as described for other patients with cancer. Careful monitoring is necessary to limit the risk of hemorrhagic complications. Anticoagulation should be avoided in the presence of active intracranial bleeding, recent surgery, preexisting bleeding diathesis such as thrombocytopenia (platelet count <50 coagulopathy="" font="" l="" or="">
  • For elderly patients, anticoagulation is recommended for established VTE as described for other patients with cancer. Careful monitoring and dose adjustment is necessary to avoid excessive anticoagulation and further increase in the risk of bleeding

For full article including great summary charts and diagrams as well as other key player guidelines, click here.
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Saturday, February 22, 2014

Personalized Cancer Treament, From Just a Blood Sample

Personalized Cancer Treament, From Just a Blood Sample - The Crux |

"A technique being developed by San Diego–based Epic Sciences can determine whether a cancer patient is an appropriate candidate for a drug, and even whether the drug is losing its efficacy.

In research presented last month at the Personalized Medicine World Conference in Palo Alto, CA, Epic described how their technology can be used to reliably pick out rare cells from a blood sample. In the case of cancer, these rare, circulating tumor cells could one day tell an oncologist not only whether a patient’s cancer has returned, but also whether it’s growing resistant to the current treatment regimen—something only expensive scans and invasive biopsies can do with any accuracy today."

Read the full article here

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Thursday, February 13, 2014

Medications Can Affect Sexes Differently

English: Chemical structure of zolpidem
English: Chemical structure of zolpidem (Photo credit: Wikipedia)
Sex matters: Drugs can affect sexes differently - CBS News:

"Ambien, Zolpidem, is now the only prescription drug in the country with a different suggested dose for men and women. But we’ve discovered it is far from an isolated example of differences between the sexes we never imagined.  More and more, scientists are realizing that the differences are dangerously understudied and that pervasively and fundamentally, sex matters.
Take aspirin. Low-dose aspirin lowers the risk of heart attacks in healthy men; but in healthy women, turns out it doesn’t though it does protect women against stroke.

And drugs are just the beginning.  Sex differences have been found in pain receptors, liver enzymes, even the wiring of the brain."

Read full article: click here
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Sunday, February 9, 2014

Could Electronically Controlled Drugs Reduce Adverse Effects? (CNET)

Could electronically controlled drugs reduce side effects? | Cutting Edge - CNET News:

In the realm of oncology this could have especially dramatic ramifications.


"Reporting in the journal ACS Nano, researchers led by Dr. Xinyan Tracy Cui at the University of Pittsburgh say their new approach allows them to electronically control the release of very specific amounts of drugs to certain parts of the body. To do this, they incorporated extremely thin nanosheets of graphene oxide that were loaded with the anti-inflammatory drug dexamethasone into a polymer scaffold that conducts electricity. By zapping the nanosheets with an electric current, they were able to release the drug -- using the thickness of the sheets to control how much drug was being carried, and the number and magnitude of zaps to control how much of the drug was released."

Full article: click here

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Thursday, January 23, 2014

Fentanyl Transdermal Patch Application Sites

English: 2D structure of fentanyl
English: 2D structure of fentanyl (Photo credit: Wikipedia)
We know that fentanyl patches should be applied to dry, noninflamed, non-irradiated, hairless skin. Body hair may be trimmed but not shaved. Be sure to press the patch firmly in place for 60 seconds or more. If problems with adherence, use Tegaderm or Micropore.

Fact or Fiction From Medscape:

Q: Is it true that fentanyl patches infuse more quickly in patients with very little subcutaneous fat?

A: No. The amount of fentanyl absorbed is proportional to the surface area of the patch. The absorption rate does not vary to any clinically significant extent between the chest, abdomen, and thigh.[5] Fentanyl is released from the patch into top layers of the skin (stratum corneum and epidermis), and it accumulates within these layers to form a depot. The drug is released slowly into the systemic circulation via small blood vessels within the dermis. Fat tissue should not impair release, as the drug is released directly from the skin into the blood supply.[2,5]

Furthermore, fentanyl exhibits wide tissue distribution to the lungs, kidneys, heart, spleen, brain, muscles, and body fat -- indicating a high extravascular volume of distribution (3-8 L/kg). It takes about 6 days to reach steady-state plasma concentrations after initiating fentanyl patch therapy.[5]

  • Muijsers BBR, Wagstaff AJ. Transdermal fentanyl: an updated review of its pharmacological properties and therapeutic efficacy in chronic cancer pain control. Drugs. 2001;61:2289-2307. Abstract
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Learn Something New qD: Methadone and Verapamil are Structurally Similar

English: Synthesis of methadone Deutsch: Synth...
English: Synthesis of methadone Deutsch: Synthese von Methadon (Photo credit: Wikipedia)
structural formula of Verapamil
structural formula of Verapamil (Photo credit: Wikipedia)
In a new series at OncoPRN, look for unique facts in the world of medications, oncology and palliative care

From Medscape:

"Methadone appears to have a molecular structure similar to that of verapamil and may exhibit similar cardiac properties, such as calcium channel blockade.[10] One study demonstrated that methadone, unlike morphine, significantly lowered heart rate in rats (p<0 .05="" span="">[10]

10 Seyler DE, Borowitz JL, Maickel RP. Calcium channel blockade by certain opioids. Fundam Appl Toxicol 1983;3:536-42.

The potential of methadone to cause adverse effects similar to verapamil must be taken under consideration clinically in any patient taking methadone or is to start methadone.
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Thursday, January 16, 2014

No More Needles? 7 Ways Scientists are Attempting to Move Beyond Shots (TED Blog)

No more needles? 7 ways scientists are attempting to move beyond shots | TED Blog:

A shot through a puff of air

"In 2012, Jack You of Seoul National University unveiled a device that delivers drugs through a laser pulse. The pulse lasts 250 millionths of a second and, through a series of reactions described on, creates a narrow jet of medicine that is just larger than the width of a human hair. “The impacting jet pressure is higher than the skin tensile strength and thus causes the jet to smoothly penetrate into the targeted depth underneath the skin,” explains Yoh. This device is intended to get medicine to the epidermal level."

Full article link: click here

TED - ideas worth sharing!

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About Onco-PRN

Welcome and thanks for visiting Onco-P.R.N. - The oncology website with a focus on all things oncology pharmacy/pain/palliative care-related. It is intended to be an information resource for those pharmacist and relevant health care professionals involved in whatever fashion with cancer and palliative care. Stay tuned for the latest and greatest links and information with respect to: oncology medications, continuing education, pharmaceutical care initiatives, pain and symptom control, supportive care topics, and whatever else that might fit into the theme.

*Note: This website is not affiliated with Alberta Health Services (AHS) or CAPhO and the opinions expressed herewithin are that of the author(s).

Pharmacy History

"The earliest known compilation of medicinal substances was ARIANA the Sushruta Samhita, an Indian Ayurvedic treatise attributed to Sushruta in the 6th century BC. However, the earliest text as preserved dates to the 3rd or 4th century AD.
Many Sumerian (late 6th millennium BC - early 2nd millennium BC) cuneiform clay tablets record prescriptions for medicine.[3]

Ancient Egyptian pharmacological knowledge was recorded in various papyri such as the Ebers Papyrus of 1550 BC, and the Edwin Smith Papyrus of the 16th century BC.

The earliest known Chinese manual on materia medica is the Shennong Bencao Jing (The Divine Farmer's Herb-Root Classic), dating back to the 1st century AD. It was compiled during the Han dynasty and was attributed to the mythical Shennong. Earlier literature included lists of prescriptions for specific ailments, exemplified by a manuscript "Recipes for 52 Ailments", found in the Mawangdui tomb, sealed in 168 BC. Further details on Chinese pharmacy can be found in the Pharmacy in China article."

From Wikipedia:

Journal of Palliative Medicine - Table of Contents

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