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Guidance on Converting from Divalproex Sodium (Depakote) to Valproic Acid

As hospices operate with limited funds, minimizing drug costs is important. Therapeutic substitution, where one drug is replaced with a less expensive drug, is one tool to help with this. One substitution we’re occasionally asked about is using valproic acid (VPA) (Depakene) in place of divalproex sodium (Depakote). VPA costs about half as much as […]

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Rectal Drug Administration at End of Life

The oral route is by far the most popular and convenient means of drug administration, even in the hospice setting. However, for various reasons (e.g., dysphagia, nausea / vomiting, bowel obstruction, obtundation) as many as 70% of hospice patients will need their medications to be administered by non-oral routes.a-c Rectal drug administration is probably done […]

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ALS Symptom and Disease Management in Hospice

ALS (Amyotrophic Lateral Sclerosis), also known as Lou Gehrig’s disease, is an incurable progressive neurodegenerative disorder that leads to weakness, spasticity, and incoordination of the muscles involved in speaking, swallowing, breathing, and ambulation. Background1-4 Its onset most often occurs between the ages of 40 and 70, with a median survival time of 30 months, but […]

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Best Practices for Drug Administration via Enteral Tubes

Occasionally, hospice clinicians may encounter patients with enteral feeding tubes (FTs). These tubes are used to provide enteral nutrition (EN) in individuals with a functioning GI tract who are otherwise unable to be fed orally.1 There are numerous types of tubes out there which are generally classified by insertion site and where in the body […]

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Handling Drug-induced QTc Interval Prolongation in Hospice

If you’ve ever used software that checks for drug interactions, you’ve come across alerts regarding QT interval prolongation. But you work in hospice…are these still significant and what can you do about them? Let’s start with some basics1 -6: QT interval – a measure of ventricular repolarization in the heart QTc interval – QT interval […]

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Fosfomycin for treating lower urinary tract infection (UTI)

A group home owner is requesting antibiotics for a hospice patient who’s been increasingly confused over the last several days and has foul smelling urine. You order a culture & sensitivity (C&S) that reveals bacterial growth in the urine and resistance to multiple antibiotics. The susceptible antibiotics listed on the report aren’t ideal because they […]

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How do I convert from brexpiprazole to aripiprazole?

Earlier this year, the FDA expanded the list of approved indications for brexpiprazole (Rexulti®) to include the treatment of dementia-related agitation due to Alzheimer’s disease, making it the first antipsychotic (or any drug class for that matter) to gain FDA approval for treating agitation in patients with any type of dementia. Despite its new approval, […]

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SGLT2 Inhibitors: More than Diabetes Drugs

Known for their role in managing diabetes, sodium-glucose cotransporter 2 (SGLT2) inhibitors like Farxiga (dapagliflozin) and Jardiance (empagliflozin) also improve symptoms, function, and quality of life in patients with heart failure (HF).1 So it’s no surprise that they were added to the latest HF guidelines, even for patients without diabetes.1 The 2022 American Heart Association […]

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A Review of Loop Diuretics: Considerations for Drug Selection

Loop diuretics are essential medications for managing fluid overload and edema caused by conditions like heart failure, liver disease, or chronic kidney disease.1-4 They work by decreasing renal sodium and chloride reabsorption with the end result being  water excretion through urination (diuresis).1-3 You can learn more about loop diuretic pharmacology here. By far, furosemide is […]

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CAMouflage: Which CAMs represent hidden danger for your heart failure patients?

Complementary and alternative medicines (CAM) are popular among patients because they’re readily available and perceived to be safe since they can be purchased over-the-counter without a prescription.1 While these products are relatively easy to obtain, they aren’t regulated like traditional medications. Importantly, CAM manufacturers aren’t generally required to demonstrate that products are safe or effective.1,2 […]

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Subcutaneous Medication Administration at the End of Life

The oral route is by far the most common way medications are administered – even in the hospice setting. However, it’s not always feasible for a number of reasons – dysphagia, nausea/vomiting, or obtundation to name a few.1,2 Administering drugs subcutaneously (SC/SQ) is one method used to overcome patients’ inability to swallow and absorb oral […]

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The Link Between Pain and Behavioral and Psychological Symptoms of Dementia (BPSD)

Treating patients with severe dementia is complex and challenging. The frustrating reality is that these individuals are usually unable to communicate basic needs. In turn, unmet needs contribute to the behavioral and psychological symptoms of dementia (BPSD) — in particular, agitation, aggression (verbal and/or physical), apathy, and depression.1,2 BPSD are disruptive and distressing to the […]

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Auvelity (dextromethorphan-bupropion) – A New, Fast-Acting Antidepressant

One of the problems with starting traditional antidepressants in hospice patients is that they might take too long to start working (typically a few weeks) and/or reach their full effect (up to 8 weeks). To get around this, some hospice clinicians will prescribe methylphenidate or ketamine to treat depression more rapidly; the onsets are about […]

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Considerations for Daliresp (roflumilast) Use in Hospice

Managing drug therapy in terminally ill COPD patients can certainly be challenging. Patients may be resistant to changing long-term medication regimens.1 Patients and caregivers may even interpret medication adjustments as giving up, patient abandonment, or as a suggestion that death is imminent.1 In this patient population, especially, some medications that were once effective may no […]

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Adlarity: A New Way to Deliver Donepezil

About 6.5 million Americans over 65 have Alzheimer disease and that number’s expected to balloon to 14 million by 2060.1 Many transition to hospice services, so hospice clinicians are sure to encounter patients taking the latest branded medications. One is a drug approved by the U.S. Food and Drug Administration (FDA) in March 2022 called […]

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What are the differences between diltiazem dosage forms?

With seemingly innumerable generic variants among dosage forms, diltiazem undoubtedly causes more confusion than any other drug when it comes to generic substitutions. As of August 2022, the FDA Orange Book lists a whopping 117 active diltiazem formulation/strength/manufacturer combinations. So, how do prescribers and pharmacists sort this mess out? Among those 117 products are “injectable”, […]

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Albuterol vs. Levalbuterol: What’s the Difference?

Albuterol and levalbuterol are short-acting beta-2 agonists (SABAs) that are used to manage acute breathlessness associated with asthma, COPD, or bronchospasm.1-3 Both drugs exert their primary effects by binding to beta-2 receptors in the lungs, which causes smooth muscle relaxation and bronchodilation.1-3 So, what’s the difference between the two? Albuterol is a racemic mixture, meaning it contains […]

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Factors that influence NSAID selection

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat pain and inflammation.1,2­With more than 20 different (but similarly effective) NSAIDs on the market, why would a provider prescribe or recommend one NSAID over another?3-5 Cox-Selectivity NSAIDs inhibit cyclooxygenase (COX) enzymes to prevent the production of prostaglandins, which are chemical mediators of pain and inflammation.1-6 There […]

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Inhaled Isopropyl Alcohol for Nausea

Antiemetics like prochlorperazine, haloperidol, or ondansetron are often prescribed to alleviate nausea in hospice patients, but there are always situations where symptoms don’t respond, contraindications exist, or medications aren’t readily available. One outside-the-box remedy that hospice clinicians might consider adding to their nausea management toolbox is inhaled isopropyl alcohol vapor. Some compelling evidence for using […]

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Deprescribing Proton Pump Inhibitors

An Update from the American Gastroenterological Association Deprescribing (the planned process of reducing a medication’s dose or stopping it completely) is now a relatively well-known term among hospice clinicians.1 Clear deprescribing guidance is lacking for many drugs, but this isn’t the case for proton pump inhibitors (PPIs). In addition to robust resources from Deprescribing.org and […]

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In the News: New Oral Antiviral Drugs Added to the Armamentarium Against COVID-19

Lately, it seems like new developments concerning the COVID-19 pandemic have been flying around at a head-spinning pace. You’ve probably been bombarded with news of a highly contagious variant, sky-rocketing case numbers, or constantly evolving clinical guidance. One of the more encouraging developments is that oral antiviral drugs for COVID-19 have finally arrived. In late […]

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Treating impending status epilepticus with intranasal midazolam

As a pediatric neurology pharmacist, my role is to ensure safe and accurate use of medications. For patients with seizures, this includes addition of a rescue medication for prevention of status epilepticus (SE). Despite the fact that intranasal midazolam is evidence-based, inexpensive, accessible, and well-tolerated, it’s an underutilized option in all clinical settings, including hospice […]

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Oscar the Cat, Meet Dr. Peyo the Horse

Just like Oscar the cat can identify and comfort patients who are near death, it seems that another unusual suspect has a keen sense for helping humans who are approaching the end of life. Peyo (affectionately nicknamed “Dr. Peyo”) is a 15-year-old former show stallion that literally roams the halls of the palliative care center […]

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In The News: Are Barnacles the Answer for Bleeding Humans?

Thankfully, most hospice patients will never experience significant bleeding. That said, when it does occur in can be extremely traumatic. Patients with end-stage renal or liver disease, cancer (especially head/neck and large lung tumors), and those receiving anticoagulation are at higher risk for serious bleeding. OnePoint’s Clinical Symptom Guide, now in its 3rd edition, details numerous […]

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In the News: Aduhelm – A Breakthrough Drug or Break the Bank?

Earlier this year in June, the U.S. Food and Drug Administration (FDA) approved a new Alzheimer disease (AD) drug for the first time since 2003.1 Biogen’s Aduhelm (aducanumab) is a monoclonal antibody infusion that’s administered every 4 weeks and targets amyloid beta plaque aggregates in the brain – an underlying cause of AD.2,3 Aduhelm is […]

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NOACs, Insulins, and COPD Drugs in Hospice: Where Are We Now?

We hope you were able to join the March and April presentations from our 2021 clinical webinar series, Budget Busters – Best Practices with NOACs, Insulins, and COPD Drugs in Hospice. Throughout the webinar, our Senior Clinical Pharmacist, Melissa Corak presented pearls and practical strategies to promote cost avoidance in circumstances where hospices would otherwise […]

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In the News: LIFE Trial Sheds Light on Entresto Use in Advanced Heart Failure

ACE-inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are mainstays of heart failure treatment. But, if you have heart failure patients on your census, it might seem like more of them are taking sacubitril/valsartan (marketed as Entresto) – a sign that providers are keeping up with the 2021 update to the American College of Cardiology’s (ACC) […]

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One Minute Consult: Fact or Fiction? Atarax is Better for Itch and Vistaril is Better for Anxiety and Sleep

Hydroxyzine is a first generation histamine (H1) antagonist that’s been on the market since the 1950’s.1 Its mechanisms of action are unique. Not only does it compete with histamine for H1 receptor sites in the GI tract, blood vessels, and respiratory tract, but it also it exhibits activity at muscarinic, serotonergic, and dopaminergic receptors in various parts […]

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Apple iPhone 12 and Implanted Cardiac Devices: Social Distancing or Magnetic Attraction?

Most of us don’t think twice about where we keep our cell phones as we go about our daily business. However, for people with implanted cardiac devices, storing the phone in a shirt or jacket pocket near the chest could have serious unintended consequences. Pacemakers and implantable cardioverter defibrillators (ICDs) are both small battery-powered devices […]

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Wait... Shouldn't that be Yellow?

A Quick Overview of the Causes of Urinary Discoloration Terminally ill patients may experience a variety of changes and new symptoms as the end of life approaches. Urinary symptoms may be especially troublesome for patients, family members, caregivers, and clinicians. Hospice patients commonly experience incontinence, retention, and decreased output. Another distressing change that patients may […]

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Oscar the Cat - Feline Prognosticator

  Being a prognosticator, or a predictor, is one of many hats that hospice clinicians wear. The ability to provide an accurate prognosis plays a crucial role in many clinical decisions. In addition to clinical experience, hospice clinicians use tools like the Palliative Performance Scale (PPS) to help predict survival. Believe it or not, there’s one very […]

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A creative solution (or suspension) for overcoming barriers to Nuedexta® use in hospice

Pseudobulbar affect (PBA), also called emotional lability, is a condition of uncontrollable laughing or crying without provocation that isn’t consistent with a patient’s emotional state. PBA is most often observed in patients with neurological disorders such as amyotrophic lateral sclerosis (ALS), multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, brain tumors, or as a sequela of stroke. […]

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Battle of the Gabapentinoids: Gabapentin Vs. Pregabalin

Neuropathic pain is pain caused by a lesion or disease of the somatosensory system1 and is often described as sensations of burning, tingling, shooting, sharpness, stabbing, or like electrical shocks. It is associated with conditions seen in many hospice patients including cancer, diabetes, and stroke. Neuropathic pain may also be a complication of neuromuscular diseases […]

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In the News: Deprescribing Antihypertensives in Hospice, Using Results from the OPTIMISE Trial

When patients transition to hospice, deprescribing can be used as a tool to align treatment plans with changing goals of care. Deprescribing is the process of discontinuing inappropriate, ineffective, or unnecessary medications and is often used in an attempt to manage polypharmacy and improve patient outcomes.1 Medications used to treat hypertension (collectively referred to as […]

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In the News: How to Dispose of Unused Medications

The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was signed into law by President Trump in October 2018. This legislation is aimed at addressing the opioid epidemic sweeping through the nation, with thousands of lives lost or ruined due to rampant abuse of prescription pain medications. […]

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In the News: Beers Criteria

In early 2019, the American Geriatrics Society (AGS) released an update to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, otherwise referred to as the Beers Criteria. The Beers Criteria provides a framework for safe medication prescribing in older adults, based on an expert panel’s systematic review of available evidence surrounding drug-related […]

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News+Views: Rectal Administration of Anticonvulsants

There is a need for alternative routes of administration in hospice and palliative care patients who often suffer from nausea and vomiting, dysphagia, gastrointestinal obstruction, and mental status changes, all of which may limit intake of oral medications.  Compared to common alternative routes such as the intravenous and intramuscular routes, the rectal route of administration […]

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1 Minute Consultation: "Which Potassium Supplement Should I Order for a Patient With Dysphagia?"

Diuretics can be especially useful to the hospice clinician for managing fluid retention or edema that commonly occurs in patients with heart failure, cirrhosis, and cancer. Unfortunately, long-term use of loop and thiazide diuretics can lead to hypokalemia, which can be particularly challenging to treat in patients with dysphagia given the fact that many potassium […]

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Questions from readers: Is one probiotic better than another?

With so many different probiotics on the market, it’s hard to know which ones to use and when to use them. They’re commonly promoted as agents to help strengthen the immune system or recolonize the GI tract with “good bacteria.” Probiotics are found in foods, dietary supplements, infant formulas, and medical foods with strain compositions, […]

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In the News: Hospice and Palliative Care Consensus Group Issues Methadone Safety Guidelines

In 2014, the American Pain Society (APS), College on Problems of Drug Dependence, and the Heart Rhythm Society released clinical practice guidelines that focused primarily on safe methadone prescribing practices. The APS guidelines included information regarding patient education, dosing and titration methods, recommendations for electrocardiograph (ECG) and adverse event monitoring. Unfortunately, these guidelines didn’t account […]

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Realm of Relatedness: A disease state assignment to the use of memantine

Medications are prescribed for many reasons, usually for labeled indications but other times off-label. Knowing why medications are prescribed is essential to help understand the continued need for therapy as well as to determine payment responsibility in this time of Medicare Part D risk. Namenda (memantine) is well known for its labeled use in treating […]

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K. or Nay?

Ketamine is currently enjoying a surge in popularity. Though the year 2017 is still young, a PubMed search of articles with “ketamine” in the title limited to 2017 showed that there’ve already been 106 such publications released this year. Practical Pain Management named oral ketamine for pain management as their Practical Clinical Advance of 2016. […]

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Diving into Diversion

Diving into Diversion (Photo by Derek Gavey, CC BY 2.0) There is a lot of buzz about the “opioid epidemic” our nation is currently facing, but haven’t opioids always been popular? According to the Centers for Disease Control and Prevention (CDC), the number of deaths due to opioid overdoses has more than doubled since the […]

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Controlled Substances in Hospice

   Best Practices for Ordering Controlled Substance Prescriptions Handling Errors What happens if pharmacists discover an error in a controlled substance prescription? Nobody’s perfect. Mistakes happen, including when writing prescriptions. While some errors can be corrected easily, others require a do-over, particularly in the case of controlled substances. OnePoint Patient Care’s highly trained pharmacists are […]

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5 Ways to Prevent Drug Diversion

OPPC’s mission to provide our patients, their caregivers and their family members with the highest quality of care, reliability and support means that we take the issue of drug diversion extremely seriously. In hospice, drug diversion is the transfer of a legally prescribed controlled substance from the intended patient to another individual for any illicit […]

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