Evidence-Based Approach to Cutaneous Treatments

This morning, I attended the concurrent session on the evidence-based cutaneous treatment of nausea, pain, and neuropathy. This was overall a good session, although it reinforced the need for more research in this area since some of what we are practicing in this area is not highly evidence-based. Some of the salient points:

Cutaneous treatment of nausea:

  • N/V represents a common reason for PC consultation and admission, and is one of the most common admissions for ‘hospice failure’
  • We should have clinical practice guidelines since they reduce practice variation and may lead to better less costly care at the end of life
  • Topical gels are widely used in ~60% hospice pts; Advantages- known and inexpensive (eg NSAIDS for arthritis). Disadvantages – limited data about absorption and effectiveness of other commonly used gels (lorazepam, benadryl, haloperidol)
  • ABH (ativan, benadryl, haldol) gel guideline formation would be helpful.
  • However, there is no data showing that any of the drugs are absorbed from the skin in patients in therapeutic amounts
  • There was a paper by Bleicher, et al in 2008 – improved nausea, vomiting- but retrospective, no control group, other agents allowed.
  • ABH is <$1 a dose . If it works- great- could possibly avoid admission for symptom control, if not, admission for N/V might mean $2500/5 days
  • Study ongoing to collect pilot data on absorption of ABH gel.
  • Take home point: data for absorption and utility of ABH gel is limited, prelim evidence shows absorption is poor, and more research in this area is needed (and some recent efforts to obtain funding on this topic have been less successful)

Cutaneous Absorption of Morphine

  • Recent paper in J pain symptom mgmt (JPSM) – Judith Paice, March 2008: “Morphine bioavailability from a topical gel formulation in volunteers” – she noted in her experience that providers were using topical morphine, but since the drug is not lipid soluble , she asked whether there is really any evidence that this is absorbed?
  • Some studies of topical morphine delivered to open skin ulcers– there is some bio-availability (Ribero JPSM 2004)… but does it impair wound healing?
  • For this study, Judith Paice compounded a morphine gel formulation with PLO matrix applied to wrist
  • Randomized, placebo controlled, small sample of healthy volunteers, studied the topical morphine alongside SC morphine
  • SC – showed 100% bioavailability
  • Topical – showed very very low Cmax, bioavailability -> N/A (All plasma samples obtained after topical morphine admin had either no detectable morphine present or something below the limit of quantification)
  • Take home points: Bioavailability of morphine when administered SC is consistent with what we arleady know, and morphine is a poor candidate for transdermal drug delivery (at least, on INTACT skin)

Speaker #3 discussed other SC and IV medications for treatment of nausea, and consider checking the handout for this discussion since many medications were mentioned- too many to list here!

Overall this was a great seminar and the speakers illustrated the need for continued evidence-based studies for our practice patterns, and hopefully these will lead to development of clinical guidelines.

Aaron Olden, MD

University of Rochester Faculty

Rochester, NY

1 thought on “Evidence-Based Approach to Cutaneous Treatments

  1. I also attended this session and was very happy to see they used critical drug information skills to evaluate the literature and didn’t just recommend these agents without the supporting evidence. There was this global mention of terms like inexpensive and <$1.00 per dose for some of these products for pain and nausea and vomiting and I would have to disagree. I would remind everyone this may be true for cost of the ingredients, but often retails pharmacies charge compounding fee’s and labor to compound and often lead to much higher prices. I often see much higher costs in the community setting for these products ($2-$5 dollars per dose). I agree 100% with the idea of protocol’s for these products as I find hospices use these as 1st line therapy because it’s easy to administer.
    I have a couple of concerns with that model. 1) It often leads to an overall higher cost per patient day for the hospice 2) It takes away from the “thought process” of thinking about the sources and causes of nausea and vomiting.
    There is good data that states if you evaluate the symptoms and likely causes you can often treat nausea/vomiting successfully without having to combine multiple drugs into a gel or supp. I have worked with hospices all around the country and helped them put into place nausea and vomiting protocols combining patient presentation of symptoms and most likely cause and have watch their compound use come down to almost zero with great success and their cost per patient day drop.

    Jason Kimbrel, Pharm.D., BCPS
    HospiScript Services
    Columbus, Ohio

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