Subject(s)
Catheters , Emergency Service, Hospital , Enema/instrumentation , Gastrointestinal Agents/administration & dosage , Lactulose/administration & dosage , Administration, Rectal , Enema/adverse effects , Enema/methods , Gastrointestinal Agents/adverse effects , Hepatic Encephalopathy/drug therapy , Humans , Lactulose/adverse effects , Male , Middle AgedABSTRACT
CONTEXT: The oral route is compromised for nearly all patients approaching death. When agitation, seizures, or other intractable symptoms occur, a quick, discreet, comfortable, and effective alternate route for medication delivery that is easy to administer in the home setting is highly desirable. OBJECTIVES: To characterize the early absorption profile, variability, and comfort of phenobarbital given in microenema suspensions delivered via the Macy Catheter(®) (MC) vs. the same dose given via suppository. METHODS: This was a randomized, open-label, crossover study comparing the early absorption profile of equal doses of phenobarbital administered rectally in three treatment phases: phenobarbital suppository and two different microenemas with phenobarbital tablets crushed and suspended in 6 mL (MC-6) or 20 mL (MC-20) of tap water. RESULTS: Mean plasma phenobarbital concentrations at 10 minutes were 12× higher for MC-20 and 8× higher for MC-6 compared to suppository. Concentrations achieved in 30 minutes via MC-20 took almost three hours to achieve with suppository. Mean AUC values were higher for MC-20 and MC-6 (82% and 46%, respectively) vs. suppository (P < 0.05). There was less variability in absorption for MC-20 and MC-6 (1.4- to 1.9-fold difference) compared to a 4.4-fold difference via suppository. MC administrations were reported as "not uncomfortable" compared to suppositories, which were reported as "mildly uncomfortable" (P < 0.05). CONCLUSION: These results suggest phenobarbital oral tablets crushed and suspended in water and administered via the MC is superior to suppository in delivering the medication reliably and rapidly.
Subject(s)
Hypnotics and Sedatives/administration & dosage , Hypnotics and Sedatives/pharmacokinetics , Phenobarbital/administration & dosage , Phenobarbital/pharmacokinetics , Administration, Rectal , Adult , Area Under Curve , Catheterization , Cross-Over Studies , Female , Hospice Care , Humans , Male , Suppositories , Young AdultABSTRACT
The oral route is compromised for nearly all patients at the end of life (EOL). This article reviews the benefits and burdens of the usual alternative routes of medication delivery when the oral route fails and presents a case study on the use of a new innovation for the rectal delivery of medication to control EOL symptoms. A 62-year-old male hospice patient with end-stage metastatic prostate cancer presented with severe symptoms (Face, Legs, Activity, Cry and Consolability scale score, 9/10) that were uncontrollable with medications given via oral or sublingual routes. The patient goals were to remain at home with optimal symptom management. Rapid relief of symptoms was accomplished by the administration of medications already present in the home delivered with a new rectal catheter that provides discreet access for ongoing medication administration. Significant relief was noted within 20 minutes of dosing. The patient died peacefully 18 hours later, meeting his EOL goals, and the family was empowered to provide effective care for the patient at home. The family found the intervention easy to use. This case demonstrates how this new innovation can be used to ensure rapid symptom management and decreased burden of care by facilitating immediate and easy use of medications already present in the home.
