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Palliative care of chronic progressive lung disease

Shuchita A Patel and Andrew N Davies
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DOI: https://doi.org/10.7861/clinmedicine.14-3-325
Clin Med June 2014
Shuchita A Patel
ARoyal Surrey County Hospital NHS Foundation Trust, Guildford, UK
Roles: Specialty registrar in palliative medicine
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Andrew N Davies
BRoyal Surrey County Hospital NHS Foundation Trust, Guildford, UK
Roles: Consultant palliative medicine physician
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Editor – We read with interest the review on palliative care for patients with chronic progressive lung disease (Clin Med February 2014 pp 79–82). The authors recommend opioids and benzodiazepines for the symptomatic management of breathlessness. However, although there is reasonable evidence to support the use of opioids in this scenario,1,2 a recent systematic review concluded that ‘there is no evidence for a beneficial effect of benzodiazepines for the relief of breathlessness in patients with advanced cancer and COPD [chronic obstructive pulmonary disease]’.3 Moreover, TJR Harrison reported ‘no correlation between symptom relief and level of anxiety’ in his study of lorazepam for the management of breathlessness in patients with advanced cancer.4 In other words, there is no evidence to support the use of benzodiazepines to manage breathlessness, even in patients with co-existent anxiety.

Many physicians are wary of prescribing opioids and benzodiazepines in patients with chronic lung disease due to concerns about their safety.5 Recently, Ekström et al reported that the administration of low dose opioids (ie ≤30 mg oral morphine equivalence/day) to patients with ‘severe’ COPD was not associated with an increased risk of hospitalisation or death.6 However, higher doses of opioids did appear to lead to increased mortality. In contrast, Ekström et al reported that the administration of low (and high) dose benzodiazepines was associated with an increased risk of hospitalisation and death.6 Interestingly, the concurrent use of low dose opioids and low benzodiazepines did not appear to lead to increased hospitalisation or mortality.

Footnotes

  • Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk

  • © 2014 Royal College of Physicians

References

  1. ↵
    1. Jennings AL,
    2. Davies AN,
    3. Higgins JPT,
    4. et al.
    A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002;57:939–44.doi:10.1136/thorax.57.11.939
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Johnson MJ,
    2. Bland JM,
    3. Oxberry SG,
    4. et al.
    Opioids for chronic refractory breathlessness: patient predictors of beneficial response. Eur Respir J 2013;42:758–66.doi:10.1183/09031936.00139812
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Simon ST,
    2. Higginson IJ,
    3. Booth S,
    4. et al.
    Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant disease in adults. Cochrane Database Syst Rev 2010;20:CD007354.
    OpenUrl
  4. ↵
    1. Harrison TJR.
    A comparison of the effectiveness of oral lorazepam and placebo in relieving breathlessness associated with advanced cancer [dissertation]. Bristol: Bristol University, 2004.
  5. ↵
    1. Young J,
    2. Donahue M,
    3. Farquhar M,
    4. et al.
    Using opioids to treat dyspnea in advanced COPD: attitudes and experiences of family physicians and respiratory therapists. Can Fam Physician 2012;58:e401–7.
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Ekström MP,
    2. Bornefalk-Hermansson A,
    3. Abernethy AP,
    4. Currow DC
    . Safety of benzodiazepines and opioids in very severe respiratory -disease: national prospective study. BMJ 2014;348:g445.doi:10.1136/bmj.g445
    OpenUrlAbstract/FREE Full Text
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Palliative care of chronic progressive lung disease
Shuchita A Patel, Andrew N Davies
Clinical Medicine Jun 2014, 14 (3) 325; DOI: 10.7861/clinmedicine.14-3-325

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Palliative care of chronic progressive lung disease
Shuchita A Patel, Andrew N Davies
Clinical Medicine Jun 2014, 14 (3) 325; DOI: 10.7861/clinmedicine.14-3-325
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