Managing Palliative Care Challenges for Patients With Complex Symptoms

In an interview with the Pharmacy Times, Justin Kullgren, PharmD, FAAHPM, Palliative Medicine Clinical Pharmacist Specialist and PGY2 Pain Management & Palliative Care Residency Program Director at The Ohio State University Wexner Medical Center, James Cancer Hospital, shares insights into palliative care and common challenges faced by pharmacists treating patients with complicated symptoms.

Pharmacy Times: Could you provide an example of a patient case that involved complicated symptoms and how you managed/treated that case?

Kullgren: Recently, I had a patient who had a really, really atypical pain diagnosis. [He] had lung cancer that was treated with definitive radiation treatment, kind of like the thoracic area. And within a week or 2 after this, [the patient] developed this profuse allodynia… So, we gave this individual a very low dose, intermittent intravenous (IV) ketamine push, and very low dose, like 10 milligrams, a very, very [inaudible]. And I was in the room with the patient, and within about a minute he's going, I could see it in his eyes, and he goes “I'm starting to feel something here…” So very profound pain syndrome. Got a wonderful response. So, we're pretty excited, right? So, we started ketamine infusion very low dose, which is protocol at our institution. We come back and assess the patient the next day, “Like yeah, not as good as it was when you gave me that injection the other day. But still, better than what it was. A couple days go by, and the pain comes back. And it's where we were from baseline, which doesn't make any sense, right? Because they gave you a small dose intermittent IV injection. Now we're giving you an even higher dose per hour infusion is not helping. So, we add on different medication, we add on a little bit of methadone for both the pain response, as well as seeing if we can approach it from a way. And you get some benefit from methadone. [We] still try the ketamine, no response and increase it. Which again was so odd that an IV injection worked [better] at a smaller dose than continuous infusion through IV. So, we stopped and we're consulting neurology, we’re consulting interventional pain medicine, and no one has really anything to offer per se for this individual. Finally, I’m like you know what, I'm not exactly sure, but I've seen a patient or 2 sometimes respond to oral ketamine. So, we had our pharmacy guy—very fortunate to work in an institution where our pharmacist within our cancer center, are willing to go out of their way to find recipes and make things. And they made a ketamine IV, mixed it, and the patient took it. Now the interesting about ketamine is the whole bioavailability is roughly 30%. So, the amount this individual is getting us a very, very low compared to what he was getting before. And sure enough, we start oral ketamine and his pain gets a lot better. And we do that every 6 hours for a day or 2. We start to de-escalate the dose, taking maybe [inaudible], because we know it takes 4 or 5 days. Sure enough, as we start to de-escalate appropriately, his oral ketamine pain comes back. So, what do we do? Well, this goes back to getting this patient availability to try to try get this on the outpatient side, get insurance to pay for it, the closest pharmacy was couple hours away. This took a lot of coordination with this individual to find the lowest effective dose, find a pharmacy and find a way to get this guy access to medication.

Pharmacy Times: What do you wish pharmacists understood about hospice and palliative care in terms of patient care for patients with complicated symptoms?

Kullgren: So, I think, number 1, pharmacists across all healthcare systems, in the hospital, at community pharmacies, long-term care, you are all going to be involved in these patients— it’s just to what degree. And we definitely at the hospice and palliative care are trying to do the easy things first, right? We want to do those therapies that are conventional, that are going to have the least amount of risk for our patients, or at least side effects for our patients. But we do manage a bit of really complex patients. And it's why I come to work every day to really hoping to make a difference. But honestly, the best care occurs when we do work as a team. And I'm fortunate here where I work that we have an internal messaging system, where I am messaging the pharmacist, that are oftentimes helping with dispensing of these medications and counseling families, to give them a heads up. And the additional information, the additional counseling that those patients get from my colleagues in those environments only make their care better. We often will do the same thing or reach out to the community pharmacist when they're picking medications elsewhere. But I would say if something doesn't make sense, call us and ask. I mean, I absolutely love when one of our colleagues, one of us call and say, “Hey, like, this just doesn't really add up to me, can you help me understand?” Because what I know then is that patient has so much better opportunity to have a positive outcome from that. And likewise, if it's not going well, oftentimes that community pharmacist or hospital pharmacist, they're the first ones to know. When we had that relationship, they reached back out, and we had a much quicker turnaround for the next steps.