Naloxone should be coprescribed with opioids for all patients at risk for overdose

New guidelines from the US Department of Health and Human Services (HHS) recommend that naloxone should be prescribed or coprescribed with opioids to individuals at high risk of an overdose, including, but not limited to: individuals who are on relatively high doses of opioids, take other medications which enhance opioid complications, or have underlying health conditions.

The guideline also recommends that doctors should also educate patients and those who are likely to respond to an overdose, including family members and friends, on when and how to use naloxone.

The following patients should be prescribed or coprescribed naloxone:

·         Are receiving opioids at a dosage of 50 morphine milligram equivalents (MME) per day or greater

·         Have respiratory conditions such as chronic obstructive pulmonary disease (COPD) or obstructive sleep apnea (regardless of opioid dose)

·         Have been prescribed benzodiazepines (regardless of opioid dose).

·         Have a non-opioid substance use disorder, report excessive alcohol use, or have a mental health disorder (regardless of opioid dose)

Patients at high risk for experiencing or responding to an opioid overdose have also been defined. These include individuals:

·         Using heroin, illicit synthetic opioids or misusing prescription opioids

·         Using other illicit drugs such as stimulants, including methamphetamine and cocaine, which could potentially be contaminated with illicit synthetic opioids like fentanyl

·         Receiving treatment for opioid use disorder, including medication-assisted treatment with methadone, buprenorphine, or naltrexone

·         With a history of opioid misuse that were recently released from incarceration or other controlled settings where tolerance to opioids has been lost

(Source: https://www.hhs.gov/opioids/sites/default/files/2018-12/naloxone-coprescribing-guidance.pdf)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Severe comorbid COPD increases mortality risk in heart failure patients

Heart failure and chronic obstructive pulmonary disease (COPD) are common diseases of aging. Besides being common in old age, both diseases share common risk factors and pathophysiology. As a result, the two often co-exist and influence each other’s clinical course.

This observation has been validated in a new nested case-control study of more than 50,000 UK patients with heart failure from the UK, which found that the greater severity of COPD is associated with increased chances of hospitalizations and increased risk of death in those patients who also have heart failure.  Hence, optimal care of patients with comorbid heart failure and COPD requires accurate diagnosis and targeting of severe COPD markers to prevent admissions and death.

The study showed that the increased risk of death and hospitalization associated with COPD significantly differs by medication intensity and the severity of airflow limitation.

Chronic obstructive pulmonary disease was not associated with any increased risk of death when patients were managed by inhaler therapies, until prescribing intensity reached triple inhaler therapy and risks of both outcomes were significantly higher in those prescribed oral corticosteroids and oxygen therapy. The use of spirometry in the population studied was limited, but its use indicated the group of patients with more severe heart failure and COPD, who also had worse outcomes for those with the most severe airflow limitation

The major clinical implications of these findings are:

·         To improve HF prognosis, it is important to accurately identify and effectively manage comorbidities.

·         COPD-associated risk differed significantly according to medication intensity in patients with heart failure; hence, it is a potential indicator of disease progression. 

·         Comparison of patients with heart failure and COPD with those without COPD showed that mortality was higher in those who had more severe airflow limitation from GOLD stages 1 through 4. 

·         COPD in women with heart failure was associated with a 15% higher risk of death than in men. 

These findings are reported in JAMA Network Open, Dec. 14, 2018.

(Source: Association of medication intensity and stages of airflow limitation with the risk of hospitalization or death in patients with heart failure and chronic obstructive pulmonary disease. JAMA Netw Open. 2018;1(8):e185489)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

World COPD Day: Chronic cough, a novel phenotype of COPD

A new study has suggested that chronic cough is not just a symptom of COPD; instead, it should be considered as an important phenotype during the determination of high-risk groups of patients with COPD, particularly with regard to future acute exacerbation of COPD (AECOPD). 

The study published in the International Journal of Chronic Obstructive Pulmonary Disease included 1,613 COPD patients, patients with chronic cough only, those with sputum only, those with chronic bronchitis and those without cough and sputum were compared with regard to dyspnea, lung function, quality of life (QoL) and risk of AECOPD.a

Compared with patients without chronic cough, those with chronic cough had a lower forced expiratory volume in 1 second (FEV1) (% predicted) and diffusing capacity of the lungs for carbon monoxide (DL_CO) (% predicted), more severe dyspnea and worse QoL.

Chronic cough, and not chronic sputum, was also found to be an independent risk factor for future acute exacerbation of COPD (AECOPD). Hence, it is important to identify patients with chronic cough irrespective of sputum to identify the high-risk patients and evaluate the severity of disease to establish the prognosis.

(Source: Koo HK, Park SW, Park JW, et al. Int J Chron Obstruct Pulmon Dis. 2018 May 30;13:1793-1801)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA