Transdermal formulations, though not the preparation of choice, need to be continued in moribund patients, in whom they might have been initiated. Variability in absorption due to poor circulation, inability to dose titrate rapidly and practical issues are considerations surrounding the use of transdermal route in this setting. In case of worsening pain, additional doses… — read more

“Transdermal buprenorphine and fentanyl have been found to be unsatisfactory in less than 5 percent individuals”. Though why it has been labelled as unsatisfactory has not been clearly defined, this statement might lend itself to various interpretations. Lack of efficacy (due to inconsistent plasma levels) and unsuitability underlying intolerable adverse effects are a few that… — read more

Is there a consensus on the minimum intensity of pain on NRS that qualifies itself to deserve the breakthrough pain designation?Does breakthrough pain have to be at least moderate in intensity? These questions presented themselves after participating in the third round of a recently completed Delphi study on breakthrough pain. A recent systematic review by… — read more

I recall having a conversation with a patient admitted under my care and informing her about my plans to not seek an extension in my contractual position and seeking employment elsewhere. While reflecting on this interaction, I was forced to acknowledge that her demeanour, the way she carried herself and the overtly political manner in… — read more

There is one recent patient death that seems to be occupying centre space in my mind, one that demands a respectful closure. Can my words make up for a family’s permanent loss? Being witness to the drama that played out following the demise of an admitted patient with advanced hepatobiliary cancer and bilateral percutaneous biliary… — read more

CVS Atrioventricular block – carbamazepine, oxcarbazepine and lacosamide Heart failure – oxcarbazepine (SIADH-related, requires sodium monitoring) and pregabalin (calcium-channel mediated fluid redistribution) increase chances of fluid retention, weight monitoring. CNS Psychiatric effects are commonest with levetiracetam, topiramate, vigabatrin and zonisamideSuicidal ideation is a known class effect (mood disturbance and suicidal thoughts may require further assessment).Phenobarbital… — read more

Paraneoplastic sweating and fever are distinct pathophysiological processes, which might occur concurrently, whose treatment involves differing targets. While fever is usually caused by central hypothalamic reset in thermoregulatory mechanisms,PGE2 mediated and NSAID responsive, sweating which is mediated by an efferent sympathetic cholinergic response of eccrine glands, may occur as an independent phenomenon (separate from the… — read more

Motilin receptor (MTLR) agonist. Indicated in delayed gastric emptying in selected patients refractory to metoclopramide and domperidone (third line prokinetic with possible utility in secondary prophylaxis of malignant bowel obstruction). Concern about tachyphylaxis necessitates prescription of low doses (theoretical possibility of mitigation with low doses), start with suspension 50-100 mg q.d.s.,30 minutes before meals and… — read more

To gastroenterology for feasibility of palliative biliary stenting in malignant biliary obstruction, to urology for assessing feasibility of stenting in hydroureteronephrosis, to neurology for confirming compressive myelopathy, to neurology again for ruling out brachial plexus involvement in the absence of demonstrable recurrent disease, to nuclear medicine for metastatic neuroendocrine tumor, to orthopaedics to rule out… — read more

Events of the recent past have led to two important realizations, the absence of a legislative guidance acknowledging the specialist’s rights as the first among equals in opioid prescribing and a studied silence on his rights to correct the correctable medical issues. The continuation of a service envisaged as a specialist endeavor without a postgraduate… — read more