Development of a List of Essential Medicines for Palliative Care: Background and Process

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Development of a List of Essential Medicines for
Palliative Care Background and Process

• Liliana De Lima
• Salzburg, April 30 May 3

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Background

• March 2005 Agreement with WHO to work in three
  areas
• WHO Cancer Technical Group (KF)
• Essential Medicines for PC
• Education in PC

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Building a List of EM for PC Background

• Request from WHO
• Based on the Consensus of Experts
• Initial Criteria Safety, Efficacy
• Why not Cost Effectiveness?

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WHO Model List of EM (2005)

• Section 8.4 - Medicines used in palliative care
• The WHO Expert Committee on the Selection and
  Use of Essential Medicines recommended that all
  the drugs mentioned in the WHO publication Cancer
  Pain Relief with a Guide to Opioid Availability,
  second edition, be considered essential. The
  drugs are included in the relevant sections of
  the Model List, according to their therapeutic
  use, e.g. analgesics.

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Medicines mentioned in Cancer Pain Relief with a
Guide to Opioid Availability (2nd Ed)

• ASA, alcohol, amitriptyline, betamethasone,
  bisacodyl, bupivacaine, buprenorphine,
  carbamazepine, choline magnesium, codeine,
  chlorocresol, chlorpromazine, cyclizine,
  desipramine, dexamethasone, dextropropoxyphene,
  diazepam, diclofenac, diflunisal, dihydrocodeine,
  dimenhydrinate, docusate, haloperidol,
  hydromorphone, hyoscine butylbromide, ibuprofen,
  indometacin, imipramine, levorphanol, lidocaine,
  methadone, morphine, naloxone, naproxen,
  oxycodone, paracetamol, pethidine, phenol,
  prednisone, prednisolone, prochlorperazine,
  senna, standardized opium, tramadol,
  trisalicylate, valproic acid.

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Building a List of EM for PC Process

• 1. Selection of a Committee on Essential
  Medicines
• Neil MacDonald - Canada (Chair)
• Carla Ripamonti Italy (Co-Chair)
• LDL USA (Coordinator)
• Kathy Foley - USA
• David Currow - Australia
• Eduardo Bruera - USA
• External advisors
• Peter Glassman and Karl Lorenz (VA, USA)
• Mary Callaway (OSI - USA)

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Building a List of EM for PC Process

• 2. Identification of the most appropriate
  process
• Identify the most common
• symptoms in palliative care
• Identify the most
• appropriate medications
• to treat those symptoms

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Building a List of EM for PC Process3.
Identifying the Most Common symptoms in PC (IAHPC
EM Committee)

• Insomnia
• Mouth Problems
• Nausea
• Pain
• Sweating
• Terminal Restlessness
• Terminal Respiratory Congestion
• Vomit

• Anorexia Cachexia
• Anxiety
• Constipation
• Delirium
• Depression
• Diarrhea
• Dyspnea
• Fatigue
• Hiccups

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Building a List of EM for PC Process

• 4. Build up of the Initial List - Method
• Email sent on February 23rd
• IAHPC board
• 15 additional MDs practicing PC
• Propose appropriate medications for these
  symptoms

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Building a List of EM for PC Process

• 4. Results - Initial List
• 34 physicians responded (15 from developing
  countries)
• Initial count 147 entries
• Non medications were deleted (multivitamins, O2
  therapy)
• Names were verified for accuracy and converted
  into INNs (International Nonproprietary Name)
• Commercial names were deleted
• Total Medications resulting in the first list 120

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Building a List of EM for PC Process

• 5. Second List - Method
• An online survey was designed using a modified
  Delphi process with the medications resulting
  from Step 4 (online survey)
• 21 rating panels
• Participants were asked to rate medications 1-9
  on Efficacy and Safety

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Building a List of EM for PC Process

• 5. Second List Method
• Invitation sent by email to 122 physicians and
  pharmacologists
• Total Developing countries 77
• Latin America 31
• North America 35
• Western Europe 31
• Eastern Europe 15
• Central and SE Asia 16
• Australia/NZ 14
• Sub Saharan Africa13
• Middle East 8
• First email sent April 20th
• Second reminder April 23
• Third reminder April 27

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Building a List of EM for PC Process

• 5. Second List Results
• Total responses71 (58.2)
• Total number of medications in which more than
  50 of the respondents rated between 7-9 both in
  Efficacy and Safety 11

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Building a List of EM for PC Process

• 6. Meeting in Salzburg - Working Groups Work,
  work, work!
• 7. Final Step The third and final list will be
  submitted to WHO

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