Is ibuprofen (Nonsteroidal Anti-Inflammatory Drug) or citalopram (Selective Serotonin Reuptake Inhibitor) advised for a patient who does not want to pursue medical treatment and is considering hospice care?

Medication Management in Hospice Care

For a patient considering hospice care who does not want to pursue medical treatment, ibuprofen is preferred over citalopram as it directly addresses pain management, which is a primary concern in end-of-life care. 1, 2

Pain Management in Hospice Care

First-Line Approach

• Ibuprofen is recommended as a first-line treatment for pain management in hospice patients 1
• The National Comprehensive Cancer Network recommends NSAIDs like ibuprofen for initial pain management, with a maximum daily dose of 3200 mg 1
• For patients with mild pain (1-3/10), acetaminophen and/or NSAIDs are the appropriate first step according to the WHO analgesic ladder 2

Special Considerations with Ibuprofen

• Caution is required when using ibuprofen in patients at high risk for:
  • Renal toxicity (age >60, compromised fluid status, concomitant nephrotoxic drugs)
  • GI toxicity (age >60, history of peptic ulcer disease, alcohol use)
  • Cardiac toxicity (history of cardiovascular disease) 1
  • Bleeding disorders or thrombocytopenia 1

Monitoring and Management

• If renal toxicity develops (BUN or creatinine doubles), discontinue ibuprofen 1
• For GI upset, consider discontinuing or switching to a COX-2 inhibitor 1
• Discontinue if liver function tests increase beyond three times the upper limit of normal 1

Why Citalopram is Not Preferred

• Citalopram (an SSRI) is primarily indicated for depression, not pain management 1
• While depression is common in end-of-life care, the American College of Physicians recommends addressing pain as a priority symptom 1
• SSRIs may take up to 6 weeks to show effect, making them less suitable for immediate symptom management in hospice care 1
• For patients at the end of life, focus should be on immediate symptom relief rather than long-term psychiatric management 2

Alternative Pain Management Options

Opioid Therapy

• If pain is moderate to severe or unresponsive to NSAIDs, opioids are the mainstay of therapy 1, 2
• Regular around-the-clock dosing with breakthrough dosing is recommended 2
• A bowel regimen should be prescribed concurrently to prevent constipation 1

Non-Pharmacological Approaches

• Consider complementary approaches such as:
  • Positioning and relaxation techniques 1
  • Physical therapy when appropriate 1
  • Heat or cold therapy 2

Addressing Other Common Hospice Symptoms

Dyspnea

• Opioids are first-line treatment for unrelieved dyspnea 1, 2
• Oxygen therapy for hypoxemia or subjective relief 1
• Non-pharmacologic interventions: sitting upright, hand-held fans 1

Depression and Anxiety

• For immediate relief of anxiety, benzodiazepines may be considered 2
• For longer hospice stays where depression is a concern, sertraline has been studied extensively and appears to have a lower risk of QTc prolongation than citalopram 1

Common Pitfalls to Avoid

• Inappropriate medication continuation: Discontinue medications that don't contribute to comfort 2
• Undertreatment of pain: Regular assessment of pain is essential 1
• Overreliance on as-needed (PRN) regimens: Adherence to PRN analgesic regimens is only about 51% 3
• Ignoring patient preferences: About 30% of terminally ill patients may not want additional pain treatment despite experiencing pain 4

Remember that the goal of hospice care is to improve quality of life with a focus on comfort and symptom management. Pain control should be prioritized, making ibuprofen a more appropriate choice than citalopram for initial management in this setting.