Dr Bee Wee, Consultant and Senior Clinical Lecturer in Palliative Medicine, Sir Michael Sobell House and University of Oxford, UK; Chair of the Task Group on management of chronic cough, Science Committee of the Association for Palliative Medicine of Great Britain and Ireland (APM)
Anybody who has suffered a chronic cough that simply will not go away knows how irritating and debilitating that can be – even more so those who have advanced disease. Comprehensive evidence-based guidelines already exist, produced by the British, European and American respiratory physicians, but none of these is aimed at cough related to advanced progressive cancer or non-malignant disease.
This journey started when a medical student at Oxford University approached me; Juliet was keen to focus her Final Honours School project on palliative care. At the same time, within the APM Science Committee, we were on the lookout for topics that merited guidelines for clinical practice. We were fortunate in roping in a multidisciplinary, multiprofessional group – medical, nursing and pharmacy input from palliative medicine and respiratory medicine – a lively and committed group that has been a real pleasure to work with.
We are delighted that the paper resulting from this work group has been chosen as editor’s choice for the September edition of ‘Palliative Medicine’ (Wee et al, 2012).1 This is welcome recognition of a pragmatic set of recommendations, drawing attention to the paucity of high quality research in this area.
As anybody who has done systematic reviews in palliative care knows, there was the inevitable heart-sinking period when few papers made it through the sifting process. Out of 66 records originally identified, only five studies ended up being included in our appraisal for recommendation. We then decided to include another two studies in our consideration even though they hadn’t met our inclusion criteria. They were both randomised, double-blinded placebo-controlled studies using morphine or codeine, which we commonly use in palliative care.
We decided that it would not be helpful to the practising community to simply say that we did not have a strong enough evidence to make any recommendation. Instead, we chose to be pragmatic and to include convenience, toxicity and burden of the intervention as part of our consideration. By making this clear, clinicians can draw their own conclusions. As always, the first step is to reverse whatever is reversible, then to review the current medication. After that, we advise simple linctus, then a therapeutic trial of sodium chromoglycate, then an opioid, or opioid derivative.
Finally, the usual plea – we need more research in this area, in particular with larger numbers, better-controlled studies and use of standardised tools to allow comparison across trials.
1. Wee B, Browning J, Adams A, Benson D, Howard P, Klepping G, Molassiotis A, Taylor D. Management of chronic cough in patients receiving palliative care: review of evidence and recommendations by a task group of the Association for Palliative Medicine of Great Britain and Ireland. Palliative Medicine 2012; 26(6): 780-7; originally published online 12 October 2011. (To download a copy of this paper, please see below).
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