Haider Warraich
speaker
683 appearances
3 recordings
1 series
first heard Oct 2020
last heard Dec 2021
Haider Warraich’s voice in public audio — every appearance, attributed to the second.
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As we've seen with the data with palliative chemotherapy, very few patients actually might know that to begin with, that this therapy is not likely to increase their survival.
And if anything, there are randomized controlled trials that suggest that people's survival can be shorter on chronic home inotropes.
I think everyone who is being initiated on this therapy should definitely have a palliative care consultation.
While I am a proponent for primary palliative care in the cardiology space, I think this is such an advanced therapy and with so many dimensions that I really think that this is something that cardiologists should not take on without having some type of subspecialty assistance.
There are two main types of inotropes that we have, the dibutamine, which you mentioned for your patients, and milrinone.
Milrinone is a bit more long-acting, so I actually like it better for the outpatient setting than dibutamine, simply because it's going to stain folks' system if they have an interruption between, say, changing over a bag or something, or if the PICC line falls out, etc.,
The one issue with milrinone is that it is renally cleared, so in patients with renal failure, they may have elevated levels.
And then one of the other things that you've already mentioned is how do we deal with folks who have ICDs?
Because we do know that inotropes do increase your risk of an ICD shock.
So...
Especially in the palliative setting that we're discussing, I strongly advocate that the ICD be turned off in these patients if that is aligned with someone's goals.
And then the other thing that I do while I'm on the inpatient side is I try my best to wean these things off, to be honest with you.
I think that they're a burdensome therapy.
I think there's a very small number of patients who actually benefit from it.
But if we are going to send folks out on inotropes to home or hospice or palliative care or some type of setting, I think what we can do is actually come up with a weaning protocol.
Now, one of the, I think, things that hospices, palliative care agencies are very nervous about is someone comes out on dibutamine, but what's the plan?
And is this going to be a lifelong thing, et cetera?
So coming up with a staged way to reduce the dose gently over time is a way to essentially ease that transition from the hospital to the home setting.
So those are some of my general thoughts about inotropes.
they're complicated.
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