![]() Second, citalopram caused approximately 50% increase in the single-dose area under the serum concentration/time curve of desipramine (primary metabolite or imipramine) and a corresponding reduction in the level of the subsequently formed metabolite 2-hydroxydesipramine. First, levomepromazine caused a 10-20% increase from the initial steady-state levels of the primary citalopram metabolite, desmethylcitalopram. Only two statistically significant interactions were indicated. For citalopram and its metabolites, a non-enantioselective analytical method (high-performance liquid chromatography) was used. Each subject completed three study phases-one with citalopram alone, one with one of the three other drugs, alone, and one with citalopram combined with the corresponding other drug. All volunteers were classified as extensive metabolizers of sparteine and mephenytoin. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.The pharmacokinetic interactions between the selective serotonin reuptake inhibitor citalopram, given as an oral dose of 40 mg/day for 10 days, and (1) levomepromazine (50 mg single oral dose), (2) imipramine (100 mg single oral dose), and (3) lithium (30 mmol/day orally for 5 days) were examined in three panels each of 8 healthy young male volunteers (age 20-31). A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups.Ĭonclusions and Relevance In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 ( P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients celecoxib or anti-inflammatory, 98 patients methocarbamol, 267 patients ) to V3 (236 patients, 163 patients, and 238 patients, respectively P < .001). Results A total of 832 consecutive patients (median age, 65 years 410 female and 422 male ) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Main Outcomes and Measures Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Objective To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes.ĭesign, Setting, and Participants This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version 1, October 1, 2016, to Janu V2, February 1, 2019, to Octo V3, November 1, 2020, to Ap).Įxposures After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents multiplied by 5) to calculate discharge volume. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. Importance Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion.
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