Community-based management of gastrointestinal symptoms at end-of-life in scleroderma using subcutaneous medication: a case report.

Abstract

Background: Systemic sclerosis (SSc) is a rare autoimmune connective tissue disorder often associated with severe gastrointestinal symptoms. At the end of life, managing these symptoms in the community can be challenging, particularly when patients are unable to take oral medications and wish to avoid hospital admission. This case describes the use of subcutaneous omeprazole in a community setting to manage refractory upper gastrointestinal symptoms in a patient with SSc during the final days of life.

Case description: A 51-year-old patient with advanced SSc experienced significant upper gastrointestinal symptoms, including gastro-oesophageal reflux, haematemesis, and gastric discomfort. Oral administration of medication became unreliable, and parenteral medication was clinically indicated. Hospital admission for intravenous therapy was inconsistent with the patient's preference to remain at home. Although alternative anti-secretory agents were available, the patient specifically requested omeprazole. A continuous subcutaneous infusion of omeprazole was initiated in the home setting following consultation with clinical colleagues and reference to limited published reports supporting this route. In negotiation with the family, the medication was trialled by the subcutaneous route as an infusion. The patient reported significant improvements in symptoms with the medication, which recurred when the omeprazole was reduced and improved when increased again.

Conclusions: This case illustrates the safe and effective use of subcutaneous omeprazole for managing upper gastrointestinal symptoms at the end of life in a community setting. It supports the role of flexible prescribing and individualised care to respect patient preferences. Due the unpredictable physiology of people at the end-of-life and the challenges in palliative care research, case reports and expert opinion remain vital evidence for clinical practice.