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Managing Medications and Side Effects (Power Point)

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Managing Medications and Side Effects (Power Point) Managing Medications and Side Effects (Power Point) Presentation Transcript

  • Managing Medications and Side Effects Deborah Olin Heros, MD Neuro-Oncology Department of Neurology University of Miami Miller School of Medicine Sylvester Cancer Center
  • Quality of Life Physical * Cognitive * Emotional
  • Understanding the Symptoms of Your Tumor and Treatment
    • * Symptoms as the result of tumor location
    • * Symptoms related to increased intracranial pressure (  ICP)
    • * Symptoms related to treatment
    • - Surgery
    • - Radiotherapy
    • - Chemotherapy
    • - Medication
    • Unrelated Condition
  •  
  •  
  • Symptom Management Seizures
    • Who needs to be on an anticonvulsant medication?
        • Risk dependent upon type and location of tumor
        • Overall risk 25-40%
    • * Use of anticonvulsant
    • - Compliance, monitoring levels
    • * Factors altering seizure threshold – Increasing risk for seizure
        • Sub therapeutic levels / Noncompliance
        • Fever/ Infection
        • Lack of sleep
        • Missing meals
        • Stress
        • Alcohol
        • Menses
        • New medications / Medication interactions
  • Seizures Acute Management
    • * Seizure precautions
    • - Use good judgment: do not put yourself in situation such that if you suffered a seizure, you could hurt yourself.
    • Acute management
      • Assistance and protection
      • Airway
      • Medications
      • When to call 911
    • Know your state laws regarding seizures and driving!
  • Choosing an Anticonvulsant Medication
    • How does your physician choose an anticonvulsant medication?
      • Acute management for seizure
      • Preparation for surgery
      • Type of seizure (focal vs generalized )
      • Prophylaxis
      • Route of administration ( p.o. or i.v. )
      • Side-effect profile
      • Drug interactions
        • Liver enzyme-inducing meds and chemotherapy
  • Anticonvulsants
    • Dilantin ( phenytoin)
      • Brand name vs. generic
      • Side-effects
        • Rash Allergy: Stop immediately
        • Dizziness, staggering, clumsiness
        • Sleepiness, confusion
        • Blood abnormalities
        • Gum swelling/bleeding
        • Chronic: Osteoporosis
      • Available as oral or i.v. form
    • Tegretol (carbamazepine)
      • Brand name vs generic
      • Side-effects
    • - dizziness, unsteady gait
    • - sleepiness
    • - blood abnormalities
      • Monitor blood levels
      • Oral form only
    • Depakote (valproic acid)
    • - somnolence
    • - weight gain
    • - upset stomach, nausea
    • - blood abnormalities
    • - monitor blood levels
    • -Available in oral and i.v. form
    • Topamax (topiramate)
        • Need to start gradually
        • Side-effects
            • Weight loss
            • Memory impairment
        • Also helpful to prevent migraines
        • Oral form only
    • Keppra (Levetiracetam)
      • Doses 1000-3000 mgs/day in twice daily dosing
      • Side-effects
        • Dizziness
        • Somnolence
        • Personality changes
      • Does not induce liver enzymes
      • Not approved as single agent for generalized seizures
      • Levels now available
      • Available in oral and i.v. form
    • Lamictal (Lamotrigine)
      • Needs to be started gradually
      • Side-effects
        • Rash
        • Does not induce liver enzymes
      • Levels now available
      • Oral form only
    • Neurontin (gabapentin)
    • - drowsiness
    • Oral form only
    • Phenobarbital
      • - sleepiness, sluggishness
      • - depression
    • Available in oral and i.v. form
  • Anticonvulsants Dilantin® (phenytonin) Lamictal® (lamotrigine) Luminal® (phenobarbital) Tranxene® (clorazepate) Tegretol® (carbamazapine) Valium® (diazepam) Depakote® (valproic acid) -suppository available as Diastat Neurontin® (gabapentin) Ativan® (lorazepam) Trileptal® (oxcarbazepine) Klonopin® (clonazepam) Topamax® (topiramate) Lyrica ® (pregabalin)
  • Headaches - May be a sign of increased pressure either from tumor growth or effects of treatment - Monitor persistence and pattern - May occur if steroid tapered too quickly Headaches that awaken from sleep or are worse upon arising in a.m. are often due to  pressure. - Treatment: dexamethasone
  • Increasing Neurologic Deficits - May be a sign of increased pressure either from tumor growth or effects of treatment - May occur if steroid tapered too quickly - Acute: bleeding a possible cause - May be transient and related to fatigue or seizure
  • Increasing Somnolence Many Causes: - increased pressure dexamethasone or appropriate therapy - anticonvulsant medications (check levels, adjust) - other medications (review with physician) - seizures (observe for seizure activity, check levels) - infection (look for source) - abnormal blood studies glucose (dexamethasone) ↑ Na ( sodium ) ↓
  • Anxiety - often due to or worsened by steroids - component may be “ situational” - treated with Xanax®, Ativan®, or antidepressant medication Anti-anxiety agents: Xanax® (alprazolam) Tranxene® ( clorazepate) Ativan® (lorazepam) Paxil® ( paroxetine) Klonopin ® (clonazepam)
  • Depression
    • may be “organic” as a result of tumor / treatment
    • - reactive, situational component
    • - “ Emotional lability”
    • - personality changes
    • - treat with antidepressant medication
    • Anti-Depressants :
    • Zoloft® (sertraline) Celexa® (citalopram)
    • Paxil® (paroxetine)
  • Personality Changes
    • Location of tumor
    • Medications
      • Dexamethasone
      • Anticonvulsants
        • Keppra ®
        • Lyrica ®
  • Fatique - may be related to medication or associated with radiation therapy - may occur during dexamethasone taper - check hormone levels (yearly beginning 1 year after radiotherapy) Stimulants: Dexamethasone Zoloft® (sertraline) Ritalin® (methylphenidate) Dexedrine® (dextroamphetamine) Provigil® (modafinil) Adderall® (dextroamphetamine & racemic amphetamine)
  • Insomnia - most often result of dexamethasone (avoid PM dose) (change dose, timing) - sleep-wake cycle may be altered ( use stimulating medication in the day, sedating medication at night) - Medication may be helpful - Benzodiazipine - Antidepressant
  • Dexamethasone The most effective treatment for increased intracranial pressure - timing and dose of medication - Side Effects anxiety, irritability, depression, mood lability insomnia * Avoid evening dosing increased appetite elevation of blood sugar (diabetes mellitus) muscle wasting (myopathy) skin fragility (bruising) * Skin protection
  • Dexamethasone Stomach ulcers and increased acid secretion * Take with food, use medicine to protect your stomach * Report symptoms of pain to your doctor Stomach Protectants Zantac® (ranitidine) Prilosec® (omeprazole) Pepcid® (famotidine) Nexium® (esomeprazole) Tagamet® (cimetidine) Protonix® (pantoprazole) Prevacid® (lansoprazole) Aciphex® (rabeprazole) Antacids (eg. Maalox, Tums)
  • Dexamethasone * Change in appearance (“cushinoid appearance”) * Osteoporosis * Joint pain “arthritis-like” with taper * Never stop suddenly * Rate of taper determined by original dose, amount of swelling present, and duration of steroid therapy. Therefore, the higher the dose and the longer you have been on steroids, the slower taper.
  • Quality of Life
    • Optimize medications and Minimize Toxicity
    • Be Informed
    • Communicate with Health Care Team
    • Compliance