Managing Medications

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Managing Medications and Side Effects
Deborah Olin Heros, MD Neuro-Oncology Departmen
t of Neurology University of Miami Miller School
of Medicine Sylvester Cancer Center
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Quality of Life
Physical Cognitive Emotional
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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

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Symptom ManagementSeizures

• 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

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SeizuresAcute 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!

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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

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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

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• Tegretol (carbamazepine)
• Brand name vs generic
• Side-effects
• - dizziness, unsteady gait
• - sleepiness
• - blood abnormalities
• Monitor blood levels
• Oral form only

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• Depakote (valproic acid)
• - somnolence
• - weight gain
• - upset stomach, nausea
• - blood abnormalities
• - monitor blood levels
• -Available in oral and i.v. form

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• Topamax (topiramate)
• Need to start gradually
• Side-effects
• Weight loss
• Memory impairment
• Also helpful to prevent migraines
• Oral form only

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• 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

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• Lamictal (Lamotrigine)
• Needs to be started gradually
• Side-effects
• Rash
• Does not induce liver enzymes
• Levels now available
• Oral form only

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• Neurontin (gabapentin)
• - drowsiness
• Oral form only

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• Phenobarbital
• - sleepiness, sluggishness
• - depression
• Available in oral and i.v. form

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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)
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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
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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
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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) ?
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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)
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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)

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Personality Changes

• Location of tumor
• Medications
• Dexamethasone
• Anticonvulsants
• Keppra
• Lyrica

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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) Stim
ulants Dexamethasone Zoloft
(sertraline) Ritalin (methylphenidate) Dexedr
ine (dextroamphetamine) Provigil
(modafinil) Adderall (dextroamphetamine
racemic amphetamine)
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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
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DexamethasoneThe 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
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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)
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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.
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Quality of Life

• Optimize medications and Minimize Toxicity
• Be Informed
• Communicate with Health Care Team
• Compliance