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Fast Fact and Concept #61: Psychostimulants in Palliative Care

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Title: Fast Fact and Concept #61: Psychostimulants in Palliative Care

Author(s): Vicki Jackson; Susan Block

Educational Objective:
Review the indications, application, and dosing of psycho-stimulants in the terminally ill patient.

Teaching Points:
More than 95% of patients experience fatigue near the end of life. Chemotherapy, radiation, and administration of opioids all tend to increase tiredness. Depression is also a common cause of suffering at the end of life; about 25% of cancer patients with early stage disease develop depression, in advanced illness more than three-quarters of all patients have symptoms of depression. Both fatigue and depression can be treated with one of the psycho-stimulants: dextroamphetamine, methylphenidate, or pemoline. Psycho-stimulants act rapidly and are well-tolerated. These medications have 6 potentially beneficial effects for patients with terminal illness:

  1. Mood elevation
  2. Improved energy
  3. Potentiate analgesic effect of opioids
  4. Counter opioid-induced sedation
  5. Increase appetite
  6. Improve cognition

For depression, psycho-stimulants are the drug of choice for patients with a relatively short life expectancy of weeks to months because they act quickly, usually within 24-48 hours. Psycho-stimulants are generally safe. However, they should be used with caution in patients with heart disease or cognitive disturbances (e.g. delirium). Pemoline, a milder psycho-stimulant, can rarely cause hepatotoxicity, requiring regular monitoring of hepatic function. Some patients with severe depression and a longer life expectancy benefit from starting a psycho-stimulant and then transitioning to an SSRI. Psycho-stimulants are also useful to augment the action of SSRIs in patients with severe depression.


Drug Onset of Action Starting Dose (mg) Usual Daily Dose (mg) Maximum Daily Dose (mg) Schedule
Dextroamphetamine <24hrs 2.5-5 10-20 60-90 8am and
Methylphenidate <24hrs 2.5 5-10 60-90 noon*
Pemoline 1-2 days 18.75 37.5 150 Twice daily

*some patients may need a late afternoon booster dose (usually ½ the am dose)

Reference:

Block, S. Assessing and Managing Depression in the Terminally Ill Patient. Annals of Internal Medicine. 2000;132(3):209-218.

Roszans M, Dreisbach A, Lertora JJL, Kahn MJ. Palliative uses of methylphenidate in patients with cancer: A review. J Clin Onc 2002;20:335-339.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #61 Use of psycho-stimulants in palliative care. Jackson V and Block S. February, 2002. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 2/2002

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Neurologic, Pain treatment, Psychiatric


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).