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Pharmacological Concerns

Related to Common Clinical

Conditions

Oncology and Parkinson’s Disease

Douglas DeRitis, RPh, PharmD & Colleen DeRitis, MA, OTR/L

Objectives• Oncology

• Medical Intervention

– Surgery

– Chemotherapy

– Radiation

• Pharmacological Issues and Barriers

• Implications for Rehabilitation

• Neurological Conditions (Parkinson's Disease)

• Medical Intervention

• Pharmacological Issues and Barriers

• Implications for Rehabilitation

• Medication Issues with Older Adults

• Common Medications that may increase confusion

• Pharmacological Issues and Barriers

• Scheduling issues

• Documentation related to barriers

Oncology

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Definitions

• Carcinogen – any cancer initiating agent capable of permanently, directly, and irreversibly changing the DNA of a cell

• Carcinogenesis – process by which normal cells are transformed to cancer cells

• Neoplasm (tumor) – a mass of excess tissue that results from abnormal cell division which may be cancerous or non-cancerous

• Cancer – Net growth of tissue from continuous abnormal production of cells that have the ability to invade and destroy other cells

www.cancer.org

www.cancer.org

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Types of Tumor Classification

• Histological – named for tissue of origin

– Carcinoma-epithelium

– Sarcoma-bone, cartilage, muscle, fibrous

connective tissue

– Lymphoma-lymphatic system

– Leukemia-blood forming organs

• Site – location of tumor

– Primary, Secondary, Metastatic, Unknown

• Behavioral – basic characteristics

Tumor Behavior - Benign

• Slow growing

• Encapsulated

• Well-differentiated

• Non-ulcerated

• Non-metastatic

• Not fixed to

surrounding tissue

• May become malignant

Meningioma

Tumor Behavior - Malignant

• Rapid growing

• Ulcerated

• Poorly differentiated

• Fixed to surrounding

tissue

• Local invasion

• Productive of mets

Meningioma

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Tumor Grading

Differentiation-definition of the structural components of the cancer cells

• Grade 1: well-differentiated

• Grade 2: non-neoplastic

• Grade 3: poorly-differentiated

• Grade 4: aggressive, poorly-differentiated– Malignant neoplasms frequently simply referred

to as “high-grade”– Tumors can change grade

Staging

T1° tumor size & extent

NLymph node involvement

MDistant metastasis

T0 No evidence N0 No regional lymph

node involvement

M0 No metastasis

Tis In situ N1-3 Increasing

regional lymph

node involvement

M1 Presence of

distant

metastasisT1-2 Increasing size,

Local extension

T3-4 Progressive

extension

Stage Groups

• In Situ

• Stage I – T1 N0 M0

• Stage II – T2 N1 M0

• Stage III – T3 N2 M0

• Stage IV – T4 N3 M1

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Progression of Disease

• Metastatic Disease

– Spread from primary site

– Other areas in the body

– Local-invasion

– Distant-travels

• Usually classified as Stage IV disease

– Chemo, RT or surgery

Metastatic prostate cancer to bone

Metastatic Disease:Tumor Type and Spread

• Breast CA– Bone

– Lung

– Liver

– Nodes

– Meninges

• Colon CA– Lung

– Liver

– Nodes

• Head and Neck CA– Skin

– Lung

– Nodes

• Lung CA– Bone

– Bone marrow

– Liver

– Nodes

– Brain

– Meninges

• Prostate– Bone

– Lung

– Liver

– Nodes

Chemotherapy• Administration of antineoplastic drugs

• Interrupts the cell cycle to damage and/or destroys cancer

• Orally, intravenously, or injection

• Affects cells that divide quickly

– Cancer

– Hair follicles

– Bone marrow

– GI system

– Reproductive system

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Chemotherapy• Adjuvant

• After complete surgical resection of all evidence of cancer or

after definitive treatment with radiation

• Limited time, intermittent

• Neoadjuvant

• Before surgery

• Micrometastatic disease

• Combination

• Use of more than one chemotherapeutic agent

• Resistance

• Different mechanisms of action & levels of cytotoxicity

• Shortest interval between cycles

Chemotherapy:

Common Side Effects

• Pain

• Fatigue

• Bone marrow suppression

• Alopecia

• Infertility

• GI effects

• Peripheral neuropathy

• Weakness

• Cognitive difficulties

• Anxiety

• Depression

• Changes in self esteem or self image

Thrombocytopenia

• Definition– Decrease in the number of

platelets

• Normal values– 150-400,000 mm3 (150-400K)

• Signs and symptoms– Bruising, bleeding, petechiae

• Complications– Excessive bleeding, internal

bleeding

• Treatment– Transfusion of platelets

www.csufresno.edu/.../ n140/studassign/blood.htm

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Measurement of Fatigue

www.weboflife.ksc.nasa.gov/. ../chapter4.html

• Subjective measures

– Borg Ratio of Perceived

Exertion

BORG Rating

• Borg's Ratings of Perceived Effort• Gold standard

• Dr. Gunnar Borg's

• Rates your perceived effort on a scale from 6 to 20

– 6 being "no exertion at all,"

– 13 being "somewhat hard,”– 17 being "very hard,"

– t20 being "maximal exertion."

• This feeling should reflect how heavy and strenuous the exercise feels,

• Not meant to be compared across individuals.

Cancer Pain

• Incidence

– 65-85% of patients with advanced cancer experience moderate – severe pain

• Definition

– Cancer pain

• Acute or chronic

• Several etiologies

• Often described as intractable

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Visual Analog Scale

Other Treatments

• Hormone Therapy

– Manipulation of hormones

– Most commonly used with breast, prostate, &

uterine cancers

• Immunotherapy

– Stimulates the body’s system to fight cancer

• Anti-angiogenesis

– Prevents formation of new capillaries which will

sustain tumor growth

• Radiation

Therapeutic Intervention

• “Facilitate and enable an individual…to achieve maximum functional performance,

both physically and psychologically, in

everyday living skills regardless of his or her

life expectancy”• AOTA fact sheet on The Role of OT in Oncology

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Pharmacological Rehabilitation concerns

related to cancer

• Pain & Fatigue

• Tx can cause weakness

• Co-morbidities

• Neuro deficits & meds

• Decreased function

• Precautions seizures

• Need for orthotics

• Difficulty with ADLs

Rehabilitation Implications: Vascular Issues

• Hold treatment according

to facility protocol

• Monitor INR

• Monitor signs and

symptoms of DVT and PE

• Platelets

• Bone Marrow

Suppression

Rehabilitation Implications:

Chemotherapy

• Precautions– Infection control

– Blood counts/lab results

– Impaired skin integrity

– Falls

• Interventions– Therapeutic exercise

– Bracing/Splinting for neuropathies

– Patient/family education for safety/fall prevention

www.orthotic.com/ info.html

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Parkinson’s Disease

• Abc.net.au

Parkinson’s Disease

• Two common

approaches:

– Slow loss of dopamine in

brain

– Improve symptoms

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Most common drugs used with

Parkinson’s Disease• Sinemet(Levodopa/Carbidopa)

• Dopamine Agonists

• Symmetrel

• Anticholinergics(Artane, Cogentin)

• Eldepryl and Deprenyl

• Tasmar, Comtan (COMT Inhibitors)

Dopamine Agonists

• Pramipexole (Mirapex)

• Ropinirole (Requip)

• Apomorphine (Apokyn)- used only as “rescue” drug for people with advanced PD

• Often used as first line medication

• Mimic the effects of dopamine without having

to be converted.

Dopamine Agonists

• Excessive daytime sleepiness

• Visual hallucinations

• Confusion

• Swelling of the ankles

• Dyskinesia (not as common)

• Compulsive behaviors

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Amantadine

• 300 mg to 400 mg daily.

• Releases dopamine and norepinephrine from

nerve endings in the brain.

• Anticholinergic ( supresses release of

acetylcholine )

• Treats L-dopa related motor fluctuations and

L-dopa related dyskinesias.

• Nervousness, anxiety, insomnia, agitation

Levodopa

• Larodopa

• Crosses blood brain barrier

• Peripheral conversion

• Improvement in symptoms- may take 4

months

• Side effects: nausea, vomiting, confusion,

dyskinesia, hypotension (high doses), vivid

dreams; insomnia, visual hallucinations

Carbidopa

• Dopa decaroxylase inhibitor

• Enhances the effect of levodopa

• Does not cross blood brain barrier

• Decreased dopamine in periphery and increased dopamine in brain

• Peripheral side effects decreased

• Mental side effects same

• Dyskinesia more quickly

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Sinemet (carbidopa-levodopa)

• Sinemet 10/100= 10mg carbidopa + 100mg

levodopa

• Sinemet 25/100

• Sinemet 25/250

• Sinemet CR 25/100

• Sinemet CR 50/200

COMT inhibitors

• Catechol-O-methyl transferase (COMT)

• Converts a portion of levodopa into a useless

form.

• Block the COMT enzyme from converting

levodopa into a useless form, thus making

more levodopa available in the brain. This will

reduce PD symptoms.

COMT Inhibitors

• Entacapone ( Comtan )

• Tolcapone ( Tasmar )

• Stalevo ( carbidopa, levodopa, entacapone)

• Entacapone is given with each dose of levodopa

• Tolcapone is given three times daily.

• Tolcapone: liver functions tests must be conducted at baseline, and every 6 months after therapy has started.

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COMT Inhibitors

• May exaggerate some levodopa-related side

effects especially dyskinesia.

• Confusion

• Hallucinations

• Discoloration of urine (reddish brown/ rust

colored)

• Diarrhea

The balance scale of Parkinson’s Disease

Balance of acetylcholine and dopamine

Pharmacological intervention

• Anticholinergics

– Block excitatory neurotransmitter acetylcholine in

substantia nigra

– Most effective in early disease

– Inhibit parasympathetic nerve impulses.

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Cholinergic Activity

• Mimics parasympathetic activity

• Produces, alters, or releases acetylcholine

• Increases tone and contractility of smooth

muscle– slows heart rate

• Increases normal secretions, digestive acids in

stomach, saliva, and tears.

• Decreases intra-ocular pressure

Anticholinergics

• Oldest class of drugs to treat PD

• Trihexyphenidyl ( Artane ), and benztropine

( Cogentin ) are examples.

• Most helpful to younger patients whose chief

complaint is tremor.

• Side effects may limit their usefulness.

Side Effects

• Dry mouth

• Blurred vision

• Constipation

• Urinary retention

• Increased intraocular pressure

• Confusion

• Memory impairment

• Hallucinations

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Rehabilitation Implications:

Anti-Cholinergics

– Increased heart rate (tachycardia)

– Pupil dilation (mydriasis); consequent sensitivity to bright light (photophobia)

– Loss of visual accommodation (loss of focusing ability, blurred vision)

– Double-vision (diplopia)

– Ataxia; loss of coordination

– Cessation of perspiration; consequent decreased heat dissipation leading to warm, blotchy, or red skin

– Increased body temperature

– Tendency to be easily startled

– Shaking 46

Rehabilitation Implications:

Anti-Cholinergics

• Evaluation considerations

– Note if patient is on these meds

– Be attentive to the adverse effects

• If your patient has started a new drug and you observe the new onset of adverse effects:

– Communicate!

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Common Alzheimer Medications

• Mild to Moderate: cholinesterase inhibitors

– Razadyne (Galantamine), Exelon (rivastigmine),

and Aricept (donepezil)

• Moderate to Severe: Namenda (memantine),

N-methyl D-aspartate(NMDA) antagonist

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Drugs That May Cause Confusion in

the Older AdultDrug Use

Quinidine Anti-dysrhythmia

Digoxin Used to treat CHF

Beta Blockers Anti-anginal & anti-hypertensive

Levadopa & Bromocriptine Anti-Parkinson’s

Corticosteroids Anti-inflammatory

NSAIDs Anti-inflammatory

Cimetidine (Tagamet) GI ulcers & GERD

Benzodiazepines Sleeping medications

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Drugs Given in Reduced Dosage in the

Older AdultDrug Use Possible Effect at Usual Dosage

Aminoglycoside Antibiotic, such as Gentamicin Nephrotoxicity and ototoxicity

Carbamazepine Anti-seizure medication, such as

Tegretol

Drowsiness, ataxia

Cimetidine For ulcers and GERD, such as

Tagamet

Confusion

Digoxin Used for CHF Increased toxicity

Levadopa Used for Parkinson’s Disease Hypotension

Meperidine Opioid analgesic drug, such as

Demerol

Respiratory depression that can be fatal

Metoclopramide Used to treat nausea and

vomiting, such as Reglan

Delerium

Thioridazine Used to treat schizophrenia and

psychosis, such as Mellaril

Confusion

Vitamin D Renal toxicity (in high enough doses and long

enough duration)

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The Beers List• Developed by a group of 12 clinicians with

expertise in geriatrics and led by Dr. Mark Beers.

• First released in 1991.

• Initially created to help determine which

medications should be avoided in nursing home

patients

• Residents in nursing homes particularly at risk for

suffering medication-related problems

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Documentation Pointers

• A problem list which summarizes important patient medical information, such as a patient’s major diagnoses, past medical and/or surgical history, and recurrent complaints, is documented.

• Continuity of care between multiple practitioners in the same practice is demonstrated by documentation and review of pertinent medical information.

Documentation Pointers

• A problem list which summarizes important patient medical information, such as a patient’s major diagnoses, past medical and/or surgical history, and recurrent complaints, is documented.

• Continuity of care between multiple practitioners in the same practice is demonstrated by documentation and review of pertinent medical information.

Helpful info

• cderitisotr@aol.com

• Nursing.uchc.edu –infection control

• Cdc.gov/hicpac

• www.rehabstudents.com

• Unc.edu

• Globalrph.com – blood levels

• Barthsyndrome.org

• www.nytimes.com or google blood

exam

• HEP2go.com

• www.hrsa.gov/leap/default.htm

• www.diabetesincontrol.com

• http://ndep.nih.gov/diabetes/pubs/f

eet_kit_eng.pdf

• SEMMES WEINSTEIN-

HTTP://NDEP.NIH.GOV/DIABETES/PU

BS/FEET_KIT_ENG.PDF

• Nwcaonline.com

• Apps:

• Sound Builder

• ICD9 or ICD9 Consult

• FINR Brain

• Blood Gas

• Emergency Medical Spanish

• CardioTeach

• Ihealth

• Ipharmacist

• Glucomo

• Breathe2relax

• mms mobile

• Dosecast

• Imedicine

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Questions?