spinal cord compression pharmaceutical issues

Spinal Cord

Compression:

Pharmaceutical Issues

Rebecca Mills

Debra Howe Becs Walsh

Overview

Steroids

Why?

Adverse Effects

Gastro-protection

VTE Prophylaxis

Laxatives

Analgesia

Why use steroids?

Reduce inflammation around tumour

Reduce pain and improve neurological

function

Improve physical signs - reduced injury to

spinal cord

Choice and dose of steroid

Dexamethasone Available as injection, tablets or oral solution

High anti-inflammatory (glucocorticoid) effect, with minimal mineralocorticoid effects.

Long acting

16mg per day divided into 2 doses (8am & 2pm) N.B.= approx 100mg prednisolone

Trials compared 16mg per day with 96mg per day showed more side-effects with higher dose, but no greater effect

Gradual reduction Due to high dose (>40mg Pred)

Minimise risk of acute adrenal insufficiency

Every 3 days - See reducing regimen

Some patients will continue low dose (e.g. 2mg OD) steroids.

If symptoms worsen increase dose/reduce more slowly.

References NICE Guideline CG75

STH Cancer Nursing Care Guideline CN 301

WPH Reducing regimen

Day

Dexamethasone daily

dose Administration

1-3 16mg

16mg OM or 8mg

BD

(8am & 12noon)

4-6 8mg 8mg OM

7-9 4mg 4mg OM

10-12 2mg 2mg OM

13

Discontinue (unless on

maintenance dose)

Side-effects of Corticosteroids

Gastrointestinal irritation

Increased appetite, weight gain

Impaired glucose tolerance & diabetes Increase blood glucose monitoring

Refer to diabetic team

Psychiatric reactions – “steroid-induced psychosis” (mood changes)

Adrenal insufficiency Fatigue, Anorexia, nausea & vomiting

Check temp, Na, glucose, Hb

Long-term effects of steroid therapy

Immune suppression

Reduced healing/ability to fight infection

Caution chicken pox/ measles/influenza

contacts

Osteoporosis

Muscle weakness

Glaucoma

Cushing’s Syndrome

Cushing’s Syndrome

Gastro-protection

Be aware of high risk groups History of gastro-duodenal ulcer, gastrointestinal bleeding, or

gastro-duodenal perforation.

Older age.

Concomitant use of medications that are known to increase the risk of gastrointestinal bleeding.

Advanced cancer.

Prescribe lowest dose of steroid, for shortest time Review frequently.

Prescribe Proton Pump Inhibitor Lansoprazole 15mg OD (or continue existing dose/treatment)

Review when steroid stopped.

Points to remember Take with or after food to minimise gastric

effects

Use a PPI only whilst on steroid.

Try to avoid taking steroids after 4pm

Dexamethasone tablets dissolve or liquid is available (2mg in 5ml)

Check patient knows how/when to reduce their dose

Do not assume all patients stop steroids completely.

Avoid infectious contacts

Refer diabetic patients to diabetic nurses for additional monitoring.

Bowel Management

Constipation often associated with SCC

Can be one of the presenting symptoms

Maintaining regular bowel action is

important for patient comfort

Psychological issues also need to be

overcome e.g. patients embarrassment at

needing to be assisted with toileting

Review precipitation medications

Laxatives of choice

Docusate 100-200mg BD 1st line

Add Senna 2 ON PRN

Laxido/Movicol if impaction

Alternate Glyercin/Bisacodyl suppositories

if PR intervention needed.

Enemas may be required

Bulk-forming agents are less effective (e.g.

isphaghula/Fybogel)

VTE Prophylaxis

ALL inpatients – risk assessment (blue

form or in clerking)

SCC patients – high risk

Dalteparin

Anti-embolism stockings

Pain Control

Analgesia

Review current analgesia

Ensure adequate breakthrough

Titrate according to WHO ladder

See NICE - neuropathic pain

Any Questions?