# 061 Use of Psycho-Stimulants in Palliative Care, 2nd ed

FAST FACTS AND CONCEPTS #061 PDF


Author(s): Vicki Jackson MD and Susan Block MD

Background 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.

Uses of Psycho-stimulants 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:

  • Mood elevation
  • Improved energy
  • Potentiate analgesic effect of opioids
  • Counter opioid-induced sedation
  • Increase appetite
  • Improve cognition

Practical Tips 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 a selective serotonin reuptake inhibitor anti-depressant (SSRI). Psycho-stimulants are also useful to augment the action of SSRIs in patients with severe depression.


Drug

Onset of action

Starting dose

Usual Daily Dose

Maximal Daily Dose

Schedule


Dextroamphetamine

Methylphenidate

<24hrs

<24hrs

2.5-5mg

2.5mg

10-20mg

5-10mg

60-90mg

60-90mg

8am and

noon*

Pemoline 1-2 days 18.75mg 37.5mg 150mg Twice daily


*some patients may need a late afternoon booster dose (usually 1/2 the am dose)

References

  1. Block S. Assessing and Managing Depression in the Terminally Ill Patient. Annals of Internal Medicine. 2000; 132(3):209-218.
  2. 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.

Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published September 2006. Current version re-copy-edited April 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Jackson V, Block S. Use of Psycho-stimulants in Palliative Care, 2nd Edition. Fast Facts and Concepts. September 2006; 61. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_061.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a 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.

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non-Pain Symptoms and Syndromes