February 2004

Dear Readers: Here's the Article for this Month:

Name of article:

Patient-Controlled Methylphenidate for the Management of Fatigue in Patients with Advanced Cancer: A Preliminary Report

Author(s) :Bruera E, Driver L, Barnes EA, Willey J, Shen L, Palmer JL, Escalante C.

Abstract: Journal of Clinical Oncology 2003; 21: 4439-43

Methylphenidate is a psychostimulant with a short half-life successfully used in cancer patients with other clinical symptoms such as attention deficit, cognitive impairment due to brain tumours, depression and opioid-related sedation. In uncontrolled studies carried out on a small sample of cancer patients and in a randomized placebo-controlled study on HIV patients, methylphenidate, administered twice a day (morning and lunch time) significantly improved fatigue.

In this prospective open study Bruera and Colleagues assessed the efficacy and tolerability of patient-controlled self-administration of 5 mg to 20 mg/day of oral methylphenidate for the management of cancer-related fatigue. For this study, 30 patients with advanced cancer suffering from fatigue with an intensity >4, absence of cognitive failure, on a stable dose of opioids, Hb level of at least 10, no major contraindications in using methylphenidate were enrolled. The patients were allowed to take 5 mg of methylphenidate tablet as needed every 2 hours up to a maximum of 4 tablets per day for 7 days.

The Functional Assessment for Chronic Illness Therapy-Fatigue (FACIT-F) and the Edmonton Symptom Assessment Score (ESAS) were administered at baseline, after 8 days, and after 4 weeks of follow-up. All problems connected with sleep were assessed at the same time. Side effects were evaluated daily and at the end of the 4 weeks. Furthermore 4 evaluations per day were carried out as far as fatigue intensity, pain, depression, nervousness, drowsiness, sleep at night were concerned, using a numerical scale of 0 to 10.

All patients took methylphenidate in the afternoon or evening and 93% of them took at least three daily doses. With respect to baseline, after 7 days of treatment a significant improvement was obtained (p< .001) as regards fatigue, physical and functional well-being, and fatigue subscore (FACIT-F). Other symptoms such as pain, nausea, depression, drowsiness, appetite and sleep improved significantly. In the 21 patients evaluated after 28 days of therapy, fatigue, physical well-being and overall subscores significantly improved. The intensity of fatigue decreased progressively from breakfast to evening. All patients were willing to continue with the methylphenidate treatment.

No severe adverse effects were encountered.

It is interesting to point out that when methylphenidate is used for patients suffering from fatigue, sleep and appetite improved and did not worsen.

Why I chose this article.

In advanced cancer patients, fatigue is one of the most frequent (60%-90%) and distressing symptoms. Many and different factors such as drugs, antineoplastic treatments, pain, depression, malnutrition, cachexia, anaemia contribute to cancer-related fatigue syndrome. No specific medication is available for symptom management.

In patients without any contraindications, the use of a psychostimulant such as Methylphenidate can improve fatigue symptoms and the sense of well being without any severe side effects.

Regards,

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC