Disease progression the 3 Trajectories

Most disease progress in a somewhat predictable manner. Knowledge of the expected disease trajectory is essential for prognostication. Today, let’s talk about the three types of trajectories.

  • Trajectory 1: The patient experiences relative wellness followed by a short but predictable period of decline leading to death. Typically associated with cancer diagnoses, and the expected time from terminal diagnosis to death is approximately 6 months without interventions. During the period of decline, the patient may experience symptoms of weight loss, gradual decreased ability to engage in activities of daily living, and a progressive decline in overall condition. Such patients are most likely to access palliative care and hospice services because of the predictability of the disease process.
  • Trajectory 2: is characterized by periods of relative well-being punctuated by acute exacerbations that may require hospitalization. After each exacerbations, the patient’s level of overall health declines somewhat, with a clear declinatory pattern discernable over time. This trajectory is associated with chronic illnesses such as heart failure and chronic obstructive pulmonary disease (COPD). The time from terminal diagnosis to death is longer than the process in the first trajectory and may span a period of 2 to 5 years.
  • Trajectory 3: is associated with chronic conditions such as dementia, frailty, and debility. Such diseases involved a gradual functional decline over a period of 6 to 8 years without acute exacerbation. However, patients may fall subject to acute illnesses, such as pneumonia or cardiac events, that unexpectedly lead to their death.


Corticosteroids in Hospice and Palliative Care (Reading & Sharing)

Corticosteroids may be used to treat a variety of conditions and symptoms in the palliative care patient, including cerebral edema, spinal cord compression, pain, nausea/vomiting, malignant bowel obstruction, fatigue, and loss of appetite.

***Tumor edema is a common complication of primary or metastatic brain tumors and may cause significant symptoms of elevated intracranial pressure, such as headache, altered mental status, and seizures. Tumor edema may be secondary to tumor cell death, tumor growth, or related to treatment (for example, postoperative edema). The mainstay of therapy for brain tumor edema is systemic corticosteroids, most commonly dexamethasone. ***

Continue reading “Corticosteroids in Hospice and Palliative Care (Reading & Sharing)”

When the Movies Promoted Smoking (Piece of History – Reading & Sharing)

When Columbus landed in the New World in 1492, he and his men were astonished to find the native Indians smoking rolled-up tobacco leaves, the forerunners of present-day cigars. In the 16th century, Sir Walter Raleigh set London on its ear by puffing away on an elaborate pipe that he brought back from America. Soon tabacco smoking spread to Europe, and the craze was on. Doctors, noting its soothing effects, prescribed tobacco for all sorts of ailments, including lockjaw. In time, the craze was taken up by America’s new settlers. By the 1800s, cigarettes, which were really tiny cigars wrapped in paper, were a major industry, with billions being sold each year.

Continue reading “When the Movies Promoted Smoking (Piece of History – Reading & Sharing)”

Venlafaxine – Effexor (Selective Serotonin-Norepinephrine Reuptake Inhibitor /SNRI)

Venlafaxine is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) used in the palliative care setting for concurrent treatment of depressive disorders and neuropathic pain. (Neuropathic chronic pain is often resistance to standard opioid therapy and is best treated with a secondary amine tricyclic antidepressant (nortriptyline, desipramine), a selective serotonin or norepinephrine reuptake inhibitor (SSNRI) (venlafaxine, duloxetine), or a calcium channel alpha2 delta lignd (anticonvulsants) (gabapentin or pregabalin).

In the United States, there are three SNRIs that have been approved by the FDA: venlafaxine (Effexor and Effexor XR), desvenlafaxine (Pristiq), and duloxetine (Symbalta). Venlafaxine and duloxetine both block the serotonin and norepinephrine transporters, thereby inhibiting and availability to bind with the postsynaptic receptors. At lower doses, venlafazine predominantly affects serotonin reuptak, contributing to greater anxiety reduction more so than depressive symptom reduction. Duloxetine, however, appears to be a more potent and equal serotonin and norepinephrine reuptake inhibitor than venlafaxine is. These drugs are rapidly absorbed after oral intake and metabolized extensively in the liver. Time needed to reach maximum plasma concentration is 2 hours for both venlafaxine and duloxetine. Venlafaxine has a half-life of 5 hours and the active metabolite is 11 hours. Steady state is achieve in 3 to 4 days. Duloxetine has a half-life of 12 hours, reaching steady state in 3 days. Both drugs are excreted mostly in urine.

Continue reading “Venlafaxine – Effexor (Selective Serotonin-Norepinephrine Reuptake Inhibitor /SNRI)”