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. ***
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.
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.