Fatigue (PDQ®): Supportive care - Health Professional Information [NCI] - Intervention
The side effects most commonly described with psychostimulants include the following:[19,21,22,27,28]
High doses and long-term use may produce:
Patients with cancer carry a higher risk of cardiovascular complications, depending on the type of cancer and cancer treatment (e.g., cardiotoxic chemotherapy regimens). Cardiovascular complications with psychostimulants can arise even in patients without any significant risk factors. In the study using methylphenidate as an intervention for the treatment of CRF in patients with prostate cancer, 6 of 16 subjects (27%) in the methylphenidate group were discontinued because of increased blood pressure and tachycardia. It is important to note that none of these subjects were being treated with known cardiotoxic chemotherapeutic regimens such as anthracyclines. Careful and continuous monitoring of certain cardiovascular parameters (mainly blood pressure and heart rate) is critical when psychostimulants are used to treat CRF. In certain complex cases, consulting with cardiology services may be considered. Cardiovascular issues are thought to be less of a risk with modafinil and armodafinil. Risk-benefit ratio may be considered and patients may be evaluated for response and side effects when these agents are used to treat CRF.
The package inserts for all Schedule IV stimulant medications carry boxed warnings indicating risk of abuse potential and/or risk of psychological dependence. Additionally, boxed warnings for certain stimulant medications (methylphenidate and dexmethylphenidate products) indicate risk of psychotic episodes. Other stimulant medications (amphetamine, dextroamphetamine, lisdexamfetamine dimesylate, methamphetamine, and mixed salts of amphetamine products) carry boxed warnings alerting clinicians that misuse of these medications may cause serious cardiovascular adverse events, including sudden death.
Table 2. Centrally Acting Stimulants for Adult Cancer Patients
|Drug||Dosage||Comments/Primary Side Effects|
|AUC = area under the curve; MAOI = monoamine oxidase inhibitor; SSRI = selective serotonin reuptake inhibitor.|
|Dextroamphetamine (Dexedrine)||2.5 mg/d (start)||Schedule II. Major potential interactions with citalopram and venlafaxine.|
|5-30 mg/d in 2 to 3 divided doses|
|Methylphenidate (Ritalin)||2.5 mg/d (start)||Schedule II. High-fat meals may increase AUC. Peak concentration 102 hours after ingestion. Do not use with MAOIs as it can precipitate hypertensive crisis. Antidepressants that increase norepinephrine can cause increased amphetamine side effects. Concomitant use with SSRI can result in increased SSRI concentrations.|
|Titrate up to 54 mg/d (27 mg D-isomer)|
|Modafinil (Provigil)||50-100 mg (start)||Schedule IV. Avoid driving/operation of machinery until effects are known. Do not take at bedtime. Peak concentration in 2-4 hours. Food slows absorption by about 1 hour but does not affect bioavailability. Decreases efficacy of birth control pills.|
|100-200 mg every morning|
|Armodafinil (Nuvigil)||50 mg (start)||Schedule IV. Avoid driving/operation of machinery until effects are known. Do not take at bedtime. Peak concentration in 2 hours if fasting, slowed to as many as 4 hours if fed, but food does not affect bioavailability. Decreases efficacy of birth control pills.|
|25-250 mg every morning|