Medications for Fatigue

Cancer-related fatigue is common, occurring in up to 80% of patients. Distressing fatigue can be related to psychiatric or medical causes such as significant depression, frequent intense anxiety, or panic attacks, as well as sleep disturbances, pain, and electrolyte or hormonal abnormalities. It is often caused by a wide range of medications and substances. This chapter presents the various causes of fatigue to help non-prescribing clinicians distinguish fatigue from other look-alike diagnoses such as depression and make appropriate referrals to prescribers. Identifying opportunities to supplement nonpharmacologic therapies with an activating medication can improve a patient’s quality of life and joy in living. This chapter will help all clinicians become more aware of medications used to boost energy, such as energizing antidepressants, wakefulness agents, and psychostimulants, as well as the potential side effects of these medications.

Antidepressants

Although many people with cancer experience depressive moods, not all will have a major depressive episode. It is therefore important to distinguish and address subsyndromal depression from a depressive syndrome that could benefit from psychopharmacologic intervention. This chapter discusses risk factors for depression in cancer patients and provides suggestions for improving identification of depression in complicated cancer situations. The goal is to help non-prescribing clinicians more easily decide when referrals for medication are warranted and how to maintain connections and enhance communication with prescribers after medications are started. Pearls and potholes of why different medications are used for specific circumstances, and how prescribers seek to obtain more than one use out of a single medication, are described.

Conclusion

The art of diagnosing depression, anxiety, delirium, insomnia and fatigue in cancer care is not always straightforward. We have laid out pearls and potholes to assist uncovering the varied and sometimes hidden sources of that distress; to be aware of which syndromes may be amenable to a psychopharmacologic intervention; to know when to refer to prescribers or specialists in Psycho-Oncology; to hone communication techniques that will facilitate a patient’s care; to learn about the strategies Psycho-Oncologists use to choose the right medications for particular situations; and to recognize how to watch for the benefits and side effects of those medications, which if not understood by all providers and patients, can lead to premature discontinuation of potential helpful remedies or untoward side effects.

Antipsychotics

Antipsychotics in a cancer setting are often used with different goals than in a general psychiatric setting. In a cancer population, antipsychotics primarily help manage delirium, confusion, agitation, and manic episodes, but they also treat anxiety, insomnia, and nausea and can improve appetite. The potential causes of delirium are many and variable, and must be identified and addressed. However, antipsychotic medication may be needed to facilitate a medical workup to allow appropriate treatment by helping to manage symptoms such as agitation, hallucinations, delusions, and disorganized thinking. This chapter discusses pearls for recognizing delirium because confusion may start insidiously or quickly, lethargically or turbulently, sometimes from an obvious trigger, and sometimes not, and at times in an outpatient setting. Non-prescribers who understand the features of delirium and appreciate the appropriate use of antipsychotics can help educate and support patients and their families to expedite and promote timely and appropriate treatment for a potentially dangerous entity. Non-prescribing clinicians will learn the indications for use of antipsychotics in cancer care, the reasons prescribers chooses different medications in different situations, and to recognize side effects such as akathisia or restlessness, muscle rigidity, and sedation so they can communicate their observations with prescribers.

Anxiolytic (Antianxiety) Medications

Anxiety is common in cancer patients, but it is not necessarily predictable, tolerable, or inevitable. It can arise from the illness experience or as an exacerbation of a pre-existing anxiety disorder. Anxiety is commonly seen with a new cancer diagnosis, with complications of cancer treatment or medications, related to changes in body image, associated with fear of recurrence after treatment, when dealing with recurrence or progression of cancer after treatment, or when finding out that there is no further active treatment for the cancer and concerns about mortality must be engaged. Although understandable, these worries can intensify, causing severe panic or emotional paralysis, and interfere with completing cancer treatment. This chapter discusses the medical and psychiatric causes of anxiety, the medications used to treat anxiety, and the pros and cons of various choices. It is hoped that all practitioners can help educate patients about antianxiety medications, including fears about dependence, tolerance, and addiction, thereby improving outcomes.

Medications for Sleep Disturbance

Insomnia, or sleep disturbance, manifests in many ways in people with cancer. Sleep complaints may be intermittent, often related to specific situations or medical problems. They can develop into an ongoing syndrome and can severely impair a person’s quality of life with compromised energy and risk for falls. Non-prescribers are often called upon to assist with teaching healthy nonpharmacologic sleep hygiene techniques. However, it is important to recognize when a proper medication can assist or supplement good sleep habits and make a timely referral to a prescriber. This chapter discusses the potential benefits and pitfalls of medications used to induce and maintain sleep and how patients can integrate medication use into the standard nonmedication sleep-promoting techniques. All clinicians will be able to monitor for potential side effects of hypnotics (sleep medications), including cognitive and balance abnormalities, as well as compromised daytime energy and alertness, which might discourage patients from taking these medications.