Fatigue in chronically ill patients.

PURPOSE OF REVIEW: Fatigue is the most common symptom among palliative patients, often considered more distressing than pain, nausea or vomiting. This article reviews the current literature and puts forward up to date treatment recommendations. RECENT FINDINGS: Methylphenidate showed a small but significant improvement versus placebo in a recently published systematic review. Donepezil did not show a significant benefit versus placebo in a double blind, placebo-controlled study. Hypogonadism is a frequent condition that can cause fatigue in patients with advanced cancer and other chronic illnesses and androgen replacement therapy warrants further investigation. Among antidepressants, bupropion has shown encouraging results. The role of hematopoietic agents for advanced cancer patients receiving palliative care is minimal as anemia is less of a contributing factor in this setting. Cytokine receptor antagonists play an important theoretical role but further studies are needed before they could be recommended. L-Carnitine has shown encouraging results. SUMMARY: Methylphenidate is still considered the first choice of treatment among pharmacological therapies. Modafinil shows promise, but insufficient studies have been conducted in this setting. Bupropion may have benefits in treating depression and fatigue. Among complementary therapies, L-carnitine has the most potential. Further studies are needed before cytokine receptor antagonists and androgen replacement therapy can be recommended.

Management of expected and unexpected opioid-related side effects.

Intolerable side effects contribute to poor outcomes among patients managed with opioids, and negotiating these side effects remains an important clinical challenge. Evidence-based approaches to minimizing the side-effect burden from opioids compiled from the literature, and including clinical practice recommendations, focus on (1) reducing the doses of systemic opioids, (2) managing the adverse symptoms of opioids, (3) integrating opioid rotation, and (4) changing the route of administration. These broad strategies, and specific recommendations for individual side effects of opioids, including those that often go unrecognized within the following organ systems: neurologic, cardiopulmonary, gastrointestinal, urologic, endocrinologic, dermatologic, and immunologic, are considered herein. In addition, specific patient populations, opioid metabolites, and clearance issues are considered. In particular, novel medications and better alternatives to preexisting treatments for specific opioid side effects, such as peripheral opioid antagonists, may ameliorate the management of patients taking long-term opioid therapies.