Cancer Treatment Today » Gastroenterology

Prophylaxis for stress ulcers – pro

M Levin, MD — Wed, 13 Feb 2013 21:21:43 +0000

A variety of medical factors can create stress and place a patient at at risk of gastroduodenal ulcerations and bleeding. Among teh most common are prolonged mechanical ventilation, coagulopathy, multiple injuries, spinal cord injury, injury, acute renal failure, and administration of high-dose steroids. The latter usually ocurrs in the setting of chemotherapy.

A variety of interventions have been studied, including: Histamine-2 receptor antagonists, Proton pump inhibitors , Cytoprotective agents. All of these options are supported by published clinical studies. Several have been found to be ineffective or harmful: Use of antacids has been associated with a potential increase in the risk of hemorrhage. Enteral feeding also has failed to show significant increases in gastric PH but some proponents remain.

Guillamondegui OD, Gunter OL Jr, Bonadies JA, Coates JE, Kurek SJ, De Moya MA, Sing RF, Sori AJ. Practice management guidelines for stress ulcer prophylaxis. Chicago (IL): Eastern Association for the Surgery of Trauma (EAST); 2008. 24 p. [58 references]
http://www.east.org/resources/treatment-guidelines/stress-ulcer-prophylaxis

ASHP therapeutic guidelines on stress ulcer prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm. 1999;56:347-379.(note will be updated in 2012)

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Octreotide in gastrointentinal angiodysplasia – pro

M Levin, MD — Tue, 18 Dec 2012 22:40:34 +0000

Angiodysplasias are usually asymptomatic but they can cause of GI bleeding in 3–6% of all patients and are a more common cause of beeeding in the elderly. It is notoriously difficult to treat. A number of reports suggest that it is a valuable adjunct in the treatment of gastro-inestinal dysplasia and can decrease bleeding. There are no supportive guidelines to my knowledge but the role of somatostatin analogues for refractory bleeding GI angiodysplasias has been systematically reviewed by Brown et al.
He concluded: “A significant number of patients with bleeding gastrointestinal angiodysplasia respond to treatment with octreotide by reducing the need for blood products. As all the included studies had small sample sizes, multicenter randomized trials are needed to confirm these findings. However, it seems reasonable to administer octreotide especially in patients with refractory bleeding, inaccessible lesions and in patients at high risk for other interventions.”.

Rivera M, Lucero J, Guerrero A, Márquez JL, Montes R, Suñer M, Ruiz A, Valdivia MA, Mateos J. Octreotide in the treatment of angiodysplasia in patients with advanced chronic renal failure.Nefrologia. 2005;25(3):332-5.

Junquera F, Saperas E, Videla S, et al. Long-term efficacy of octreotide in the prevention of recurrent bleeding from gastrointestinal angiodysplasia. Am J Gastroenterol 2007; 102:254.

Brown C, Subramanian V, Wilcox CM, Peter S. Somatostatin analogues in the treatment of recurrent bleeding from gastrointestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci 2010; 55:2129.

Scaglione G, Pietrini L, Russo F, et al. Long-acting octreotide as rescue therapy in chronic bleeding from gastrointestinal angiodysplasia. Aliment Pharmacol Ther 2007; 26:935.

Molina-Infante J, Perez-Gallardo B. Somatostatin analogues for bleeding gastrointestinal angiodysplasias: when should thalidomide be prescribed?. Dig Dis Sci. Jan 2011;56(1):266-7.

Bon C, Aparicio T, Vincent M, et al. Long-acting somatostatin analogues decrease blood transfusion requirements in patients with refractory gastrointestinal bleeding associated with angiodysplasia. Aliment Pharmacol Ther 2012; 36:587.

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For a discussion of thalidomide see here

Interferon for VIPoma – pro

M Levin, MD — Fri, 14 Dec 2012 16:48:17 +0000

The VIPoma syndrome is rare and difficult to treat and for this reason, ti is not well studied. It is usually caused by a neuroendocrine tumor located in the pancreas or other organs and present primarily with diarrhea. Treatment relies on resection and octreotide but occasionally interferon or steroids can be used as adjuncts (Best Practice, Eppocrates). On the other hand, other reviews do not mention interferon or mention it in combiantion with 5FU, which itself is basd on older and limited literature.
Eriksson B, Oberg KSOActa An update of the medical treatment of malignant endocrine pancreatic tumors. Oncol. 1993;32(2):203.

http://bestpractice.bmj.com/best-practice/monograph/876/treatment.html, 2012

https://online.epocrates.com/u/2942876/VIPoma/Treatment/Tx+Details

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Octreotide for Malignant Bowel Obstruction – pro

M Levin, MD — Thu, 09 Aug 2012 19:29:09 +0000

Malignant bowel obstruction (MBO) is a common and very difficult problem to manage at the end of the course of ovarian cancer, Surgery can help but is not always possible and often only temporarily effective. It should not be undertaken in patients known to have poor prognostic criteria for surgical intervention such as intra-abdominal carcinomatosis, poor performance status and massive ascites. Nasogastric drainage should generally only be a temporary measure and is nto comfortable. Self-expanding metallic stents are an option in malignant obstruction of the gastric outlet, proximal small bowel and colon. Medical treatment of pain and anuses can help. Soomatostatin analogues (e.g. octreotide) reduce gastrointestinal secretions and a number of reports over the last two decades confirm its limited but significant place in treating MBO. Octreotide can reduce secretions with or without anticholinergics , such as hyoscine hydrobromide. Octreotide can also diminish the hypertensive state in the lumen that causes the distension-secretion-distention cycle, which can lead to total obstruction if not treated.

Two randomized prospective studies were and a recent combination study with with metoclopramide, dexamethasone confirm octreotide effectiveness in MBO.

Ripamonti C, Mercadante S, Groff L, Zecca E, De Conno F, Casuccio A. Role of octreotide, scopolamine butylbromide and hydration in symptom control of patients with inoperable bowel obstruction having a nasogastric tube. A prospective, randomized clinical trial. J Pain Symptom Manage 2000;19:23–34.

Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Supportive Care in Cancer 2000;8:188–91.

Carla Id, Ripamonti, Alexandra M. Easson, Hans Gerdes Management of malignant bowel obstruction Eur J Cancer 4 4 ( 2 0 0 8 ) 1 1 0 5 –1 1 1 5

Cancer Care Ontraion, https://fr.cancercare.on.ca/common/pages/UserFile.aspx?fileId=34421, 2003

Yasuo Shima et al, Clinical Efficacy and Safety of Octreotide (SMS201-995) in Terminally Ill Japanese Cancer Patients with Malignant Bowel Obstruction Jpn. J. Clin. Oncol. (2008) 38 (5): 354-359

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Incivik – pro

M Levin, MD — Thu, 09 Aug 2012 19:01:51 +0000

Telaprevir is the first hepatitis C drug that has demonstrated activity in patients who have failed prior therapy. In patients who received peginterferon alfa-2a and ribavirin for a year, the addition of telapravir for 24 weeks achieved a sustained virologic response(SVR) of 53% compared to 14% in patients who did not receive telapravir.It is thought that some patients who accomplish this outcome may be cured of Hepatitis, a feat rarely accomplished before. In a second randomized controlled trial (REALIZE) of patients who had previously relapsed or had only a partial response, rates of SVR were higher in patients treated with telaprevir (83% to 88%) compared to 24% in controls. In a third trial (ADVANCE) for previously untreated patients, patients taking telaprevir had a SVR (69% to 75%) versus 44% in the control group.

Revill, P., Serradell, N., Bolos, J., Rosa, E. (2007). “Telaprevir”. Drugs of the Future 32 (9): 788.

Irena Melnikova (2008). “Hepatitis C therapies”. Nature Reviews Drug Discovery 7 (10): 799–800.

McHutchison JG, Manns MP, Muir AJ, et al. (2010). “Telaprevir for previously treated chronic HCV infection”. N Engl J Med 362 (14): 1292–303.

Zeuzem S, Andreone P, Pol S, et al. (2011). “Telaprevir for retreatment of HCV infection.”. N Engl J Med 364 (25): 2417–28.
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Jacobson IM, McHutchison JG, Dusheiko G, et al. (2011). “Telaprevir for previously untreated chronic hepatitis C virus infection.”. N Engl J Med 364 (25): 2405–16

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Treatment of Sclerosing Mesenteritis – pro

M Levin, MD — Mon, 06 Aug 2012 16:08:41 +0000

Sclerosing mesenteritis, also called mesenteric panniculitis, is a rare non-neoplastic disease that affects the small bowel mesentery with chronic fibrosing inflammation. Although a relatively benign condition, sclerosing mesenteritis can have a prolonged debilitating course with a fatal outcomeThere are few data on the natural history and therapeutic options for this condition. Tamoxifen in combination with prednisone is teh most common treatment, and most patients respond. I did not find any reports of the use of Rituxan.

Savvas Hiridis et al, Sclerosing mesenteritis affecting the small and the large intestine in a male patient with non-Hodgkin lymphoma: a case presentation and review of the literature
Journal of Medical Case Reports 2008, 2:388

Akram S, Pardi DS, Schaffner JA, Smyrk TC.

Sclerosing mesenteritis: clinical features, treatment, and outcome in ninety-two patients.
Clin Gastroenterol Hepatol. 2007 May;5(5):589-96.
Pemberton, John D, Idiopathic Sclerosing Orbital Inflammation: A Review of Demographics, Clinical Presentation, Imaging, Pathology, Treatment, and Outcome Ophthalmic Plastic & Reconstructive Surgery: January/February 2012 – Volume 28 – Issue 1 – p 79–83