1. Spinal Cord Compression Pharmaceutical Issues Rebecca Mills Senior Clinical Pharmacist

2. Points to Cover  Steroids Dose Adverse effects Counselling  Thromboprophylaxis  Laxatives

3. Steroids  Reduce inflammation around the tunour & cord oedema Reduce pain Preserve neurological function Increase number of patients who remain ambulatory  High dose initially  Reduce rapidly  Where good results possible to stop steroid treatment completely

4. Choice and dose of steroid  Use dexamethasone  Dose is 16mg per day divided into 2 doses (N.B.= approx 100mg prednisolone)  Trials compared 16mg per day with 96mg per day showed more side-effects with higher dose  Give after Breakfast and Lunch.  Reduce dose over 2 weeks can cause problems if stopped suddenly. If symptoms worsen increase dose/reduce more slowly. Some patients may be on maintenance steroids.

5. WPH Reducing regimen DayDexamethasone daily dose Administration 1-316mg16mg OM or 8mg BD (8am & 12noon) 4-68mg8mg OM 7-94mg4md OM 10-122mg2mg OM 13Discontinue

6. Adverse Effects  Gastric irritation Take after food. PPI cover  Lansoprazole 15mg OD  Only for the duration of the steroids.  Increased Appetite  Impaired glucose tolerance  Mood disturbances  Fluid retention

7. Long-term adverse effects  Osteoporosis  Muscle weakness  Reduced healing/ability to fight infection Care around people with chicken pox/ measles/influenza  Glaucoma  Impaired healing  “Cushing’s Syndrome”……

8. Points to remember  Take steroids with or after food  Avoid take steroids later than 4pm  Dexamethasone can be dispersed in water & given via PEG/NG (off license)  Dexamethasone liquid is available  If the patient has had other courses of steroids in the last year they may need to reduce the dose more slowly  Avoid contact with anyone with suspected chicken pox or shingles.  Check the patient understands how to reduce their dose.

9. Thromboprophylaxis  Active Cancer  Reduced Mobility  Inpatient hospital stay = VTE Risk  Prescribe thromboprophylaxis unless contra-indicated.  Consider if thromboprophylaxis is indicated on discharge – immobility?

10. Laxatives  Constipation often associated with mSCC  Can be one of the presenting symptoms  Maintaining regular bowel action is important for patient comfort  Psychological issues also need to be overcome e.g. patients embarrassment at needing to be assisted with toileting

11. Laxatives  Oral laxatives may be ineffective or inappropriate  Reflex bowel Patient has little/no awareness of bowel fulness Reflex function of the rectum remains Fast acting rectal measures most appropriate Bisacodyl suppositories or sodium citrate enemas (15- 30mins to effect) If hard stools, glycerol suppository  Flaccid bowel May need digital removal No laxatives recommended

12. Pain Control  Analgesia WHO Pain ladder NICE neuropathic pain guidance  Bone Pain Zoledronic Acid (IV)  Check Renal function Denosumab (SC) Licensed for prevention of skeletal events

13. Any Questions?