Medication Summary
The goals of pharmacotherapy are to induce remission, reduce morbidity and prevent complications.
Corticosteroids
Class Summary
These agents reduce edema around tumor, frequently leading to symptomatic and objective improvement.
Dexamethasone (Active Injection D, Dexamethasone Intensol, DexPak, DoubleDex)
The postulated mechanisms of action of corticosteroids in brain tumors include reduction in vascular permeability, cytotoxic effects on tumors, inhibition of tumor formation, and decreased CSF production.
Prednisone (Deltasone, Rayos, Prednisone Intensol)
Used adjunctively with chemotherapeutic medications. Glucocorticosteroid; elicits mild mineralocorticoid activity and moderate anti-inflammatory effects; controls or prevents inflammation by controlling rate of protein synthesis, suppressing migration of polymorphonuclear leukocytes (PMNs) and fibroblasts, reversing capillary permeability, and stabilizing lysosomes at cellular level; in physiologic doses, corticosteroids are administered to replace deficient endogenous hormones; in larger (pharmacologic) doses, they decrease inflammation
Prednisolone (Pediapred, Orapred ODT, Millipred, Millipred DP, Veripred 20)
Used adjunctively with chemotherapeutic medication, reversing capillary permeability, and stabilizing lysosomes at cellular level; Coticosteroids also decrease inflammation.
Anticonvulsants
Class Summary
Anticonvulsants are employed in management of seizures presenting as complication of disease
Valproic acid (Depacon, Depakene, Depakote, Depakote ER, Depakote Sprinkles)
May increase levels of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in brain; may enhance or mimic action of GABA at postsynaptic receptor sites; may also inhibit sodium and calcium channelsUsed to control seizures, including generalized motor seizures and complex partial seizures
Levetiracetam (Keppra, Keppra XR, Roweepra, Spritam)
Antiepileptic mechanism unknown; may inhibit voltage-depedent N-type calcium channels; may bind to synaptic proteins that modulate neurotransmitter release; through displacement of negative modulators may facilitate GABA-ergic inhibitory transmission
Lorazepam (Ativan, Lorazepam Intensol)
A benzodiazepine. A sedative hypnotic with short onset of effects and relatively long half-life. Increases the action of gamma-aminobutyric acid (GABA), a major inhibitory neurotransmitter in the brain; May depress all levels of CNS, including limbic and reticular formation. Indicated for status epilepticus as complication of disease
Diazepam (Diastat, Diastat AcuDial, Diazepam Intensol, Valium)
A benzodiazepine. Extremely lipid-soluble agent that quickly enters brain in first pass and often stops seizures in 1-2 min. Rapidly distributes to other stores of body fat. Increases the action of gamma-aminobutyric acid (GABA), a major inhibitory neurotransmitter in the brain; Indicated for status epilepticus as complication of disease
Phenytoin (Dilantin, Phenytek, Dilantin Infatabs, Phenytoin Infatabs)
Sodium transport inhibitor indicated for management of generalized motor seizures and complex partial seizures
General Anesthetics, Systemic
Class Summary
These agents stabilize the neuronal membrane so the neuron is less permeable to ions. This prevents the initiation and transmision of nerve impulses, thereby producing anesthetic effect
Propofol (Diprivan, Fresenius Propoven)
Propofol, an IV anesthetic agent, is active on the glutamate and GABA-A receptors, whereas benzodiazepines are active only against the GABA receptors. Only slightly soluble in water, but highly soluble in lipids. CNS penetration primarily depends on cerebral blood flow. Emergence from anesthesia is relatively fast, even with prolonged infusions. Causes global CNS depression, presumably through agonist actions of GABA receptors; Indicated for treatment of status epilepticus presenting as complication of disease
Antineoplastics
Class Summary
Antineoplastic agents are employed to reduce tumor burden and induce remission. Some agents may also reduce angiogenesis, and metastasis. Selection and use depends on systemic disease, tumor type, and stage
Cisplatin
Platinum coordination compound that inhibits DNA synthesis, cross-links and denatures strands of DNA and disrupts DNA function by covalently binding to DNA bases
Cyclophosphamide
Metabolites interfere with malignant cell growth by cross-linking tumor cell DNA; non-cell cycle specific with potent immunosuppressive activity
Ifosfamide (Ifex)
Synthetic analog of cyclophosphamide. Exerts its cytotoxic effect via alkylation of DNA, leading to interstrand and intrastrand DNA crosslinks, DNA-protein crosslinks, and inhibition of DNA replication
Temozolomide (Temodar)
Imidazotetrazine derivative prodrug whose active metabolite, the reactive compound 5-(3-methyltriazen-1-yl),imidazole-4-carboxamide (MTIC), methylates guanine-rich areas of DNA that initiate transcription, which leads to DNA double strand breaks and apoptosis
Etoposide (Toposar)
A glycosidic derivative of podophyllotoxin that exerts a cytotoxic effect by stabilizing the normally transient covalent intermediates formed between the DNA substrate and topoisomerase II. The drug leads to single-stranded and double-stranded DNA breaks that arrest cellular proliferation in the late S or early G2 phase of cell cycle.
Teniposide (Vumon)
Semisynthetic podophyllotixin derivative which inhibits topoisomerase II to cause DNA strand breaks by inhibiting DNA strand-passing and DNA ligase activity., Prevents cells from entering mytosis by delaying the transit of cells through the S phase and causing arrest in late S or early G2 phase of the cell cycle.
Mitomycin
Anthracycline antibiotic which crosslinks DNA,,primarily with guanine and cytosine, preventing replication and transcription. Cell-cycle nonspecific but acts primarily against cells in late G and early S phases.
Irinotecan (Camptosar)
Semisynthetic derivative of camptothecin, an alkaloid extract from the Camptotheca acuminate tree. Inactive in its parent form. Converted by the carboxylesterase enzyme to its active metabolite from, SN-38.SN-38 binds to and stabilizes the topoisomerase I-DNA complex and prevents the relegation of DNA after it has been cleaved by topoisomerase I, inhibiting DNA replication.
Vinorelbine (Navelbine)
Semi-synthetic vinca alkaloid which inhibits mitosis at metaphase by depolymerizing microtubules. Disrupts the mitotic spindle, causing the cell to arrest at metaphase. It is specific for the M and S phase of the cell cycle. By blocking glutamic acid utilization may also interfere with nucleic acid and protein synthesis
Fluorouracil (Adrucil)
Fluoropyrimidine analog. Cell cycle-specific with activity in the S-phase as single agent and has for many years been combined with biochemical modulator leucovorin. Has activity as single agent that inhibits DNA replication and transcription. Classic antimetabolite anticancer drug with chemical structure similar to endogenous intermediates or building blocks of DNA or RNA synthesis.
Capecitabine (Xeloda)
Fluoropyrimidine carbamate prodrug form of 5-fluorouracil (5-FU). Capecitabine itself is inactive. Undergoes hydrolysis in liver and tissues to form the active moiety (fluorouracil), inhibiting thymidylate synthetase, which in turn blocks methylation of deoxyuridylic acid to thymidylic acid. This step interferes with DNA and to a lesser degree with RNA synthesis.
Gefitinib (Iressa)
EGF receptor is present on normal and cancer cells and plays a role in cell growth and proliferation. Gefitinib reversibly inhibits the kinase activity of wild-type and certain activating mutations of epidermal growth factor receptor (EGFR) preventing autophosphorylation of tyrosine residues associated with the receptor, thereby inhibiting further downstream signaling and blocking of EGFR-dependent proliferation
Erlotinib (Tarceva)
Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor; may also block angiogenesis and cellular proliferation. Erlotinib exhibits higher binding activity for EGR exon 19 deletion or exon 21 L858R mutations than for the wild type receptor. Causes apoptosis by inhibiting intracellular phosphorylation, which in turn prevents downstream signaling
Sorafenib (Nexavar)
Multikinase inhibitor of intracellular ((CRAF, BRAF, and mutant BRAF) and cell surface (KIT, FLT-3, RET, RET/PTC, vascular endothelial growth factor receptor [VEGFR]-1, VEGFR-2, VEGFR-3, and platelet-derived growth factor receptor-beta) kinases. which are involved in tumor angiogenesis, cell signaling and apoptosis
Sunitinib (Sutent)
Sunitinib inhibits cellular signaling by targeting multiple receptor tyrosine kinases, such as platelet-derived growth factor receptors, and vascular endothelial growth factor receptors, which play a role in both tumor angiogenesis and tumor cell proliferation
Lapatinib (Tykerb)
Tyrosine kinase inhibitor, blocking phosphorylation of EGF-receptor and HER2 kinase, which in turn blocks the activation of downstream second messengers responsible for cell proliferation and survival in ErbB- and ErbB-expressing tumors., Indicated in combination with capecitabine for patients with advanced or metastatic breast cancer whose tumors overexpress HER2 and who have received prior therapy including anthracycline, a taxane, and trastuzumab
Vemurafenib (Zelboraf)
Inhibitor of some mutated forms of BRAF serine-threonine kinase, including BRAF V600E, reducing cellular proliferation; Also inhibits other kinases in vitro (eg CRAF, ARAF, wild-type BRAF, SRMS, ACK 1, MAP4K5, FGR) at similar concentrations
Monoclonal Antibodies
Class Summary
This is a form of drug delivery that specifically targets the tumor cells, thus reducing the systemic side effects of chemotherapy and at the same time being more effective than routine forms of chemotherapy agents.
Trastuzumab (Herceptin)
Trastuzumab is a monoclonal antibody that binds to the human epidermal growth factor receptor 2 protein (HER-2) extracellular domain. It inhibits the proliferation of cells overexpressing HER-2 protein.
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Management of recurrent metastasis.
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Multiple brain metastasis in a patient with known non-small cell lung adenocarcinoma. There was also systemic disease in the liver.
Tables
Primary Tumor Site |
Percentage (%) |
Lung |
21 |
Breast |
9 |
Melanoma |
40 |
Lymphoma, mainly non-Hodgkin |
1 |
GI tract |
3 |
Genitourinary tract |
11 |
Osteosarcoma |
10 |
Head and neck |
6 |
Group |
Karnofsky Performance Status |
Systemic Disease |
Median Survival, mo |
Age 65 y or younger |
70 or higher |
Controlled primary disease; no extracranial metastases |
7.1 overall; 13.5 for single metastasis, 6 for multiple metastases |
Age 65 y or older |
70 or higher |
Uncontrolled systemic disease; extracranial metastasis |
4.2 overall; 8.1 for single metastasis, 4.1 for multiple metastases |
Any age |
Any |
Any |
2.3 |
