From the Guidelines
For a patient with glioma undergoing radiation therapy who is experiencing increased headache and confusion, the most appropriate initial management would be to increase the dexamethasone dose to 8-16 mg/day, as recommended by the ESMO clinical practice guidelines 1. This approach is based on the understanding that corticosteroids, such as dexamethasone, allow for rapid reduction of tumor-associated edema and improve clinical symptoms 1. The current dose of 4 mg daily can be increased to 8-12 mg daily, divided into 2-3 doses, and maintained until symptoms improve, then gradually tapered to the lowest effective dose. The patient's medication regimen, including Bactrim DS, Dilantin, Keppra, lacosamide, Protonix, and sertraline, should be reviewed to ensure that there are no potential interactions with the increased dexamethasone dose. Some key points to consider in the management of this patient include:
- Urgent neuroimaging (MRI with contrast if possible) to evaluate for tumor progression, radiation necrosis, or cerebral edema 1
- Neurosurgical consultation to assess for possible mass effect requiring intervention
- Optimization of anticonvulsant levels to ensure adequate seizure control, as the increased confusion may be related to seizure activity despite the current antiepileptic regimen 1
- Evaluation for infection, as the patient is on Bactrim prophylaxis and immunosuppressed from steroids and radiation
- Monitoring of glucose levels, as corticosteroids can affect glucose metabolism 1. It is essential to note that prolonged steroid therapy after tumor resection or for prophylaxis during radiotherapy in asymptomatic patients is not recommended, and rapid tapering and discontinuation of corticosteroids is advised to avoid toxicity associated with prolonged exposure to steroids 1.
From the Research
Treatment of Increased Headache and Confusion in Glioma Patients Undergoing Radiation Therapy
The patient is currently taking several medications, including dexAMETHasone, Dilantin, Keppra, lacosamide, Protonix, and sertraline. To address the increased headache and confusion, we need to consider the potential interactions between these medications and the radiation therapy.
Medication Interactions and Side Effects
- The patient is taking dexAMETHasone, which can cause increased intracranial pressure, leading to headaches 2.
- Dilantin (phenytoin) is an antiepileptic drug that can cause cognitive impairment, including confusion 3, 4.
- Keppra (levetiracetam) is also an antiepileptic drug, but it has been shown to have fewer side effects compared to phenytoin, including less cognitive impairment 3, 4, 5.
- Lacosamide is another antiepileptic drug that can cause dizziness, headache, and fatigue 4.
Radiation Therapy and Cognitive Sequelae
- Radiation therapy can cause cognitive sequelae, including memory loss, attention deficits, and processing speed deficits 6.
- The risk of cognitive deficits after cranial radiation therapy is associated with high radiation dose, large fraction size, and larger field size 6.
Potential Treatment Adjustments
- Consider switching from phenytoin to levetiracetam monotherapy, as levetiracetam has been shown to have fewer side effects and better seizure control 3, 4, 5.
- Monitor the patient's cognitive function and adjust the medication regimen as needed to minimize cognitive impairment.
- Consider reducing the dose of dexAMETHasone or switching to a different corticosteroid to minimize the risk of increased intracranial pressure and headaches 2.