What are the recommendations for an 86-year-old patient with a history of metastatic bladder cancer to the bone, recent hematuria, and long-term use of alprazolam (2mg qhs for 30 years) for anxiety?

From the Guidelines

For an 86-year-old patient with metastatic bladder cancer to the bone, recent hematuria, and long-term alprazolam use, I strongly recommend a multidisciplinary approach addressing both cancer management and medication concerns, prioritizing the patient's quality of life and minimizing morbidity and mortality. The patient should undergo immediate urological evaluation for the hematuria, which may require cystoscopy, imaging studies, and possibly transurethral resection if bleeding is significant, as suggested by 1. Oncology consultation is essential to reassess the current cancer treatment plan, considering age-appropriate options such as modified chemotherapy regimens, immunotherapy (particularly checkpoint inhibitors like pembrolizumab), or palliative radiation therapy specifically targeting painful bone metastases, as discussed in 1. Regarding the alprazolam use, I advise against abrupt discontinuation due to the risk of severe withdrawal after 30 years of use, and instead recommend implementing a gradual tapering schedule, reducing by 0.25mg every 2-4 weeks as tolerated, while potentially introducing alternative anxiety management strategies such as cognitive behavioral therapy or a longer-acting benzodiazepine like diazepam during the transition, as supported by 1 and 1. Pain management should include a tiered approach starting with scheduled acetaminophen (1000mg three times daily), adding an NSAID if renal function permits, and judicious use of opioids for breakthrough pain, with careful consideration of the patient's overall health status and potential interactions with other medications. Regular monitoring of renal function, electrolytes, and complete blood count is necessary given the cancer history and potential medication effects. Additionally, the patient's anxiety and depression should be managed using a stepped-care model, offering the most effective and least resource-intensive intervention based on symptom severity, as recommended by 1. This approach should prioritize the patient's quality of life, minimize morbidity and mortality, and be guided by the most recent and highest-quality evidence available.

From the FDA Drug Label

WARNINGS Dependence and Withdrawal Reactions, Including Seizures Certain adverse clinical events, some life-threatening, are a direct consequence of physical dependence to alprazolam tablets. In contrast, patients treated with doses of alprazolam tablets greater than 4 mg/day had more difficulty tapering to zero dose than those treated with less than 4 mg/day To discontinue treatment in patients taking alprazolam tablets, the dosage should be reduced slowly in keeping with good medical practice. It is suggested that the daily dosage of alprazolam tablets be decreased by no more than 0. 5 mg every three days

The patient is taking 2mg of alprazolam qhs, which is less than 4mg/day. Recommendations for this patient include:

• Slowly tapering the dosage of alprazolam by no more than 0.5mg every three days to minimize the risk of withdrawal reactions, including seizures.
• Monitoring the patient closely for signs of withdrawal, such as anxiety, insomnia, and muscle twitching.
• Considering alternative treatments for anxiety, such as non-benzodiazepine medications or therapy, to reduce the risk of dependence and withdrawal. 2

From the Research

Patient Recommendations

The patient is an 86-year-old with a history of metastatic bladder cancer to the bone, recent hematuria, and long-term use of alprazolam (2mg qhs for 30 years) for anxiety. Based on the available evidence, the following recommendations can be made:

• Palliative radiation therapy (RT) is an effective treatment for symptom management, including hematuria and pain, in patients with metastatic bladder cancer 3, 4, 5.
• RT can provide long-term symptomatic control and improve quality of life, although it must be balanced against the potential for toxicity 4.
• Various radiotherapy protocols have been developed for managing symptoms, including hypofractionated regimes (21 Gy in 3 fractions) and single doses (8 Gy) 4, 6.
• A higher dose of RT may not be associated with improved response rates for hematuria and frequency, but may provide a longer duration of hematuria response and reduced response of dysuria 6.

Considerations for Alprazolam Use

• The patient has been taking alprazolam for 30 years, which may indicate a high risk of dependence and potential for withdrawal symptoms if the medication is suddenly stopped or reduced.
• However, there is no direct evidence in the provided studies to address the management of alprazolam in this patient population.

Multidisciplinary Team Approach

• A multidisciplinary team approach is essential for providing comprehensive care to patients with complex health needs, including those with metastatic bladder cancer 7.
• This approach ensures that all aspects of the patient's care are addressed, including symptom management, disease control, and quality of life.