Patients With Cancer

Tamoxifen, toremifene : hot flashes, insomnia, mood disturbance; at high doses tamoxifen can cause confusion

Anastrozole (Arimidex), letrozole (Femara), exemestane (Aromasin) : hot flashes, fatigue, mood swings, and irritability; cognitive effects are not known

Raloxifene (Evista ): no cognitive side effects noted

Leuprolide (Lupron), goserelin (Zoladex) : hot flashes, fatigue, and mood disturbance

Leuprolide (Lupron), goserelin (Zoladex) : hot flashes, fatigue, and mood disturbance

Flutamide (Eulexin), bicalutamide (Casodex), nilutamide (Nilandron) : as above

Dose-related, variable psychiatric side effects including insomnia, hyperactivity, hyperphagia, depression, hypomania, irritability, and psychosis

Treated by ad hoc antipsychotics easily with cancer patients

Other drugs with benefit: lithium, valproate, lamotrigine, and mifepristone

Dexamethasone (Decadron) 9 mg equals 60 mg of prednisone; psychiatric side effects are associated with this dose level

Steroids used as part of an antiemetic treatment with chemotherapy infusion, with lymphoma protocols as high as prednisone 100 mg for 5 days, with nervous system radiation treatment to reduce swelling, with taxanes to reduce side effects

Depression, cognitive impairment, hypomania, psychosis, fatigue, and malaise

Responsive to antidepressants, hypnotics, antipsychotics, stimulants, and antianxiety agents

Associated with autoimmune thyroiditis that may increase or decrease thyroxine; check thyroid function

May inhibit metabolism of some antidepressants by P450 enzymes CYP1A2, CYP2C19, CYP2D6

Interferon-β has less neurotoxicity

Delirium, flu-like syndrome, dose-dependent neurotoxicity, and hypothyroidism

Neurotoxicity is dose-related and usually reversible. Fatigue and malaise are noted. Seizure and SIADH are uncommon. Postural hypotension may be an aspect of autonomic neuropathy

Less toxicity is noted with vinblastine and vinorelbine

Mild reversible delirium

A weak MAO inhibitor

Antidepressant use must consider the timing of procarbazine or risk serious interactions

Disulfiram-like effect; avoid alcohol

Depression, lethargy, and delirium with treatment

High-dose IV treatment (over 18 g/m ² per course) can cause confusion, obtundation, seizures, and coma, cerebellar dysfunction, and leukoencephalopathy. Older patients with multiple treatments are more susceptible. Delirium and somnolence can be seen 2–5 days into treatment. Those with renal impairment are more vulnerable

Rare somnolence, delirium, and rare progressive leukoencephalopathy

The primary neurotoxicity is cerebellar, but encephalopathy with headache, confusion, disorientation, lethargy, and seizures has also been seen

Rare deficiency of enzyme that metabolizes dihydropyrimidine dehydrogenase (DPD) is associated with greater exposure and more toxicity

Fatigue is the most common side effect

Cerebellar syndrome and rarely seizure or confusion or parkinsonism may be noted

High-dose IV thymidine may be an antidote for toxicity

Related to 5-FU, but with less neurotoxicity

Causes neurotoxicity particularly when the route is intrathecal or high-dose IV (usually over 1 g/m ² ). The toxicity, which is usually reversible, is related to peak level and duration of exposure. Leptomeningeal disease or other conditions that break the blood–brain barrier may impair drug clearance. Prolonged exposure allows the drug to pass through the ependyma of the ventricles to cause leukoencephalopathy. The risk is greater in patients also exposed to cranial radiation. Intrathecal methotrexate may also cause seizures, motor dysfunction, chemical arachnoiditis, and coma. Serum levels are followed closely; folinic acid (leucovorin) rescue is an antidote. Alkalinization may lower the serum level

There is a dose- and route-related risk of delirium

An anti-folate given with supplements of folate, intramuscular vitamin B ₁₂ , and dexamethasone. It is associated with a 10% rate of depression and fatigue

Fatigue, flu-like syndrome, and a rare autonomic neuropathy

Postural hypotension and rare disorientation

Delirium, only at high doses, rare leukoencephalopathy

Rare leukoencephalopathy