Treatment of Medical Complications in Patients with Brain Tumors

Patients with primary brain tumors and those with cerebral metastases are at risk throughout their illness for several major medical problems, including vasogenic edema, seizures, and symptomatic venous thrombosis. In turn, the corticosteroids, anti-epileptic drugs, and anticoagulants used to treat these problems may produce significant adverse effects and result in important drug-drug interactions that may complicate chemotherapy. Although few Class I studies address any of these issues, guidelines can be offered to maximize quality of life and minimize hospital readmissions. Optimal management of brain edema involves minimizing corticosteroid use and tapering the steroid dose slowly to avoid steroid withdrawal symptoms. Prophylaxis of Pneumocystis pneumonia is necessary for patients requiring corticosteroids for more than 1 month. Anti-epileptic drugs (AEDs) should be avoided unless patients experience seizures. If possible, non-CTY (P450) enzyme-inducing drugs should be chosen. AED levels should be obtained frequently during corticosteroid taper. Multimodality venous thrombosis prophylaxis should begin at the time of the original surgery with external leg compression and unfractionated subcutaneous heparin or a low molecular weight heparin (LMWH). Brain tumor patients with symptomatic venous thrombosis or pulmonary embolism can be anticoagulated safely with warfarin or with LMWH, and LMWHs are preferable from the standpoints of efficacy, safety, and convenience for long-term outpatient treatment of venous thrombosis. Clinicians should be aware of potential drug-drug interactions between prescribed AEDs and chemotherapy and possible interactions with complementary and alternative therapies chosen by their patients. They also should be aware of interventions to minimize late sequelae of brain tumors and their treatment, including cognitive decline, depression, and increased stroke risk.