Thalidomide

INTRODUCTION

Indications

Cutaneous manifestations of moderate-to-severe erythema nodosum leprosum (ENL). Prevention (maintenance) and suppression of recurrent ENL. Newly diagnosed multiple myeloma (with dexamethasone). Unlabeled Use: Behçet's syndrome. HIV-associated wasting syndrome. Aphthous stomatitis (including HIV associated). Crohn's disease.

Action

May suppress excess levels of tumor necrosis factor-alpha (TNF-alpha) in patients with ENL and alter leukocyte migration by altering characteristics of cell surfaces. Therapeutic Effects: ↓ skin lesions in ENL and prevention of recurrence.

Adverse Reactions/Side Effects

CNS: dizziness, drowsiness. CV: bradycardia, edema, orthostatic hypotension, thromboembolic events (↑ risk with dexamethasone in multiple myeloma). GI: constipation. Derm: rash, photosensitivity. Hemat: neutropenia. Neuro: peripheral neuropathy. Misc: SEVERE BIRTH DEFECTS, hypersensitivity reactions, increased HIV viral load.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Monitor signs of hypersensitivity reactions or anaphylaxis, including pulmonary symptoms (tightness in the throat and chest, wheezing, cough, dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician or nursing staff immediately if these reactions occur.

• Assess heart rate, especially during exercise (See Appendix G). Report bradycardia or symptoms of increased arrhythmias, including palpitations, chest discomfort, shortness of breath, fainting, and fatigue/weakness.

• Assess blood pressure (BP) when patient assumes a more upright position (lying to standing, sitting to standing, lying to sitting). Document orthostatic hypotension when systolic BP falls >20 mm Hg or diastolic BP falls >10 mm Hg.

• Assess peripheral edema using girth measurements, volume displacement, and measurement of pitting edema (See Appendix N). Report increased swelling in feet and ankles or a sudden increase in body weight due to fluid retention.

• Monitor signs of venous thrombosis (lower extremity swelling, warmth, erythema, tenderness) and thromboembolism (shortness of breath, chest pain, cough, bloody sputum). Notify physician immediately, and request objective tests (Doppler ultrasound, lung scan, others) if thrombosis is suspected.

• Be alert for signs of neutropenia including fever, sore throat, and other signs of infection. Report these signs to the physician or nursing staff.

• Be alert for signs of peripheral neuropathy (numbness, tingling, decreased muscle strength). Establish baseline electroneuromyographic values at the beginning of drug treatment whenever possible, and reexamine these values periodically to document drug-induced changes in peripheral nerve function.

• If treating erythema nodosum leprosum, assess the number, size, and redness of skin nodules to help determine if drug treatment is successful in suppressing cutaneous lesions.

• Assess dizziness and drowsiness that might affect gait, balance, and other functional activities (See Appendix C). Report balance problems and functional limitations to the physician and nursing staff, and caution the patient and family/caregivers to guard against falls and trauma.

Interventions

• For patients who are medically able to begin exercise, implement appropriate resistive exercises and aerobic ...