Methylphenidate for Management of Fatigue in the Palliative Care Setting

A Cochrane review of five RCTs (N = 426) evaluating the use of psychostimulants for the management of cancer-related fatigue (i.e., a persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with normal functioning and is not relieved by rest3) found that methylphenidate slightly improved symptom scores.4 Four of the included studies evaluated methylphenidate, and one evaluated dexamphetamine.3,5-8 All of the studies used standardized survey instruments to measure fatigue symptoms. The methylphenidate group had a two-point reduction in fatigue symptom scores on the FACIT-F; this was the minimum clinically significant difference that was detectable.4 High-quality but small RCTs demonstrated that methylphenidate modestly reduced fatigue symptom scores in ambulatory adult patients with human immunodeficiency virus infection,9 older patients with Parkinson disease,10 and adults with sarcoidosis.11 Patients with human immunodeficiency virus who were treated with methylphenidate had a 1.3-point improvement (out of 10 possible points) on the Piper Fatigue Scale. Recommendations from Others Guidelines from the National Comprehensive Cancer Network state that treatment with methylphenidate or modafinil (Provigil) may be considered in select patients with terminal cancer and fatigue.13 A statement from the British Columbia Medical Services Commission states that psychostimulants such as methylphenidate, dextroamphetamine, and modafinil may be beneficial in managing fatigue when no correctable underlying cause can be found.14 The European Association for Palliative Care guidelines state that methylphenidate may have a role in the management of opioid-induced sedation and cognitive failure in patients for whom opioid dose reduction or dose rotation is impractical or inappropriate.15 Address correspondence to Eriko Onishi, MD, at onishi@ohsu.edu.