Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Thursday, September 6, 2012

What is your stroke protocol?

Definition:  The plan for a course of medical treatment or for a scientific experiment.

Isn't this by definition what Physiatrists or PM&R doctors supposed to do? Or is yours like mine was; hand you off to the therapists with ET, evaluate and treat, nothing scientific there and no way to monitor progress against your goals. You did discuss your goals with your doctor, didn't you? 100% recovery. I had no goal discussion with my doctor.
Wouldn't you think that stroke rehab would have the same type of detail as below?

Check out what colon cancer has from  Medscape
http://emedicine.medscape.com/article/2005487-overview

Adjuvant chemotherapy for patients with resectable colon cancer

Stage 0 and I:
  • Patients do not require adjuvant therapy

Adjuvant chemotherapy for resectable colon cancer

Stage IIA, B and C (node-negative)[1, 2, 3] :
The value of adjuvant therapy in stage II disease is at best controversial; however, the following regimens may be used:
  • Capecitabine 1250 mg/m2 PO BID on days 1-14; repeat cycle every 21d for 8 cycles or
  • Leucovorin 500 mg/m2 given as a 2-h infusion and repeated weekly for 6wk plus  5-fluorouracil (5-FU) 500 mg/m2 given as a bolus 1h after the start of leucovorin and repeated 6 times weekly; every 8wk for 4 cycles or
  • Leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU bolus 400 mg/m2, then  1200 mg/m2/day for 2d (total 2400 mg/m2 over 46-48h) continuous infusion; repeat every 2wk
Stage II adjuvant chemotherapy in high-risk or intermediate-risk patients:
Adjuvant therapy for high-risk patients with stage II is an option, and common regimens include use of 5-FU and leucovorin with or without oxaliplatin or capecitabine.[1]
  • mFOLFOX6: Oxaliplatin 85 mg/m2 IV over 2h on day 1 plus  leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2d continuous infusion; repeat every 2wk or
  • FLOX: 5-FU 500 mg/m2 IV weekly plus  leucovorin 500 mg/m2 IV weekly for 6wk (days 1, 8, 15, 22, 29, and 36) of each 8-wk cycle plus  oxaliplatin 85 mg/m2 IV administered on days 1, 15, and 29 of each 8-wk cycle for 3 cycles or
  • Capecitabine 1250 mg/m2 PO BID on days 1-14; repeat cycle every 21d for 8 cycles

Adjuvant therapy for resectable cancer

Stage III (node-positive)[2, 3] :
The following regimens are acceptable adjuvant therapies for stage III disease for resectable colon cancer:
  • mFOLFOX6: Oxaliplatin 85 mg/m2 IV over 2h on day 1 plus  leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d continuous infusion; repeat every 2wk or
  • FLOX: 5-FU 500 mg/m2 IV weekly plus  leucovorin 500 mg/m2 IV weekly for 6wk (days 1, 8, 15, 22, 29, and 36) of each 8-wk cycle plus  oxaliplatin 85 mg/m2 IV administered on days 1, 15, and 29 of each 8-wk cycle for 3 cycles or
  • Capecitabine 1250 mg/m2 PO BID on days 1-14; repeat cycle every 21d for 8 cycles or
  • CapeOx: Oxaliplatin 130 mg/m2 over 2h on day 1 plus  capecitabine 1000 mg/m2 PO BID on days 1-14 every 3wk for 8 cycles or
  • Leucovorin 500 mg/m2 given as a 2-h infusion and repeated weekly for 6wk plus  5-FU 500 mg/m2 given as a bolus 1h after the start of leucovorin and repeated 6 times weekly; every 8wk for 4 cycles or
  • Leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU bolus 400 mg/m2, then  1200 mg/m2/day for 2d (total 2400 mg/m2 over 46-48h) continuous infusion; repeat every 2wk

Neoadjuvant therapy for resectable metastatic disease

Neoadjuvant therapy for resectable metastatic disease is usually administered for approximately 2-3mo, limiting the development of hepatotoxicity.[3] Regimens for adjuvant and neoadjuvant therapy are similar.
  • mFOLFOX6: Oxaliplatin 85 mg/m2 IV over 2h on day 1 plus  leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d continuous infusion; repeat every 2wk or
  • FOLFIRI: Irinotecan 180 mg/m2 IV over 30-90min on day 1 plus  leucovorin 400 mg/m2 IV infusion to match duration of irinotecan infusion on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d (total 2400 mg/m2 over 46-48h) continuous infusion; repeat every 2wk
  • CapeOx with or without bevacizumab: Oxaliplatin 130 mg/m2 over 2h on day 1 plus  capecitabine 1000 mg/m2 PO BID for 14d; repeat every 3wk plus bevacizumab 7.5 mg/kg IV every 3wk

Chemotherapy for advanced or metastatic disease

Stage IV:
Chemotherapy for advanced or metastatic disease includes the use of multiple drugs as single agents or as combination regimens.[4, 5, 6, 7, 8, 9]
First-line chemotherapy for bevacizumab candidates:
  • mFOLFOX6 plus bevacizumab: Bevacizumab 5 mg/kg over 30-90min on day 1 plus  oxaliplatin 85 mg/m2 IV over 2h on day 1 plus  leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d continuous infusion; repeat every 2wk for 4-6 cycles with reevaluation for maintenance therapy (1 g of calcium gluconate and 1 g of magnesium sulfate may be give over 15min preinfusion and postinfusion to reduce the risk of neurotoxicity) or
  • FLOX plus bevacizumab: Bevacizumab 5 mg/kg over 30-90min on days 1, 15, and 29 plus  oxaliplatin 85 mg/m2 on days 1, 15, and 29 plus  leucovorin 500 mg/m2 on days 1, 8, 15, 22, 29, and 36 plus  5-FU 500 mg/m2 on days 1, 8, 15, 22, 29, and 39 for 2 cycles followed by reevaluation or
  • FOLFIRI plus bevacizumab: Bevacizumab 5 mg/kg over 30-90min on day 1 plus  irinotecan 180 mg/m2 IV over 30-90 min on day 1 plus  leucovorin 400 mg/m2 IV infusion to match duration of irinotecan infusion on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2d (total 2400 mg/m2 over 46-48h) continuous infusion; repeat every 2wk for 4-6 cycles with reevaluation for maintenance therapy or
  • CAPEOX plus bevacizumab: Bevacizumab 7.5 mg/kg over 30-90min on day 1 plus  oxaliplatin 130 mg/m2 over 2h on day 1 plus  capecitabine 1000 mg/m2 PO BID for 14d; repeat every 21d for 4 cycles followed by reevaluation for maintenance therapy or
  • Capecitabine plus bevacizumab (in patients not able to undergo treatment with oxaliplatin or irinotecan): Bevacizumab 7.5 mg/kg on day 1 plus  capecitabine 1250 mg/m2 PO BID for 14d; repeat cycle every 21d for 8 cycles, then  reevaluate for maintenance or
  • DeGramont regimen plus bevacizumab (in patients not able to undergo treatment with oxaliplatin or irinotecan): Bevacizumab 5 mg/kg over 30-90min on day 1 plus  leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU bolus 400 mg/m2, then  1200 mg/m2/day for 2-d (total 2400 mg/m2 over 46-48h) continuous infusion; repeat every 2wk for 4-6 cycles with reevaluation for maintenance therapy or
  • Bevacizumab plus 5-FU and leucovorin (Roswell Park) (in patients unable to undergo treatment with oxaliplatin or irinotecan): Bevacizumab 5 mg/kg over 30-90min on day 1 plus  leucovorin 500 mg/m2 over 2h plus  5-FU 500 mg/m2 bolus every 2wk for 4-6 cycles with reevaluation for maintenance therapy
First-line chemotherapy for patients who are not candidates for bevacizumab[7, 8, 9, 10] :
  • mFOLFOX6: Oxaliplatin 85 mg/m2 IV over 2h on day 1 plus  leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d continuous infusion; repeat every 2wk for 4 cycles or
  • FLOX: Oxaliplatin 85 mg/m2 on days 1, 15, and 29 plus  leucovorin 500 mg/m2 on days 1, 8, 15, 22, 29, and 36, followed by 5-FU 500 mg/m2 on days 1, 8, 15, 22, 29, and 39 for 2 cycles followed by reevaluation or
  • FOLFIRI: Irinotecan 180 mg/m2 IV over 30-90min on day 1 plus  leucovorin 400 mg/m2 IV infusion to match duration of irinotecan infusion on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d (total 2400 mg/m2 over 46-48h) continuous infusion; repeat every 2wk for 4 cycles or
  • Capecitabine: Capecitabine 1250 mg/m2 PO BID on days 1-14; repeat cycle every 21d until progression or
  • Roswell Park regimen: Leucovorin 500 mg/m2 IV weekly for 6wk over 2h followed by 5-FU 500 mg/m2 IV bolus weekly for 6wk; repeat cycle every 8wk or
  • CapeOx: Oxaliplatin 130 mg/m2 over 2h on day 1 plus  capecitabine 1000 mg/m2 BID for 14d every 21d for 4 cycles followed by reevaluation for maintenance therapy or
  • mFOLFOX6 plus cetuximab (only for KRAS wild-type tumors): Cetuximab 400 mg/m2 loading dose on day 1, then  cetuximab 250 mg/m2 weekly plus  oxaliplatin 85 mg/m2 IV over 2h on day 1 plus  leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d continuous infusion; repeat every 2wk for 4 cycles, then reevaluate or
  • FOLFIRI plus cetuximab (only for KRAS wild-type tumors): Cetuximab 400 mg/m2 loading dose over 2h on day 1, then  cetuximab 250 mg/m2 over 1h weekly plus  irinotecan 180 mg/m2 IV over 30-90min on day 1 plus  leucovorin 400 mg/m2 IV infusion to match duration of irinotecan infusion on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d (total 2400 mg/m2 over 46-48h) continuous infusion; repeat every 2wk for 4 cycles, then reevaluate or
  • Referral for clinical trial
Second-line chemotherapy for metastatic disease[11, 12, 13] :
  • FOLFIRI (if FOLFOX, CapeOx, CapeOx plus bevacizumab or FOLFOX plus bevacizumab used as first-line chemotherapy): Irinotecan 180 mg/m2 IV over 30-90min on day 1 plus  leucovorin 400 mg/m2 IV infusion to match duration of irinotecan infusion on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d (total 2400 mg/m2 over 46-48h) continuous infusion; repeat every 2wk for 4 cycles, then reevaluate or
  • FOLFIRI plus cetuximab (only for KRAS wild-type tumors and if FOLFOX, CapeOx, CapeOx plus bevacizumab or FOLFOX plus bevacizumab used as first–line chemotherapy): Cetuximab 400 mg/m2 loading dose over 2h on day 1, then  cetuximab 250 mg/m2 over 1h weekly plus  irinotecan 180 mg/m2 IV over 30-90min on day 1 plus  leucovorin 400 mg/m2 IV infusion to match duration of irinotecan infusion on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d (total 2400 mg/m2 over 46-48h) continuous infusion; repeat every 2wk for 4 cycles and then reevaluate or
  • mFOLFOX6 (if FOLFIRI or FOLFIFI plus bevacizumab used as first-line chemotherapy): Oxaliplatin 85 mg/m2 IV over 2h on day 1 plus  leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2-d continuous infusion; repeat every 2wk for 4 cycles or
  • CapeOx: Oxaliplatin 130 mg/m2 over 2h on day 1 plus  capecitabine 1000 mg/m2 BID for 14d every 21d for 4 cycles followed by reevaluation for maintenance therapy or
  • mFOLFOX6 plus cetuximab (only for KRAS wild-type tumors and if FOLFIRI or FOLFIRI plus bevacizumab used as first-line chemotherapy): Cetuximab 400 mg/m2 loading dose on day 1 over 2h, then  cetuximab 250 mg/m2 over 1h weekly plus  oxaliplatin 85 mg/m2 IV over 2h day 1 plus  leucovorin 400 mg/m2 IV over 2h on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1, then  1200 mg/m2/day for 2d continuous infusion; repeat every 2wk for 4 cycles and then reevaluate or
  • Irinotecan 125 mg/m2 over 90min weekly with reevaluation after 8wk or
  • Cetuximab 400 mg/m2 over 2h on day 1, then  250 mg/m2 over 1h weekly with reevaluation after 8wk or
  • Panitumumab 6 mg/kg over 60-90min every 2wk with reevaluation after 8wk or
  • Modified FOLFOX6 plus bevacizumab (if FOLFIRI used upfront and bevacizumab never used as first-line chemotherapy; note higher dose of bevacizumab as second-line chemotherapy): Bevacizumab 10 mg/kg over 30-90min on day 1 plus  oxaliplatin 85 mg/m2 over 2h on day 1 plus  leucovorin 400 mg/m2 over 2h plus  5-FU 400 mg/m2 IV bolus on day 1, followed by 5-FU 2400 mg/m2 IV continuous infusion over 46h every 2wk for 4-6 cycles with reevaluation for maintenance therapy (1 g of calcium gluconate and 1 g of magnesium sulfate may be give over 15min preinfusion and postinfusion to reduce the risk of neurotoxicity) or
  • CAPEOX plus bevacizumab (if FOLFIRI used upfront and bevacizumab never used as first-line chemotherapy; note higher dose of bevacizumab as second-line chemotherapy): Bevacizumab 15 mg/kg over 30-90min on day 1 plus  oxaliplatin 130 mg/m2 over 2h on day 1 plus  capecitabine 1000 mg/m2 BID for 14d every 21d for 4 cycles followed by reevaluation for maintenance therapy or
  • FOLFIRI plus bevacizumab (if FOLFOX or CAPEOX used upfront and bevacizumab never used as first-line chemotherapy): Bevacizumab 10 mg/kg over 30-90min on day 1 plus  irinotecan 180 mg/m2 over 90min on day 1 plus  leucovorin 400 mg/m2 over 2h on day 1 plus  5-FU 400 mg/m2 IV bolus on day 1 followed by 5-FU 2400 mg/m2 IV continuous infusion over 46h every 2wk for 4-6 cycles with reevaluation for maintenance therapy or
  • Aflibercept 4 mg/kg IV infused over 1 hr q2weeks plus FOLFIRI in mCRC resistant to or has progressed after an oxaliplatin regimen; administer before any component of FOLFIRI regimen on the day of treatment
  • Referral for clinical trial
Note: In the above regimens, cetuximab can be replaced with panitumumab at 6mg/kg every 2wk if anaphylaxis is experienced with cetuximab.
Third-line chemotherapy for metastatic disease:
  • Panitumumab 6 mg/kg over 60-90min every 2wk for KRAS wild-type tumors only with reevaluation after 8wk or
  • Any regimen incorporating an EGFR antibody for patients with KRAS wild-type disease using a cytotoxic backbone not previously tried or
  • Referral for clinical trial

Summary of guiding principles in the treatment of metastatic colorectal cancer

  • Importance of differentiating between M1a (1 organ site of metastatic disease) and M1b (more than 1 organ site) in view of curative potential of 1 organ site
  • Selection of oxaliplatin or irinotecan as part of cytotoxic backbone upfront in metastatic disease is based primarily on toxicity profile
  • Bevacizumab improves survival as first-line and second-line therapy and works with irinotecan- and oxaliplatin-based therapy
  • Addition of bevacizumab to irinotecan, fluorouracil, and leucovorin (IFL) significantly improved the response rate, overall survival, and progression-free survival
  • The addition of bevacizumab to fluorouracil-based combination chemotherapy results in statistically significant and clinically meaningful improvement in survival among patients with metastatic colorectal cancer
  • Interruption in therapy is not ideal for patients; some form of therapy should always be continued after a stable disease state is obtained
  • Single-agent maintenance bevacizumab may be a feasible option for patients receiving bevacizumab + CapeOx as induction therapy
  • There are no data on maintenance anti-EGFR therapy
  • Anti-EGFR antibody therapy should be given only to patients with KRAS wild-type tumors
  • Anti-EGFR antibody therapy and bevacizumab should never be combined
  • Progression-free survival (PFS) and overall survival (OS) in randomized clinical trials using both FOLFOX and FOLFIRI cytotoxic backbones has been improved only in those patients with KRAS wild-type tumors
  • The data on BRAF status are still preliminary in terms of predictive value, but there is a suggestion that even in the setting of KRAS wild-type tumors, BRAF mutation abrogates the effect of anti-EGFR antibody therapy; it is, however, prognostic of a worse outcome
  • Optimal use of all therapeutic agents improves survival in patients with metastatic disease
  • It is reasonable to leave the primary therapy in place and start treatment for metastatic disease
  • A multidisciplinary approach is necessary to deal with the complicated issue of potentially resectable or marginally resectable metastatic disease
  • Pharmacogenomics profiling beyond KRAS mutation status is not yet standard of care
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