Fever and Sweating
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Causes of generalised sweating
Explanation to patient and family
Non-pharmacological interventions
General pharmacological interventions
Review assessment and management
Fever
Normal body temperature ranges from 36,1ºC - 37,4ºC, maintained by thermoregulatory mechanisms. High temperatures are a result of either hyperthermia or fever. Hyperthermia is due to abnormal thermoregulation, whereas fever occurs with normal thermoregulation but with an abnormal hypothalamic set point.
Causes of fever
- Infection, especially important in neutropenic patients
- Tumour (para-neoplastic syndrome)
- Blood transfusion
- Drugs, e.g. some chemotherapy drugs and some antibiotics e.g., vancomycin and amphotericin
- Drug withdrawal – opioids, benzodiazepines
- Neuroleptic malignant syndrome – rare but may be fatal. Occurs with neuroleptic drugs and presents with fever, rigidity, confusion and autonomic instability.
Sweating
Sweating is very important component of thermoregulation in humans. It is most commonly the excessive sweating that is most distressing to patient, and may result in fatigue, drowsiness and confusion. Patients may complain of generalised or localised sweating
Causes of generalised sweating
- Non-disease states
- Warm environment
- Exercise
- Menopause
- Disease States, including co-morbidities
- Fever from various causes as listed above
- Tumour related, e.g., Hodgkin’s Lymphoma, tumours with liver metastases, pheochromocytoma, functional neuroendocrine tumours
- Endocrine disorders such as diabetes mellitus or insipidus, thyrotoxicosis and pituitary disorders
- Ischaemic Heart Disease
- Primary disorders of sweating
- Surgical or chemical female menopause, e.g., androgen treatment, radiation, chemotherapy
- Male menopause due to orchidectomy, GNRH or oestrogen use
- Drugs: tamoxifen, aromatase inhibitors, opioids, TCAs and steroids
Causes of localised sweating
- Spinal cord lesion
- Cerebrovascular Accident
- Intrathoracic mass
- Peripheral Neuropathy
Assessment
Detailed history including:
- history of current illness,
- other chronic illnesses,
- medications and other treatments,
- physical symptoms, especially extent and location of sweating,
- impact on patient’s quality of living.
Meticulous examination
- All body systems
- Any sites of foreign bodies
Investigations
- Urine, sputum and blood cultures as required
- CXR, if necessary
Management
Disease Specific palliative therapy:
- Fever
- Infection – treat appropriately with antibiotics. Even at end of life, infections may be treated as a palliative measure, relieving not only fever but associated symptoms, e.g., pain or cough. However this decision must be individualised for each patient.
- Paraneoplastic Fever – is best managed by anti-neoplastic treatment. However this may not be possible, then use antipyretics.
- Blood Transfusion – manage according to guideline on blood transfusion.
- Drug-related – ideally withdraw the drug, however if not possible, manage with antipyretics (see below).
- Neuroleptic Malignant Syndrome – stop the neuroleptic and supportive treatment.
- Co-morbid causes, e.g. endocrine; treat underlying cause.
- Sweating
- Fever – treat the cause
- Tumour – anti-neoplastic treatment, if possible
- Endocrine and other co-morbid causes – treat the cause
- Hot flushes
- for biological or induced postmenopausal states in women, oestrogen therapy is very effective, however some women have relative or absolute contraindications to oestrogen therapy. For women with ovarian failure for any reason and in men who have had androgen ablation therapy, megestrol acetate 40mg daily may provide relief. Full effect takes place after 2 -3 weeks. It may be necessary to titrate up monthly in increments of 10mg- 20mg to achieve the lowest effective dose.
- Other non-hormone therapies for hot flushes have demonstrated efficacy in reducing discomfort between 40-60%. These include SSRIs, SSNRIs, gabapentin, and alpha adrenergic agonists :
- Venlafaxine extended release 75mg daily, start with 37,5mg daily
- Paroxetine CR 12,5mg daily or Paroxetine 10mg daily
- Gabapentin up to 300mg tds
- Fluoxetine 20mg daily
- Clonidine 0,1mg daily is associated with troubling side effects
If one medication is not effective in reducing hot flushes, it is possible to switch to another. It is important to note that paroxetine should not be used with tamoxifen due to detrimental drug interactions. Hot flushes in men appear to respond to the agents listed above, except clonidine. They may also respond to the anti-androgen, cyproterone acetate.
Explanation to patient and family
Once an assessment is made, explain the cause of the sweating to the patient and the family. Discuss possible treatment options and non-pharmacological interventions, which could alleviate the patient’s discomfort. It may not be possible to alleviate the sweating completely, however a reduction of 40-50% is often tolerated.
Non-pharmacological interventions
- Encourage patient to wear loose fitting, cotton clothing
- Provide a fan for cooling
- Tepid sponging and regular washing
- For hot flushes, relaxation techniques and deep breathing may reduce intensity by 40-50%
- Encourage oral fluids to prevent dehydration
General pharmacological interventions
- Paracetamol and non-aspirin containing NSAIDs, such as naproxen may be effective in reducing fever and sweating. However some patients are relatively asymptomatic with the fever and experience sweating during defervescence. It may then be necessary to discontinue the antipyretics.
- High dose steroids may have a role in chronic lymphatic leukaemia
- Clinical experience has shown benefit from cimetidine 400mg-800mg bd, in idiopathic and malignancy-related sweating.
Review assessment and management
Regularly review the patient’s condition and response to interventions. Consider changing medication such as NSAIDS, if the current formulation is no longer effective