Relapse management

Relapse management. Using relapse prevention methods to control drug use rather than stop it entirely. 

The measurement of ER has become a standard assay in the clinical management of breast cancer. The presence of ERa identifies those breast cancer patients with a lower risk of relapse and better clinical outcome. Receptor status also provides a guideline for those tumors that may be responsive to hormonal intervention. But only about half of ER-positive patients respond to hormonal therapies. Of those who respond initially, most will eventually develop an estrogen unresponsive disease following a period of treatment even though ERa is often still present. Mutant receptors and constitutively active r eceptors as well as hormone-independent activation of the ERa are discussed. The involvement of ER 3 isoforms is under investigation. 

An important initial intervention for a minority of alcohol-dependent patients is the management of alcohol withdrawal through detoxification. The objectives in treating alcohol withdrawal are relief of discomfort, prevention or treatment of complications, and preparation for rehabilitation. Successful management of the alcohol withdrawal syndrome is generally necessary for subsequent efforts at rehabilitation to be successful treatment of withdrawal alone is usually not sufficient, because relapse occurs commonly. 

The treatment staff must be aware of countertransference issues, and anticipate relapses and failures. For both patient and staff, it helps to define and accept limited goals. Appropriate security measures are necessary, so that staff can feel safe also, staff need to be educated about not taking unnecessary risks in handling these patients. Staff frustration has to be recognized and managed. 

While pharmacologic agents may help prevent relapse, psychotherapy should be the core therapeutic intervention. Motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), 12-step facilitation (TSF), behavioral couples therapy (BCT), community reinforcement approaches, and contingency management are the best-studied forms of psychotherapy in this group of patients. 

Ultrasensitive assays for PSA contribute to the earlier detection of prostate cancer relapse and (or) residual disease in prostatectomized patients as well as the more timely evaluation of response to current therapies. PSA determinations can be useful in detecting metastatic or persistent disease in patients following surgical or medical treatment of prostate cancer. Persistent elevation of PSA following treatment, or an increase in the pretreatment PSA concentrations, is indicative of recurrent or residual disease. Hence, PSA is widely accepted as an aid in the management of prostate cancer patients, and serum levels are most useful when sequential values are obtained and monitored over time. After complete removal of the prostate gland (radical prostatectomy), PSA levels should become very low or undetectable. A rise of the serum PSA level in prostatectomy patients indicates residual prostate tissue, recurrence, or metastasis of the disease (13, 16, 24, 36). 

Lyseng-Williamson, K. and Plosker, G. 2002. Management of relapsing-remitting multiple sclerosis - defining the role of subcutaneous recombinant interferon-(3-la (Rebif). Disease Management and Health Outcomes 10(5), 307-325. 

Management of stages III and IV indolent lymphoma is controversial because standard approaches are not curative. Time to relapse is only 18 to 36 months. After relapse, response can be reinduced however, response rates and durations decrease with each retreatment. 

Every patient who uses tobacco should be offered at least brief treatment. All patients attempting tobacco cessation should be offered practical counseling (problem-solving/skills training), social support, stress management, and relapse prevention. 

Interventions are more effective when they last greater than 10 minutes, involve contact with a professional, provide at least four to seven sessions, and provide nicotine-replacement therapy (NRT). Group and individual counseling is effective, and interventions are more successful when they include social support and training in problem-solving, stress management, and relapse prevention. 

Historically, the treatment of alcohol use disorders with medication has focused on the management of withdrawal from the alcohol. In recent years, medication has also been used in an attempt to prevent relapse in alcohol-dependent patients. The treatment of alcohol withdrawal, known as detoxification, by definition uses replacement medications that, like alcohol, act on the GABA receptor. These medications (i.e., barbiturates and benzodiazepines) are cross-tolerant with alcohol and therefore are useful for detoxification. By contrast, a wide variety of theoretical approaches have been used to reduce the likelihood of relapse. This includes aversion therapy and anticraving therapies using reward substitutes and interference approaches. Finally, medications to treat comorbid psychiatric illness, in particular, depression, have also been used in attempts to reduce the likelihood of relapse. 

Upon stopping treatment with cyclosporine, relapse will occur in approximately 6 weeks (50% of patients) to 16 weeks (75% of patients). In the majority of patients, rebound does not occur after cessation of treatment with cyclosporine. Continuous treatment for extended periods longer than 1 year is not recommended. Consider alternation with other forms of treatment in the long-term management of patients with this disease. 

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