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Questions pertaining to medical or patient care

What are the recommendations/contraindications for concurrent HBO and Chemotherapy/Radiation?
Published: 20 January 2016

What are the recommendations/contraindications for concurrent HBO and Chemotherapy/Radiation?

This answer is from the recognized physician expert in the field of hyperbaric medicine dealing with oncological disease – John Feldmeier, DO.

“There is no easy answer to this question. We still struggle to answer the question of whether patients with a remote history can have HBO2.

Although I believe that in almost all cases this would be safe. There is very little published data with concurrent therapy. The issue of concurrent chemo/ HBO2 has next to no published information and really has become a fairly recent issue because patients are now living longer with active malignancy. There are more and more options for systemic treatment and quality of life issues are pertinent for patients even when they have active disease. The scenario where this becomes an issue is when a patient has had prior radiation, has a complication, needs HBO2 but is receiving chemo probably because recurrent or residual cancer has been found.

Chemo comes in many varieties with traditional cytotoxic drugs in at least 8 categories and now with more options including immune therapies and anti-angiogenic therapies. It is impossible to make a universal recommendation applicable to all chemotherapies.

Some of these drugs mediate their anti-tumor response through free radicals which cause chemical bond breaks in the DNA leading to reproductive death. Some are antibiotics: some are spindle cell blockers etc., etc. Those that mediate cytotoxicity through free radicals are likely to have their effect enhanced in the tumor and normal tissues.

This was the basis of using HBO2 as a sensitizer to radiation done from late 50's to early 70's. Since the therapeutic goal is to enhance QOL, this would not be perceived as an appropriate effect.

As I am sure, most of you know Eric Kindwall's book declares there to be a contraindication to Adriamycin and Cisplatin. This precaution is based on pretty weak evidence. On the other hand Dick Clarke has done a preliminary study with colleagues at U of Chicago using HBO2 along with Cisplatin and radiation without signs of increased toxicity.

I am especially concerned about Bleomycin and Avastin. Jake Freiberger, MD of Duke U. has reviewed their experience in treating patients with a PAST not concurrent history of Bleomycin exposure without a demonstrable ill effect. I would not give Bleo concurrently with HBO2. Avastin and some of the other so called biologics (Erbitux) target growth factors including VEGF to exert their effect. Since we enhance VEGF with HBO2 are we diminishing the anti-cancer effects of Avastin? Will HBO2 be effective if VEGF is being suppressed by the Avastin? We don't know.

My operational recommendation is: 1)to avoid chemo and HBO concurrently whenever possible.2) If you do give concurrently wait a few half-lives perhaps 4 or 5 to see serum levels significantly lowered before resuming HBO2 after each chemo administration. Half-lives for all the drugs are published. Avastin is 60 days!! 3) I would avoid Avastin and some of the other biologics as well as Bleomycin as concurrent therapies.“

I wanted to ask whether you had any knowledge of clinical circumstances or literature regarding having a patient with a 20+ year old mechanical aortic valve undergo HBO2. The valve has not been pressure tested by the manufacturer?
Published: 05 February 2016

I wanted to ask whether you had any knowledge of clinical circumstances or literature regarding having a patient with a 20+ year old mechanical aortic valve undergo HBO2. The valve has not been pressure tested by the manufacturer?

There are no pressure-sensitive components in a mechanical valve, since it contains no gas pockets. There are no issues with respect to hyperbaric oxygen therapy regarding a prosthetic valve.

Do you have any information regarding HBOT and concurrent use of chemotheapeutic agents 1) ixabepilone and 2) faslodex?
Published: 12 July 2017

Do you have any information regarding HBOT and concurrent use of chemotheapeutic agents 1) ixabepilone and 2) faslodex?

None of the drugs have a published experience discoverable on a pub med search.

Based on mechanisms of action I doubt any of the drugs wiuld have their toxicities enhanced by HBO2. However, as you know, the decision to treat a patient with HBO2 who is receiving these drugs is the managing physicians decision and our input is meant only to provide guidance based on the information that is discoverable.

Please see the attachment.

docxChemotx_and_HBO_3_drugs.docx

Can you clarify? For dx of DFU 3 or higher, one of the qualifiers for HBO is that patient failed 30 days of wound care. If the patient''s wound was only a DFU 2 during those 30 days, does that count or does the wound need to be a DFU 3 during those 30 days?
Published: 04 December 2018

Can you clarify? For dx of DFU 3 or higher, one of the qualifiers for HBO is that patient failed 30 days of wound care. If the patient''s wound was only a DFU 2 during those 30 days, does that count or does the wound need to be a DFU 3 during those 30 days?

CMS clearly states must be Wagner Grade III or higher. See links below for the NCD and also for the UHMS CPG for Diabetic Foot Ulcer.

The question concerns a 49-year-old otherwise healthy woman who presented in 2017 with complaints of progressive noise magnification and severe headaches.
Published: 05 December 2018

The question concerns a 49-year-old otherwise healthy woman who presented in 2017 with complaints of progressive noise magnification and severe headaches.

There are several anecdotal reports of HBO2 for brain necrosis. In some radiosurgery series, the incidence of brain necrosis is as high as 25%.As with all CNS injuries early intervention is likely to have a higher rate of success. Determinants of outcome obviously include neurologic symptom response, but some series report decreases in steroid requirements and improvement on brain imaging mostly MRI. In my reading of the literature Avastin does not give consistent response.

I would recommend at least 40 treatments at 2.4 ATA. Many patients appear to require a good number of treatments for sustainable response, perhaps well over 60.To my knowledge no one has reported a higher likelihood of seizures during HBO with this group. If seizure activity is part of the picture adequate coverage with anti-convulsants is obviously needed.

See the below abstract and some pdf of slides from one of my presentations.

John Feldmeier