INTRODUCTION

Excessive sweating is a common problem in patients with advanced cancer. It can be directly related to the disease or may occur without any evident cause. It can be localized or generalized. It is usually more common at nights. The major causes of excessive sweating in advanced malignancy are:

• Infections – acute or chronic
• Malignancies – lymphomas, breast cancer, prostate cancer, neuroendocrine tumours, renal cell cancer, pheochromocytoma, carcinoid syndrome
• Hormonal deficiencies – menopausal or post-castration
• Endocrine – hyperthyroidism, hyperpituitarism, hypoglycaemia
• Medications – barbiturates, opioids, pilocarpine, SSRIs, tamoxifen, aromatase inhibitors, gonadotrophin analogues, tricyclic antidepressants (paradoxical)
• Autonomic neuropathy
• Paraneoplastic sweating
• Emotional – anxiety, fear, stress

ASSESSMENT

• Assessment must determine the underlying cause of excessive sweating, effectiveness of treatment and impact on quality of life for the patient and their family (refer to the Guideline – Symptom Assessment)

• Investigations(If appropriate)
• White blood cell count
• Urine routine and culture
• Blood culture
• Chest radiograph

MANAGEMENT

• Correct the correctable
• Treat the underlying cause
• Treat the infection
• Hormonal deficiency
• Hormone replacement treatment if appropriate
• Megestrol acetate 40mg OD, with a trial reduction to 20mg after 1 month, if effective
• Medroxyprogesterone 5 – 20mg PO bd – qid
• Non-hormonal
• Venlafaxine 37.5mg PO OD (modified release once daily), increasing to 75mg PO OD (modified release once daily) after 1 week
• Clonidine 100mcg hsod or 0.05 mg tid, increasing up to 1.2mg/24 hours; 40% response rate, may cause nocturnal restlessness, and is ineffective in men
• Drug induced – Review medication and prescribe alternative
• If a tricyclic antidepressant or an SSRI is the cause, switch to mirtazapine or venlafaxine
• Consider switching opioids
• Non-pharmacological measures
• Reduce room temperature – increase ventilation, use fans
• Use loose cotton clothing
• Avoid very hot drinks, spicy food
• Less bed-covers
• Avoid plastic covers on pillows and mattress
• Tepid sponging
• Adequate fluid intake
• Pharmacological measures
• Sweating with pyrexia
• Paracetamol 500 – 1000mg PO qid or prn
• Non-steroidal anti-inflammatory drug (NSAID), e.g. ibuprofen 200 – 400mg PO tid or prn or Diclofenac 50mg PO tid
• Sweating without pyrexia
• Non-steroidal anti-inflammatory drug (NSAID):
• Naproxen 250mg PO bd or
• Diclofenac 50mg PO tid or
• Indomethacin 25mg PO tid
• If NSAIDS fails, prescribe an anti-muscarinic medication:
• Amitriptyline 25 – 50mg PO OD
• Hyoscine butyl bromide 10mg PO tid or 40mg/24 hours by CSCI
• Glycopyrronium 2mg PO tid
• If anti-muscarinic fails, other options are:
• Propranolol 10 – 20mg PO bd – tid
• Cimetidine 400 – 800mg PO bd
• Olanzapine 5mg PO bd
• Thalidomide 100mg PO OD (use as last resort only)

---

REFERENCES

• Haider, A., Solish, N. Focal hyperhidrosis: diagnosis and management. Canadian Medical Association Journal. (2005); 172(1): 69-75
• Pittelkow, M.R., Loprinzi, C.L., Pittelkow, T.P. (2015) Pruritis and sweating in Palliative Medicine. Oxford Textbook of Palliative Medicine (pp. 724-739)
• Twycross, R. Sweating in advanced cancer. Indian Journal of Palliative Care. (2004); 10(1): 1-11