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Thera IX > 10 Chemotherapy Induced N/V Hsu > Flashcards

10 Chemotherapy Induced N/V Hsu Flashcards

1
Q

What are the Emesis (N/V) risk factors?

A

Type of chemotherapy and dosage! Previous episodes of N/V! Age < 50 years. Female. History of motion sickness. High anxiety (anticipatory). History of low alcohol consumption (chronic alcoholism = decreased risk of emesis)

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2
Q

What is Acute Onset Emesis?

A

Occurs several minutes to hours after chemotherapy. Peaks in 5-6 hours and resolves within 24 hours

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3
Q

What is Delayed Onset Emesis?

A

Occurs > 24 hours after chemotherapy. Common drugs: Cisplatin > Carboplatin > “AC” Doxorubicin + Cyclophosphamide

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4
Q

What is Anticipatory Emesis?

A

Occurs prior to chemotherapy

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5
Q

What is Breakthrough Emesis?

A

Occurs while already on antiemetic therapy. Patients generally given additional medications PRN

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6
Q

What are the Emesis Neurotransmitters (NT)?

A

Primary NT pathways (Serotonin, Substance P/NK, Dopamine). Other NT associated with Nausea (Corticosteroids, Cannabinoid, Opiates, Histamine, Acetylcholine)

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7
Q

What are the 5HT3 Receptor Antagonists used?

A

Ondansetron (Zofran). Granisetron (Kytril, Sancuso). Dolasteron (Anzemet). Palonosetron (Aloxi)

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8
Q

Which 5HT3 Receptor Antagonist is used as a patch?

A

Granisetron (Sancuso)

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9
Q

Which 5HT3 Receptor Antagonist can only be given IV?

A

Palonosetron (Aloxi)

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10
Q

Which 5HT3 Receptor Antagonist has efficacy in delayed N/V?

A

Palonosetron (Aloxi) d/t its long half-life (~40 hrs)

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11
Q

What are the general class indications of 5HT3 Receptor Antagonists?

A

Prevention of chemotherapy, radiation, post-op N/V. Effective as mono and combination therapy. Most commonly used agent for mod-high emetogenic risk

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12
Q

What are 5HT3 Receptor Antagonists NOT effective for?

A

Breakthrough emesis

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13
Q

What are 5HT3 Receptor Antagonists LESS effective for?

A

Delayed N/V with the exception of Palonosetron (long half-life)

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14
Q

What are the ADRs associated with 5HT3 Receptor Antagonists?

A

HA (dose/rate dependent). QT prolongation. Constipation > diarrhea

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15
Q

What are the corticosteroids used?

A

Dexamethasone (Decadron) - preferred steroid for N/V

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16
Q

How is Dexamethasone (Decadron) administered?

A

PO or IV

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17
Q

What are the common ADRs associated with Dexamethasone (Decadron)?

A

GI stomach upset. CNS (insomnia, mood changes). Lab changes (increased glucose and WBC)

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18
Q

What is the MOA of NKI-Antagonist (Emend)?

A

Substance P/Neurokinin I (NKI) receptor antagonist - GI and CNS receptor activity. No dopamine or serotonin receptor affinity

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19
Q

What are the ADRs associated with NKI-Antagonists?

A

Hiccups! GI. LFT elevation. Emend regimen AE are similar to 5HT3 alone

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20
Q

What are the DDIs with NKI-Antagonists?

A

3A4 inhibitor and substrate, 2C9 inducer. Decrease Dexamethasone dose by 50%!!!!

21
Q

What is the indication for NKI-Antagonists?

A

Prevention of acute and delayed nausea and vomiting associated with moderate to high emetogenic chemotherapy. IV formulation = 150mg on day 1 ONLY

22
Q

What is done for high emetogenicity dosing?

A

NKI-Antagonists to be used in combination with steroids and 5HT3 antagonist as a specific regimen

23
Q

What are the NKI-Antagonists used?

A

Aprepitant or Fosaprepitant

24
Q

What is the MOA of Dopamine Receptor Antagonists?

A

Antagonize dopamine receptors in the chemo trigger zone of the CNS. Increases GI motility via cholinergic response from peripheral dopamine antagonism. Both help decrease N/V

25
Q

What are the Dopamine Receptor Antagonists used?

A

Metoclopramide (Reglan). Prochloperazine (Compazine)

26
Q

What are the ADRs associated with Dopamine Receptor Antagonists?

A

CNS - EPS (parkinson’s like symptoms). Manage with anticholinergic drugs

27
Q

What are the Dopamine Receptor Antagonist uses?

A

May be used as single agents for CINV for LOW emetic regimens (Give one dose 30-60 minutes prior to chemo). Primarily for breakthrough N/V given PRN. Not as effective as serotonin antagonists

28
Q

Which Dopamine Receptor Antagonist requires renal adjustment?

A

Metoclopramide (Reglan). Renal Cl < 40 = 50% dose

29
Q

What are some Adjunctive antiemetic drug therapy agents?

A

Benzodiazepines (Lorazepam)

30
Q

What is the MOA of Lorazepam (Ativan)?

A

Acts on GABA receptors to produce anxiolytic effects

31
Q

What are the ADRs associated with Lorazepam?

A

CNS (drowsiness, dizziness, confusion). Respiratory depression (don’t use with other CNS depressant agents)

32
Q

What are the uses of Benzodiazepiens?

A

First line for anticipatory N/V. Not recommended as single agents for treatment or prevention of N/V

33
Q

What are the directions for Lorazepam use?

A

Anticipatory: Start the night before chemotherapy and take a dose the morning of chemotherapy. May also be given PRN Q4-6 hrs (anxiety or nausea)

34
Q

What is Dronabinol (Marinol)?

A

Cannabinoid, another antiemetic for mild to moderate CINV refractory or intolerant to other antiemetics

35
Q

What is Promethazine (Phenergan)?

A

Another antiemetic used for breakthrough emesis

36
Q

What is a BBW associated with Promethazine (Phenergan)

A

Severe tissue injury, DO NOT give SQ

37
Q

What are the antipsychotic agents that can be used for emesis?

A

Olanzapine (Zyprexa). Haloperidol (Haldol)

38
Q

What are some GI agents that can be used for emesis?

A

H2 blockers, PPIs, H1 blockers (antihistamines; diphenhydramine). NOT for monotherapy. May add as adjunctive therapy, particularly if patient has history of dyspepsia

39
Q

What are the principles of Antiemesis?

A

PO and IV formulations have equal efficacy. Generally try PO first if tolerated (or for home use). Choose IV if actively vomiting (breakthrough emesis) or unable to take orals

40
Q

Which agents have the highest causes of emesis?

A

CIsplatin. Combo: Cyclophosphamide + Doxorubicin (Anthracycline). Carmustine

41
Q

Which agents cause minimal emesis?

A

Targeted agents (monoclonal antibodies). TKIs (orals) - minimal to low emetogenicity

42
Q

What treatment plan is given to High Risk (>90%)?

A

Combination therapy required. 5-HT3 Serotonin Receptor Antagonist (any) + Dexamethasone + Emend (PO or IV)

43
Q

How long is each agent used for?

A

Aprecitant (Emend) for 3 days (120mg PO, 80mg PO, 80mg PO). Dexamethasone for 4 days (12mg, 8mg, 8mg, 8mg). 5HT3 Antagonist used only on day 1

44
Q

What is Dexamethasone use like for Moderate Risk?

A

Steroids past day 1 not required for moderate emetic regimens

45
Q

What is used for low risk emesis?

A

Single agent treatment (Dexamethasone, Reglan, Compazine). Add PRN meds as appropriate

46
Q

What is best for delayed emesis?

A

Aprepitant (Emend), but not always indicated. Steroids are a good choice but expensive

47
Q

What is the treatment duration for Delayed Emesis?

A

3 days for high, 2 days for moderate

48
Q

What are some key points for breakthrough emesis?

A

Consider around the clock rather than PRN (prevention > treatment). IV may be better than PO if vomiting. Serotonin antagonists are a poor choice

49
Q

What are the key points of Anticipatory Emesis?

A

Benzodiazepines (start the night prior to chemotherapy and can give a dose the morning of chemo). Controlling acute and delayed emesis will decrease risk of future anticipatory emesis

Thera IX (29 decks)

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