11: Managing Nutrition Side Effects

Question 1

CTCAE (Severity) Grades and Description:
Anorexia and Early Satiety

Answer 1

1 - loss of appetite without changing eating habits
2 - oral intake altered without significant wt loss or malnutrition; oral supplements started
3 - associated with significant wt loss or malnutrition; EN/PN indicated
4 - life-threatening consequences, urgent intervention indicated
5 - death

Question 2

Considerations for:
Anorexia and Early Satiety

Answer 2

evaluate:
conditions that impact digestion
meds that may be causing digestion/GI issues (pain meds, antacids, H2-receptor antagonists, PPI, antiemetics, etc)
pt’s use of recommended symptom management strategies and meds - figure out any impediments to adherence
assess food/fluid intake

Question 3

Nutrition and Behavior Interventions for:
Anorexia and Early Satiety

Answer 3

small/frequent meals of HCHP foods
set a schedule
maximize intake at time of day appetite is best
oral supplements
consume liquids separate from meals
use foods that are easy to prepare/serve
keep convenience foods (frozen meals, bars, supplements) on hand
approach eating as part of treatment
engage in light activity to help move food through the GI

Question 4

Pharmacotherapy for:
Anorexia and Early Satiety

Answer 4

Antihistamines - Periactin in children
steroids
progestational agents (provera, megace)
prokinetic agents (reglan)
cannabinoids (marinol, syndros, cesamet)
antidepressants (Remeron–off label use)

Question 5

CTCAE (Severity) Grades and Description:
Taste & Smell Changes

Answer 5

1 - altered taste, no change in diet
2 - altered taste with change – noxious or unpleasant taste; loss of taste

Question 6

Considerations for:
Taste & Smell Changes

Answer 6

assess etiology of the changes – chemo changes my be transient during treatment cycle; radiation may be processive and more permanent
evaluate for candidiasis
encourage good oral hygiene
assess food/fluid intake
investigate foods that illicit the sense of dysgeusia or ageusia
ID which flavors the patient does perceive as accurate/pleasant/tolerate and modify intake using this profiles

Question 7

Nutrition and Behavior Interventions for:
Taste & Smell Changes

Answer 7

Little/Off Taste: use fruity/salty, +marinades, herbs/spices/lemon/etc, remind hot foods (spicy) is not a flavor but a sensation so likely not to help

Bitter/acidic/metallic Taste: sweet foods with meals, sweet/sour beverages, strongly flavored spices like onion/garlic, sugar-free lemon drops/gums/mints to improve mouth taste, alternative protein like chicken/eggs/tofu, use bamboo/plastic silverware or chopsticks to reduce metal taste

Salty Taste: naturally sweet foods, boiled foods reduce flavor, low-sodium products

Sweet Taste: bland/sour flavors, dilute juices, choose veggies over fruit

Smell issues: cold/room temp foods, avoid strong odor foods (fish, cabbage), avoid cooking areas during meal prep, avoid lengthy cooking processes (crockpot), vent cooking areas

Extra tips: small/frequent meals, oral supplements, cup with a lid an straw for cold/room temp to reduce exposure to flavor/odors, approach as part of treatment, educate patient about time frame of changes and recovery

Question 8

Pharmacotherapy for:
Taste & Smell Changes

Answer 8

cleansing rinse: 3/4 tsp salt, 1 tsp baking soda, 4 c water. rinse mouth with 1 c of mixture 3-4 times/day

“miracle fruit” might help
Herbal Tea (gymnema sylvestra) consumed before meals, may inhibit sweet taste
zinc supplements have NOT been proven to help with loss for ENT patient

Question 9

CTCAE (Severity) Grades and Description:
Constipation

Answer 9

1 - occasional/intermittent symptoms, occasional use of softeners/laxatives/diet mods/enema

2 - persistent symptoms with regular use of laxatives/enemas, limiting ADLs

3 - Obstipation with manual evacuation indicated, limited self-care ADLs

4 - life-threatening consequences, urgent intervention indicated

5 - death

Question 10

Considerations for:
Constipation

Answer 10

evaluate:
bowel habits/pattern and changes with treatment
frequency of bowel movements and volume/character of stool
use of meds that may slow gastric emptying and influence GI function
patient’s use of recommended meds and bowel regimen for symptom management, explore with the patient any impediments to adherence

assess food/fluid intake

Question 11

Nutrition and Behavior Interventions for:
Constipation

Answer 11

Aim for min 64-80 oz
Add +32 oz fluid if using medicinal fibers
adequate fiber intake overall — increase to goal
daily routine that includes a hot beverage/hot cereal/or high-fiber food to stimulate bowels
add food-related probiotics or other supplements to help
engage in light activity
hen on opioids — combination of stimulant laxative plus a stool softener is well tolerated
schedule adequate bathroom time and privacy
report if there hasn’t been a movement for more than 3 days

educate on:
importance of adequate hydration, fiber intake and total food intake
effect of each med on bowel function

Question 12

Pharmacotherapy for:
Constipation

Answer 12

Insoluble fiber
Medicinal fiber – metamucil/benefiber
stool softener – colace/surfak
lubricants – mineral oil
osmotic laxatives – miralax/MoM
stimulant laxative agents – dulcolax/senokot/ex-lax
opioid antagonist – relistor/symproic
herbals – probiotics, slippery elm, aloe juice

Question 13

CTCAE (Severity) Grades and Description:
Diarrhea

Answer 13

1 - increase of less than 4 stools/day over baseline, mild increase in ostomy output compared to baseline

2 - increase to 4-6 stools/day over baseline; moderate increase in ostomy output compared to baseline, limiting instrumental activities ADLs

3 - increase to 7+ stools/day, hospitalization indicated; severe increase in ostomy; limited self-care ADL

4 - life-threatening consequences, urgent intervention indicated

5 - death

Question 14

Considerations for:
Diarrhea

Answer 14

Assess etiology — osmotic, malabsorptive, secretory, infectious, chemo, radiation enteritis, GI mucositis, GVHD, pancreatic insufficiency

Evaluate pattern and changes with treatment, frequency/volume/consistency

Assess for risk factors of dumping syndrome, lactose intolerance, fat malabsorption

Review meds that could be impacting GI function

Review pt’s use of recommended bowel regimen for symptom management & meds, work to resolve impediments of adherence

Food/fluid intake review

Question 15

Nutrition and Behavior Interventions for:
Diarrhea

Answer 15

small/frequent meals
adequate hydration
low fat, low-insoluble-fiber, or low lactose—or any combo as needed
increase soluble fiber foods
if gas/bloated, limited gas-forming foods
eliminate caffeine/alcohol/highly spiced foods
avoid sorbitol and other sugar-alcohol containing products

educate patient on electrolyte-containing foods/fluids, use of oral rehydration salts/products/recipes if needed, use of lactase enzyme products and subs if needed

Question 16

Pharmacotherapy for:
Diarrhea

Answer 16

Opioid receptor agonist–loperamide/imodium or lomotil
Hormonal-octreotide/sandostatin
opioids-paregoric
anti-inflammatory/anti-diarheal–peptobismol or kaopectate
bile acid sequestrant–cholestyramine/questran
anticholinergics–diphenhydramine/benadryl
medicinal fibers–metamucil, konsyl, citrucel
preventive for gut radiotherapy-ethyol
amino acids- L-glutamine (may reduce duration), Enterade
Probiotics (maybe, with caution)

Question 17

CTCAE (Severity) Grades and Description:
Dysphagia

Answer 17

1 - symptomatic, able to eat regular diet

2 - symptomatic and altered eating or swallowing

3 - severely altered eating or swallowing; tube feeding, PN or hospitalization indicated

4 - life-threatening consequences, urgent intervention indicated

5 - death

Question 18

Considerations for:
Dysphagia

Answer 18

assess etiology of it
review swallow study and SLP recs
assess food/fluid intake

Question 19

Nutrition and Behavior Interventions for:
Dysphagia

Answer 19

alter food textures as per SLP
thickeners as needed per SLP
moist foods of similar texture to help with cohesive bolus in mouth
avoid dry foods and foods that separate into pieces (rice/crackers)
moisten dry foods with gravies/sauces
alternate solid food and liquids
eat/drink in upright position
avoid distractions and limit talking while eating
avoid straws unless recommended by SLP
for Odynophagia–use pain meds or topical anesthetics/strays/lozenges
Practice chin-tuck swallowing and double swallowing to help food clear the pharynx
practice verbalization after swallowing liquids to help clear the pharynx

educate patient on:
strategies to address QOL concerns – thickened water
strategies to address impediments to adherence
which medications need to be taken with cohesive foods or in liquid form
dysphagia guidelines as per IDDSI
use of slurry textures

Question 20

Pharmacotherapy for:
Dysphagia

Answer 20

Topical anesthetics–lidocaine spray/Xylocaine
Analgesia–opioids
Thickeners–simply thick gel, thicken right, thicken up, thick & easy, thick it

Question 21

CTCAE (Severity) Grades and Description:
Fatigue

Answer 21

1 - fatigue relieved by rest

2 - fatigue not relieved by rest; limited instrumental activities of ADLs

3 - fatigue no relieved by rest; limiting self-care ACL

Question 22

Considerations for:
Fatigue

Answer 22

evaluate for anemia, hydration status, unintentional wt loss and sarcopenia
consider appropriateness of MVI or mineral supplement
assess actual food/fluid intake

Question 23

Nutrition and Behavior Interventions for:
Fatigue

Answer 23

small/frequent meals and snacks
consider taking oral supplements to promote adequate energy intake
keep nonperishable snacks at bedside
plan a larger meal for when the appetite is best
consume soft, easy to chew foods if eating is difficult
consider frozen meals, meal boxes, or grocery pick up services
use easy-to-prepare meals, snacks, prepared foods
save energy by limiting “duties or chores” as much as possible
continue to preform ADL and light activities
monitor wt weekly, report wt loss, and monitor hydration
consider PT consult for muscle strengthening
avoid excessive daytime sleep to help improve nighttime sleep quality

Question 24

Pharmacotherapy for:
Fatigue

Answer 24

blood transfusions
erythropoietin given as epoetin alfa (epogen, procrit)

Question 25

CTCAE (Severity) Grades and Description: Malabsorption

Answer 25

2 - altered diet, oral intervention indicated 3 - inability to aliment adequatley, PN indicated 4 - life-threatening consequences, urgent intervention indicated 5 - death (1 not listed)

Question 26

Considerations for: Malabsorption

Answer 26

evaluate pattern of bowel habits and changes associated with surgery, diagnosis and treatment evaluate frequency of stooling/volume/color/consistency/possible EPI check fecal elastase Evaluate patients ability to manage the bowel regimen and use of enzymes--note the timing of the enzymes use vs food/beverage intake. Titrate up the dose until efficacy is achieved, allow 1-2 weeks for each change in dosage. work with patient to limit impediments of adherence some enzymes need a PPI concurrently to maintain effectiveness Pt shouldn't sprinkle or mix contents of enzyme capsules on dairy products or consume foods with ph >4. should be mixed well with foods, tell patients to sprinkle them on applesauce immediately before eating a meal assess for lactose intolerance review food/fluid intake

Question 27

Nutrition and Behavior Interventions for: Malabsorption

Answer 27

for bloating/gas: avoid straws/swallowing air/carbonated beverages/chewing gum; chew slowly/thoroughly with mouth closed for bloating/cramping/gas from milk products: low lactose diet, use of lactase-treated dairy or lactase pills/drops for gas from veggies: avoid cruciferous veggies, beans/legumes, or take enzyme supplement with a-galactosidase and invertase (beano) for bulky/foul smelling stools/fatty stools: take enzymes before first bite and if taking more than one pill, take second halfway through; recommend medium-chain triglycerides to augment calorie intake if needed; educate patient on fat malasorption and using fat-gram counters or mobile nutrition apps to help track intake and assess enzyme adequacy; educate patient on which foods/beverages don't need enzymes; educate on appropriate dosage

Question 28

Pharmacotherapy for: Malabsorption

Answer 28

Gas-X, Lactaid, Beano Probiotics, with caution Enzymes: Dosing per fat-gram content--- 500-1000 lipase units per g of fat do NOT exceed 4000 lipase units per g of fat do NOT exceed 2500 lipase units per kg of body weight/meal or 10,000 units per kg of body weight/day Dosing per meal/snack--- 20,000-75,000 lipase units per meal, 5000-50,000 lipase units per snack Dosing per kg of body weight--- 500 lipase units/kg for meals, increasing as tolerated 250 lipase units/kg for snacks, increasing as tolerated

Question 29

CTCAE (Severity) Grades and Description: Nausea/Vomiting

Answer 29

Nausea: 1 - loss of appetite without alterations in eating habits 2 - oral intake decreased without significant wt loss, dehydration or malnutrition 3 - inadequate oral energy or fluid intake; tube feeding, PN or hospitalization indicated Vomiting: 1 - intervention not indicated 2 - outpatient IV fluids, medical intervention indicated 3 - tube feeding, PN or hospitalization indicated 4 - life-threatening consequences 5 - death

Question 30

Considerations for: Nausea/Vomiting

Answer 30

access etiology of N/V--- anticipatory, acute (24 after chemo), delayed (1-7 days after chemo), breakthrough (occurs despite prophylactic meds, requiring "rescue" meds), refractory (all meds have failed) eval pt's ability to manage meds, work to address impediments of adherence assess for presence of constipation for radiotherapy-only treatment--assess the site or radiation/field size/total dose. high risk treatments are total body, upper abd, and craniospinal for chemo, with or without RT, assess the emetogenic potential of the chemo agent evaluate the timing and patterns of N/V associated with the treatment cycle, medication use, and food/beverage intake assess food/fluid intake

Question 31

Pharmacotherapy: Nausea/Vomiting

Answer 31

Acute - serotonin antagonists (5-HT3 receptor antagonists --- ondansetron/zofran, dolasetron/anzemet, granisetron/kytril, palonosetron/aloxi, tropisetron/navoban Delayed--dopamine antagonists, particularly phenothiazines --- prochlorperazine/compazine, promethazine/phenergan Delayed--Neurokinin-1 (NK-1) receptor antagonists -- aprepitant or fosaperpitant/Emend, netupitant and palonsetron/akynezo, rolapitant/varubi Benzamindes: methoclopramide/reglan cannabinoids: dronabinol/marinol, liquefied dronabinol/syndros, nabilone/cesamet Benzodiazapines: lorazepam/ativan, diazepam/valium --- anticipatory Corticosteroids: dexamethasone/decadron, prednisone Combo meds for CINV prophlaxis: a steriod + 5-HT3 + NK-1 with or without benzamide --- decadron+Zofran+Emend plus possibly reglan Investigational complementary therapies: ginger tea, ginger ale, 0.5-1 ginger extract, acupressure bracelets, acupuncture, massage, transcutaneous electrical nerve stimulation, relaxation techniques, and self-hypnosis

Question 32

Nutrition and Behavior Interventions for: Nausea/Vomiting

Answer 32

small/frequent meals bland/starchy foods and clear liquids--room temp avoid greasy, high-fat foods and highly seasoned foods consume liquids between meals limit exposure to cooking odors by avoiding food prep areas and use exhaust fans or open windows avoid/limit strong-smelling lotions, soaps, perfumes, and air fresheners rest with head elevated for 30 minutes after eating time meals for when nausea meds are working their best take pain meds with crackers or light foods

Question 33

CTCAE (Severity) Grades and Description: Oral Mucositis and Esophagitis

Answer 33

Mucositis: 1 - asymptomatic or mild symptoms; intervention not indicated 2 - moderate pain/ulcer that doesn't interfere with oral intake, modified diet indicated 3 - severe pain; interfering with oral intake 4 - life-threatening consequences; urgent intervention needed 5 - death Esophagitis: 1 - asymptomatic or mild symptoms; intervention not indicated 2 - symptomatic, altered eating or swallowing, oral supplements indicated 3 - severely altered eating or swallowing, tube feeding/PN/hospitalization indicated 4 - life-threatening consequences; urgent intervention needed 5 - death

Question 34

Nutrition and Behavior Interventions for: Oral Mucositis and Esophagitis

Answer 34

Cryotherapy during admin of 5-FU bolus and high-dose melphalan chemo. Have patients consume ice chips, ice water or frozen ice pop for 30 minutes to reduce possible development of mucositis choose foods lower in acidity avoid strong seasoning/spices moisten dry foods with sauces/gravies choose soft foods serve foods at cool/room temperature prepare smoothies with low acid fruits, such as melons, bananas, peaches and add yogurt/milk/tofu limit carbonated beverages avoid alcohol-containing mouthwashes

Question 35

Considerations for: Oral Mucositis and Esophagitis

Answer 35

assess etiology of mucositis and esophagitis: HSCT, chemo, biotherapy, radiation, GVHD evaluate for oral infections evaluate patient's ability to adopt recommended symptom management strategies and meds; work to address impediments to adherence encourage good oral care using soft toothbrush or toothette and woven dental floss advise the patient to keep dentures clean and limit their use if increasing irritation advise avoiding alcohol ingestion and tobacco use recommend lip balm to moisten lips assess food/fluid intake

Question 36

Pharmacotherapy: Oral Mucositis and Esophagitis

Answer 36

amino acids: L-glutamine (may reduce mucositis) Topical anesthetics: gels/rinses containing lidocaine, codeine, or morphine Analgesia: opioids, anti-inflammatory agents topical anti-inflammatory gels: gels with dexamethasone Mucosal barriers and protectants: zinc gluconate and taurine (Gel-X); adherent gel (Gelclair) Soothing Rinse: 3/4 tsp salt, 1 tsp baking soda, 4 cups water. Rinse/gargle with 1 cup of mixture 3-4 times/day anti-infective prophylaxis: rinse, swish, and spit with topical analgesic, anti-inflammatory, and coating agent (viscous lidocaine, diphenhydramine, aluminum hydroxide and magnesium hydroxide suspension----aka Magic Mouth Wash) 3-4 times/day Mucositis may require antiviral prophylaxis medications

Question 37

CTCAE (Severity) Grades and Description: Oral Candidiasis

Answer 37

1 - asymptomatic, local symptomatic management 2 - oral intervention indicated (antifungal) 3 - IV antifungal intervention indicated

Question 38

Considerations for: Oral Candidiasis

Answer 38

assess etiology: onc treatments may reduce blood counts, making patients susceptible to infections; note the timing of infection within treatment cycle, transplant and so on

Question 39

Nutrition and Behavior Interventions for: Oral Candidiasis

Answer 39

practice effective oral hygiene, using saltwater rinses, and avoid mouthwashes that contain alcohol replace/sanitize toothbrushes, oral appliances, and dentures choose soft textured foods, low acid foods and beverages, and avoid carbonation consume active-culture yogurt several times daily

Question 40

Pharmacotherapy for: Oral Candidiasis

Answer 40

polyene antifungal: nystatin/mucostatin Azole antifungal: fluconazole/diflucan gemicidal mouthwash: chlorhexidine gluconate/peridex probiotics: use with caution salt cleansing rinse

Question 41

CTCAE (Severity) Grades and Description: Xerostomia

Answer 41

1 - symptomatic (dry/thick saliva) without significant dietary alteration; unstimulated saliva flow >0.2 ml/min 2 - Moderate symptoms; oral intake alternations (copious water, other lubricants, diet limited to purees and/or soft/moist foods); unstimulated saliva flow 0.1-0.2 ml/min 3 - inability to adequately aliment orally; tube feeding or PN indicated; unstimulated saliva <0.1 ml/min

Question 42

Considerations for: Xerostomia

Answer 42

assess etiology: chemo-induced might be transient; radiation-induced changes to the oral cavity typically occur in the 2nd week of radiation and may be permanent. Encourage good oral hygiene

Question 43

Nutrition and Behavior Interventions for: Xerostomia

Answer 43

small/frequent meals alternate bites/sips at meals add broth/gravies/sauces to meals and moisten dry foods in liquids sip liquids throughout the day; aim for 8-10 c of fluid daily; carry a water bottle swish and spit with club soda or carbonated water use a humidifier at home to moisten the air practice good oral hygiene suck on hard candy, frozen grapes or melon balls avoid mouthwash that contains alcohol avoid alcoholic drinks and tobacco products

Question 44

Pharmacotherapy for: Xerostomia

Answer 44

Mouth conditioners/artificial salivias: biotene, BioXtra, Caphosol, Glandosane, Salivart; Xero-Lube, MouthKote, Xyliments Prophylaxis therapy: amifostine (Ethyol); Pilocarpine (Salagen) Salt cleansing rinse