11: Managing Nutrition Side Effects Flashcards
CTCAE (Severity) Grades and Description:
Anorexia and Early Satiety
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
Considerations for:
Anorexia and Early Satiety
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
Nutrition and Behavior Interventions for:
Anorexia and Early Satiety
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
Pharmacotherapy for:
Anorexia and Early Satiety
Antihistamines - Periactin in children
steroids
progestational agents (provera, megace)
prokinetic agents (reglan)
cannabinoids (marinol, syndros, cesamet)
antidepressants (Remeron–off label use)
CTCAE (Severity) Grades and Description:
Taste & Smell Changes
1 - altered taste, no change in diet
2 - altered taste with change – noxious or unpleasant taste; loss of taste
Considerations for:
Taste & Smell Changes
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
Nutrition and Behavior Interventions for:
Taste & Smell Changes
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
Pharmacotherapy for:
Taste & Smell Changes
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
CTCAE (Severity) Grades and Description:
Constipation
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
Considerations for:
Constipation
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
Nutrition and Behavior Interventions for:
Constipation
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
Pharmacotherapy for:
Constipation
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
CTCAE (Severity) Grades and Description:
Diarrhea
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
Considerations for:
Diarrhea
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
Nutrition and Behavior Interventions for:
Diarrhea
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
Pharmacotherapy for:
Diarrhea
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)
CTCAE (Severity) Grades and Description:
Dysphagia
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
Considerations for:
Dysphagia
assess etiology of it
review swallow study and SLP recs
assess food/fluid intake
Nutrition and Behavior Interventions for:
Dysphagia
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
Pharmacotherapy for:
Dysphagia
Topical anesthetics–lidocaine spray/Xylocaine
Analgesia–opioids
Thickeners–simply thick gel, thicken right, thicken up, thick & easy, thick it
CTCAE (Severity) Grades and Description:
Fatigue
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
Considerations for:
Fatigue
evaluate for anemia, hydration status, unintentional wt loss and sarcopenia
consider appropriateness of MVI or mineral supplement
assess actual food/fluid intake
Nutrition and Behavior Interventions for:
Fatigue
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
Pharmacotherapy for:
Fatigue
blood transfusions
erythropoietin given as epoetin alfa (epogen, procrit)
CTCAE (Severity) Grades and Description:
Malabsorption
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)
Considerations for:
Malabsorption
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
Nutrition and Behavior Interventions for:
Malabsorption
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
Pharmacotherapy for:
Malabsorption
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
CTCAE (Severity) Grades and Description:
Nausea/Vomiting
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
Considerations for:
Nausea/Vomiting
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
Pharmacotherapy:
Nausea/Vomiting
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
Nutrition and Behavior Interventions for:
Nausea/Vomiting
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
CTCAE (Severity) Grades and Description:
Oral Mucositis and Esophagitis
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
Nutrition and Behavior Interventions for:
Oral Mucositis and Esophagitis
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
Considerations for:
Oral Mucositis and Esophagitis
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
Pharmacotherapy:
Oral Mucositis and Esophagitis
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
CTCAE (Severity) Grades and Description:
Oral Candidiasis
1 - asymptomatic, local symptomatic management
2 - oral intervention indicated (antifungal)
3 - IV antifungal intervention indicated
Considerations for:
Oral Candidiasis
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
Nutrition and Behavior Interventions for:
Oral Candidiasis
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
Pharmacotherapy for:
Oral Candidiasis
polyene antifungal: nystatin/mucostatin
Azole antifungal: fluconazole/diflucan
gemicidal mouthwash: chlorhexidine gluconate/peridex
probiotics: use with caution
salt cleansing rinse
CTCAE (Severity) Grades and Description:
Xerostomia
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
Considerations for:
Xerostomia
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
Nutrition and Behavior Interventions for:
Xerostomia
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
Pharmacotherapy for:
Xerostomia
Mouth conditioners/artificial salivias: biotene, BioXtra, Caphosol, Glandosane, Salivart; Xero-Lube, MouthKote, Xyliments
Prophylaxis therapy: amifostine (Ethyol); Pilocarpine (Salagen)
Salt cleansing rinse
