5.5 Complications of Chemotherapy

Question 1

What are the ways Chemo can be given?

Answer 1

Oral, IV, into cavities (intraperitoneal, intrathecal) or into large blood vessels

Question 2

What are the general acute causes of toxicity from chemo?

Answer 2

Alopecia/hair loss 
Nauseau or vomiting 
Oral toxicity 
Enterotoxicity 
Bone Marrow 
Amennorhoea 
Teratogenesis 
Hypersensitivity reactions 
Dermatological reactions 
Social toxicity

Question 3

What are the acute class specific toxicities?

Answer 3

Nephrotoxicity: MTX 
Neurological complications 
Interstitial pneumonitis: bleomycin 
Cardiac 
Haemorrhage cystitis

Question 4

What are the general late causes of toxicity from chemo?

Answer 4

Infertility 
Early menopause/low androgen levels in men: Osteoporosis, increased CV disease, sexual dysfunction 
Myelosuppression 
Vascular disease 
Neuropathy 
Renal impairment 
Cognitive impairment

Question 5

What are the late class specific toxicities

Answer 5

Second malignancy
Cardiac failure
Pulmonary fibrosis

Question 6

What are the 3 types of chemo induced nausea and vomiting?

Answer 6

Acute emesis (first 24 hours) 
Delayed emesis (>24h post chemo) 
Anticipatory emesis

Question 7

What are the neurotransmitters involved in chemo induced nausea and vomiting?

Answer 7

Dopamine
Serotonin (acute)
Substance P (delayed)

Question 8

What are the anti nausea drugs given for CINV?

Answer 8

Metoclopamide
Dexamethasone
5-HT3 antagonists (ondansatron, palonosetron)
NK-1 receptor antagonists: Aprepitant

Question 9

What is the mechanism of Aprepitant?

Answer 9

Blocks substance P binding to the NK-1 receptor - improves acute and delayed

Question 10

What is the treatment for anticipatory emesis?

Answer 10

achieve initial good control

- Benzodiazepines around time of chemo (Lorazepam, alprazolam)

Question 11

What is the most common oral toxicity from chemo?

Answer 11

Oral mucositis

Question 12

What do you need to exclude in moderate-severe mucositis?

Answer 12

HSV infection

Question 13

What are the gastro toxicities

Answer 13

Diarrhoea
Constipation
Neutropenic enterocolitis
Clostridium difficile-associated colitis

Question 14

What are the anti-diarrhoeal agents?

Answer 14

Loperamide, diphenoxylate

Question 15

What increases in risk with neutropenic fever?

Answer 15

Bacterial sepsis
Invasive fungal infections
Viral infections: HSV, VZV, CMV

Question 16

What is the definition of neutropenic fever?

Answer 16

Neutrophils 38.3 on one occasion, >38 on two 1 hour apart

Question 17

What is important in the assessment of the neutropenic patient?

Answer 17

Establish a source of the infection: damaged oral or gut mucosa, skin breaks, central venous catheter, community acquire pneumonia
Ask about infectious symptoms (cough, sore throat, diarrhoea, urinary symptoms, rash)
Ask about catheter
Any sick contacts

Question 18

What is the examination in neutopenic patient?

Answer 18

Signs of infection 
Examine skin, mucosa and surgical scars 
Catheter 
Examine chest 
Abdo exam looking for tenderness  
Perianal exam (perianal sepsis) 
AVOID DIGITAL RECTAL 
Cardiac to exclude murmur

Question 19

What is the assessment of neutropenic patient that indicates infection?

Answer 19

Temperature

- They do not have the immune system to mount a normal response

Question 20

What is the treatment for neutropenic fever?

Answer 20

Antibiotics - Broad spectrum

Empiric considered when there is a known outbreak of a resistant organism

IV fluid
Oxygen support
Examine twice daily initially
Modify antibiotics according to culture

Question 21

What drug is associated with cardiomyopathy?

Answer 21

Anthracycline - not reversible

Trastuzumab (Herceptin) - reversible