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Pamela - Naplex 2023 > Chapter 61 - Oncology 1 > Flashcards

Chapter 61 - Oncology 1 Flashcards

1
Q

Carcinoma

A

Cancer that starts in skin or in the tissues that line or cover internal organs.

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2
Q

Leukemia

A

Cancer of the leukocytes (WBCs); leukemia is referred to as blood cancer.

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3
Q

Lymphoma

A

Cancer of the lymphatic system.

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4
Q

Multiple Myeloma

A

A type of bone marrow cancer.

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5
Q

Sarcoma

A

Cancer in connective tissue (tissue that connects, supports, binds or separates other tissues), including fat, muscle, blood vessels and bone. Osteosarcoma is a type of bone cancer.

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6
Q

Skin Cancers:
Basal Cell & Squamous Cell Carcinomas and Melanoma

A

Basal Cell and Squamous Cell Carcinoma: common, unlikely to metastasize, rather simple to remove surgically or with topical treatment.

Melanoma: skin cancer that forms in the melanocytes [the skin cells that produce the pigment (melanin) that colors skin]. Least prevalent type of skin cancer (2%), but most deadly.

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7
Q

Breast Cancer Screening

A

40-44 years –> Annual mammograms are optional

45 - 54 years –> Begin yearly mammograms

> =55 years –> Mammograms every 2 years or continue yearly

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8
Q

Cervical Cancer Screening

A

21-29 years –> Pap smear every 3 years
30-65 years –> Papsmear+ HPV (Human papillomavirus) DNA test every 5 years

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9
Q

Colon Cancer Screening

A

> = 45 years (M/F)

Stool-based tests (if positive, follow with a colonoscopy)
■ Highly sensitive fecal immunochemical test (FIT) every year Highly sensitive guaiac-based fecal occult blood test (gFOBT) every year
■ Multi-targeted stool DNA test (MT-sDNA) every 3 years

Visual exams of the colon and rectum:
■ Colonoscopyevery10years
■ CT colonography (virtual colonoscopy) every 5 years
■ Flexible sigmoidoscopy (FSIG)every 5 years

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10
Q

Lung Cancer Screening

A

55 - 74 years

Annual CT scanof chest if all of the following:
■ In good health
■ Have at least a 30 pack-year smoking history
■ Still smoking or quit smoking within the past 15 years

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11
Q

Prostate Cancer Screening

A

> = 50
If a patient chooses to be tested, it involves:
■ Prostate specific antigen (PSA) test (blood test)
■ +/- a digital rectal exam (DRE)

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12
Q

amifostine (ethyol) is given …

A

with cisplatin to prophylactically reduce risk of nephrotoxicity

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13
Q

dexrazoxane is given …

A

with doxorubicin to prophylactically reduce risk of cardiomyopathy

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14
Q

Chemotherapy drugs is CI in

A

Pregnancy and breastfeeding
use a form of contraception

Male and female patients must avoid conceiving during treatment.

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15
Q

Bleomycin Max dose

A

Lifetime cumulative dose: 400 units
Reason: Pulmonary fibrosis

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16
Q

Doxorubicin Max dose

A

Lifetime cumulative dose: 450 - 550 units/m2 (BSA)
Reason: Cariotoxicity

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17
Q

Cisplatin Max dose

A

Dose per cycle not to exceed 100 mg/m’
Reason: Nephrotoxicity

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18
Q

Vincristine Max dose

A

Single dose “capped” at 2 mg
Reason: Neuropathy

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19
Q

drugs that cause: Myelosuppression

A

Almost all classic chemotherapy drugs, except:
Asearaginase, bleomycin, vincristine, most monoclonal antibodies (MAbs) and many tyrosine kinase inhibitors (TKls)

Monitoring: Complete blood count (CBC) with differential, temperature, bleeding, fatigue, shortness of breath

Management:
Neutropenia: colony-stimulating factors (CSFs)
Anemia: RBC transfusions, and (in palliation only) erythropoiesis-stimulating agents (ESAs)
Thrombocytopenia: platelet transfusions (when very low, especially if bleeding)

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20
Q

Drugs that cause: Nausea & Vomiting

A

Cisplatin, cyclophosphamide, ifosfamide, doxorubicin, epirubicin

Monitoring: Patient symptoms of nausea and vomiting and dehydration

Management:
Neurokinin-1 receptor antagonist (NK1-RA),
Serotonin-3 receetor antagonist (5HT3-RA),
dexamethasone, metoclopramide, prochlorperazine
IV/PO fluid hydration

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21
Q

Drugs that cause: Mucositis

A

Fluorouracil, methotrexate, capecitabine, irinotecan and many TKls (afatinib, ponatinib, sorafenib, sunitinib)

Monitoring: S/sx of superinfection of oral ulcers with herpes simplex virus or thrush (Candida species)

Management:
Symetomatic treatment: mucosal coating agents,
topical local anesthetics (e.g., lidocaine viscous), antifungals, antivirals

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22
Q

Drugs that cause: Diarrhea

A

Fluorouracil, methotrexate, capecitabine, lrinotecan and many TKls

Monitoring: Frequency of bowel movements, hydration status, potassium and other electrolytes

Management:
IV/PO fluid hydration, antimotility medications (e.g.,loperamide)
lrinotecan: atropine for early-onset diarrhea

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23
Q

Drugs that cause: Diarrhea

A

Vincristine, pomalidomide, thalidomide

Monitoring:
Frequency of bowel movements

Management:
Stimulant laxatives, polyethylene glycol (PEG3350, Miralax)

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24
Q

Treatment that causes: Xerostomia

A

Caused by radiation therapy to the head or neck regions

Monitoring:
Dry mouth

Management:
Artificial saliva substitutes, pilocarpine, amifostine

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25
Q

Drugs that cause: Cardiotoxicity

A
  • CARDIOMYOPATHY
    Anthracyclines, HER2 inhibitors (ado- trastuzumab, trastuzumab, pertuzumab, lapatinib), fluorouracil

Monitoring:
Left ventricular ejection fraction (LVEF),lifetime cumulative dose of anthracycline

Management:
Do not exceed recommended lifetime cumulative dose of 450-550 mg/m 2 for doxorubicin; give dexrazoxane prophylactically in select patients receiving doxorubicin

  • QT PROLONGATION
    Arsenic trioxide, many TKls (dasatinib, nilotinib, vemurafenib, dabrafenib, trametinib, crizotinib, ceritinib, erlotinib, gefitinib, lapatinib, sorafenib, sunitinib) and leuprolide

Monitoring: ECG, K, Mg, Ca

Management:
Keep K, Mg, Ca within normal limits, consider holding therapy if QTc > 500 msec

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26
Q

Drugs that cause: Pulmonary Toxicity (pulmonary fibrosis or pneumonitis)

A
  • Pulmonary fibrosis
    Bleomycin, busulfan, carmustine, lomustine
  • Pneumonitis
    Methotrexate
    immune therapy MAbs targeting CTLA- 4 or PD-1: atezolizumab, durvalumab,
    ipilimumab, nivolumab, pembrolizumab

Monitoring:
- Oxygen saturation, ABGs, symptoms (shortness of breath, dyspnea on exertion)
- Maximum lifetime dose of bleomycin 400 units

Management:
- Symptomatic management
- Stop therapy
- Steroids (if an autoimmune mechanism is suspected) for immunotherapy agents

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27
Q

Drugs that cause: Hepatotoxicity

A

Antiandrogens (bicalutamide, flutamide, nilutamide), folate antimetabolites {methotrexate, pemetrexed, pralatrexate), pyrimidine analogantimetabolites {cytarabine, gemcitabine), many tyrosine kinase inhibitors, ipilimumab, pembrolizumab, nivolumab, atezolizumab, durvalumab

Monitoring:
LFTs, jaundice, ascites

Management:
- Symptomatic management
- Consider stopping therapy
- Steroids (if an autoimmune mechanism is suspected) for immunotherapy agents (e.g., for CTLA·4 or PD· 1
- immune therapy MAbs - atezolizumab, durvalumab, ipilimumab, nivolumab and pembrolizumab)

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28
Q

Drugs that cause: Nephrotoxicity

A
  • Cisplatin
  • Methotrexate (high doses), pemetrexed, pralatrexate, carfilzomib, bevacizumab, nivolumab, pembrolizumab, ipilimumab, atezolizumab, durvalumab

Monitoring
BUN, SCr, urinalysis, urine output, creatinine clearance

Management
Amifostine (Ethyol) can be given prophylactically with cisplatin to reduce the risk of nephrotoxicity
Ensure adequate hydration
Do not exceed maximum dose of 100 mg/m’/cycle for cisplatin

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29
Q

Drugs that cause: Hemorrhagic cystitis

A

lfosfamide (all doses),cyclophosphamide (higher doses, e.g., > 1 gram/m’)

Monitoring:
Urinalysis for blood, symptoms of dysuria

Mesna (Mesnex) is always given prophylactically with ifosfamide (and sometimes with cyclophosphamide) to reduce the risk of hemorrhagic cystitis
Always ensure adequate hydration

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30
Q

Drugs that cause: Neuropathy

A
  • Peripheral Neuropathy
    Vinca alkaloids {vincristine, vinblastine, vinorelbine)
    Platinums (cisplatin, oxaliplatin)
    Taxanes{paclitaxel, docetaxel, cabazitaxel)
    Proteasome inhibitors (bortezomib, carfilzomib), thalidomide, ado·trastuzumab, cytarabine (high doses), brentuximab

Monitoring:
S/sx of paresthesias (pain, tingling, numbness)

  • Autonomic Neuropathy
    Vinca alkaloids

Monitoring:
- Constipation
- Symptomatic treatment with drugs for neuropathic pain

  • Vincristine
    Many recommend limiting the dose of vincristine to 2 mg per week (regardless of BSA calculated dose)

-Oxaliplatin
Causes an acute cold-mediated sensory neuropathy; instruct patients to avoid cold temperatures and avoid drinking cold beverages

-Bortezomib
SC administration is associated with less peripheral neuropathy than IV administration

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31
Q

Drugs that cause: Thromboembolic risk (clotting)

A

Aromatase inhibitors (e.g.,anastrozole, letrozole), SERMs (e.g.,tamoxifen, raloxifene), immunomodulators (thalidomide, lenalidomide, pomalidomide)

Monitoring:
S/sx of DVT/PE, stroke, Ml

Management:
Consider thromboprophylaxis risk factors based on the patient’s risk factors

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32
Q

CHEMOTHERAPY ADJUNCTIVE TREATMENT- cisplatin

A

Amifostine (Ethyol) and hydration

Prophylaxis to prevent nephrotoxicity

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33
Q

CHEMOTHERAPY ADJUNCTIVE TREATMENT - Doxorubicin

A

Dexrazoxane (Zinecard,Totect)

Prophylaxis to prevent cardiomyopathy

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34
Q

CHEMOTHERAPY ADJUNCTIVE TREATMENT - Fluorouracil

A

Leucovorin or levoleucovorin (Fusilev)

Given with fluorouracil to enhance efficacy (as a cofactor)

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35
Q

CHEMOTHERAPY ADJUNCTIVE TREATMENT - Fluorouracil or capecitabine

A

Uridine triacetate (Vistogard)

Antidote: use within 96 hours for an overdose or to treat severe, life-threatening or early-onset toxicity

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36
Q

CHEMOTHERAPY ADJUNCTIVE TREATMENT - lfosfamide

A

Mesna /Mesnex) Hydration

Prophylaxis to prevent hemorrhagic cystitis

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37
Q

CHEMOTHERAPY ADJUNCTIVE TREATMENT- Irinotecan

A

Atropine
Prevent or treat acute diarrhea

Loperamide
Treat delayed diarrhea

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38
Q

CHEMOTHERAPY ADJUNCTIVE TREATMENT - Methotrexate

A

Leucovorin or levoleucovorin (Fusilev)
Given prophylactically after methotrexate to dec myelosuppression and mucositis in high-dose therapy

Glucarpidase (Voraxaze)
An antidote to dec excessive methotrexate levels due to acute renal failure

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39
Q

capecitabine is a …

A

prodrug of 5 fu developed to mimic the continuous infusion of 5fu while avoiding complications of iv administration

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40
Q

what is Myelosuppression

A

Myelosuppression (dec in bone marrow activity, resulting in fewer (RBCs, WBCs and platelets) is a complication of most chemotherapy regimens

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41
Q

Epoetin alfa

A

Epogen,Procrit

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42
Q

Darbepoetin alfa

A

Aranesp

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43
Q

Filgrastim

A

Neupogen
Nivestym, Zarxio

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44
Q

Pegfilgrastim

A

Neulasta

only used as prophylactic

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45
Q

WBC nadir

A

The lowest point that WBCs and platelets reach is called the nadir, which occurs {with most drugs} about 7 - 14 days after chemotherapy.

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46
Q

RBC nadir

A

The RBC nadir is much later, generally after several months of treatment, due to the long life span of RBCs (-120 days).

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47
Q

trilaciclib (Cosela)

A

In early 2021, the kinase-inhibitor trilaciclib (Cosela) was approved to decrease myelosuppression from extensive-stage small cell lung cancer treatment.

It is given as an IV infusion within four hours prior to the start of platinum/etoposide or topotecan- containing chemotherapy regimens.

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48
Q

Neutropenia

A

Neutropenia, a type of leukopenia, is a low neutrophil count that is assessed by calculating an absolute neutrophil count {ANC).
The more significant the neutropenia (i.e., the lower the ANC), the higher the risk of infection.

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49
Q

ANC calculation

A

ANC cells/mm3 = WBC x (% segs + % bands)/100

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50
Q

Neutropenia anc

A

< 1,000 cells/mm’

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51
Q

Severe Neutropenia anc

A

< 500 cells/mm’

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52
Q

Profound Neutropenia anc

A

< 100 cells/mm3

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53
Q

Growth Colony Stimulating Factors

A

(G-CSFs,or simply CSFsor “myeloid growth factors”) stimulate the production of WBCs in the bone marrow.
Myeloid refers to the granulocyte precursor cell, which differentiates into neutrophils, eosinophils and basophils.

CSFs are given prophylactically after chemotherapy to shorten the time that a patient is at risk for infection due to neutropenia and reduce mortality from infections.

They are used to prevent {or reduce) neutropenia, not for acute treatment.

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54
Q

do not give filgrastim is ANC is

A

> 10, 000 cells/mm3

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55
Q

filgrastim dosing

A

5 mcg/kg/day given IV/SC daily (round to the nearest 300 mcg or 480 mcg vial size); treat through post-nadir recovery (until ANC >2,000-3,000 cells/mm3)
10 mcg/kg/day used for bone marrow transplant

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56
Q

Pegfilgrastim dosing

A

1 prefilled syringe (6 mg) SC once
per chemo cycle (pegfilgrastim is pegylated, extending the half-life)

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57
Q

Sargramostim dosing

A

250 mcg/m/day given IV/SC daily; treat through post-nadir recovery

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58
Q

Sargramostim brand

A

Leukine

Limited to use in stem cell transplantation

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59
Q

tbo-filgrastim brand

A

Granix
biosimilar to filgrastim

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60
Q

Biosimilars to peg-filgrastim

A
  • apgf (Nyvepria)
  • bmez (Ziextenzo)
  • cbqv (Udenyca)
  • jmdb (Fulphila)
61
Q

se of Filgrastim/ pegfilgrastim/ tbo-filgrastim:

A

bone pain, fever, glomerulonephritis, generalized rash, injection site reaction

62
Q

se of Sargramostim

A

fever, bone pain, arthralgias, myalgias, rash, dyspnea, peripheral
edema, pericardia! effusion, HTN, chest pain

63
Q

monitoring with csf

A

CBC with differential, pulmonary function, weight, vital signs

64
Q

1) how should you store csf

2) when should you administer?

3) what should patients report as SE

4) when should pegfilgrastim be given

A

1) Store in refrigerator; protect vials from light

2) Administer first dose no sooner than 24 hours after chemo; can be up to
96 hours after chemo

3) Patients should report any signs of enlarged spleen (pain in left upper abdomen ~ or respiratory distress syndrome)

4) Pegfilgrastim: must document when given; should have at least 12 days to the next chemo cycle

65
Q

1) when do you start emperic abx?

A

Infection can be difficult to diagnose; fever may be the only sign of infection in a neutropenic patient (i.e., the increase in WBC count will not be present).

Empiric antibiotics are started immediately if a fever occurs.

66
Q

Neutropenia Diagnosis Requirements

A

fever:
Oral temperature > 38.3°C (101°F) x 1 reading, or
Oral temperature > 38.0°C (100.4°F) sustained for > 1 hour

Neutropenia:
Absolute neutrophil count (ANC<) 500 cells/mm3, or
ANC that is expected to dec to < 500 cells/mm3 during the next 48 hours

67
Q

low risk of infection

A

Expected ANC< 500 cells/mm3 for <= 7 days
No comorbidities

Initial empiric abx: Oral anti-pseudomonal antibiotics
- Oral anti-pseudomonal antibiotics
Ciprofloxacin or levofloxacin PLUS
- Amoxicillin/clavulanate (G+) or clindamycin (G+ & anaerobic) (if allergic to penicillin)

68
Q

high risk of infection

A

Expected ANC <= 100 cells/mm’ for > 7 days
&/or
Presence of comorbidities
&/or
Evidence of renal or hepatic impairment (CrCl< 30 ml/minor LFTs > 5x ULN)

Initial empiric abx: Intravenous anti-pseudomonal beta-lactams
- Cefepime or
- Ceftazidime or
- Meropenem or
- lmipenem/cilastatin or
- Piperacillin/tazobacta

69
Q

What levels are used to assess anemia.

What are the normal levels

A

Hemoglobin

Normal Hgb levels are 12 - 16 g/dL for females and 13.5 - 18 g/dL for males {hematocrit is 36 - 46% females; 38 - 50% males).

70
Q

What are the 3 ways for resolution of anemia (ttmt)

A
  • without treatment
  • RBC transfusion
  • erythropoiesis-stimulating agent (ESA)
71
Q

ESA types

ESA risks

When should you use ESA

A

ESAs include:
- epoetin alfa (Epoqen, Procrit),
- epoetin alfa-epbx (Retacrit) and
- the longer-acting darbepoetin alfa (Aranesp).

ESAs can shorten survival and inc tumor progression (i.e., they can contribute to cancer growth).

Therefore, ESAs are for palliation and are not recommended to be used in patients receiving chemotherapy with curative intent.

72
Q

What criteria should be met to minimize the risks of ESAs in patients with chemotherapy-induced anemia

A

■ Use ESAs only in patients with non-myeloid malignancies where anemia is due to the effect of the chemotherapy.

■ Upon initiation of ESA therapy, there must be a minimum of two additional months of planned chemotherapy.

■ Initiate ESAs only when the Hgb is < 10g/dL.

■ Use the lowest dose needed to avoid RBCtransfusions.

73
Q

…, … and … must be assessed since ESAs will not work well to correct the anemia if iron levels are inadequate.

Levels of … and … may need to be evaluated, especially if there is a poor response to the ESA

A

Serum ferritin, transferrin saturation (TSAT) and total iron-binding capacity (TIBC) must be assessed since ESAs will not work well to correct the anemia if iron levels are inadequate.

Levels of folate and vitamin Bl2 may need to be evaluated, especially if there is a poor response to the ESA

74
Q

The normal range for platelets is …

A

150,000 - 450,000/mm3

75
Q

The risk for spontaneous bleeding is increased when the platelet count is < …

A

10,000 cells/mm3

76
Q

Platelet transfusions are generally indicated when:

A
  • the count falls below 10,000 cells/mm3
  • or< 30,000 cells/mm 3 if active bleeding is present
77
Q

What should you avoid in patients who are thrombocytopenic.

A

Intramuscular injections and medications that affect platelet functioning, such as NSAIDs

78
Q

Patient factors that increase the risk of nausea and vomiting include:

A
  • female gender,
  • age < 5O years,
  • anxiety, depression,
  • dehydration,
  • history of motion sickness
  • history of nausea and vomiting with prior regimens
79
Q

Acute CINV
1) Onset
2) Risk factors
3) Major neurotransmitters
4) Drug therapy

A

1) Within 24 hours after chemo

2) Female gender, age < 5O years, anxiety, depression, dehydration, history of motion sickness and history of nausea and vomiting with prior regimens.

3) Serotonin and Substance P

4) 5HT3 receptor antagonists (5HT3-RA). NK1 receptor antagonists (NK1-RA), dexamethasone and olanzapine

80
Q

Delayed CINV
1) Onset
2) Risk factors
3) Major neurotransmitters
4) Drug therapy

A

1) > 24 hours after chemo

2) Anthracyclines, platinum analogs, cyclophosphamide, ifosfamide, any chemo regimens with a high risk for causing acute Cl NV

3) Substance P and Dopamine

4) NK1-RA, corticosteroids, palonosetron or granisetron ER SC (only 5HT3·RAs with a labeled indication for delayed emesis) and olanzapine

81
Q

Anticipatory CINV
1) Onset
2) Risk factors
3) Major neurotransmitters
4) Drug therapy

A

1) Before chemo

2) History of CINV with previous chemo regimen

3) GammaAminobutyric Acid (GABA)

4) Benzodiazepines; start the evening prior to chemotherapy to alleviate anxiety and N/V

82
Q

What 5HT3-RA are FDA approved for delayed CINV

A
  • Palonosetron
  • Sustol (granisetron) SC
83
Q

5-HT3 RA

A
  • Ondansetron
  • Granisetron
  • Dolasetron
  • Palonosetron
84
Q

NK1 RA

A
  • Aprepitant PO
  • Fosaprepitant IV
  • Rolapitant
85
Q

1) combination: 5ht3ra & NK1RA

2) Others

3) Dexamethasone

A

1) Akynzeo
- Netupitant/palonosetron PO
- Fosnetupitant/palonosetron IV

2) Olanzapine

3) Dexamethasone

86
Q

High emetic risk chemotherapy regimen

A

3 or 4 drugs:

■ NKl-RA + 5HT3-RA + Olanzapine + Dexamethasone (preferred)
- Olanzapine +
- netupitant or fosnetupitant/ palonosetron (Akynzeo) +
- dexamethasone

■ Palonosetron + Olanzapine + Dexamethasone

■ NKl-RA + 5HT3-RA + Dexamethasone
- Netupitant or fosnetupitant/ palonosetron (Akynzeo) + dexamethasone

Can add lorazepam PRN, H2RA or PPI

87
Q

Moderate emetic risk chemotherapy regimen

A

2 or 3 drugs

■ NKl-RA+ 5HT3-RA+ Dexamethasone
- Netupitant or fosnetupitant/palonosetron

■ 5HT3-RA + Dexamethasone

■ Palonosetron + Olanzapine + Dexamethasone

Can add lorazepam PRN, H2RA or PPI

88
Q

Low emetic risk chemotherapy regimen

A

1 drug (any except NK1-RA)

■ 5HT3-RA (olasetron, granisetron ar ondansetron)
■ Dexamethasone
■ Prochlorperazine
■ Metoclopramide

89
Q

What Antiemetics can u give for Breakthrough CINV

A
  • 5HT3-RAs
  • dopamine receptor antagonists
  • cannabinoids
  • olanzapine
  • lorazepam
  • dexamethasone
  • scopolamine
90
Q

most common SE of 5HT3-RA

A
  • Usually well-tolerated by most patients
  • Migraine-like headaches
  • Constipation being common side effects.
  • Minimal sedation compared to dopamine receptor antagonists and cannabinoids.
91
Q

1) What drugs are dopamine receptor antagonists

2) SE

3) how can you treat the SE

A

1) Prochlorperazine, promethazine and metoclopramide

2) Pts might experience
- Sedation
- some anticholinergic side effects
- Extrapyramidal symptoms (EPS) such as acute dystonic reactions can occur, especially in younger patients.

3) Acute dystonic reactions should be treated with anticholinergics (benztropine, diphenhydramine).

92
Q

1) what is droperidol

2) why is it not used much? main SE?

3) where do we commonly use it?

A
  • Droperidol is an antiemetic in the same class as haloperidol (i.e., butyrophenones).
  • Droperidol has restricted use (or has been removed entirely) in most hospitals due to QT-prolongation and the risk of Torsades de Pointes.
  • Droperidol used to be commonly used for postoperative nausea and vomiting (not for CINV).
93
Q

MOA of Substance P/Neurokinin-1 Receptor Antagonist:

A

inhibit the substance P/neurokinin 1 receptor, therefore augmenting the antiemetic activity of 5HT3 receptor antagonists and corticosteroids to inhibit acute and delayed phases of chemotherapy-induced emesis

94
Q

Aprepitant brand names

dosage forms?

A
  • Emend PO
  • EmendTri-Pack
  • Cinvanti (Injection)

Capsule, injection (Cinvanti), suspension

95
Q

Aprepitant dosing regimen?

A

PO: 125 mg 1 hour before chemo on day 1, then 80 mg daily x 2 days

96
Q

Fosaprepitant Band names

dosage forms?

A

Emend IV

97
Q

Fosaprepitant dosing regimen

A

IV: 150 mg 30 minutes before chemo

98
Q

Akynzeo active ingredient (PO/IV?)

dosing regimen?

A

Netupitant + palonosetron (PO)
PO: 300/0.5 mg 1 hour before chemo

Fosnetupitant + palonosetron (IV)
IV: 235/0.25 mg 1 hour before chemo

99
Q

Rolapitant brand name?

dosage form?

dosing regimen?

A

Varubi

Tablet, injection

PO: 180 mg 1-2 hours before chemo

100
Q

contraindications:
- Aprepitant/fosaprepitant

  • Rolapitant
A
  • Aprepitant/fosaprepitant:
    do not use with pimozide or cisapride (CYP3A4 substrates)
  • Rolapitant:
    do not use with thioridazine or pimozide (CYP2D6 substrates)
101
Q

se of nk1ra

A
  • Dizziness,
  • fatigue,
  • constipation,
  • weakness,
  • hiccups
  • Fosaprepitant: infusion site reactions
102
Q

what should you do to dexamethasone dose when used concurrently with
- Aprepitant/fosaprepitant/netupitant
- Rolapitant

A

Aprepitant/fosaprepitant/netupitant
decrease dexamethasone dose (CYP3A4 substrate) when used concurrently as an antiemetic

Rolapitant is a CYP2D6 inhibitor; dose of dexamethasone should not be decreased when used concurrently as an antiemetic

103
Q

moa of 5HT-3 Receptor Antagonists

A
  • Work by blocking serotonin, both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone.
  • All may be given once prior to chemotherapy on day 1, with the exception of the granisetron transdermal)
    patch which is started prior to day 1 of chemotherapy.
104
Q

Ondansetron

brand names

Doses

A
  • Zofran
  • Zuplenz film

PO: 8 - 24 mg
IV: 8 - 16 mg

105
Q

Granisetron

brand names

Doses

A
  • Sancuso
  • Sustol
  • PO: 1-2 mg
  • IV: 10 mcg/kg or 1 mg
  • SC (Sustol): 10 mg over 20-30 seconds
  • Patch (Sancuso):.3.1 mg/24 hour, apply 24-48 hours before chemo; may leave in place up to 7 days
106
Q

Palonosetron brand?
+ netupitant (brand?)
+ fosnetupitant (brand?)

dose?

A

Palonosetron (Aloxi)
+ netupitant (Akynzeo)
+ fosnetupitant (Akynzeo)

  • IV (Aloxi): 0.25 mg
  • PO (Akynzeo): 0.5/300 mg 1 hour before chemo
  • IV (Akynzeo): 0.25/235 mg 1hour before chemo

Palonosetron PO only available in combination with netupitant (Akynzeo)

107
Q

Dolasetron brand?

dose?

A

Anzemet

PO: 100 mg
IV: Not indicated for CINV due to i risk for QT prolongation

108
Q

can a pt take apomorphine with any 5ht3 antagonist? why?

A

Contraindication: Do not use with apomorphine (Apokyn) due to severe hypotension and loss of consciousness.

109
Q

3 warnings with 5ht3 antagonists:

A

1) Dose-dependent inc in QT interval (Torsades de Pointes) - more common with IV

2) Serotonin syndrome when used in combination with other serotonergic agents

3) Constipation, progressive ileus and gastric distension (Sustol)

110
Q

side effects with 5ht3 antagonists

A

1) Headache,
2) constipation,
3) fatigue,
4) dizziness,
5) injection site reactions (Sustol)

111
Q

Of the 5HT-3RAs, only … and … have FDA-approval for delayed CINV

A

palonosetron
Sustol

112
Q

Dexamethasone
1) Brand?
2) doses: high/ mod/ low risk

A

(Decadron)

  • All off-label dosing
  • High risk: 12 mg PO/IV on day 1 of chemo, then 8 mg PO daily days 2-4
  • Moderate risk: 12 mg PO/IV on day 1 of chemo, then 8 mg PO/IV days 2-3
  • Low risk: 8-12 mg PO/IV on day/s of chemo
113
Q

CI with CS

A
  • Systemic fungal infections,
  • Cerebral malaria
114
Q

SE with CS

A

Short-term side effects include
- Inc appetite/weight gain
- Fluid retention,
- Emotional instability (euphoria, mood swings, irritability, acute psychosis),
- Insomnia,
- GI upset

  • Higher doses inc BP and blood glucose (especially in patients with diabetes)
  • CS can inc the risk of osteoporosis and bone loss
115
Q

MOA of Dopamine Receptor Antagonists

A

work by blocking dopamine receptors in the CNS, including the chemoreceptor trigger zone.

116
Q

Prochlorperazine
1) brand?
2) dose?
3) Boxed warning?

A

1) Compazine, Compro

2)
- 10 mg IV/PO Q6H PRN
- May give 25 mg suppository PRQ12H PRN

3) BBW: inc mortality in elderly patients with dementia- related psychosis.

117
Q

Promethazine
1) brand?
2) dose?
3) Boxed warning?

A

1) Phenergan, Promethegan

2) 12.5-25 mg PO/IM/IV/PR Q4-6H PRN

3)
- Do not use in children < 2 years of age (risk of respiratory depression).
- Do not give via intra-arterial or SC administration.
- IV route can cause serious tissue injury if extravasation occurs.
- Deep IM injection is preferred.

118
Q

Metoclopramide
1) brand?
2) dosage forms?
3) dose?
4) Boxed warning?

A

1) Reglan

2) Tablet, ODT, injection
Gimoti nasal spray- diabetic gastroparesis

3) Doses:
- 10-20 mg PO/IV Q4-6H PRN
- highly emetic regimens: 0.5-2 mg/kg/dose PO/IV Q6H PRN
- CrCI < 40 ml/min: give 50% of the dose

4) BBW:
- Tardive dyskinesia (TD) that can be irreversible.
- Discontinue metoclopramide if signs or sx of TD.
- Inc risk of developing TD with inc duration of treatment & total cumulative dose.
- Avoid treatment with metoclopramide for > 12 weeks.
- dec dose with renal impairment.

119
Q

Olanzapine
1) brand
2) dosage form
3) moa
4) dose
5) SE

A

1) Zyprexa

2) Tablet, ODT, injection

3) Works through several mechanisms (e.g..dopamine, 5HT, histamine)

4) 10 mg PO on the day of chemo, and on days 2-4
5mg PO Q4H PRN, max of 20 mg/day

5) Mild (sedation, orthostasis…) when used for CINV

120
Q

Droperidol
1) Dosage form
2) indication
3) BBW

A

1) Injection
2) Indicated only for post-operative N/V, NOT FOR CINV

3) BBW
- QT prolongation and serious arrhythmias.
- All patients should have a 12-lead ECG prior to receiving droperidol and continue for 2-3 hours after completing treatment.
- Contraindicated if baseline QT is prolonged.

121
Q

SE of dopamine antagonists

A
  • Symptoms of Parkinson disease may be exacerbated. Avoid use in patients with Parkinson disease
  • Sedation, lethargy, hypotension
  • Acute EPS (common in children
    –> Antidote: diphenhydramine or benztropine
  • Can dec seizure threshold
  • Neuroleptic malignant syndrome (NMS)
  • QT prolongation
  • Strong anticholinergic side effects (e.g.,constipation) except with metoclopramide (diarrhea).
122
Q

Cannabinoids
1) MOA
2) SE

A

1) May work by activating cannabinoid receptors within the central nervous system and/or by inhibiting the vomiting control mechanism in the medulla oblongata.

2) Somnolence, euphoria, inc appetite, orthostatic hypotension, dysphoria, lowering of the seizure threshold, use with caution in patients with histories of substance abuse or psychiatric disorders.

3) Note: Solution contains 50% alcohol.

123
Q

Dronabinol
1) brand
2) class
3) refrigerate or no need?
4) labeled dose?

A

1) Marinol, Syndros

2) Capsules: C-III
Solution: C-II

3) Refrigerate

4) Labeled dosing: 5mg/m2 PO prior to chemo and Q2-4H after chemo for up to 6 doses/day.
Most patients respond to 5 mg 3-4 times/day.

124
Q

Nabilone
1) brand
2) class
3) refrigerate or no need?
4) labeled dose?

A

1) Cesamet
2) C-11
3) No refrigeration needed
4) 1-2 mg PO BID, continue for up to 48H after last chemo dose

125
Q

Benzodiazepines
1) MOA

A

Enhance GABA (an inhibitory neurotransmitter) to decrease neuronal excitability, which results in alleviation of anxiety and suppression of anticipatory nausea and vomiting.

126
Q

Lorazepam
brand
controlled class
dose

A

Ativan
C-IV

0.5-2 mg PO or IV Q6H PRN
Start the evening prior to
chemotherapy

127
Q

Chemotherapy-induced diarrhea treatment

A

Antimotility agents:
loperamide and diphenoxylate + atropine,

maximum dose of loperamide is 16 mg/day when treating CID

128
Q

Agents that commonly cause CID that occurs several
days after chemotherapy.

A

Fluorouracil, capecitabine and irinotecan
Many TKis, especially those targeting VEGF or EGF (sorafenib and sunitinib)

129
Q

The risk of diarrhea is increased when … is used
in combination with … or when used in patients
with dihydropyrimidine dehydrogenase (DPD) deficiencies (not common).

A

fluorouracil (or the prodrug capecitabine)
leucovorin

130
Q

… causes early-onset diarrhea that occurs during the infusion of the drug and is often accompanied by symptoms of cholinergic … such as ….

A

Irinotecan
excess
abdominal cramping, rhinitis, lacrimation and salivation.

131
Q

Treatment for cholinergic excess is the anticholinergic drug …

A

atropine

132
Q

chemo drugs that can cause mucositis

A

5-fu, methotrexate

133
Q

is oral mucositis self limiting?

A

it could be, but sometimes it requires treatment

134
Q

treatment of oral mucositis

A

viscous lidocaine 2%
magic mouthwash
systemic analgesic

frequent rinsing with NaCl solution (salt water) to retain the moisture

oral mucositis increases the risk of candida infection –> treatment:
nystatin oral suspension
clomitrazole troches

135
Q

how do you administer (Dose) Lidocaine Viscous

BBW?
warning?
SE?
Notes to pt?

A

2% topical solution for mouth/ throat

15 ml swish and spit/ swallowed Q3H PRN

BBW:
Avoid use in patients < 3 years of age due to reports of seizures, cardiopulmonary arrest and death

Warning:
Exceeding the recommended dose can result in high plasma levels and serious adverse effects (seizures, cardiopulmonary arrest), methemoglobinemia

SE:
Dizziness, drowsiness, confusion, hypotension

Note:
Avoid ingestion of food for 60 minutes following dose due to risk of impaired swallowing and aspiration

136
Q

Pilocarpine
brand
indication
warning
se
notes

A

Xerostomia
Salagen

5-10 mg PO TIO
Hepatic impairment:
- Moderate: 5 mg BID
- Severe: avoid use

WARNINGS
Use with caution in patients with cholelithiasis, nephrolithiasis, cardiovascular, disease, asthma, bronchitis, COPD

SIDE EFFECTS
Cholinergic side effects: flushing, sweating, nausea, urinary frequency

NOTES
Avoid administering with high-fat meal

137
Q

Chemodrugs that could cause Hand-foot syndrome (erythrodysesthesia)

A

capecitabine,
fluorouracil,
cytarabine,
liposomal doxorubicin
tyrosine kinase inhibitors (TKis)
sorafenib and sunitinib.

138
Q

HAND-FOOT SYNDROME MANAGEMENT

A

■ Limit daily activities to reduce friction and heat exposure to hands and feet.

■ Avoid long exposure to hot water (washing dishes, showers). Takeshorter showers in lukewarm water.

■ Avoid use of dishwashing gloves as the rubber will hold in heat.

■ Avoid increased pressure on soles of feet (no jogging, aerobics,
power walking or jumping).

■ Avoid increased pressure on palms of hands (no use of garden tools, screwdrivers, knives for chopping or performing other tasks that require squeezing hand/s on a hard surface).

-Cooling hands/feet with cold compresses provides temporary relief of pain and tenderness.
- Emollients (Aquaphor, Udder cream, bag balm) –> to retain moisture
- Steroids and pain meds –> for inflammation & pain

139
Q

Tumor lysis syndrome (TLS) has occurred with most cancer types, but most commonly occurs with … and …

A

leukemia
non-Hodgkins lymphoma

140
Q

When the cell is lysed, the intracellular components that enter the bloodstream include …

A

potassium, phosphate, purines and pyrimidines

141
Q

what does tls cause?

A

The phosphate that is released into the bloodstream will bind to calcium, which can cause hypocalcemia.
Calcium and phosphate can also precipitate in soft tissues.

TLS causes acute hyperkalemia (which can cause arrhythmias), hyperphosphatemia and hypocalcemia (low serum calcium, in addition to causing anorexia and nausea, can cause seizures) and hyperuricemia.

142
Q

use of xanthine oxidase inhibitor and rasburicase in tls?

usual dose of allopurinol in gout and in tls?

A

The xanthine oxidase enzyme: convert large amounts of purines into uric acid, causing acute hyperuricemia, which crystallizes, as with gout.

The uric acid crystals damage the kidneys, which can progress to acute renal failure.

Allopurinol is a xanthine oxidase inhibitor that blocks the conversion of purines into uric acid.

The usual initial dose of allopurinol for gout is ~100 mg daily.
For tumor lysis syndrome, higher doses (400 - 800 mg/day) are used and continued for 10-14 days after chemotherapy.

Rasburicase is an expensive medication that is added to allopurinol when allopurinol and hydration fail to control the uric acid level or is not a reasonable option (e.g., with risk of allopurinol-induced rash/severe skin reactions).

Rasburicase converts uric acid to a more water-soluble metabolite (allantoin), which is easily excreted.

Rasburicase is contraindicated in G6PD deficiency. Discontinue immediately and permanently in any patient developing hemolysis.

Both allopurinol and rasburicase are initially given with IV normal saline (NS), which increases urine output to speed up excretion of some of the excess intracellular components.

143
Q

what happens in HYPERCALCEMIA OF MALIGNANCY

how can you treat them?

what level of calcium is considered mod/severe? sx?
how do you treat it

A

Certain cancers cause calcium to leach from bone, causing hypercalcemia and bones that are weak and prone to fracture.

hydration and loop diuretics

Moderate to severe hypercalcemia (calcium > 12 mg/dL) is symptomatic, with nausea, vomiting, fatigue, dehydration and confusion.

Treatment includes IV hydration with normal saline and medication to lower calcium levels.

144
Q

Hydration with normal saline and loop diuretics

moa
onset
degree of hypercalcemia

A
  • inc renal calcium excretion
  • min to hrs
  • Mild (oral or IV hydration) Moderate
    Severe
145
Q

Calcitonin
- brand
- dose
- moa
- onset
- degree of hypercalcemia

A
  • Miacalcin
  • 4-8 units/kg IM/SC Q12H
  • Inhibits bone resorption, inc renal calcium excretion
  • 2-6 hours
  • Moderate/ Severe
146
Q

IV Bisphosphonates

Zoledronic acid:
Pamidronate

moa
onset
degree of hypercalcemia

A

Zoledronic acid:
- Zometa
- 4 mg IV once, may repeat in 7 days if needed.
- Do not infuse over < 15 minutes due to increased risk of renal toxicity.
- Dose does not need to be adjusted for mild-moderate renal insufficiency when used for hypercalcemia.

(Do not confuse with Reclast, which is dosed at 5 mg IV yearly for osteoporosis)

Pamidronate
- 60-90 mg IV over 2-24 hrs once, may repeat in 7 days if needed.

MOA: Inhibits bone resorption by stopping osteoclast function
Onset: 24-72 hours
Mild/ Moderate/ Severe

147
Q

Denosumab
-brand
-dose
- moa
- onset
- degree of hypercalcemia

A
  • Xgeva
  • 120 mg SC on days 1, 8 and 15 of the first month, then monthly
    (Do not confuse with Prolia which is dosed at 60 mg SC every 6 months for osteoporosis

-Monoclonal antibody that blocks the interaction between RANKL and RANK (a receptor on osteoclasts), preventing osteoclast formation

  • 24 - 72 hours
  • mod - severe
148
Q

Degree of hypercalcemia:
- mild
- mod
- severe

corrected calcium formula

A
  • Mild: corrected calcium< 12 mg/dL,
  • Moderate: corrected calcium 12-14 mg/dL,
  • Severe:corrected calcium> 14 mg/dL,
    or presence of symptoms.

Corrected Calcium (mg/dL) =Calcium (reported)+ /(4 - Albumin) x 0.8}

Pamela - Naplex 2023 (32 decks)

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