chemo Flashcards
Chemotherapy ADE include
hypersensitivity n/v mucositis alopecia neuropathy cutaneous reactions extravasation thrombosis MC: Myelosuppression! lowest blood cell count usually 10-14days after admin of chemo, and recovery w/in 3-4 wks -anemia a few months after 1st dose -neutropenia, then thrombocytopenia
What are the 5 phases of chemo induced nausea/vomiting
Acute: w/in 1-2 hrs of chemo. Tx with Ondansetron
Delayed: >24 hours after admin. Tx w/ Aprepitant, fosaprepitant, or rolapitant
Anticipatory: prior to admin in those who had significant n/v with chemo before. Tx w/ prophylactic benzos (diazepam, lorazepam) the night before admin
Breakthrough: occurs despite prophylaxis. Tx with prochlorperazine or phenothiazine around the clock
Refractory: poor response to all antiemetics. Tx w/ glucocorticoids (DXM)
Where can mucositis occur
Gi mucosa
Inflammation as ulcers, local infection, can’t eat drink or swallow, systemic microbial invasion
Mucositis is MC associated with
5-FU Doxorubicin Methotrexate Multikinase inhibitors (nibs) mTOR inhibitors (rolimus)
Patients at high risk for mucositis are
Poor dentitions
those on high dose chemo
those on radiation involving oropharynx
-prevent mucositis with good oral hygiene! go to the dentist before chemo Tx, rinse mouth w/ backing soda and salt water frequently between courses of chemo
What analgesics can be used to Tx mucositis
Mouthwash!
viscous lidocaine*
diphenhydramine liquid
Dyclonine sucrets*
How can you manage local infection 2/2 mucositis
Candida: Clotrimazole troches or nystatin oral suspension for thrush. Oral fluconazole or IV antifungals for more severe
Reactivation of HSV: Acyclovir
What is Palifermin
Keratinocyte Growth Factor that binds to KGF receptor resulting in proliferation, differentiation, and migration of epithelial cells on tongue, buccal, esophagus, and salivary glands
Palifermin is approved for
high dose chemoradiotherapy prior to stem cell transplant
ADE of Palifermin are
*Increased amylase and lipase
change in taste, mouth or tongue discoloration
How do you treat mucositis that manifests as diarrhea and abdominal pain
IVF, electrolyte supplement
Lomotil or Loperamide (non-infectious antispasmodics)
Octreotide: somatostatin analog, esp for severe diarrhea
What cutaneous reactions are associated with chemo
localized rash photosensitivity skin hyperpigmentation nal changes hand-foot syndrome/acral erythema (diffuse edema & erythema on palms and soles) -generally reversible and self limited
Cutaneous reactions are associated with
Cytarabine
5-FU
Bleomycin
How do you treat cutaneous reactions
Emollients if w/ dry skin
topical/systemic abx if rash gets infected
steroids to prevent itching and inflammation
Acral erythema: PO B6 (pyridoxine) QD, cold packs to extremities during chemo admin
What is hand foot skin reaction
Associated with multikinase inhibitors, FU, capecitabine, and liposomal doxorubicin
Localizes to areas of pressure/friction (hands, feet)
Can prevent w/ daily moisturizer
Can treat with urea cream, topical steroids, and pain meds (gabapentin, NSAIDs)
What is alopecia
Most distressing but usually temporary hair loss
W>M
All body, not just scalp.
MC associated with Taxane and Docetaxel
How do you treat alopecia
Cool caps to decrease blood flow to the scalp
What is extravasation
When chemo gets out of the blood and into surrounding structures (ex. IV line was not patent)
Causes prolonged pain, tissue sloughing, infection, and loss of mobility
What causes extravasation
Vesiacants: agents that cause severe tissue damage if they escape the vasculature Antracyclines Actinomycin D Vinca alkaloids Mitomycin C Nitrogen mustard Takanes (Taxol*)
How do you treat extravasation
Apply ice packs to affected area EXCEPT:
Vinca alkaloids better managed by applying heat*
Sodium thiosulfate to neutralize nitrogen mustard
Hyaluronidase to improve outcome after vinca alkaloids, etoposide, and taxanes
Topical dimethyl sulfoxide for anthracycline and mitomycin C
Dexrazone IV (totect) for anthracycline!
How do you prevent extravasation
good admin technique
Use large veins in forearms
give slowly through running IV line
Pref. thru central venous cath
When is myelosuppression MC seen
when chemo is given at the same time as radiation to chest or pelvic region
What cells are affected in chemo related myelosuppression
WBC (esp PMN): most significantly affected, rapid proliferation, short lifespan (6-12 hrs)
PLT: much less than PMN. 5-10 day lifespan
RBC: affected least. 120 day lifespan
When is myelosuppression good
Myelotoxicity is a desired therapeutic effect in patients with AML during induction therapy
What is the MC hematologic complication of chemotherapy
Anemia
Depends on type and duration of therapy, type and stage of malignancy
What conditions are known to cause anemia in cancer patients
chemo and radiation chronic GI blood loss nutrient deficiency (Fe, folate) bone marrow invasion by tumor hemolysis renal dysfunction anemia of chronic disease
How do you treat anemia in a cancer patient
RBC transfusion
Recombinant human erythropoietic products (epoetin alfa, darbapoetin alfa)
Before initiating recombinant human erythropoietin, you must
eval underlying condition and initiate specific therapy;
Iron deficiency? give Iron
B12 or folate supplementation
Chronic bleeding? determine site
How do you treat with human recombinant erythropoietin
Start Sx pts when Hgb <10
Target Hgb is 10-12
Indication of response: Hgb increase by 1g, ferritin decline or reticulocyte increase s/p 2-4 wks
Reassess Hgb after 4-6 weeks (sr erythropoietin levels dont really help)
Mild ADE of recombinant human EPO (epogen) include
pain at injection site rash flu-like Sx seizures HTN
Severe ADE of recombinant human EPO are
decreased survival (advanced breast, head and neck, lymphoma, and non-small cell lung cancer)
thrombosis
pure red cell aplasia
What is neutropenia
ANC falls <500
risk of infection is directly proportional to duration of neutropenia
S/Sx of are absent (no WBC respond) so rely on fever as indication of infection! start abx asap
What percent dose should you receive based on granulocyte count
> 2000: 100% of dose
1000-2000: 5-% of dose
<1000: 0%
What agents are used as colony stimulating factors in neutropenia
G-CSF (granulocyte): Filgrastim, Pegfilgrastim
GM-CSF (granulocyte/macrophage): Sargramostim. promotes proliferation of neutrophils, eosinophils, macrophages, monocytes. stimulate megakaryocytes, but no effect on PLT
Giving CSF allow
admin of subsequent chemotherapy courses on schedule= enhanced dose intensity
Not consistently translated into improved tumor response or survival
When can you use CSF
primary prophylaxis: prevent neutropenia in 1st chemo cycle
Secondary: prevent recurrent neutropenia in those who had neutropenia previously w/ chemo
What are ADE of CSF
Bone pain (give APAP)
Increased LDH, alk phos, uric acid, and liver transaminases
pleural and pericardial effusions w/ high doses; also capillary leak syndrome and thrombus formation
low grade fever, myalgias, arthralgias, lethargy, mild HA
mild erythema at subQ injection sites
generalized maculopapular rash
-Occur bc of drug’s ability to bind neutrophils to endothelial cells, and activate monocytes and macrophages= release cytokines IL1 and TNF
When do you dose CSF
24-72 hours after chemo
Stop the day before chemo
Pegfilgrastim is long lasting G-CSF and should be stopped w/in 14 days of next chemo dose
How do you treat thrombocytopenia
Platelet transfusion!
reserved for PLT <10, active bleeding, or pending surgery
Who experiences significant thrombocytopenia w/ prior cycle of chemo Oprelvekin
Those with secondary non-myeloid malignancies
What is Oprelvekin (IL-11) associated with
Fluid retention (edema, dilutional anemia, dyspnea, pleural effusions) Cardiotoxicity (tachy, AFib, Aflutter, HF)
What is the most significant factor in the future of thrombocytopenia Tx
Megakaryocyte stimulating factor
What neuropathy is associated with chemo
sensory, motor, autonomic, or combination
Mild: paresthesias of fingers and toes
Constipation
-MC with Vinca alkaloids and taxane drugs
Cardiotoxicity is associated with
Anthracyclines (Doxorubicin, Daunomycin, Idarubicin, Epirubicin)
-MUGA screen scan show you LVEF. If >50%, give antracyclines
What is Cisplatin associated with
nephrotoxicity and neurotoxicity
peripheral neuropathy, painful paresthesias
Ototoxicity +/- deafness
How do you treat nephro/neurotoxicity associated w/ Cisplatin
vigorous hydration prior, during, and after admin
monitor renal fxn and lytes for low mag, K, and Na
Give amifostin IV over 15 min prior to cisplatin for protection
What can be used instead of cisplatin
Second gen platinum analog, Carbaplatin!
Non-nephrotoxic but still myelosuppresive
Common Bleomycin toxicities are
Edema of IP joints
Hardening of palmar and plantar skin
Anaphylaxis, serum sickness like reaction
Serious or fatal pulmonary fibrotic rxn, esp in elderly
With bleomycin, monitor for
non-productive cough, dyspnea, and pulmonary infiltrates
If present, dc drug, start high dose corticosteroids, and start empiric abd pending cultures
