Chemotherapy Complications CINVD/Mucositis Flashcards
For each type of CINV describe it
- Anticipatory
- Acute (onset, peak and how long after chemo)
- Delayed (onset, occurs with, and risk)
- Breakthrough
- Due to a conditioned response from occurrence of CINV
- Onset 1-2 hrs, peak 4-6 hrs, < 24 hrs
- Onset > 24 hrs after chemo, occurs w/high emetic risk regimens and risk lasts for 3 days
- AFter appropriate prophylactic medication
CINV Risk factors Patient Specific :
1. gender
2. age?
3. history of ?
4. Alcohol consumption levels?
5. History of __ or ___
CINV Risk factors TX specific :
1. chemotx agent
2. dosage
3. schedule
- female
- younger age!
- motion sickness or nausea w/preg , prior hx of chemotx
- low alcohol consumption
- depression, anxiety
For each Grade, state the Nausea level and vomiting episodes
- Grade 1
Grade 2
Grade 3
Grade 4
- Loss of appetite w/o changes in eating habits
-1-2 episodes of vomiting in 24 hrs - oral intake decr w/o signif weight loss, dehydration, malnutrition
3-5 episodes vomiting in 24 hrs - inadequate oral caloric or fluid intake ; tube feeding, TPN or hospitlization indicated
->=6 episodes in 24 hrs - Life threatening consequences, urgent intervention needed
For the following High emetic risk agents (> 90% frequency of emesis), state the specific dose
- Carboplatin
- Cyclophosphamide
- Doxorubicin
- Ifosfamide
- Which combo of chemo is considered HEC?
- AUC >=4
- > 1500 mg / m^2
- > = 60 mg / m^2
- > = 2 g/m^2 per dose
- AC combo w/anthracycline and cyclophosphamide
What are our goals of therapy ? (6)
Prevent –>
malnutrition
Metabolic imbalance
anorexia
decline in performance status
esophageal tears
lack of adherence to potentially beneficial tx
Anti-Emetic Agents : 5-HT3 Antags
1. Granisetron (KYTRIL)
a. what dosage forms?
b. dose?
- Ondansetron (ZOFRAN)
a. what dosage forms?
b. Dose? - Palonosetron (Aloxi)
a. dosage forms?
b. dose? - What are the general AE’s for this class? (3)
- If Palonosetron (3 days) or granisetron SQ or patch (7 days) given, what should you consider for breakthrough nausea?
- IV , PO, SQ or patch
b. 1 mg IV or 2mg PO once
10 mg SQ (redose in 7 days)
3.1 mg / 24hr patch (apply 24-48 hrs prior to first dose) - IV, PO, SL, ODT
b. 8-16 mg IV or 16-24 mg PO
Max 32 mg/day PO or 16 mg IV single dose or 0.45 mg/kg/day ! - IV or PO
b. 0.25 mg IV or 0.5 mg PO once (only redose after 3 days) - HA, constipation , QTC prolongation (primarily with ZOFRAN 16 mg IV)
- Need to consider alt agent
What are the 2 combo therapy products (NK1 + 5HT3) ?
Netupitant 300 mg / Palonosetron 0.5 mg PO x 1 30 min prior to chemotx
Fosnetupitant 235 mg / palonosetron 0.25mg x 1 30 mins prior to chemotx
ANTI EMETIC AGENTS : NK1 RECEPTOR ANTAGS
- Fosaprepitant (EMEND) IV
- Dose
-AE’s - Aprepitant (EMEND) PO
-Dose
-In future, what days will u require dosing on ? - Aprepitant (Cinvanti) IV
-Dose - Rolapitant (Varubi) IV OR PO
-Dosing for IV and PO
-when would u redose?
-What causes the hypersensitivity rxn in pt’s with this drug? - General class AE’s
- It is indicated for?
- Which drugs do you have to consider a CYP3a4 interaction for?
- 150 mg IVPB once
-infusion related reactions due to polysorbate 80 - 125 mg PO
-Dosing required on days 2-3 - 130 mg IVPB once
- 166.5 mg IV or 180 mg PO
-2 weeks
-Soybean oil component - Hypersensitivity, fatigue and DDI’s
- Only for PREVENTION of CINV, not tx
- Fosaprepitant and aprepritant (Early inhib and late inducer)
ANTIEMETIC AGENTS : Dexamethasone
- Dose
- AE’s ?
- Generaly avoid with ___ and ___
- COnsider extending if pt’s experiencing ___
- Caution in pt’s with ___
- When should u dose to avoid insomnia?
- 8-12 mg PO or IV once daily
- Insomnia, hyperglycemia, incr appetite, mood changes, dyspepsia (consider H2 blocker or PPI)
- Cellular therapies , immune checkpoint inhibs
- delayed nausea
- diabetes
- In morning
PROCHLORPERAZINE (Compazine )
- Dosage forms?
- Dose
- AE’s ? CI with ?
OLANZAPINE (Zyprexa)
1. Dosage forms?
2. Dosing ?
3. AE”s?
4. COnsider using if ur pt cant tolerate ___ but caution with use with ?
5. Since the elderly are more sensitive to this medication, which dose should u start with ?
6. when should this med be dosed ?
LORAZEPAM (Ativan)
1. Dosage forms?
2. Dose?
3. U can consider this drug for what kind of nausea?
- PO and IV
- 10 MG PO q6hrs
- Sedation, CI with metoclopramide
- PO and IV
- 2.5-10 mg PO QHS
- Sedation, EPS, ortho hypo, metabolic effects
- dexamethasone , BZD’s
- 2.5-5 mg total
- bedtime
- PO and IV
- 0.5-1 mg PO or IV q6hr prn
- anticipatory or breakthrough (1mg PO night before tx and repeat 1-2 hrs prior to chemotx)
Which 5HT3 agent is typically used for HEC ?
Palonosetron
Prevention of Acute and Delayed Emesis with HEC!
- Option 1 preferred !
-state agents and dosing on day 1/day of chemo
-state agents and dosing on days 2-4 - Option 2 (no Nk1ra)
- Option3 (no 2nd gen anti-psychotic)
- For any of the listed options, what medication + dose would you send your patient home with to begin on day 4?
- Olanzapine 5 mg PO x 1
Fosaprepitant 150 mg IV x 1
Palonosetron 0.25mg IV x 1
Dexamethasone 12 mg PO/IV x 1
Olanzapine 5 mg PO Qhs
Dexamethasone 8mg PO qam
- Olanzapine 5 mg PO X1
Palonosetron 0.25mg IV x 1
Dexamethasone 12 mg PO/IV x 1
Olanzapine 5 mg PO Qhs
Dexamethasone 8mg PO qam
- Fosaprepitant 150 mg IV x 1
Palonosetron 0.25mg IV x 1
Dexamethasone 12 mg PO/IV x 1
Dexamethasone 8 mg PO QAM
- Ondansetron 8 mg PO q8hrs prn N/V to
Prevention of Acute and Delayed Emesis with MEC : State day 1 and days 2-3 dosing
- Option 1
- Option 2 (no NK1ra)
- Option 3 (no antipsych)
- Palonosetron 0.25mg IV x 1
Dexamethasone 12 mg PO/IV x 1
Dexamethasone 8 mg PO QAM
- Olanzapine 5mg PO x 1
Palonosetron 0.25mg IV x 1
Dexamethasone 12 mg PO/IV x 1
Olanzapine 5mg PO QHS
- Fosaprepitant 150mg IV x 1
Palonosetron 0.25mg IV x 1
Dexamethasone 12 mg PO/IV x 1
+/- Dexamethasone 8mg PO Qam
Prevention of Emesis with Low emetic risk
- Start when ?
- Repeat how often ?
- What agents/doses can you use? (4)
- Start prior to anti cancer tx
- Repeat daily for multi day doses of anti cancer therapy
- Dexamethasone 8-12mg PO/IV once
Metoclopramide 10-20 mg PO/IV once
Prochlorperazine 10 mg PO/IV once
5HTR3 RA PO once
What methods can u use for anticipatory CINV? (4)
See chart for other breakthrough therapy of CINV
- Prevention
- Behavioral therapy
- acupuncture/acupressure
- anxiolytic therapy –> lorazepam 0.5-2 mg PO the night before tx and repeat 1-2 hrs prior to anti cancer tx
SEE CHART
Chemo induced Diarrhea Grading : For each Grade describe the stool episodes
Grade 1
Grade 2
grade 3
Grade 4
- increase of < 4 stools per day above baseline
- incr of 4-6 stools per day above baseline which limit activities of daily living
- incr of >= 7 stools per day above baseline
-hospitalization needed
-limiting self care - Life threatening
urgent intervention needed
Types of Diarrhea
- 5FU/Capecitabine what kind
- 2 types of diarrhea w/irinotecan?
- Watery or bloody –> variable severity
- Acute < 24 h after tx due to cholinergic properties of irinotecan
delayed > 24h after tx
Risk factors for CID !!!!
1. Age
2. Sex
3. ECOG score?
4. B
5. B
6. Which cycle of chemotx?
7. Cycle duration
8. Concomitant ___
9. Concomitant _____,___,____ or ___
- > 65 yrs
- Female
- ECOG Performance status of >=2
- Bowel inflamm or malabsorption , malignancy
- Biliary obstruction
- 1st
- greater than 3 weeks
- concomitant neutropenia
- concomitant mucositis, vomiting, anorexia , anemia
RF for 5FU induced Diarrhea :
- Sex
- Race
- age
- BMI?
- Hx of
- Deficiency in ?
- 5FU + ____
- Slightly incr risk with what admin method?
Female
caucasian
advanced age
normal BMI
diabetes
DPYD*2A (decr CL of 5FU)
Leucovorin
BOLUS
RF for Irinotecan-Induced Diarrhea
- What kind of dosing ?
- Homozygous presence of ?
- Poor ___
- Elevated ___
- HIstory of ___
- Low ____
- What age
- G
- C
Weekly irinotecan dosing
UGT1A1*28 polymorphism (less glucoronidation of SN38)
Performance status
serum creatinine
radiation to abdomen or pelvis
white blood cell count
> 70 yo
Gilbert syndrome
Crigler Najjar syndrome type 1
TX Options : Loperamide
- Loperamide
dose?
What have high doses been associated with ?
- 4 mg PO x 1 then 2 mg PO after each loose BM w/MAX of 24mg/day
paralytic ileus
TX options : Octreotide
- Dose
- How and wen can u incr dose?
- 100-150 mcg SQ
- May incr dosage at 50mcg increments after 24 hrs to 500 mcg TID or as a continuous IV infusion (25-50 mcg/hr)
Management : Uncomplicated Vs Complicated
- Uncomplicated is defined as which stages? describe sx’s
- Complicated is which stages?
-It can be grade 1 or 2 with >=1 of the following (List the following )
- Grade 1 or 2
–> No complicating signs or sx’s - grade 3 or 4
-Cramping
-Grade 2 N/V
-Fever
-Sepsis
-Neutropenia
-Frank bleeding
-Dehydration
How would you manage uncomplicated?
Complicated?
- DIet modifications
Oral hydration
Loperamide - Admission to hospital
Octreotide
IV fluids
ABX if warranted
Initial management of Uncom Diarrhea
NON PHARM :
- What do u do with chemotherapy ?
- What kind of diet mods?
- State how u would orally hydrate them
- Name a pharm tx
- Withold chemo if grade 2 –> resume when sx’s resolve and consider dosage reduction
- Stop all lactose containing products, stop ALC, stop high osmolar supps, BRAT diet
- Oral hydration with 8-10 large glasses of clear liquids containing salt
-diluted sports drinks , broth, decaff tea - Loperamide 4 mg PO x 1 then 2 mg after each loose BM (max of 24 mg/day)
Initial management of Complicated Diarrhea
1. admit where
2. What to do with chemo ?
3. Work up what ?
4. Complete __ and ___
5. admin ____
6. Octreotide at what dose?
7. admin of ___ prn if clinically indicated
- hospital
- DC, resume when sx’s resolve and consider restarting chemotx at decr dosage
- stool work up (blood, fecal leukocytes, Cdiff, Salmonella, E COli, Cbacter , infectious colitis)
- Blood counts (PLT, Hgb, Hct) and metab panel (K, Mg, Na)
- IV fluids
- Starting dose of 100-150 mcg SC TID or IV if pt is severly dehydrated
- IV antibiotics (fluoroquinolone)(if pt is febrile, hypotensive, peritoneal signs, neutropenia, bloody diarrhea)
Irinotecan Induced Diarrhea
- Early phase begins when ?
-__ dependent
-Sx duration ?
-Prevention using ?
-TX using ? - Late phase begins when ?
-Can occur at any ____
Median onset of ___ with ___ dosing
Median onset of ___ w/weekly dosing
TX is ?
- < 24 h after infusion
dose
30 mins
Atropine 0.25-1mg SQ/IV 30 min prior to infusion
Atropine 0.25-1mg SQ/IV - > 24 hrs after irinotecan
- dosage or frequency
- 6 days, q3weekly
11 days, weekly dosing
Loperamide 4 mg PO after 1st loose BM then 2 mg PO q2H until 12h with no diarrhea
Risk Factors for Mucositis :
- Patient related : S,B,A,F,P
- Tx related : C, D ,D , S, H/R, C, P, R + C
- Smoking , baseline oral hygiene , age , female, pre tx nutritional status
- Chemotherapy (s phase cycle specific have the highest risk) , Duration, dose intensity, schedule, hepatic/renal impairment, concomitant therapy, prior mucotoxic therapy, radiation + chemotherapy
Which drugs have the highest risk for mucositis?
5FU (Bolus )
MTX
Cytarabine
Doxorubicin
Etoposide
Melphalan
