Chemotherapy-Induced Nausea and Vomiting (CINV) Flashcards
CINV occurs most commonly with which drugs
CISPLATIN**
Carboplatin
Cyclophosphamide
Anthracyclines (doxorubicin/ daunorubicin)
CINV risk factors
- female sex
- younger age
- pretreatment anxiety
- Hx of motion sickness or morning sickness during pregnancy
- Hx of N/V with previous chemo cycles
CINV can be classified as:
- Acute*
- Delayed*
- Anticipatory*
- Breakthrough*
- refractory
Acute CINV definition
Acute: occurs WITHIN 24H after chemo and peaks around 5-6H
Delayed CINV definition
Delayed: occurs > 24H after chemo
Anticipatory CINV definition
Anticipatory: occurs BEFORE TREATMENT and develops as a CONDITIONED RESPONSE from a previous negative experience
Breakthrough CINV definition
Breakthrough: occurs at ANY TIME after chemo, despite the use of prophylaxis, and requires rescue antiemetics
refractory CINV def
refractory: occurs when prohylaxis and/or rescue treatment is not effective
List Neurokinin-1 Receptor Antagonists (NK1 RAs)
Aprepitant
Fosaprepitant
Rolapitant
List Serotonin Receptor Antagonists (5HT3 RAs)
Ondansetron
Dolasetron
Granisetron
Palonosetron (combo products available)
List Dopamine Receptor Antagonists
Olanzapine
Haloperidol
Metoclopromide
Prochlorperazine
Promethazine
Other CINV agents
Dexamethasone
Lorazepam
Dronabinol
when should antiemetic regimens be given
(one dose of each drug) at least 30 min before chemotherapy
when can Lorazepam be added to the antiemetic regimens
if needed for ANTICIPATORY N/V- start the night before treatment and repeated the day of treatment
List the major neurotransmitters responsible for CINV
- Serotonin
- Dopamine
- GABA
- Substance P
- Neurokinin
IV Chemotherapy Risk for Acute/Delayed N/V
*HIGH EMETIC RISK: 90% frequency of acute emesis
note: CISPLATIN, any regimen containing BOTH an anthracycline and cyclophosphamide)**
Q: Antiemetic Regimen
- 3 or 4 Drugs *
*** PREFERRED: (NK1 RA) + (5HT3 RA) + (Olanzapine) + (Dexamethasone)
- (NK1 RA) + (5HT3 RA) + (dexamethasone)
- (Palonosetron) + (olanzapine) + (dexamethasone)
IV Chemotherapy Risk Acute/Delayed N/V:
Moderate emetic risk: 30-90% frequency
Q: Antiemetic regimen
- 2 or 3 drugs *
- (NK1 RA) + (5HT3 RA) + (dexamethasone)
- (5HT3 RA) + (dexamethasone)
- (Palonosetron) + (olanzapine) + (dexamethasone)
IV Chemotherapy Risk for Acute/Delayed N/V:
Low emetic risk: 10 -30%
Q: Antiemetic regimen
- 1 Drug *
- 5HT3 RA (think “dog” ; dolasetron, ondansetron, granisetron)
- dexamethasone
- metoclopramide
- prochlorperazine
IV Chemotherapy Risk:
Minimal emetic risk: < 10%; the majority of mAbs
Q: Antiemetic regimen
NO ROUTINE PROPHYLAXIS
MOA: Substance P/ NK1 RA:
inhibits the sub P/NK1 receptor, thereby augmenting the antiemetic activity of 5HT3 receptor antagonists and corticosteroids
Q: List drugs
- Aprepitant (EMEND, emend Tri-Pack, Cinvanti)*
- Fosaprepitant (EMEND)*
- Rolapitant (Varubi)
which subtance P/NK1 drug is given IV
fosaprepitant (Emend)
note: aprepitant (Cinvanti is also IV, all others are PO)
fosaprepitant IV is converted to aprepitant within how many minutes after the end of the infusion
within 30 min after the end of the infusion
which drugs inhibit the metabolism of dexamethasone (to INCREASE dexamethasone levels)
aprepitant, fosaprepitant and netupitant (combo drug w/palonosetron)
which drug do you NOT administer at less than 2-week intervals
rolapitant
5HT3 RA drugs
- Ondansetron (Zofran)*
- Granisetron (Sancuso)*
- Palonosetron (Aloxi)*
- Dolasetron (Anzemet)
Q: which 5HT3 RA is available in PO, IV, SC, and PATCH*
Q: Patch directions
- granisetron (Sancuso is patch formulation)*
- 3.1 mg/24 H, apply 24-48H before chemo; may leave in place up to 7 DAYS
side effects of 5HT3 RAs
HA, CONSTIPATION*, fatigue, dizziness, injection site rxn
Contraindication of 5HT3 RAs
do NOT use with APOMORPHINE (Apokyn)* due to severe hypOtension
Warnings with 5HT3 RAs
- dose- dependent QT- PROLONGATION (Torsades de Pointes)- more common with IV administration
LIMIT IV DOSE of ONDANSETRON to 16 mg** (lowest risk is w/palonosetron) - SEROTONIN SYNDROME* (when used in combo with other serotonergic agents)
- hypersensitivity rxns
Q: list corticosteroid drug
Q: contraindications
Q: side effects
- Dexamethasone (Decadron)*
- systemic fungal infections
- short-term s/e include INCREASED APPETITE, wt gain, FLUID RETENTION, emotional instability (mood swings, irritability, acute psychosis), INSOMNIA*, Gi upset/dyspepsia
- higher doses INCREASE BP AND BLOOD GLUCOSE* (esp in pts w/diabetes)
MOA: BZD
ENHANCES GABA* (an inhibitory neurotransmitter), which decreases neuronal excitability and results in the alleviation of anxiety and suppression of ANTICIPATORY N/V*
Q: List BZD drug
Q: when to start
- Lorazepam (ATIVAN)*
- start the EVENING prior to chemotherapy (and day of chemo) if used for anticipatory N/V
MOA Dopamine Receptor Antagonist:\
BLOCK DOPAMINE RECEPTORS* in the CNS including the CHEMORECEPTOR TRIGGER ZONE
Q: list drugs
Olanzapine (ZYPREXA)*
Prochlorperazine*
Promethazine (Phenergan*, Promethegan)
Metoclopramide (REGLAN)*
Haloperidol (Haldol*)
which dopamine RA agent should DECREASE DOSE BY 50% when CrCl is <60
Metoclopramide (Reglan)
Boxed Warnings for:
Q: Promethazine
Q: Metoclopramide
- promethazine: do NOT use in kids < 2 yrs of age (risk of respiratory depression)**
can cause serious TISSUE INJURY due to EXTRAVASATION if administered intra-ARTERIALLY, SC,or IV** - metoclopramide: TARDIVE DYSKINESIA (TD) that can be IRREVERSIBLE* (d/c if s/sxs occur; risk increase with renal impairment)
do NOT use > 12 weeks*
Warnings for Dopamine RAs
Avoid use in pts with PARKINSON DISEASE (can EXACERBATE sx’s)
S/E of Dopamine RAs
SEDATION, LETHARGY, ACUTE EPS (antidote is Benadryl or benztropine)
decrease seizure threshold
strong anticholinergic s/e (constipation) except with metoclopramide (prokinetic effect causing diarrhea)
Q: List Cannabinoid drugs
Q: How to store them
Q: s/e
- DRONABINOL*
MARINOL* (C III- capsules) - Refrigerate*
- SOMNOLENCE, EUPHORIA, INCREASED APPETITE*
