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Hematology/Oncology > Chemotherapy Induced Nausea/Vomiting (3) > Flashcards

Chemotherapy Induced Nausea/Vomiting (3) Flashcards

1
Q

Impact of CINV

A

Decrease in…
-nutrition and weight
-physical and mental health
-desire to continue chemotherapy
-quality of life

Increase in…
-medical complications
-dehydration
-electrolyte imbalances
-cost of medical care

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2
Q

Acute vs delayed CINV

A

Acute = n/v that occurs within the first 24 hours after chemotherapy

Delayed = n/v that occurs after the first 24 hours after chemotherapy
-can last up to 7 days after chemo

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3
Q

Anticipatory CINV

A

N/v that is a learned reflex or psychological response that occurs before chemotherapy
-can be triggered by sights/sounds/smells/tastes/thoughts
-often occurs due to poor n/v control in previous chemo cycles (so patients get anxious that it will happen again - because they are anticipating that it will happen)

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4
Q

Breakthrough CINV

A

This is n/v that occurs AFTER chemotherapy despite proper prophylaxis
Because of this patients may require “rescue medications” (that they can use prn)

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5
Q

Refractory CINV

A

This is n/v that occurs during subsequent cycles despite optimized antiemetic prophylaxis
-we continue to add on agents (use multiple agents with multiple MOAs)
-important to tell patients that medications will probably not eliminate n/v but just limit it

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6
Q

Which pathways/centers lead to n/v when stimulated

A

High Centers
(5HT3, NK1, D2, GABA)
-from memory, fear, dread, anticipation

Cerebellum
(M, H1)
-inner ear

Chemoreceptor trigger zone
(5HT3, D2, M, CB, opioid)
-blood bone emetics

Solitary Tract Nucleus
(5HT3, NK1, D2, M, H, CB)

When all these are triggered - leads to vomiting center stimulation in the medulla (NK1)

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7
Q

What factors contribute to the overall emetic risk? (2)

A

Regimen risk factors (how severely emetogenic the specific medications are)

Patient Risk Factors

(Regimen Risk + Patient Risk = Overall Emetic Risk)

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8
Q

What are patient specific factors that increase emetic risk? (5)

A
  1. Anxiety/anticipation of nausea (leads to anticipatory n/v)
  2. Female gender
  3. YOUNGER age (<50 yo)
  4. History of motion sickness
  5. History of pregnancy induced n/v
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9
Q

Which patient specific factor DECREASES emetic risk?

A

History of alcohol use (> 5 drinks per day) - this decreases risk of developing CINV

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10
Q

Which regimen factors increase emetic risk? (6)

A
  1. High emetic risk agent
  2. Moderate/high dose
  3. More frequent
  4. Longer duration
  5. Short infusion rate
  6. Radiation - higher amounts of irradiated tissue
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11
Q

IV chemo agents emetic risk categories (4)

A

Minimal emetic risk
- < 10% frequency of emesis (meaning they have n/v for less than 10% of the time)

Low emetic risk
-10-30% frequency of emesis

Moderate emetic risk
-30-90% frequency of emesis

High emetic risk
- > 90% frequency of emesis

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12
Q

Which IV chemo agents are considered to have minimal emetic risk? (2)

A

Monoclonal antibodies
Vinca alkaloids (vincristine, vinblastine, vinorelbine)

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13
Q

Which IV chemo agents are considered to have low emetic risk? (2)

A

Taxanes (paclitaxel and docetaxel)
5-Fluorourical

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14
Q

Which IV chemo agents are considered to have moderate emetic risk? (3)

A

Carboplatin
Oxaliplatin
Anthracyclines (doxorubicin)

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15
Q

Which IV chemo agents are considered to have high emetic risk? (2)

A

Cisplatin
Anthracyclines (doxorubicin) - when used in combination with cyclophosphamide

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16
Q

Oral chemotherapy emetic risk categories

A

Unlike the IV agents (which are broken up into minimal, low, moderate, or high emetic risk) - the oral agents are only broken up into 2 categories …

  1. Minimal to low emetic risk
    - < 30% frequency of emesis
  2. Moderate to high emetic risk
    - 30% frequency of emesis or greater
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17
Q

Which oral chemo agents are considered minimal/low risk? (3)
Prophylaxis consideration for these

A

Capecitabine
Tyrosine kinase inhibitors
Methotrexate

PRN drug therapy (no prophylaxis recommended)

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18
Q

Which oral chemo agents are considered moderate/high risk? (2)
Prophylaxis consideration for these

A

Etoposide
Lomustine

Prophylaxis IS recommended

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19
Q

Emetic risk categories of radiation

A

The larger the surface area exposed to radiation –> the higher the emetic potential

  1. Mild Emetogenic
    -radiation to head and neck or extremities (smaller area)
  2. Moderately Emetogenic
    -radiation to upper abdomen or pelvis or craniospinal
  3. Highly Emetogenic
    -total body irradiation, total nodal irradiation, upper half of body radiation (lots of receptors are in the upper half of the body from the gut to the brain)
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20
Q

How many days should prophylaxis be given for IV chemotherapy?

A

It depends on the emetic risk of the therapy…

High risk (> 90%) = 4 days

Moderate risk (30-90%) = 3 days

Low risk (10-30%) = 1 day

Minimal risk (< 10%) = no prophylaxis (just prn medications)

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21
Q

Barriers to CINV treatment

A

Patients may think n/v is just part of their treatment that they have to deal with or they may not want to seem weak so they don’t bring it up - so it’s important to ask patients about this

Patients may fear additional medications (side effects, costs)

Patients may fear that if they bring up these symptoms their provider will stop/lessen their chemotherapy

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22
Q

Non-pharmacologic approaches

A

Relaxation
Biofeedback therapy
Self-hypnosis
Dietary changes (avoid spicy or high fat foods)
Acupuncture

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23
Q

What are the classes of medications that can be used for CINV? (8)

A
  1. Neurokinin-1 Receptor Antagonists (NK1 RAs)
  2. 5-Seretonin Receptor Antagonists (5HT3 RAs)
  3. Corticosteroids
  4. Dopamine antagonists
  5. Atypical antipsychotics
  6. Benzodiazepines
  7. Cannabinoid receptor agonists
  8. Acid suppressing agents
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24
Q

5HT3 RA mechanism

A

Inhibits central and peripheral 5HT3 (serotonin) receptors

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25
Q

What are 5HT3 RAs indicated for in CINV?

A

Prevention of acute and delayed CINV for low to high emetogenic chemotherapy
(so basically gold standard for all severities prophylaxis)

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26
Q

Which medications are 5HT3-RAs (4)

A

Ondansetron (most popular)
Granisetron
Palonosetron
Dolasetron

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27
Q

5HT3 RA main ADR

A

QTC prolongation (dose related)
-monitor, especially if patient has cardiac issues

28
Q

Which 5HT3 RA comes in a patch?

A

Granisetron (and it also comes in an ER SQ injection)
This is helpful for preventing delayed n/v, especially useful if patients don’t want to take anything by mouth

29
Q

Which 5HT3-RA has a long half life?

A

Palonosetron
-half life is about 40 hours
(useful in regimens, we only have to give this once and it lasts long)

30
Q

5HT3 RA formulations

A

Ondansetron - IV and PO
Granisetron - IV, PO, ER SQ, patch
Palonosetron - IV only
Dolasetron - PO only

31
Q

NK1 RA MOA

A

Inhibit the substance P/neurokinin 1 receptor

32
Q

NK1 RA indication for CINV

A

Prevention of acute and delayed CINV for moderate-high emetogenic chemotherapy

33
Q

Which medications are NK1 RAs? (3)

A

Aprepitant
Fosaprepitant
Rolapitant

34
Q

NK1 RA formulations

A

Aprepitant = PO
Fosaprepitant = IV
Rolapitant = PO (no used much)

35
Q

What are the 2 combination NK1 RA/5HT3 RA products and their formulations/administration

A

netupitant/palonosetron = PO
fosnetupitant/palonosetron = IV

36
Q

NK1 RA drug interaction consideration

A

NK1 RAs are CYP3A4 inhibitors - so specifically this will interact with dexamethasone and increase its concentrations (and they are often used together for CINV)
So if using together - decrease the dose of dexamethasone

(Rolapitant specifically is a CYP2D6 inhibitor and CYP3A4 substrate- check for drug interaction)

37
Q

Which NK1 RA can be given beyond day 1?

A

Aprepitant only
-if aprepitant is started on day 1, it can be continued
-but if any of the other agents were started on day 1 that is it - can’t give those on the next day and cannot use aprepitant after

38
Q

Corticosteroid MOA for CINV

A

Act centrally; work synergistically to increase effectiveness of other CINV agents

39
Q

Corticosteroid indication for CINV

A

prevention of acute and delayed CINV in low-high emetogenic chemotherapy

40
Q

Which corticosteroid is used for CINV?

A

Dexamethasone

41
Q

Corticosteroid ADRs and considerations

A

Insomnia, GI upset, dyspepsia, agitation, weight gain, hyperglycemia

-can consider acid suppressing therapy addition to help with dyspepsia
-dose in the morning to minimize insomnia

-we generally are using for a short period of time though so long term side effects are not seen
-still, should be cautioned in patients with diabetes, elderly, or psychiatric history
(consider steroid sparing regimen)

42
Q

Dexamethasone formulation

A

IV or PO

43
Q

Dexamethasone has a DDI with which drug class used for CINV?

A

NK1 RAs - they will increase the level of dexamethasone (CYP3A4 inhibitors)
So, dexamethasone dose should be decreased if being used together

44
Q

Dopamine antagonist MOA

A

blocks dopaminergic receptors in the brain

45
Q

Dopamine antagonist indication for CINV

A

Used for breakthrough treatment (prn)
And prevention of low emetogenic chemotherapy

46
Q

Which medications are dopamine antagonists? (3)

A

Prochlorperazine
Metoclopramide
Haloperidol (more potent and more side effects- not typically used)

47
Q

Dopamine antagonist 2 BBWs

A
  1. Increased risk of death in elderly patients with dementia related psychosis
  2. Tardive dyskinesia (often irreversible)
48
Q

Dopamine antagonist ADRs

A

Sedation, hypotension, anticholinergic effects, dystonia’s, extrapyramidal symptoms
QTc prolongation
neutropenia (which may already be occurring because of cancer treatment)

Lots of side effects for these so we don’t really use them unless we have to (which is why they often only added for breakthrough treatment)

49
Q

What screening needs to be done before using prochlorperazine?

A

ANC
do not use if ANC < 1000

50
Q

Metoclopramide should be used at __________ doses to…

A

Should be used at LOW doses to avoid extrapyramidal symptoms

At higher doses it inhibits serotonin

51
Q

Dopamine antagonist formulations

A

Prochlorperazine = PO, IV, IM
Metoclopramide = PO only
Haloperidol = PO/IV

52
Q

Atypical antipsychotic MOA

A

blocks multiple neurotransmitters - dopamine, serotonin, histamine, acetylcholine

53
Q

Which atypical antipsychotic is the only one approved for CINV?

A

Olanzapine

54
Q

Olanzapine indication for CINV

A

prevention of acute and delayed CINV in moderately to highly emetogenic chemotherapy
or for breakthrough CINV

55
Q

Olanzapine ADRs

A

Drowsiness, dizziness, orthostatic hypotension
-patient should start with taking this in the evening, sedation should improve over time

hyperglycemia, weight gain
EPS
QTc prolongation

Lots of side effects but it works really well, so we still use it

56
Q

Olanzapine formulation

A

PO only

57
Q

Olanzapine BBW

A

increased risk of death in elderly patients with dementia related psychosis

58
Q

Cannabinoid receptor agonist indication for CINV

A

Used for prophylaxis if refractory to other antiemetics

59
Q

Cannabinoid drugs and formulation

A

Dronabinol (PO)
Nabilone (PO)

60
Q

Cannabinoid ADRs

A

Dizziness, somnolence

Increased appetite (this may be beneficial for some patients who struggle with this)

Withdrawal symptoms of abrupt discontinuation after continuous use

61
Q

Benzodiazepine indication for CINV

A

Used for anticipatory CINV

62
Q

Which benzodiazepines are used for CINV and what are their formulations?

A

Alprazolam (PO)
Lorazepam (PO, IV, SL)

63
Q

Benzodiazepine ADRs

A

Sedation
Dizziness
Disorientation

64
Q

Acid suppressing agent indication for CINV

A

Added for prophylaxes of CINV if patients have underlying GERD, heartburn, or dyspepsia

65
Q

Which 2 classes of acid suppressing agents are used for CINV and which formulations?

A

Histamine 2 receptor antagonists (PO)
Proton pump inhibitors (PO)

Hematology/Oncology (17 decks)

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