Chemotherapy - side effects

Question 1

Which side effect of chemotherapy is a health professional likely to be most concerned about?

Answer 1

Myelosuppression

Question 2

Which 2 side effects of chemotherapy is a patient likely to be most concerned about?

Answer 2

Nausea and vomiting and hair loss

Question 3

Which two drugs dont cause myelosupression?

Answer 3

vincristine, bleomycin

Question 4

What are the predisposing factors to infection?

Answer 4

¥ Neutropenia
¥ Loss of cell-mediated and humoral immunity (knocking out b and t cells – reduces ability to fight infections). Rituximab affects B cells and chemo drug like Fludarabine affects T cells.
¥ Mucosal damage – need to take sure patients are optimising their mouth care regimens so make sure using mouthwashes and soft toothbrushes – if you have mucositis then it’s a portal for infection with low blood count then can cause life threatening infection.

Question 5

How can you manage neutropenia?

Answer 5

Primary prophylaxis

• G-CSF – drug. Mobilising and prevent neutropenia. Stimulates neutrophil production and this will be given as primary prophylaxis – 5 or 7 days of G-CSF after chemo cycle to reduce risk of neutropenia.

Secondary prophylaxis

• may have had a complication (been admitted to hospital with infection after first cycle of chemo), then future cycle add G-CSF to prescription to prevent risk of further complications with further cycles. If patient have neutropenia can give G-CSF as an inpatient to boost their cell count.
• Prophylactic antibiotics or antifungals
• May have to delay or dose reduce chemotherapy – e.g. patient with low neutrophils (0.6 e.g.) need to go home and come back in a weeks time and then can give chemo at that point.
• If patient presents with neutropenia and fever (medical emergency) – needs prompt treatment with broad spectrum antibiotics

Question 6

What is a patient group direction

Answer 6

PGD – patient group direction – give drug without a prescription (accessing drug immediately). Nurses will be allowed to start on IV antibiotics 0 borad spectrum antibiotics (meropenem or tazasin e.g.)

Question 7

What drug would you give for someone that is has neutropenia and fever with a low risk?

Answer 7

oral antibiotics or IV antibotics for a few days with a step down approach

Question 8

What drug would you give for someone that is has neutropenia and fever with a high risk?

Answer 8

more than one drug – e.g. using vancomycin with broad spectrum like meropenem or penicilin

Question 9

What are the effects of cytotoxic drugs on GI tract?

Answer 9

• Nausea and vomiting
• Oral mucositis
• Diarrhoea

Question 10

How can nausea and vomittiing be subdivided?

Answer 10

• Acute (first 24 hours)
• Delayed (24 hours onwards)
• Anticipatory – often the hardest to manage – when patient sees building and starts to fell sick or sight of nurse is enough for them to be sick.

Question 11

What are the classes of anti-emetics?

Answer 11

• Dopamine antagonists e.g. haliperiodol, metoclopramide domperidone
• 5-HT3 antagonists e.g. Ondansetron, granestron, palemysetron
• Antihistamines e.g. cyclizine
• NK1 antagonists e.g. aprepritant
• Anticholinergics e.g. Hyoscine hydrobromide and hyoscine butlybromide (less used)
• Corticosteroids e.g. Dexamethasone
• Miscellaneous e.g. Cannabinoids CBD - E.g. nabilone (not really effective)

Question 12

What are high High emetogenic risk (>90%) drugs?

Answer 12

• Any SCT schedule, cisplatin (leads to serious nausea and vomiting) based chemo – need antiemetics

Question 13

What are Moderate emetogenic risk (30-90%) drugs?

Answer 13

CHOP, DA, FLAG

Question 14

What are minimal emetogenic risk (<10%) drugs?

Answer 14

Fludarabine, vincristine, bleomycin

Question 15

What risk factors are associated with people who are more prone to nausea and vomitting?

Answer 15

• Young age
• Female more likely to feel sick than males
• History of motion sickness
• History of morning sickness
• Adjuvant treatment
• Alcohol may have a protective effect (heavy drinker less likely to be sick)

Question 16

What are the symptoms of oral mucositis?

Answer 16

• Symptoms include pain, dry mouth, altered taste, ulceration (can lead to secondary infection).

Question 17

What are common chemo drugs that can cause mucositis?

Answer 17

5-FU, methotrexate, anthracyclines, cytarabine

Question 18

What are the preventataive measures for oral mucositis?

Answer 18

• Good oral hygiene including use of mouthwashes after brushing teeth
• Sucking ice cubes? – causes vasoconstriction so lessens the effect of chemotherapy (harder for chemo to get to the lining of the mucosa) – i.e. mephan

Question 19

How can you treat oral mucositis?

Answer 19

• Mouthwashes (usually with anaesthetic – e.g. Difflam)
• Topical steroids
• Sucralfate (currently difficult to get hold of) – used to treat stomach ulcers - protects mouth
• Antacid and oxetacaine (Mucaine®)
• Lignocaine gel – local anaesthetic
• A number of newer treatments are not classed as drugs but as medical devices
• Episil®, Gelclair® (most widely prescribed), Mucodis® - products that line the lining of the mouth – protect and allow healing – no actual active ingredient

Question 20

Diarrhoea is a common side effect of which 2 chemo drugs?

Answer 20

• Most often seen with 5-FU and irinotecan. Also occurs with majority of nibs
  Managed with loperamide (may need to exceed usual max dose (so double the dose)), codeine and even octreotide if very severe

Question 21

Which chemo drugs can cause alopecia?

Answer 21

Anthracyclines - (Ifosfamide/Cyclophosphamide)

Taxanes - Bleomycin Etoposide

Scalp cooling

Question 22

What is Plantar palmar erythrodysesthesia (PPE) (hand-foot syndrome) a common side effect of which drugs?

Answer 22

Commonly seen with 5-FU / capecitabine and with some of the nibs e.g. sunitinib, sorafenib, dabrafenib

Question 23

What are the symptoms of Plantar palmar erythrodysesthesia (PPE)?

Answer 23

• Can result in tenderness, redness, tingling and peeling of the skin on the palms and soles. Patients may even have difficulty walking

Question 24

How can you manage Plantar palmar erythrodysesthesia (PPE)?

Answer 24

• dose interruption and reduction
• chiropody
• urea based emollients
• cushioned footwear
• avoid long exposure to hot water
• oral analgesia
• pyridoxine (vitamin B6) – normally a high dose of 50mg TDS

Question 25

Which drug is used to prevent tumour lysis syndrome?

Answer 25

Prevent with hydration and allopurinol – xanthine oxidase inhibitor
- Allopurinol prevents formation of uric acid but inhibiting the enzyme

• Consider rasburicase (recombinant urate oxidase as humans lack this enzyme) for high-risk patients:

Avoid giving allopurinol and rascuricase at the same time – as they can counteract each other

Question 26

Which types of chemo drugs are likely to cause reproductivity toxicity?

Answer 26

Alkylating agents

Question 27

Which chemo drug is likely to cause pulmonary toxicity?

Answer 27

Bleomycin

Question 28

Which chemo drug is likely to cause nephrotoxicity?

Answer 28

Commonly seen with cisplatin, ifosfamide and methotrexate

For high dose MTX, give sodium bicarbonate infusions alkalinise urine to prevent the drug precipitating in the renal tubules (this is what MTX causes)

Question 29

Which chemo drug is likely to cause neurotoxicity?

Answer 29

Most often seen with cisplatin, oxaliplatin, vinca alkaloids (vincristine), bortezomib, thalidomide

Question 30

Which chemo drug is likely to cause cardiotoxicity?

Answer 30

¥ Mainly associated with anthracyclines (e.g. doxorubicin) but also seen with 5-FU, cyclophosphamide

Can try and prevent with a drug called dexrazoxane, different administration schedules (longer infusions) or alternative drugs e.g. mitoxantrone