Chemotherapy TRAEs Flashcards
What are causative agents of mucositis?
What are risk factors of mucositis?
What is the general pathophysiology for mucositis?
What is the grading for mucositis?
inflammatory –> epithelial –> ulcerative –> healing
What are strategies for mucositis prevention?
- Oral care
- Diet
- Oral Care
- Regular brushing with a soft-bristled toothbrush
- Regular flossing
- Use baking soda mouth rinses
- Avoid mouthwashes with alcohol
- Diet
- Adopt a soft diet
- Consume non-irritating foods
- Avoid crunchy, abrasive, spicy foods
- Use smaller bites and chew slowly
What’s the management for mucositis?
Mouth rinses/paste
- Magic mouthwash: diphenhydramine, sucralfate, Maalox
- 5-15 mL swish and spit (can swallow) up to four times daily
- Xyloxylin mouthwash: diphenhydramine, lidocaine, Maalox
- 5-15 mL swish and spit up to four times daily
- Dexamethasone 0.5 mg/5 mL alcohol free
- 10 mL four times daily (for patients on Everolimus)
- Triamcinolone paste: triamcinolone acetonide 0.1% dental paste
- Apply periodontally two to three times daily
- Use paste for a few mouth sores but wash for multiple
- Use lidocaine for those who have pain all around
Opioids
- Oral: liquid formulations of opioid products may be considered in the outpatient setting
- Intravenous: PCA may be utilized in admitted patients
Antimicrobials
- Not routinely used unless suspected infection
Nutritional Support
- Monitor nutritional intake and weight
- A soft diet and liquid diet are more easily tolerated
- Consider total parental nutrition (TPN) if inpatient and unable to tolerate oral diet
- MD Anderson has a Nutrition Support (NST) team to assist with management of these patients
- Mucositis this severe is seen more commonly in SCT patients
Dry mouth
- Xerostomia or hyposalivation may occur – these can further aggravate inflamed tissue
- Sip water as needed
- Biotene and other saliva substitutes
- Chew sugarless gum to stimulate salivary flow
- HFS aka ______________.
- Describe the clinical manifestations
- Causative agents?
- HFS aka Palmar-Plantar Erythrodysesthesis (PPE)
- Characterized as local inflammatory tissue reaction
- Starts with a localized tingling sensation on the palms/soles of the feet and can affect other common pressure points (such as the waistline and bra lines)
- Painful erythema, dryness, cracking, edema, and rash à burning pain, blistering, ulceration, and desquamation
- Common causative agents in gynecology malignancies:
- Liposomal Doxorubicin**
- ~50%
- Lenvatinib
- Docetaxel
- 5-Fluorouracil and Capecitabine (~40% with capecitabine)
- Liposomal Doxorubicin**
What is the CTCAE grading for HFS?
What are prevention strategies for HFS?
Thick creams
- Udder Cream, Lubriderm, Corona cream BID à keeps skin moisturized (avoid scented lotions)
- Typically doesn’t require the urea-based creams used with 5-fluorouracil
Avoid prolonged sun and hot water exposure
Avoid increased pressure on the soles of the feet or palms of hands and tight clothing
Regional cooling during liposomal doxorubicin infusion (MD Anderson practice)
- Ice packs (but the half life of doxil is longer than the infusion time of course)
What is the treamtent of HFS?
- Pain relievers: acetaminophen or ibuprofen
- May required medium to high potency steroid creams (ex: triamcinolone or clobetasol) or a methylprednisolone dose pack if severe
- Liposomal doxorubicin - consider holding therapy and/or decreasing dose by increments of 5-10 mg/m2
- Liposomal doxorubicin 40 mg/m2 (as single agent) ->35 -> 30 mg/m2
- Liposomal doxorubicin 30 mg/m2 (in combination) -> 25 -> 20 mg/m2
- Lenvatinib – consider holding therapy and decreasing as follows: 20 mg -> 14 -> 10 -> 8 mg
What are the clinical symptoms of peripheral neuropathy?
What are the causative agents of PN?
Clinical symptoms of PN
- Pain
- Numbness
- Tingling in fingers and toes
- Pain sensation (often presenting in a glove and stocking pattern)
Causative agents of PN
- Taxanes: Paclitaxel** and Docetaxel
- Platinums: Cisplatin** and Carboplatin
- How do taxanes promote peripheral neuropathy?
- Taxane-related PN occurs in ____% of patients (usually mild) and increases in severity with cumulative doses > _____ mg/m2
- What are risk factors for PN?
- Taxanes promote formation of abnormal microtubule bundles leading to disruption of normal cell function and proliferation
- Taxane-related neuropathy occurs in 90% of patients (usually mild in presentation) – increases in severity with cumulative doses > 1,400 mg/m2 of paclitaxel
- Risk factors include pre-existing neuropathy, older age, and higher doses per cycle
What is the CTCAE grading for peripheral neuropathy?
What are non-pharma and pharm treatment for symptoms of peripheral neuropathy?
Non-pharmacologic treatment
- No current prevention modalities
- Examine feet and skin daily
- Wear loose clothing
- Adjust water temperate to avoid burns
- Wear comfortable shoes
- Use railings or other devices for support when moving around
Pharmacologic treatment
- Anticonvulsants
- Gabapentin or pregablin
- Antidepressants
- Amitriptyline or duloxetine
- Pain medications
- Vitamin B6 100 mg PO daily
What are therapy adjustments for peripheral neuropathy?
Paclitaxel Dose Adjustments
- Consider reducing by 15-25% depending on severity
- Ex: 175 mg/m2 –> 150 mg/m2 –> 135 mg/m2
- Consider changing frequency
- Ex: every 3 weeks –> weekly
- Less frequently done in clinical practice
Changing Chemotherapy Agents
- Cisplatin –> carboplatin
- Paclitaxel –> docetaxel (not albumin-bound paclitaxel)
What are the clinical manifestations of dermatitis?
What is traits of immunotherapy-related dermatitis?
What is the CTCAE grading of dermatitis?
Clinical manifestations
- A general term used to describe commonly occurring skin irritations
- Commonly presents as itchiness, dryness, swelling, or reddening, but in more serious cases, can present as blistering, oozing, crusting or flaking
- Commonly caused by irritants, allergens, food or medication exposure, and immune system dysfunction
Immunotherapy related dermatitis
- Typically presents within the first two cycles of treatment (the first several weeks)
- Incidence of all-grade dermatologic toxicity with PD-1/PD-L1 inhibitors is 17%-40%
- Characterized by the presence of macules and papules (or morbilliform rash)
- Associated symptoms include: pruritis, burning, tightness
How do you treat immunotherapy-related dermatitis?
What is the grading for MEKi-related dermatitis and how do you manage?
