CINV Flashcards

1
Q

what are some triggers to the chemoreceptor trigger zone

A

pregnancy, cytotoxic agents

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2
Q

what occurs upon afference impulses to vomiting center (VC)

A

efference impulses to salivation, resp, GI muscles

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3
Q

define acute CINV

A

n/v occurring within 24 hours of chemo

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4
Q

define delayed CINV

A

n/v occurring at least 24 hours post-chemo, often peaks 48-72 hours

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5
Q

define breakthrough CINV

A

n/v that occurs within 5 days post chemo despite optimal anti-emetic regimen used; requires rescue therapy with other antiemetics

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6
Q

define refractory CINV

A

n/v that occurs in subsequent chemo cycles despite maximum antiemetic protocol

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7
Q

define anticipatory CINV

A

n/v triggered by sensory stimuli associated with chemo admin

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8
Q

risk factors for CINV

A

females, history of motion sickness, previous CINV, pregnancy, younger age, anxiety (anticipatory)

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9
Q

what is the goal of antiemetic therapy

A

complete prevention (0-1 episodes/24 hours) for at least 3 days for high risk (HEC) or 2 days for moderate risk (MEC) after the last dose of chemotherapy

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10
Q

which drug class is the foundation of most CINV prophylaxis

A

the “setrons” - aka 5-HT3 RA
ondansetron, granisetron, palonosetron

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11
Q

which setron is best for delayed emesis

A

palonosetron

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12
Q

side effects of the setrons

A

headache, constipation
route/dose dependent risk of QT prolongation (mostly with IV ondansetron >16 mg)

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13
Q

which class of antiemetics is a good preventative for HEC, ESPECIALLY delayed CINV, but NOT for breakthrough

A

NK-1 inhibitors
aprepitant
fosaprepitant

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14
Q

drug interactions with the NK-1 inhibitors?

A

inhibits metabolism of dexamethasone so must reduce dexamethasone dose by 50%
other important CYP3A4 interactions (ex do not combine with ifosfamide)

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15
Q

which class of antiemetics is good for acute emesis, delayed emesis, HEC, MEC, even low emesis regimens but
NOTTTTT for brain tumors??

A

adrenal corticosteroids- dexamethasone!

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16
Q

pearls for dexamethasone?

A

dose reduce with aprepitant/fosaprepitant
may be modified when the chemo regimen already includes a steroid
not recommended with immunotherapies
not used in brain tumors

17
Q

adverse effects of dexamethasone

A

HTN, DM, GI upset/bleeding, agitation, itching, nerves, vomiting

18
Q

which drug is the newest preventative, also used for breakthrough CINV, can be used prn or for palliative care nausea, and has replaced haloperidol in many settings

A

olanzapine

19
Q

olanzapine adverse effects

A

increased risk of EPS when used with metoclopramide or haloperidol
QT prolongation
CNS depression
risk for falls in elderly
orthostatic hypotension

20
Q

which drug classes are used for prevention

A

setrons
NK-1 inhibitors
adrenal corticosteroids
olanzapine

21
Q

which drug classes are used for breakthrough

A

benzodiazepines (lorazepam)
metoclopramide
cannabinoids
phenothiazines or haloperidol

22
Q

how is lorazepam used for CINV?

A

it is not a true antiemetic, more an amnestic. helpful for anticipatory emesis when started prior to triggers

23
Q

side effects of metoclopramide

A

EPS

24
Q

what cannabinoid may be used for breakthrough CINV

A

dronabinol. also useful for appetite
no evidence supports marijuana over this

25
Q

side effects for phenothiazines/haloperidol

A

CNS depression, fall risk, EPS, QT prolongation
IV use- hydroxyzine, promethazine- severe tissue injury- contraindication for peripheral vein injection

26
Q

how to build the regimen

A

start with risk level of regimen
consider concurrent meds/diseases (QT, Beers, DDI)
consider effects on lifestyle (is sedation ok)
PO vs IV drugs
plan for breakthrough needs rather than wait

27
Q

how long to protect patients for period of CINV risk

A

HEC at least 3 days
MEC at least 2 days after last dose of chemo

28
Q

is PO or IV 5-HT3 RA more efficacious

A

they have equivalent efficacy when used at the appropriate dosing

29
Q

what is the best approach for minimal and low emetic risk regimens?

A

avoid scheduled antiemetics- opt for breakthrough approach

30
Q

what to do for breakthrough plan

A

it is easier to prevent n/v than treat it
always give a prn medication for immediate action
in the future- may need to change the initial preventative regimen

31
Q

definition of high emetic risk

A

> 90% frequency of emesis

32
Q

recommendation for high emetic risk regimen

A

4 drugs

33
Q

definition of moderate emetic risk

A

> 30-90% frequency of emesis

34
Q

recommendation for moderate emetic risk

A

3 drug regimen

35
Q

non-pharm strategies

A

eat small meals
drink water, sports drinks, pedialyte, flat ginger ale
eat cool foods
avoid hot foods, candles, perfumes
sniff good smells- aromatherapy, mint
fresh air

36
Q

what if multiple consecutive days of chemo?

A

delayed CINV may superimpose on acute
5HT3 RA prior to every day’s dose
dexamethasone daily then continued 2-3 days after
NK1 inhibitors daily, then 2-3 days after

37
Q

what are some of the high risk (>90%) for CINV drugs

A

anthracycline/cyclophosphamide
carmustine
cisplatin
cyclophosphamide
dacarbazine
mechlorethamine
streptozocin