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Oncology > CINV > Flashcards

CINV Flashcards

1
Q

Breakthrough CINV

A

Nausea and/or vomiting that occurs within 5 days post chemotherapy despite optimal antiemetic regimen used; requires rescue therapy with other antiemetics

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2
Q

Refractory CINV

A

Nausea and/or vomiting that occurs in subsequent chemotherapy cycles despite maximum antiemetic protocol

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3
Q

What is the importance of VC?

A

Afferent impulses to VC trigger efferent impulses to salivation, resp, GI muscles

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4
Q

Anticipatory CINV

A

Nausea and/or vomiting that is triggered by sensory stimuli associated with chemotherapy administration

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5
Q

List key neurotransmitters/drug classes (NT) that mediate CINV

A
  • Histamine antagonist
  • Muscarinic antagonist
  • Dopamine antagonist
  • Cannabinoids
  • 5HT3 antagonist
  • Substance P (Neurokinin-1)
  • Benzodiazepine
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6
Q

What are the risk factors of CINV?

A
  • Females
  • h/o motion sickness
  • previous CINV
  • pregnancy
  • younger age
  • anxiety (anticipatory)
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7
Q

What is the goal of treatment of CINV?

A

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

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8
Q

What drug classes prevent CINV?

A
  • 5-HT3-RA
  • NK-1 inhibitors
  • Adrenal corticosteroids = dexamethasone
  • Olanzapine
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9
Q

Which 5-HT3 Receptor Antagonist are good for acute HEC, MEC, low risk & breakthrough emesis?

A

Any of the 3: Granisetron (Kytril), Ondansetron (Zofran)

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10
Q

Which 5-HT3 Receptor Antagonist are good for acute, HEC, MEC, and delayed emesis?

A

Palonosetron IV that may “last” for 2-3 days

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11
Q

What are the ADE of 5-HT3-RA?

A
  • non-sedating
  • no EPS risk
  • headache
  • constipation most common
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12
Q

What are the counseling points for 5-HT3-RA?

A
  • Route and dose-dependent risk of prolongation of the QT interval
    • Most often associated with IV ondansetron when doses exceed 16 mg dose (FDA max)
  • Also risk in congenital QTc or acquired QTc prolongation, electrolyte abnormalities
    • Palonosetron, granisetron do not contain this warning
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13
Q

NK1 Antagonist

A
  • Preventative for HEC, esp those with delayed nausea and emesis
    • Combined with 5-HT3 RA, steroid, +/- olanzapine for HEC
  • NOT for breakthrough
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14
Q

What are the ADEs of NK1 antagonist?

A
  • Fosaprepitant, aprepitant, netupitant inhibit metabolism of dexamethasone – must reduce dexamethasone doses by 50%
  • Also other important CYP3A4 metabolism effects – check interactions, esp with chemotherapy such as ifosfamide, other medications
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15
Q

Dexamethasone

A
  • Should be continued for 2-3 days for regimens with delayed emesis risks
  • Dose reductions when given with aprepitant or FOSaprepitant (inhibition of DXM metab)
  • May be modified or omitted when the chemotherapy regimen already includes a steroid (like in ALL)
  • NOT used in brain tumors as antiemetic may reduce chemotherapy passage through BBB
  • NOT recommended with immunotherapies and cellular therapies
  • HEC, MEC, low - acute, delayed, breakthrough
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16
Q

What are some ADE of Dexamethasone?

A
  • HTN
  • DM
  • GI upset/bleeding
  • agitation
  • “itching” or “nerves” or even vomiting when given rapid IVP
17
Q

Olanzapine

A
  • The “newest” preventative, also breakthrough CINV
  • Highly effective, latest addition as a 4-drug regimen for HEC, can be used prn, also used for palliative care nausea
  • HEC, MEC, breakthrough, refractory - acute, delayed
18
Q

What are some ADE of Olanzapine?

A
  • Caution incl. when used with metoclopramide or haloperidol – increased EPS
  • Risk of prolongation of QT interval
  • CNS depression
  • Use with caution in patients at risk for falls (e.g., elderly, debilitated, frail), or at risk for orthostatic hypotension
19
Q

What is the dose of Olanzapine?

A

5 mg daily pre-chemotherapy, then daily x 2-3 days post-HEC
* can also be prn daily for breakthrough

20
Q

What are some breakthrough options?

A
  • Benzodiazepine (Lorazepam)
  • Metoclopramide
  • Cannabinoids
  • Phenothiazines or Haloperidol
21
Q

ADRs of Benzodiazepine

A
  • CNS depression - fall risk for elderly
  • Hypotension
22
Q

ADRs of Metoclopramide

A

EPS reactions

23
Q

ADRs of Phenothiazines or Haloperidol

A
  • CNS depression
  • Increased EPS risks with concurrent haloperidol or metoclopramide
  • QT prolongation risk
24
Q

Phenothiazines

A

Promethazine, prochlorperazine - breakthrough, low risk

25
Q

Antihistamine/anticholinergics

A

Benadryl, scopalamine - acute, breakthrough

26
Q

What parenteral anticancer agents have high emetic risk?

A
  • AC with anthracycline and cyclophosphamide
  • Carboplatin
  • Carmustine
  • Cisplatin
  • Cyclophosphamide
  • Doxorubicin
  • Dacarbazine
  • Ifosfamide
27
Q

What is the treatment option A for high emetic risk?

A

Before chemo:
1. Olanzapine
2. NK1 RA
3. 5-HT3 RA
4. Dexamethasone

Days 2,3,4
1. Olanzapine
2. Aprepitant if it is used before
3. Dexamethasone

28
Q

What is the treatment option B for high emetic risk?

A

Before chemo:
1. Olanzapine
2. Palonosetron
3. Dexamethasone

Days 2,3,4
1. Olanzapine

29
Q

What is the treatment option C for high emetic risk?

A

Before chemo:
1. NK1 RA
2. 5-HT3 RA
3. Dexamethasone

Days 1, 2, 3:
1. Aprepitant if it was used before
2. Dexamethasone

30
Q

Which parenteral anticancer agents are moderate emetic risk?

A
  • Busulfan
  • Carboplatin
  • Carmustine
  • Cyclophosphamide
  • Cytarabine
  • Daunorubicin
  • Doxorubicin
  • Irinotecan
  • Methotrexate
31
Q

What is the treatment option D for moderate emetic risk?

A

Before chemo:
1. 5-HT3-RA
2. Dexamethasone

Days 2, 3, 4:
1. Dexamethasone
OR
1. 5-HT3-RA

32
Q

What is the treatment option E for moderate emetic risk?

A

Before chemo:
1. Olanzapine
2. Palonosetron
3. Dexamethasone

Days 2,3,4
1. Olanzapine

33
Q

What is the treatment option F for moderate emetic risk?

A

Before chemo:
1. NK1 RA
2. 5-HT3 RA
3. Dexamethasone
​
Days 2, 3, 4:
1. Aprepitant if it was used before
2. Dexamethasone

34
Q

If multiple CONSECUTIVE Days of chemotherapy

A
  • 5-HT3 RA prior to each day’s doses
  • Dexamethasone daily, then continued 2-3 days post chemo
  • NK1 RA

Oncology (14 decks)

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