CINV Flashcards
Which chemo agents have high emetic risk?
Cisplatin Carmustine Dacarbazine Cyclophosphamide (over 1500 mg/m2) Streptozocin Dactinomycin Mechlorethamine
Which agents cause delayed emesis?
Cisplatin (onset 1-6 hours, duration 24-120)
Carboplastin (onset 2-6, duration 1-48)
Cyclophosphamide (onset 6-12, duration 6-36)
Doxorubicin (2-6, 6-24)
Ifosfamide (3-6, 24-72)
Mitomycin (2-6, 18-24)
What are the serotonin antagonists? When do we use them? Adverse effects?
All the setrons (set = serotonin) Ondansetron Granisetron Dolasetron Palonosetron (long acting)
Used for ACUTE n/v in moderate/high emetic risk
Worry about QT prolongation (don’t use in arrhythmia pts)
Which 5ht antagonist is good for delayed CINV?
Palonosetron ONLY
Which 5ht antagonist is bad for RINV?
Dolasetron
Palonosetron
Which 5ht antagonist is good for PONV?
All of them!!!
What are the corticosteroids? When are they used? Adverse effects?
Dexamethasone, prednisone, methylprednisolone
Used as monotherapy for low risk, or with 5HT antagonists in high risk
Effective for acute and delayed (she italicized delayed). Also useful for PONV and RINV.
Worry about mood changes, hyperglycemia, weight gain, insomnia
What are the NK1 antagonists? When are they used? Adverse effects?
Aprepitant, fosaprepitant, netupitant, rolapitant (Pitant = Petite, NK sounds like MK like Marykate who is petite)
They’re used in combination with dexamethasone and a 5ht antagonist to prevent HIGH risk N/V for acute and delayed (italicized delay)
Worry about fatigue, hiccups, anorexia, dyspepsia
Drug interactions with the NK1 antagonists?
Fosaprepitant/aprepitant:
CYP3A4 substrate (inhib and induc) and 2c9 inducer
Doses of steroid need to be reduced if used for antiemetic
Avoid with ifosfamide
Netupitant
CYP3a4 substrate and inhibitor
Reduce doses of steroids
Rolapitant
CYP3a4 substrate, cyp2d6/p-gp inhibitor, do not have to reduce dexamethasone!!
What are the dopamine antagonists? Use? Adverse effects?
Phenothiazines (promethazine, prochlorperazine), metoclopramide, butyrophenones (droperidol, haloperidol)
Metoclopramide increases GI motility to decrease food in stomach!!
Used in low-risk or moderate/high if other agents intolerable; used for PRN/rescue as well!
Worry about EPS, sedation
Metoclopramide - abdominal pain (increases GI motility)
Phenothiazines - anticholinergic (sleepy), confusion, ECG changes
Butyrophenones - black box for QT prolongation, hyppotension, arrhythmias
What are the antihistamines? Place in therapy? Adverse effects?
Diphenhydramine, meclizine, scopolamine patch
Adjunctive for motion sickness (not alone) or used as a rescue
Adverse effects: drowsiness, confusion, blurred vision, dry mouth
What are the anxiolytics? Place in therapy? Adverse effects?
Benzodiazepines (lorazepam, alprazolam)
Used for anticipatory n/v, breakthrough, and adjunctive
Safety: Sedation, disorientation, hypotension, respiratory depression
What are the cannabinoids? Place in therapy? Adverse effects?
Dronabinol, nabilone
Refractory CINV and appetite stimulant
Side effects - drowsiness, confusion, hallucinations, mood changes, memory loss
What is olanzepine? Place in therapy? Adverse effects?
2nd gen antipsychotic
Prevents delayed and breakthrough CINV
Side effects: sedation, dry mouth, weight gain
When you have high emetic risk, what do you use?
Day one:
5HT antagonist and Dexamethasone
Day 2-3
Dexamethasone and aprepitant
Day 4
Dexamethasone
When you have moderate emetic risk, what do you use?
Day one:
5HT antagonist
Dexamethasone
Days 2-3
Aprepitant (NCCN)
Dexamethasone
When you have low emetic risk, what do you use?
Dexamethasone on day one, only
Or prochloreprazine or metoclopramide or 5HT antaogonist
Recommendations for multiday chemotherapy?
Continue for each day of chemo and 2 days after
NCCN: If high risk, continue for 3 days after at least
What is anticipatory n/v?
Seeing/smelling something chemotherapy related and suddenly feeling sick
Give lorazepam (0.5-2 mg)
Should antiemetics for breakthrough tx be given prn or at specific times?
At specific times!
Radiation induced N/V - high risk?
High risk is total body irradiation
5HT antagonist before each fraction until 24 hours after (steroid daily for fractions 1-5 with or without dexamethasone)
Radiation induced N/V - moderate risk?
Upper abdomen, craniospinal
5HT antagonist before each fraction with or without steroid daily for fractions 1-5
Radiation induced N/V - low risk?
5HT antagonist before each fraction or as needed
Sccheduled prior to each fraction if N/V occurs
Radiation induced N/V - minimal risk?
Breast, head and neck, extremities
As needed dopamine or 5HT antagonist, schedule if N/V occurs
