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Stage 4 Content > Clinical chemotherapy > Flashcards

Clinical chemotherapy Flashcards

1
Q

What are the 4 different types of Chemotherapy-induced nausea and vomiting (CINV)

A
  • Acute - patients experience n&v within 24hrs of chemo
  • Delayed - patients experience n&v after 24hrs but within 2-5 days
  • Anticipatory - conditional response that occurs after chemotherapy treatment. can be triggered by sight and smell
  • Breakthrough - occurs despite prophylaxis treatment
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2
Q

What drugs can be used for CINV

A
  • Ondansetron and Palonsetron
  • Aprepitant
  • Dexamethasone
  • Metoclopramide
  • Cyclizine
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3
Q

What is the MOA of Ondansetron and Palonsetron?

A

They are selective serotonin (5HT3) receptor antagonist

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4
Q

What is the MOA of Aprepitant

A

It is a neurokinin-1 (NK1) receptor antagonist and is a relatively new drug

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5
Q

What is the MOA of Dexamethasone

A

It is a corticosteroid that can be used for high risk acute or delayed CINV

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6
Q

What is the MOA of Metoclopramide

A

It is a D2 receptor antagonist and tends not to be used longer than 5 days because it prolongs the QT interval

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7
Q

What is the MOA of Cyclizine

A

It is a H1 receptor antagonist and has anti-muscarinic activity

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8
Q

What are the 2 pathways of CINV

A

-Peripheral pathway - it is primarily involved in the acute phase of CINV.
Chemoreceptors: (5HT3 and D2 in the GI tract) and liver are involved.

-Central pathway - it is predominantly involved in the delayed phase of CINV.
The receptors involved in the chemoreceptors trigger zone are D2, 5HT3, NK1

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9
Q

How can Dexamethasone be used for CINV?

A

For Acute CINV - use IV before chemotherapy

For delayed CINV - use orally for a few days after chemo

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10
Q

How is Ondasetron used for CINV?

A
  • it can increase QT prolongation but that is dose-dependent
  • smaller doses used if over 75 years old
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11
Q

Compare palonsetron to ondansetron

A

Palonsetron has a longer half life (40hrs) in comparison to Ondansetron (5hrs)

So if palonsetron is given in the acute phase of chemo then it is not required to take home

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12
Q

What is mucositis/stomatitis and drugs commonly cause it?

A

Inflammation and damage of the mucous membranes - lining of the mouth and other part of the GI tract.

The antimetabolite drugs such as 5-FU, Capcitabine, Methotrexate commonly cause it

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13
Q

How is mucositis/stomatitis managed

A

Oral hygiene advice:

  • avoid spicy food
  • use a soft toothbrush
  • brush 2-3x a day

could use mouthwash such as chlorohexidine gluconate

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14
Q

What is Hand-foot syndrome (palmar plantar erythrodysesthesia) and drugs commonly cause it?

A

Patients hand and foot become red & sore then peels and ulcerate.
May require dose reduction or delay in chemotherapy in this case.

capecitabine is the most common cause of this.

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15
Q

How is Hand-foot syndrome (palmar plantar erythrodysesthesia) managed

A

Use moisturising cream for hand and feet so skin doesn’t dry out

Can use Udder cream that contains urea

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16
Q

How does Capcitabine cause Hand-foot syndrome

A

It is a pro-drug and the enzyme which breaks it down is found a lot in the hand and feet

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17
Q

What is the most common cause of chemotherapy-induced diarrhoea

A

Irinotecan (used to treat colorectal cancer) - its metabolite (SN38) causes diarrhoea

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18
Q

How do you treat diarrhoea WITHIN 24 hrs of having Irinotecan

A

Atrapine subcutaneous

19
Q

How do you treat diarrhoea AFTER 24 hrs of having Irinotecan

A

High dose Loperamide

20
Q

What can myleosuppresion lead to?

A

Anaemia - so fatigue

Neutropenia - so more likely to have an infection

Thrombocytopenia - so more likely to have a bleed

21
Q

What is the common side effect of FEC-T

A
  • Neutropenia
  • Can give GCSF (Granulocyte colony-stimulating factor) which stimulates the bone marrow to produce granulocyte and bone marrow and release it into the blood.
22
Q

What is neutropenic sepsis

A

a patient with low levels of neutrophils + an infection

it is a medical emergency that is a urgent referral.

23
Q

How is neutropenic sepsis treated

A

Broad spectrum antibiotics

24
Q

What is a common side effect with kinase inhibitors (-nib)?

A

Can develop an acne kind rash - more likely w/ EGFR inhibitors

Hair problems

  • their hair becomes brittle and thin.
  • eyelash becomes very long - common with EGFR inhibitors
25
Q

What advice/ treatment can be given for the acne kind rash linked to kinase inhibitors

A

The patient can moisturise or topical antibiotics/steroids can be used

26
Q

How does neuropathic pain occur in palliative care

A

the cancer tumour grows and pressed on nerves

27
Q

What is the neuropathic pain ladder?

A

Step 1: TCA (e.g amitriptyline) or AC

Step 2: TCA (e.g amitriptyline) AND AC (e.g Gabapentin)

Step 3: TCA (e.g amitriptyline) AND alternative AC (e.g valproate)

Step 4: specialist use Ketamine or methadone

28
Q

What is the MOA of amitriptyline for neuropathic pain and its side-effects

A

It prevents the re-uptake of noradrenaline or serotonin and takes 3-7 days to see the effect

Taken at night for neuropathic pain

side-effects: drowsiness and constipation

29
Q

What are the side-effects of Gabapentin

A

Drowsiness and dizziness

it is an analogue of PABA and binds to site in the CNS

30
Q

What classes of laxative are there?

A

Stimulant - e.g Senna

Softner - e.g docusate

Bulk formers - ispaghula husk

Osmotic - movicol, lactulose

31
Q

How is breathlessness managed?

A
  • oxygen prescribed for hypoxaemic patients ONLY

- low dose opioid could be used e.g morphine 1-2 mg

32
Q

What are the causes of N&V

A
  • chemotherapy
  • biochemical imbalance
  • fear and anxiety
  • raised intracranial pressure
  • muscle contraction
33
Q

What is the most common adverse effect of DOXORUBICN (and other anthracyclines) and how is it managed?

A
  • cardiotoxicity by generating OH radicals

- it is a dose limiting problem so there’s a max lifetime dosage (450mg/m2)

34
Q

What is the most common adverse effect of Cyclophosphamide and how is it managed?

A

Haemorrhagic cystitis because of acrolin byproduct which is reactive and carcinogenic so causes damage to bladder

  • Give mesna to react with acrolin
  • aggressively hydrate
35
Q

Why is FOLINIC ACID, Potassium chloride and sodium bicarbonate used after the treatment of methotrexate?

A

Potassium chloride and sodium bicarbonate;
-it ionises methotrexate which is acidic so methotrexate becomes more water soluble so can be excreted renally

FOLINIC ACID:
-Can form methyl donor and formyl donor w/out using dihdryfoloate reductase (DHFR) - the enzyme methotrexate inhibits. This means normal DNA can still be synthesised.

36
Q

What are the 3 types of pain

A

Somatic pain - pains in the bone or muscle - deep, dull ache

Visceral pain - pain related to internal organs - can be throbbing/pressure pain

Neuropathic pain - pain in nerves - can be burning/stinging

37
Q

What is the WHO analgesic pain ladder

A

Step 1 - Non-opioid - paracetamol

Step 2- weak opioid - 15-30mg codeine every 4 hrs PRN + adjuvant

Step 3 - strong opioid - morphine 10mg every 4 hrs PRN + non-opioid/adjuvant

38
Q

How do you titrate a strong opioid from a weak opioid

A
  • add up codeine dose used in last 24hrs then divide by 10
  • divide the dose achieve by 2 to get the BD dose
  • IR breakthrough opioid is 1/6 TDD
39
Q

How do you titrate a patients dose who has not had a weak opioid

A
  • titrate immediate release opioid 4hrly PRN
  • so add up what the patient had in 24hrs then divide by 2 to get a MR opioid BD
  • IR opioid PRN - 1/6th TDD
40
Q

How is fentanyl used?

A
  • used for stable pain
  • can be used in renal impairment
  • has a matrix and resvovoir patch.
  • damage to resovioir patch can cause dose dumping
  • the patch should be replaced every 72 hrs
  • it should not be placed on hot skin as it can lead to over dose
41
Q

What is the antiemetic treatment ladder

A
  • Step 1: no antiemetics pre-chemo, metoclopramide take home
  • Step 2: IV Dexamethasone pre chemo, Metcolopramide take home
  • Step 3: IV Ondansetron/Dexamethasone pre-chemo, then Ondansetron/dexamethasone/metoclopramide take home
  • Step 4: Same as step 3 with either Aprepitant in addition or Palonsetron instead of Ondansetron (IV/oral)
  • Step 5: As step 4 with BOTH Aprepitant AND Palonsetron in place of Ondansetron (IV&oral)
42
Q

What are the signs and symptoms of hypercalcemia and how is it managed

A

signs and symptoms:

  • drowsiness/confusion/coma
  • nausea/vomiting/constipation
  • thirst/polyuria

Diagnosis:
blood test - ionised calcium levels or corrected calcium

Management:

  • rehydrate
  • bisphosphonate - given in severe cases eg Zoledronic acid IV - its potent and lasts a month
43
Q

What are the signs and symptoms of superior vena cave obstruction (SVCO) and how is it managed

A

signs and symptoms:

  • breathlessness
  • swollen neck
  • visible swollen veins
  • oedema on the face, hand and neck

Management:

  • stent to open up the vein
  • high dose dexamethasone
  • radiotherapy to the tumour
44
Q

What are the signs and symptoms of spinal cord compression and how is it managed

A

signs and symptoms - can be non-specific:

  • pins and needles in hand and feet
  • paralysis of lower limbs
  • urinary or faecal incontinence

Management:

  • high dose dexamethasone for inflammation and oedema
  • radiography

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