Cumulative Final-Oncology (Weddle) Flashcards
Anticipatory N/V
Learned response conditioned by severity and duration of previous emetic reactions from prior chemo cycles
**May be provoked by sight, smell, sound
Acute N/V
Within 24H of chemo
Delayed N/V
> 24H after chemo
Breakthrough N/V
N/V that occurs even if on scheduled anti-emetics prior to chemo
Refractory N/V
N/V that persists despite appropriate anti-emetics
Enterochromaffin cells lining the GI tract contain large stores of ______
Serotonin; released in mass quantities + triggers N/V
Neurotransmitters implicated in CINV
Dopamine, Histamine, Acetylcholine, serotonin, substance P
Adding level ___ or ____ agents increases the emetogenicity of the combination regimen by 1 level per agent
3 or 4
Risk factors for CINV
-Women>men
-Young>old
-Prior hx of motion sickness
-Previous hx of morning sickness
-Anxiety/high pre-treatment anticipation of nausea
-Chronic ethanol may be protective
Oral therapy is (>, =, <) IV therapy
=
Which classes will we always have for emetogenicity?
5HT3 antagonist and dexamethasone (steroid)
RF for mucositis
-Pre-existing oral lesions
-Poor dental hygiene
-Ill-fitting dentures
-Combined modality tx (chemo + radiation)
Prevention + tx of mucositis
-Avoid rough food, spices, salt, and acidic fruit
-Eat soft foods/liquid, soft cheeses, and eggs
-Avoid smoking and alcohol (+ alcohol-based mouthwash)
General mouthcare strategies for mucositis
-Baking soda rinses
-Soft-bristle toothbrush
-Saliva substitute
Pain management options for mucositis
-Topical anesthetic: Lidocaine, diphenhydramine, antacids, mary’s magic mouthwash
-Oral cryotherapy (ice chips)
-Sucralfate (not commonly used)
-Opioids ATC if mod-sev mucositis
-PCA pump is common (if this severe, change chemo for next round)
Only thing to help mucositis is ____
WBC count increasing
Low WBC count is _____
neutropenia
Low platelet count is ____
thrombocytopenia
Low RBC count is ____
anemia
Nadir definition
Absolute lowest WBC count during a cycle of chemo
ANC=_____x_____
WBC x % granulocytes
Typical guidelines to safely administer chemotherapy
WBC > 3000 OR ANC > 1500 AND platelet > 100000
Febrile neutropenia definition
Neutropenia + fever (>101) –> must get to hospital and tx with antibiotics
Use primary prophylaxis for neutropenia if we know:
the pt’s chemo regimen is expected to cause >20% incidence of febrile neutropenia
Use secondary prophylaxis for neutropenia is we know:
Pt experienced neutropenic complication from previous cycle of chemo
Agents for neutropenia
Filgrastim and Pegfilgrastim
Filgrastim frequency
1 injection every day
Pegfilgrastim frequency
***NON-LINEAR PK
On-Pro or 1 time injection 1 time after chemo
Who decides which biosimilar to use for neutropenia?
The insurance company
ADR of filgrastim
-Flu-like sx
-Bone and joint pain
-DVT
Tx for thrombocytopenia
Platelets (only give if <10,000 or symptomatic)
Significance of anemia in cancer
FATIGUE; pts report it is more troubling than N/V/pain
Chemo-induced anemia is defined as _______
Hgb <11 or >2 g/dL drop
Tx for anemia
-If pt is symptomatic (hard time getting around)
>Transfuse as indicated
>Consider ESA (risk: shortened overall survival and/or increased risk of tumor progression)
>Perform iron studies
ESAs are not recommended for patients that…
-Are receiving myelosuppressive chemo for CURING disease
-In pts with cancer NOT receiving chemo
-In pts receiving non-myelosuppressive chemo
Do not use ESA to correct Hgb > ____
12 g/dL
Difference between epoetin and darbepoetin
Darbepoetin has a prolonged half-life
Prior to ESA, must get baseline _____ test
iron
Importance of oral iron + food
Iron absorption will be decreased if food is eaten 2h before or 1 hour after iron ingestion
How to tx myalgia/arthraligia
NSAID or opioid
How to tx hemorrhagic cystitis
Hydration + Mesna
How to tx HF from doxorubicin
Dexrazoxane
How to tx peripheral neuropathy
Change infusion rate
Adjunctive pain med (gabapentin/amitriptyline)
How to tx pulmonary toxicity from bleomycin
CCS
Problem with type 1 chronic cardiac dysfunction: doxorubicin
Related to cumulative dose of anthracycline
-Once EF drops, it is irreversible
-Take off anthracycline + never put back on
Type 2 chemo cardiac dysfunction: trastuzumab
-Not related to cumulative dose
-It is reversible
-Take pt off until EF comes back up, then they can start trastuzumab again
Do not use ____ with trastuzumab
anthracycline bc increases risk for cardiac toxicity
Give ____ for anemia if extremely debilitated or severe SOB
Blood transfusion
Onset for ESA is ____
Weeks
Assessment of pain
O: Onset
P: provokes (makes it worse)
Q: quality (what does it feel like)
R: radiate
S: severity
T: time (when did the pain start)
U: understanding (how much we can improve)
What should you ask pts BEFORE starting opioids?
Are you having regular BM?
Tier 1 pain meds
Non-opioids (pain 1-3)
-Acetaminophen (Tylenol)
-Ibuprofen
-ASA
Tier 2 pain meds
Combo products/mild opioids (pain 4-6)
-Norco
-Hydrocodone/ibuprofen
-Tramadol
-Percocet
-Oxycodone/ASA
-Oxycodone/ibuprofen
-Codeine/APAP
Tier 3 pain meds
Opioids (pain 7-10)
-Morphine
-Hydromorphone
-Fentanyl
-Oxycodone
-Methadone
Does tier 2 medications have max doses?
YES
Does tier 3 medications have max doses?
NO
____is metabolized in the LIVER and has active metabolites excreted RENALLY
Morphine
**Must have liver and renal function
Use hydromorphone with caution in ____ dysfunction
Liver
Oxycodone is metabolized by ____. Use with caution in ____ dysfunction. Which dosage form is not available?
CYP2D6
Liver
IV
If pt has liver or renal dysfunction, it is safe to use ____
Fentanyl
Important info about fentanyl
-Do not start opioid naive pt on this
-Risk for addiction and abuse
-REMS protocol
-Respiratory depression may occur
-Temp-dependent increase in release
If really high dose opioid and no relief, switch to ____
Methadone; helpful for neuropathic pain
Do not give methadone to a patient with ____
Poor mental status
Get baseline ____ prior to methadone initiation
EKG
When switching between opioid agents, may reduce dose by ____% due to cross tolerance
25%
Pruritis (itching) most often seen with ___ administration
Morphine
Patients do not develop tolerance to _____
Constipation
If pt on opioids and develops respiratory depression, what is the next step?
-Hold opioid
-Give dilute naloxone
Use caution giving PCA to pts with _____
Sleep apnea
Don’t treat _____ with opioids
Anxiety/depression
____ work well for bony mets (throbbing/achy pain)
NSAIDs
Hypercalcemia etiology
Bony mets stimulate osteoclasts in bone marrow and renal calcium retention
Calcium 10-12 mg/dL (mild)
Don’t realize anything is going on
Calcium 12-14 mg/dL (moderate)
Pt begins to get confused
Calcium >14 mg/dL (severe)
Pt may get seizures/go into a coma
Corrected calcium equation
Serum Calcium + 0.8 (4-serum albumin)
***Normal calcium: 8.5-10 mg/dL
Diagnosing skeletal related events
-Symptoms (bony mets or tenderness)
-Scans (radionucleotide bone scan)
-Other scans (CT, MRI, PET)
Bony mets can cause a large release of ____ into the bloodstream
Calcium
If calcium level is mild, what is tx?
drink fluid and stay hydrated
If calcium level is moderate, what is tx?
introduce bisphosphonate (zoledronic acid, pamidronate) + HYDRATION!!!!!!!
If calcium level is severe, what is tx?
HYDRATION, bisphosphonate, calcitonin (if calcium does not drop after 24H)
How to tx refractory HCM
Denosumab
How to treat chronic HCM
Zaledronic acid or pamidronate
Why are loop diuretics not used up front?
Diuretics not used up front bc already dehydrated; once at baseline, then think about loop diuretics
If an IV bisphosphonate is needed for skeletal related events, does it need to be renally dose adjusted?
YES!!!!!!!!!!!!!!!!!!
If an IV bisphosphonate is needed for hypercalcemia or malignancy, does it need to be renally dose adjusted?
NO!!!!!!
Why would denosumab be used instead of a bisphosphonate?
It does not need to be renally dose adjusted for pts with renal dysfunction and it can be given SQ, whereas bisphosphonates can only be used IV
Radioisotopes are delivered ____ to the tumor
More specifically
SE of radioisotopes
Expensive and may cause myelosuppression
What supplements should a patient receive if they are taking bisphosphonates?
Calcium and Vitamin D
Difference between cost/time between zaledronic acid and pamidronate
Zoledronic acid: short infusion time (15 min) and ~$70
Pamidronate: longer infusion time (2H) and cheaper
Frequency and indication for denosumab
Monthly; may suppress residual osteoclast function in pts who poorly respond to bisphosphonates
Denosumab considerations
-Correct hypocalcemia prior to initiation
-Supplement calcium and vit D daily
-NO RENAL ADJUSTMENTS
-Expensive
ADR of HCM therapy
Osteonecrosis of the jaw (boney jaw)
-IV»PO
-Oral infection
-Zaledronic > Denosumab >Pamidronate
**Get baseline dental evaluation prior to tx
Possible tx options for osteonecrosis of the jaw
-Palliative
-Pain control
-Chlorhexidine
-Antibiotics
-Conservative surgery
Do not use bisphosphonates if CrCl < ___ ml/min
30
Other ADR of denosumab»_space; zaledronic acid
Hypocalcemia
Bone pain
N/diarrhea
Fatigue
What frequency do we normally use HCM agents for?
Q3month dosing
