Cumulative Final-Oncology (Weddle) Flashcards by Meghan Collins

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

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Acute N/V

Within 24H of chemo

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Delayed N/V

> 24H after chemo

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Breakthrough N/V

N/V that occurs even if on scheduled anti-emetics prior to chemo

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Refractory N/V

N/V that persists despite appropriate anti-emetics

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Enterochromaffin cells lining the GI tract contain large stores of ______

Serotonin; released in mass quantities + triggers N/V

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Neurotransmitters implicated in CINV

Dopamine, Histamine, Acetylcholine, serotonin, substance P

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Adding level ___ or ____ agents increases the emetogenicity of the combination regimen by 1 level per agent

3 or 4

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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

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Oral therapy is (>, =, <) IV therapy

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Which classes will we always have for emetogenicity?

5HT3 antagonist and dexamethasone (steroid)

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RF for mucositis

-Pre-existing oral lesions
-Poor dental hygiene
-Ill-fitting dentures
-Combined modality tx (chemo + radiation)

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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)

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General mouthcare strategies for mucositis

-Baking soda rinses
-Soft-bristle toothbrush
-Saliva substitute

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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)

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Only thing to help mucositis is ____

WBC count increasing

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Low WBC count is _____

neutropenia

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Low platelet count is ____

thrombocytopenia

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Low RBC count is ____

anemia

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Nadir definition

Absolute lowest WBC count during a cycle of chemo

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ANC=_____x_____

WBC x % granulocytes

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Typical guidelines to safely administer chemotherapy

WBC > 3000 OR ANC > 1500 AND platelet > 100000

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Febrile neutropenia definition

Neutropenia + fever (>101) –> must get to hospital and tx with antibiotics

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Use primary prophylaxis for neutropenia if we know:

the pt’s chemo regimen is expected to cause >20% incidence of febrile neutropenia

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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?

____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

Other ADR of denosumab >> zaledronic acid

Hypocalcemia Bone pain N/diarrhea Fatigue

What frequency do we normally use HCM agents for?

Q3month dosing