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NRS 271A: optho, pulm, GU, Renal, Heme/onc > Drugs 4 Supportive Care in Oncology > Flashcards

Drugs 4 Supportive Care in Oncology Flashcards

1
Q

CA complications from the disease

A
  • superior vena cava syndrome
  • spinal cord compression
  • brain metastases
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2
Q

CA complications from chemo tx

A
  • N/V
    • mucositis
    • hemorrhagic cystitis
    • hypercalcemia
  • Febrile Neutropenia
    • tumor lysis syndrome
    • extravasation
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3
Q

Chemo-Induced N/V key receptors

A
  • 5-HT3 receptors: located in the chemoreceptor trigger zone (near BBB)
    • chemo agents → stimulate enterochromaffin cells in GI which release serotonin → binds to receptors → N/V
  • Neurokinin-1 (NK1) receptors: in emetic center of medulla
  • domapine receptors
  • muscarinic receptors
  • histamine receptors
  • cannabinoid receptors
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4
Q

Chemo-Induced N/V Risk Factors

A
  • chemo-regimen
  • radiation (esp total body) [+chemo? → more severe]
  • female >male
  • children > adults
  • h/o motion sickness
  • pregnancy-induced N/V
  • poor emetic control in previous chemo tx
  • ppl who drink more alcohol than usual tolerate it better or it is much worse
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5
Q

Types of Chemotherapy-Induced N/V

A
  • Acute:
    • occurs within 24 hours after chemo tx
  • Delayed:
    • 24 hours to 5 days after chemo tx
  • Anticipatory
    • occurs before chemo tx
      • d/t previous experience of poor control
      • risks: poor emetic control; female; young age; low chronic EtOH intake
  • Breakthrough:
    • occurs despite prophylaxis
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6
Q

Antiemetic Drugs + Dosing

A
  • 5-HT Serotonin Receptor Antagonists
    • “-setron”
      • Dolasetron: 100 mg IV and PO
      • Granisetron: 1-2mg PO, IV, Topical
      • Ondansetron: PO, IV 8-16 mg
        • → >32mg = QT prolongation
      • Palonosetron: highest potency; PO, IV 0.25-0.5mg
  • Others:
    • Aprepitant: PO 125mg NK-1 antagonist
    • Fosaprepitant: IV 150mg NK-1 antagonist
    • Dexamethasone: PO 12mg Corticosteroid
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7
Q

Mucositis

A
  • degradation of mucosal lining in oral and GI systems by chemo or radiation → d/t lack of regeneration
  • Consequences:
    • “White Patches”
    • Pain, inadequate nutritional intake, risk of infx → bacterial, fungal, or viral
  • Tx:
    • cryotherapy → ice chips
    • Antimicrobial lozenges (i.e. Mycelex: clotrimazole troche)
    • Sucralfate: GI med/antacid used to relieve pain and moisturize the mucus membrane
    • Chlorhexidine rinses (Hibiclens)
    • “Magic Mouthwash” → benadryl + Maalox (antacid) +/- Nystatin +/- TCN +/- lidocaine
    • PO morphine for pain
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8
Q

Palifermin (Keprivance)

A
  • MOA: recombinant human keratinocyte growth factor → enhances epithelial cell proliferation
  • Indication: mucositis prophylaxis and Tx
    • pts receiving high does chemo for stem cell transplant or leukemia induction
  • Dosing: 60mcg/kg/IV 3 days before → wait 24-48hrs → chemo tx → wait 24-48 hours → and x 3 days after myelotoxic tx
  • Avoid within 24 hours before or after chemo → increases severity and duration of mucositis
    • → chemo will target the rapidly growing new tissue
  • SEs:
    • Rash, fever, pruritus, edema, tongue discoloration, thickening and taste change
    • arthralgias
    • HTN → monitor before and after drug therapy
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9
Q

Definition of Febrile Neutropenia

A
  • ANC < 500 cells/mcL OR ANC <1000 cells/mcL with predicted decrease to <500 cells/mcL
  • T≥ 38C (100.4F) x 1 hour
  • T≥ 38.3C (101F)
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10
Q

ANC calculation

A

ANC = absolute neutrophil count

ANC = WBC x % neutrophils (both segs and bands)

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11
Q

Risk factors for Febrile Neutropenia

A
  • Patient Related:
    • age 60+
    • poor performance status
    • bone marrow involvement by tumor
    • poor nutrition
    • hematologic malignancy
    • elevated LDH
    • decreased hgb level
  • Therapy Related:
    • hx of extensive chemo
    • planned full dose intensity of chemo
    • high dose chemo
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12
Q

MASCC Risk Index for Febrile Neutropenia

A

Score ≥ 21 = low risk for complications and morbidity

  • severity of sxs, hypotension, COPD, dehydration, outpt onset of fever, age <60, solid tumor or hematologic malignancy without fungal infx
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13
Q

Colony Stimulating Factor

A

used to stimulate bone marrow to produce neutrophils

  • Stimulation of Neutrophils:
    • Filgrastim (Neupogen): 5mcg/kg/day SC or IV but round to 300 or 480 vial size b/c vial is expensive
    • Pegfilgrastim (Neulasta): 6 mg SC once per cycle
    • SEs for both : bone pain approx 25% of pts
  • Stimulation of Neutrophils + Eosinophils + Macrophages:
    • Sargramostim (Leukine GM-CSF): 250mcg/m2/day ( based on body surface area)
      • or round to 250-500mcg vial size
    • SEs:
      • hypotension, flushing
      • low-grade fever
      • bone pain
      • injection site rxn
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14
Q

Oral Tx for Low Risk Febrile Neutropenia

A

Cipro + Augmentin → if afebrile within 3-5 days of tx and etiology not identified continue with Cipro + Aug or switch from previous med to cipro +Aug

Children: Cefixime

Then discharge

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15
Q

IV Tx for Low Risk Febrile Neutropenia

A

Vancomycin not needed

  • Monotherapy:
    • cefepime
    • ceftazidime or Carbapenem
  • Two Drugs:
    • Aminoglycoside and
      • Antipseudomonal penicillin
      • Cefepime
      • ceftazidime or carbapenem
  • Reassess after 3-5 days:
    • if afebrile and no etiology switch to Cipro + Aug
    • if afebrile + etiology → adjust to appropriate meds
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16
Q

IV tx for high risk febrile neutropenia → no risk of MRSA

A
  • Monotherapy:
    • cefepime
    • ceftazidime or Carbapenem
  • Two Drugs:
    • Aminoglycoside and
      • Antipseudomonal penicillin
      • Cefepime
      • ceftazidime or carbapenem
  • Reassess after 3-5 days:
    • if afebrile and no etiology switch to Cipro + Aug
    • if afebrile + etiology → adjust to appropriate meds
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17
Q

IV tx for high risk febrile neutropenia → risk of MRSA

A

Vancomycin needed

  • Vancomycin and:
    • cefepime, ceftazidime or carbapenem, meropenem with or without aminoglycoside (gentamicin or tobramycin)
  • if after 3-5 days still fever:
    • if no change in condition
      • continue abx, consider d/c vanco
    • if worsening disease and if criteria for vanco are met:
      • change abx
    • if febrile through days 5-7 and resolution of neutropenia not imminent:
      • antifungal drug with or without abx change
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18
Q

Antifungals used for febrile neutropenia

A

amphotericin B (premedicate with acetaminophen and diphenhydramine), liposomal amphotericin B, caspofungin, voriconazole, posaconazole

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19
Q

Chemo-Induced Hemorrhagic Cystitis Definition and Causes

A
  • Definition: acute or insidious bleeding from the lining of the bladder
  • Causes:
    • High Dose Cyclophosphamide (Cytoxan) → used for non-hodgkin lymphoma
      • cyclophosphamide = not toxic to bladder → metabolite acrolein (which is secreted in the urine) causes edema and bladder hemorrhage
    • Ifosfamide (Ifex) → used for germ cell testicular CA or soft tissue and bone sarcomas
      • causes the release of tumor necrosis factors-alpha and interleukin -1-beta → releases nitric oxide → causes hemorrhagic cystitis
      • → also releases acrolein
      • Worse than cyclophosphamide
20
Q

Prevention of Hemorrhagic Cystitis

A
  • Mesna (2-mercaptoethane sulfonate)
    • binds to acrolein → eliminates it
      • T ½ much shorter than Cytoxan (Cyclophosphamide) and Ifex (Ifosfamide) → need to give Mesna thorugh and after the chemo infusion
      • PO Mesna dose = 2x IV dose (need to double PO dose due to 50% bioavailability)
    • Hyperhydration to dilute
      • 2L 12-24 hours before chemo; 2L 24-48 hours after last dose of chemo + Lasix IV to maintain urine output >100mL/hr
    • bladder irrigation with catheterization
      • NS 250mL -1L/hr to flush acrolein from bladder
21
Q

Causes of hypercalcemia of malignancy

and review of Ca2+ balance

A
  • occurs 10-30% → most common = breast cancer, squamous cell carcinomas of head and neck, renal CA, lung CA
  • Ca2+ level balance:
    • PTH:
      • increased renal tubular resorption
      • increased bone resorption (breakdown)
    • 1,25-dihydroxyvitamin D
      • increased Ca2+ absorption from gut
    • calcitonin:
      • decreased osteoclast activity
      • stimulates ca2+ deposition in bone
22
Q

How to calculate corrected Calcium

A

serum Ca2+ + (0.8)(4- serum albumin)

23
Q

Hypercalcemia levels and s/sxs

A
  • Levels:
    • Normal = 8.5-10.5
    • Mild = 10.5-11.9
    • Mod = 12-13.9
    • Severe = >14
  • S/sxs
    • anorexia, N/V, constipation
    • bradycardia, ECG abn, arrhythmias
    • muscle/bone: weakness, bone pain, fatigue, ataxia
    • CNS: confusion, HA, seizure, coma
24
Q

Bisphosphonate drugs

A

used to tx hypercalcemia

deposits in bone matrix and inhibits osteoclast function

  • Pamidronate 60-90mg IV over 2-24 hours
  • Zoledronic Acid 4mg IV over 15 minutes
    • also used for osteoporosis
  • SEs:
    • fever, renal dysfunction
  • pamidronate = less expensive
25
Q

Tx of mild hypercalcemia of malignancy

A

mild = 10.5-11.9

tx the underlying malignancy

  • asymptomatic:
    • encourage ambulation and increase fluid intake
      • if refractory → saline hydration + bisphosphonate +/- furosemide for fluid overload
      • if refractory (5-7 days) → repeat bisphosphonate, continue hydration
      • if refractory → calcitonin, gallium nitrate, steroids
      • if refractory → dialysis
26
Q

Tx of mod/severe hypercalcemia of malignancy

A

mod-severe = 12-13.9, or >14

  • triple therapy:
    • saline hydration + bisphosphonate + calcitonin +/- furosemide for fluid overload
    • if refractory → dialysis
27
Q

Tumor Lysis Syndrome

A

occurs in high tumor burden malignancies or high proliferative rates

  • S/sxs: uremia, visual disturbances, muscle cramping, edema, HTN, arrhythmias, seizure
  • Dx: based on labs → occurs 3 days before or 7 days after chemo Tx
    • Hyperuricemia >8
    • Hyperkalemia > 6
    • Hyperphos >4.5
    • Hypocalcemia <7
    • Renal dysfunction
  • S/sxs: uremia, visual disturbances, muscle cramping, edema, HTN, arrhythmias, seizure
28
Q

Risks for TLS

A
  • High Risk:
    • ALL, AML high grade non-hodgkin’s lymphoma (Burkitt’s Lymphoma)
    • elevated Uric Acid Level (≥ 10)
    • WBCs >50K
    • kidney tumor infiltration
    • LDH greater than 2x normal
  • Low Risk:
    • CML, solid tumor, hodgkin’s disease
    • Normal uric acid levels (<10)
    • WBCs ≤ 50K
    • no tumor infiltration in kidneys
    • LDH ≤ 2x normal
29
Q

TLS tx/ prophylaxis

A

Goals: prevent renal failure and electrolyte imbalance

  • Low Risk:
    • oral allopurinol (IV if unable to tolerate or take oral meds)
      • daily monitoring of uric acid → if normal then continue through cytotoxic therapy
        • if uric acid levels increase → switch to rasburicase daily
  • High Risk:
    • Rasburicase dose prior to cytotoxic therapy
      • monitoring uric acid every 6 hours
        • if uric acid levels are normal → do not continue
        • if uric acid levels increase → administer daily until normalize
30
Q

Allopurinol

A

inhibits xanthine oxidase: prevents the creation of uric acid

use in prophylaxis and tx of tumor lysis syndrome → low risk patients

31
Q

Rasburicase

A

converts Uric Acid Levels to allantoin

used in the prophylaxis and tx of tumor lysis syndrome → high risk pts

***Expensive*** $12,000/day

32
Q

Sucralfate

A

used to tx mucositis → GI med (antacid) used to coat the mouth and form a protective barrier

33
Q

Antiemetics used for high risk (>90&) of CINV

A
  • 5-HT3 serotonin receptor antagonist: day 1
  • Dexamethasone: days 1-4
  • Aprepitant: days 1-3 or fosaprepitant (IV formulaiton) day 1 only
34
Q

Antiemetics used for Moderate risk (30-90%) with tx CINV

A
  • without tx:
    • 5HT3 serotonin receptor antagonist: day 1
    • dexamethasone: day 1
  • With Tx (anthracycline, carboplatin, cisplatin, irinotecan cyclophosphamide, methotrexate)
    • 5HT3 serotonin receptor antagonist: day 1
    • dexamethasone: days 1-3
    • Aprepitant: days 1-3
35
Q

Antiemetics used for low risk CINV pts

A

dexamethasone: day 1 PRN or D2 antagonists (compazine, reglan)

36
Q

Aprepitant

A

NK-1 antagonist

PO: 125mg (PO formulation)

used to tx chemo-induced N/V

37
Q

Fosaprepitant

A

NK-1 antagonist

IV: 150mg (IV formulation)

used to tx chemo-induced N/V

38
Q

5-HT3 Serotonin Receptor Antagonists

A

“Don’t Go Out Puking”

  • Dolasetron: 100mg (PO or IV)
  • Granisetron: 2mg PO or 1 mg IV
  • Ondansetron: 16-24 mg PO, 8mg IV
    • dose >32 mg = QT prolongation
  • Palonosetron: 0.5mg PO, 0.25 IV
39
Q

Filgrastim (Neupogen GCSF)

A

Colony Stimulating Factor for Neutropenia

Neutrophil = effector cells

  • 5mcg/kg/day SC or vIV or round to 300 or 480 mcg vial size
  • SEs: bone pain
  • begin 1-3 days after chemo
40
Q

Pegfilgrastim (Neulasta)

A

Colony stimulating Factor used in neutropenia

longer half life than filgrastim

  • only stimulates neutrophils
  • given 1-3 days after chemo, once per cycle dosing
  • SEs: bone painb
41
Q

Sargramostim (Leukine GM-CSF)

A

Colony stimulating Factor used after induction of chemo in elderly AML (Acute myeloid leukemia) pts

  • effector cells = neutrophil, eosinophil, macrophage
  • dosing: based on body surface area
  • SEs: first dose effects: flushing, hypotension
    • low grade fever
    • bone pain
    • injection site rxn
42
Q

Mesna (2-mercaptoethane-suflonate)

A

prevents hemorrhagic cystitis

  • binds to acrolein and eliminates it
  • PO dose = 2x IV dose
    • very high first pass effect → low bioavailability
    • T½ = much shorter than Cyclophosphamide (Cytoxan) and Ifosfamide (Ifex)
43
Q

Pamidronate

A

used to tx hypercalcemia

bisphosphonate drug → deposits in bone matrix and inhibits osteoclast function

  • does not last as long as Zoledronic acid
  • less expensive
  • SEs:
    • fever, renal dysfunction
44
Q

Zoledronic Acid

A

used to tx hypercalcemia

bisphosphonate drug → deposits in bone matrix and inhibits osteoclast function

  • lasts longer than pamidronate
  • used for osteoporosis
  • SEs: fever, renal dysfunction
  • more expensive than pamidronate
45
Q

Gallium Nitrate

A

used for refractory tx of Mild symptomatic hypercalcemia

inhibits calcium resorption in bone

  • do not admin if Cr >2.5mg/dL

NRS 271A: optho, pulm, GU, Renal, Heme/onc (10 decks)

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