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oncology > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Hypercalcemia most common in patients with:

A

-non small cell lung cancer
- breast cancer
-multiple myeloma
-squamous-cell cancers of the head and neck
-urothelial carcinomas
-ovarian cancers

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2
Q

What is hypercalcemia? (and corrected calcium equation)

A

corrected calcium level of >= 10.5 mg/d:
Corrected calcium = 0.8 x (4-albumin)+ serum calcium

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3
Q

Other relevant lab values in hypercalcemia

A

-serum phosphorus
-serum creatinine
-parathyroid hormone
-parathyroid hormone related protein
-25(OH)D
-1,25(OH)2D

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4
Q

Clinical manifestations of hypercalcemia

A

Renal
-polyuria
-polydipsia
-dehydration
-decrease in GFR
GI
-constipation
-anorexia
-N/V
Neurologic
-lethargy
-confusion
-irritability
-muscle weakness
-seizure
-stupor
-coma
Cardiac
-shortened QT interval
-Widened T wave
-heart block
-asystole
-atrial and ventricular arrhthmia

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5
Q

Mechanisms of hypercalcemia

A

Humoral (most common)
Bone invasion
Rare Causes

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6
Q

Humoral hypercalcemia

A

-Increased parathyroid hormone related peptide
–increase renal tubular reabsorption of calcium–> increased phosphorus excretion through urine–> hypercalcemia + hypophosphatemia
-common in squamous cell carcinomas of the head, neck, lung, colon

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7
Q

bone invasion hypercalcemia

A

-local osteolytic activity that leads to secretion of calcium
increased calcium through signaling from tumor cells to release cytokines–> activation of osteoclasts + bone resorption through RANK and RANKL process
-common in multiple myeloma, metastatic breast cancer

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8
Q

Rare causes of hypercalcemia

A

2 different mechanisms
1) Increased production of calcitriol (vitamin D intoxication)
-common in hodgkin lymphoma
2)Ectopic PTH production
-common in patients with history of head and neck irradiation and chronic lithium therapy

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9
Q

treatment approach

A

Increase calcium excretion
-IV fluids: NS
Reduce bone resorption
-IV bisphosphonates
-SC calcitonin
-SC denosumab
Reduce intestinal absorption of calcium
-glucocorticoids

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10
Q

Hydration (hypercalcemia)

A

NS
-initial bolus of 1-2L–> continuous IV infusion at 200-500mL/hr
–lowers calcium by 1-1.5mg/dL over first 24H

Furosemide 20-40mg
-reserved for volume overload or HF
–lowers calcium by 0.5-1mg/dL

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11
Q

Inhibition of bone resorption medications

A

Bisphosphonates: inhibits osteoclast activity
-Pamidronate, Zoledronate

Denosumab: binds to RANKL to inhibit interaction between RANKL and RANK to prevent osteoclast formation

Calcitonin: directly inhibits osteoclastic bone resorption and increases excretion of calcium, phosphate, sodium, magnesium, and potassium

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12
Q

Pamidronate Dosing

A
  • corrected calcium >12 mg/dL: 90 mg IV as single dose over 2-24 hours
  • retreatment: may repeat after 7 days
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13
Q

Pamidronate Warnings

A

-bone fractures
-musculoskeletal pain
-flu-like illness
-osteonecrosis of the jaw

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14
Q

Pamidronate Clinical Pearls

A

-Not recommended in CrCL <30 mL/min or Scr >3 mg/dL; if using use with slower infusion rate

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15
Q

Bisphosphonates ADEs

A

-hypophosphatemia, hypocalcemia, hypomagnesemia, hypokalemia
-nausea
-anemia
-infusion site reaction

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16
Q

Zoledronic Acid (Reclast) Dosing

A

-corrected calcium >12 :4 mg IV as single dose
-may repeat after 7 days

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17
Q

Zoledronic Acid (Reclast) Clinical Pearls

A

-Not recommended in Scr> 4.5–> if no other alternatives, may administer 2 to 4 mg and extend infusion over 30-60 mins

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18
Q

Denosumab dosing

A

120 mg SC QW for up to 3 doses
-if hypercalcemia persistent, may continue at 120 mg every 4 weeks starting 2 weeks after initial 3 doses

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19
Q

Denosumab warnings

A

Increased risk of infection, bone fracture risk, osteonecrosis of the jaw, musculoskeletal pain

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20
Q

Denosumab ADEs

A

hypophosphatemia, hypocalcemia, headache

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21
Q

Denosumab clinical pearls

A

-No renal dose adjustment
-may be used in bisphosphonate refractory hypercalcemia

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22
Q

Calcitonin Dosing

A

*use in combination with IV Hydration or bisphosphonates
-4 units/kg IM or SC Q12H
-if hypercalcemia persists after 6 to 12 hours may increase to 8 units/lg Q6-12 hours

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23
Q

Calcitonin warnings, ADEs, and clinical pearls

A

Warnings: hypocalcemia
ADEs: facial flushing
Clinical pearls: limit therapy to 24-48 hours due to tachyphylaxis

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24
Q

Glucocorticoids (hypercalcemia)

A

MOA: inhibits 1-alpha-hydroxylase and lowers 1,25-dihydroxyvitamin-D levels
Dosing: different recommendations
-Prednisone 60 mg/day for 10 days
-hydrocortisone 200-400 mg/day for 3-4 days, then prednisone 10-20 mg/day for 7 days

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25
What is Tumor lysis syndrome?
Definition: condition caused by a mass number of cancer cells lysing in a short period of time and contents are released into the peripheral bloodstream Characterized by: increase in potassium, uric acid, phosphate decrease in calcium
26
TLS incidence
Occurs in: -non-hodgkins lymphoma -acute myeloid leukemia -acute lymphoblastic leukemia -burkitt's lymphoma
27
Higher risk of TLS in patients with:
elevated baseline uric acid nephropathy hypotension left ventricular dysfunction/HF
28
Laboratory TLS
>2 of the following within 3 days before or 7 days after initiation of treatment -hyperkalemia (>6) OR 25% increase from baseline (for all of them) -hyperuricemia (>8) -hyperphosphatemia (>4.5) -hypocalcemia (<7)
29
Clinical TLD
Presence of laboratory TLS PLUS at least one of the following: -AKI (creatinine >1.5x ULN) -seizures, neuromuscular irritability -cardiac arrhythmia
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clinical presentation of hyperkalemia
EKG abnormalities cardiac arrest fatigue
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clinical presentation of hyperuricemia
AKI crystal nephropathy
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clinical presentation of hyperphosphatemia
AKI GI upset altered mental status
33
clinical presentation of hypocalcemia
altered mental status seizures arrhythmias tetany & spasms
34
TLS treatment approach (preventative measures)
Start preventative measures before anti-cancer therapy: -Lab monitoring every 4-6 hours -Fluids: NS 150 to 300 mL/hr -allopurinol or rasburicase for elevated uric acid
35
Low risk TLS treatment approach
Monitoring
36
Intermediate risk TLS treatment approach
Hydration Allopurinol If hyperuricemic, initiate rasburicase
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High risk TLS treatment approach
Hydration Rasburicase Allopurinol- start after rasburicase
38
Allopurinol dosing
300 mg/m2/day or 10 mg/kg/day PO in 3 divided doses (8 hours) 300 mg PO daily commonly used
39
Allopurinol warnings
severe cutaneous adverse reactions (SJS/TEN)
40
Allopurinol clinical pearls
No renal dose adjustment (unless hx of CKD) does not lower uric acid levels--> prevents new formation
41
Rasburicase dosing
Weight based: 0.15-0.2 mg/kg/dose IV once daily for up to 5 days Flat: 1.5 mg or 3 mg IV as single dose (more common) -may repeat if uric acid remains >7.5 mg/dL
42
Rasburicase warnings
hemolysis in patients with G6PD deficiency
43
Rasburicase ADE
peripheral edema, skin rash, abdominal pain, constipation/ diarrhea
44
Rasburicase clinical pearls
Obtain rasburicase uric acid --> blood samples must be chilled in an ice water bath to prevent rasburicase from continuing to degrade uric acid
45
Hyperkalemia treatments
Loop diuretic: eliminate excess potassium Calcium Chloride or gluconate 1g IV over 2-3 minutes--> stabilizes cardiac cell membrane Regular insulin 10 U IV bolus--> drives potassium intracellularly Sodium Bicarbonate 50 mEq IV--> drive potassium intracellularly by increasing pH Sodium polystyrene 15-60 g PO--> Promotes GI excretions of potassium Hemodialysis or CRRT: removes potassium from blood through filtration
46
hyperphospatemia treatments
IV fluids +/- diuretics Phosphate binders: -calcium acetate -calcium carbonate -aluminum hydroxide -lanthanum -sevelamer
47
hypocalcemia treatments
do NOT treat unless symptomatic (cardiac arrhythmias, seizures, tetany) -Calcium gluconate
48
febrile neutropenia risk factors
Typically occurs 1 week after chemo -Age>65 -Pre-existing neutropenia or bone marrow infiltration with tumor -gender -low BMI or BSA -previous chemotherapy or radiation -poor performance status -comorbidities -specific genetic polymorphisms
49
What is febrile neutropenia?
ANC < 500 cells/ uL OR < 1000 and expected to drop <500 in 48 hours Single temp >38.3C (100.9F) OR >38C (100.4) for over 1 hour
50
Concerning Pathogens
Gram positive -coagulase negative staphylococci -staph aureus -enterococcus -streotococci gram negative -e coli -klebsiella pneumoniae -enterobacter -P aeruginosa fungi -candida -aspergillus viruses -herpes -varicella zoster -RSV -cytomegalovirus -influenza
51
low infection risk
Standard chemo for most solid tumors - anticipated neutropenia less than 7 days
52
intermediate infection risk
autologous hematopoietic cell transplant lymphoma multiple myeloma chronic lymphocytic leukemia purine analog therapy -anticipated neutropenia 7-10 days -CART-cell therapy
53
High infection risk
allogeneic hematopoietic cell transplant acute leukemia alemtuzumab therapy moderate to severe graft vs host disease -anticipated neutropenia >10 dyas
54
low risk prophylactic antimicrobials
bacterial: none fungal: none viral: none unless previously infected with HSV
55
intermediate risk prophylactic antimicrobials
bacterial: consider during fungal: consider during viral: during neutropenia and possibly longer PJP: consider during
56
high risk prophylactic antimicrobials
bacterial: during fungal: during viral: during and possibly longer PJP: consider during
57
what to collect if patient is presenting with febrile neutropenia
CBC w diff chest x-ray urinalysis >=2 sets of blood cultures urine culture (if symptoms or abnormal urinalysis) viral diagnostics
58
MASCC scoring tool
>=21 lower risk (higher = lower risk)
59
initial empiric therapy for low risk
Ciprofloxacin 750 mg PO BID + Augmentin 875/125 PO BID Levofloxacin 750 mg PO daily OR Moxifloxacin 400 mg PO daily
60
Initial empiric therapy for high risk
cefepime 2 g IV Q8H Zosyn (pip tazo) 45 g IV Q6H or extended infusion Meropenem 1 g IV Q8H
61
Consider MRSA Coverage if patient:
catheter related infection pneumonia mucositis skin and soft tissue infection hemodynamic insufficiency or sepsis *vancomycin, linezolid, daptomycin
62
fungal coverage?
consider in high risk patients who have hematologic malignancies or patients who become hemodynamically unstable and/or signs of sepsis -add at the 4-7 day mark
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duration of therapy
SSTI: 5-14 GRam positive or negative bacteremia: 7-14 bacterial sinusitis: 7-14 days bacterial pneumonia: 5-14 days Candida infection: 2 weeks after first negative blood culture mold infection: 12 weeks min HSV/VZV:7-10 days influenza: min 5 days of oseltamivir
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oncology (9 decks)

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