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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
Q

What is Tumor lysis syndrome?

A

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

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26
Q

TLS incidence

A

Occurs in:
-non-hodgkins lymphoma
-acute myeloid leukemia
-acute lymphoblastic leukemia
-burkitt’s lymphoma

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27
Q

Higher risk of TLS in patients with:

A

elevated baseline uric acid
nephropathy
hypotension
left ventricular dysfunction/HF

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28
Q

Laboratory TLS

A

> 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
Q

Clinical TLD

A

Presence of laboratory TLS PLUS at least one of the following:
-AKI (creatinine >1.5x ULN)
-seizures, neuromuscular irritability
-cardiac arrhythmia

30
Q

clinical presentation of hyperkalemia

A

EKG abnormalities
cardiac arrest
fatigue

31
Q

clinical presentation of hyperuricemia

A

AKI
crystal nephropathy

32
Q

clinical presentation of hyperphosphatemia

A

AKI
GI upset
altered mental status

33
Q

clinical presentation of hypocalcemia

A

altered mental status
seizures
arrhythmias
tetany & spasms

34
Q

TLS treatment approach (preventative measures)

A

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
Q

Low risk TLS treatment approach

A

Monitoring

36
Q

Intermediate risk TLS treatment approach

A

Hydration
Allopurinol
If hyperuricemic, initiate rasburicase

37
Q

High risk TLS treatment approach

A

Hydration
Rasburicase
Allopurinol- start after rasburicase

38
Q

Allopurinol dosing

A

300 mg/m2/day or 10 mg/kg/day PO in 3 divided doses (8 hours)
300 mg PO daily commonly used

39
Q

Allopurinol warnings

A

severe cutaneous adverse reactions (SJS/TEN)

40
Q

Allopurinol clinical pearls

A

No renal dose adjustment (unless hx of CKD)
does not lower uric acid levels–> prevents new formation

41
Q

Rasburicase dosing

A

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
Q

Rasburicase warnings

A

hemolysis in patients with G6PD deficiency

43
Q

Rasburicase ADE

A

peripheral edema, skin rash, abdominal pain, constipation/ diarrhea

44
Q

Rasburicase clinical pearls

A

Obtain rasburicase uric acid –> blood samples must be chilled in an ice water bath to prevent rasburicase from continuing to degrade uric acid

45
Q

Hyperkalemia treatments

A

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
Q

hyperphospatemia treatments

A

IV fluids +/- diuretics
Phosphate binders:
-calcium acetate
-calcium carbonate
-aluminum hydroxide
-lanthanum
-sevelamer

47
Q

hypocalcemia treatments

A

do NOT treat unless symptomatic (cardiac arrhythmias, seizures, tetany)
-Calcium gluconate

48
Q

febrile neutropenia risk factors

A

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
Q

What is febrile neutropenia?

A

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
Q

Concerning Pathogens

A

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
Q

low infection risk

A

Standard chemo for most solid tumors
- anticipated neutropenia less than 7 days

52
Q

intermediate infection risk

A

autologous hematopoietic cell transplant
lymphoma
multiple myeloma
chronic lymphocytic leukemia
purine analog therapy
-anticipated neutropenia 7-10 days
-CART-cell therapy

53
Q

High infection risk

A

allogeneic hematopoietic cell transplant
acute leukemia
alemtuzumab therapy
moderate to severe graft vs host disease
-anticipated neutropenia >10 dyas

54
Q

low risk prophylactic antimicrobials

A

bacterial: none
fungal: none
viral: none unless previously infected with HSV

55
Q

intermediate risk prophylactic antimicrobials

A

bacterial: consider during
fungal: consider during
viral: during neutropenia and possibly longer
PJP: consider during

56
Q

high risk prophylactic antimicrobials

A

bacterial: during
fungal: during
viral: during and possibly longer
PJP: consider during

57
Q

what to collect if patient is presenting with febrile neutropenia

A

CBC w diff
chest x-ray
urinalysis
>=2 sets of blood cultures
urine culture (if symptoms or abnormal urinalysis)
viral diagnostics

58
Q

MASCC scoring tool

A

> =21 lower risk (higher = lower risk)

59
Q

initial empiric therapy for low risk

A

Ciprofloxacin 750 mg PO BID + Augmentin 875/125 PO BID
Levofloxacin 750 mg PO daily OR Moxifloxacin 400 mg PO daily

60
Q

Initial empiric therapy for high risk

A

cefepime 2 g IV Q8H
Zosyn (pip tazo) 45 g IV Q6H or extended infusion
Meropenem 1 g IV Q8H

61
Q

Consider MRSA Coverage if patient:

A

catheter related infection
pneumonia
mucositis
skin and soft tissue infection
hemodynamic insufficiency or sepsis
*vancomycin, linezolid, daptomycin

62
Q

fungal coverage?

A

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

63
Q
A
63
Q

duration of therapy

A

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

63
Q
A
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oncology (9 decks)

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