GI toxicities Flashcards
What is mucositis?
Inflammatory, ulcerative lesions of the oral and/or GI tract
What is the cell turnover for the GI tract?
7-10 days
What is the incidence of mucositis in HD chemotherapy and HSCT?
100%
What are the sx of mucositis?
Pain
Ab bloating
NVD
Constipation
What drugs cause mucositis?
Anthracyclines Bleomycin Cyclophosphamide Taxanes Vinca alkaloids 5-FU Capecitabine Cytarabine Gemicitabine Hydroxyurea MTX Pemetrexed
What are the consequences of mucositis?
Delayed therapy Reduction in chemo intensity Increased hospital stays Poor nutrition status Increased risk of infection
What are the WHO grade scale for oral mucositis?
Grade 0: no oral mucositis Grade 1: Erythema and soreness Grade 2: Ulcers, able to eat solids Grade 3: Ulcers, requires liquid diet Grade 4: Ulcers, unable to eat anything
What is the prevention of cystitis?
Oral hygiene Oral cryotherapy Oral zinc supplementation Treat dental issues Nutrition and hydration
What is used for sx control of mucositis?
Magic mouthwash Pain control (opioids/PCA)
What is treatment of mucositis?
Palifermin
What is palifermin?
Keratinocyte growth factor
How does palifermin work?
Promotes epithelial cell proliferation, differentiation and migration
What are AEs of palifermin?
Rash
Edema
Taste disturbances
Arthralgias
What is xerostomia?
Dry mouth
What is amifostine used for?
Xerostomia in radiation of the head and neck
What disease does amifostine reduce?
Esophagitis with chemo+radiation for NSCLC
What drugs cause diarrhea?
Irinotecan 5-FU/capecitabine Cytarabine MTX TKI Anti-EGFR therapy HD conditioning regimens for SCT
What grade is classified as uncomplicated diarrhea?
Grades 1-2 w/no added RFs
How many stools per day are in grades 1-2?
<4-6 per day
What grade is classified as complicated diarrhea?
Grade 3-4 or Grade 1-2 w/presence of any added RF
What are added RFs for diarrhea?
Mod-severe cramping Sepsis Grade 2+ N/V Neutropenia Decreased performance status Blood in stool Fever Dehydration
Where is uncomplicated diarrhea treated?
Outpatient
What are ways to manage uncomplicated diarrhea?
D/C lactose-containing products and EtOH Increase fluid intake (8-10 large glasses of clear liquid/day) Small, frequent meals BRAT diet Lactobacillus for prevention Loperamide
If a patient has grade 2 diarrhea after chemo, what do we do?
Hold chemo until sx resolve and reduce dose w/next cycle
What is the loperamide dose?
4mg, then 2mg every 4 hours
What is the max daily dose of loperamide?
16mg/d (exception: irinotecan)
When do we DC loperamide?
Diarrhea free for at least 12 hours
Diarrhea persists for more than 48 hours
What is a 2nd line anti-diarrheal agent?
Octreotide
Diphenoxylate/atropine
Tincture of opium
How do we adjust dose of loperamide if diarrhea persists for at least 24 hours?
Increase dose to 2mg every 2 hours
Where do we treat complicated diarrhea?
Hospital admission
What are the treatments of complicated diarrhea?
IV fluids, electrolyte replacement
Octreotide
Further work-up
ABX
How do we work-up complicated diarrhea?
CBC
Electrolytes
Stool: blood, C diff, other infections
When does early onset diarrhea start with irinotecan administration?
During treatment or w/in 2-6 hours after administration
What is the mechanism of early onset irinotecan induced diarrhea?
Reversible cholinesterase inhibition
What are the effects of irinotecan?
Lacrimation Diaphoresis Ab cramping Flushing Diarrhea
What drug is used to treat irinotecan induced diarrhea?
Atropine 0.25-1 mg IV/SC
When does late onset diarrhea start with irinotecan administration?
1-12 days after administration
How long can late onset diarrhea last with irinotecan induced diarrhea?
2-5 days; potentially fatal
What is the mechanism of late onset irinotecan induced diarrhea?
Direct toxicity from irinotecan and SN-38
Genetic polymorphism in UGT1A1 enzyme, responsible for inactivating SN-38 via glucoronidation
What is the treatment of late onset irinotecan induced diarrhea?
HD loperamide: 4mg, then 2mg every 2 hours
No max dose
