Ischemic Heart Disease Flashcards
Nitroglycerin Contraindications?
Use in combination with ricoguat or PDE-5 inhibitors
What are the 3 beta blockers used in HF?
- Carvedilol
- Metoprolol succinate
- Bisoprolol
What is the ointmetn dosing?
For nitro
dose BID 6 hours apart
How should effient be dispensed?
In the original container
Long acting nitrates need what?
need a 10-12 hour nitrate free period to decrease tolerance
Patho of Ischemic heart disease?
Imbalance of myocardial demand (workload) and supply (blood flow)
Supply often decreased by arethrosclerosis which is CAD reduced blood flow to the heart
Ranexa MOA
inhibits late phase Na current decrease intracellular Ca
decrease myocardial oxygen demand
Preferred agent for Prinzmetal Angina?
CCBs
The ABCDE treatment for SIHD?
- A: antiplat and antiangina: BB, CCBs, Nitrates
- B blood pressure and beta blockers
- Cholesterol statins and cigs
- D diet and DM
- Exercise and education
Warnings for Nitrates 3
Hypotension, HA, tachyphylaxis (decreased effectiveness and tolerance)
Cardiac enzymes are positive in what types of ACS MI?
Negative?
NSTEMI
STEMI
Negative in UA
Effient contraindications?
Hx of TIA or Stroke
Clopidogrel is a prodrug metabolized by?
CYP 2C19 check genotype for best use
Ranexa Notes
Had no effect on HR or BP
SEs of aspirin? 3
Dyspepsia
Heartburn
Nausea
Patients with an acute MI, STEMI or Non-STEMI should be?
Transported to a hospital with PCI capabilities
What CCBs are preferred when using in combination with BBs?
DHPs
What is recommended in all patients? IHD
nitroglycerin for immediate releif
Patch instructions for LA nitrates?
on 12-14 hours off for 10-12 rotate sites
What is the goal of antianginal treatment in IHD?
Decrease myocardial pxygen demand and increase supply
Vaccine rec for IHD patietns?
Flu and pneumococcal Prevnar and Pneumovax
When are long acting nitrates indicated?
When BBs are contraindicated or as add on
Benefit of CCBs in IHD?
Non-DHPs: reduce HR
DHPs: reduce SVR afterload
All CCBs increase myocardial oxygen supply increase blood flow to the coronary arteries
WHat 4 properties does Aspirin have?
- Antiplat
- Antipyretic
- analgesic
- Anti inflammatory
What is effient indicated for?
Pts with ACS who are managed with PCI
What do nitrates do?
Decrease preload and
If patient is going for urgent CABG what shouldnt they get?
p2y12 inhibitors
SEs of Nitrates?
HA, flushing, syncope
What are the 3 GPIIb/IIIa antagonists?
Who are these for? What should they be given with?
- Abciximab
- Eptibifibatide
- Tirofiban
Option for medical management Eptibi, Tirofiban or for PCI +/- stent (all agents)
If used for PCI must be given with heparin
A complete or partial block is seen in what type of ACS?
Partial block in UA
Complete block in STEMI
What is a rare and serious SE of clopidogrel?
TTP: pale skin, fever, weakness
What is the benefit of BBs fo IHD
Decrease HR
Decrease contractility
Decrease left ventricular wall tension
Contraindications for Aspirin?
Salicylate allergy, children and teenagers due to risk of reyes
Indication for ACE in ACS?
Time it should be received?
Important to note?
Should be started within first 24 hours and continued indefinetly
In all pts with EF < 40%, those with HTN, DM, or stable CKD
ORAL
What chronic therapy should be initiated in ACS patients?
High intensity statin
Drug Treatment of ACS?
- MONA
- Morphine
- Oxygen
- Nitro
- Aspirin
- GAP
- GPIIb/IIIa antagonists
- Anticoagulants
- P2Y12 inhibtors
- BA
- Beta blocker
- ACE inhibitor
Prinzmetal Angina
Unpredicable caused by vasopasms
Anticoagulant Therapy in ACS? 3
LMWH, UFH, Bivalrudin (preferred for STEMI)
What is Yasprala and who is it used for?
Aspirin for patients at risk of developing aspirin associated gastric ulcers
Bayer, Bufferin, Ecotrin
Aspirin
What other med should be avoided with Brillinta?
Ticagrelor
Doses of aspirine above 100 mg should be avoided
Ranexa warnings?
QT prolongation
Clopidogrel warnings?
Increase bleed risk avoid use with omeprazole (prilozec) or esomeprazole (nexium)
Increased risk of thrombosis when DC prematurely
What medications should not be given during ACS?
NSAIDs
Immediate release nifedipine increases risk of death
Who should get DAPT?
3 and how long should they be on it?
For IHD
- Bare metal stent: at least 1 month
- drug eluting stent: 6 months
- Post CABG: 12 months
What therapy is recommended for IHD patients?
Antiplatelet with aspirin or clopidogrel if allergy or both in select patients
ACS?
Acute chest pain
- Not relieved by rest or nitro
- These include UA, NSTEMI, STEMI
Clopidogrel MOA?
Prodrug that irreversibly binds to P2Y12 ADP mediated platelet activation and aggregation
Ranexa
Drug interactions and dosing limits
With CYP3A4 moderate inhibitors (Dilt and verapamil) limit dose to 500 mg BID
DONT USE WITH STRONG 3A4s
If using simvastatin limit dose to 20 mg/day
Effient generic?
Prasugrel
Renexa
Ranolazine
Maintenance dose for Brillinta?
Administration notes
90 mg PO BID for 1 year then 60 mg BID
Tablets can be crushed or mixed
How to know if someone has stable ischemic heart disease?
When does pain occur?
How is it relieved?
It is predictable, happens with acitivity or stress relieved by rest or nitroglycerin
usual underlying cause of CAD
BBs should be avoided in?
Prizmetal ANgina
How is nitroglycerin given during an acute coronary sydrome?
Use one dose every 5 minutes for up to 3 doses of improvement is not seen 5 minutes after the first dose call 911
What drugs increase risk of bleeding for P2Y12s? 4
Warfarin, NSAIDs
SSRIs and SNRIs
Diagnosis of IHD
What is performed and why?
Cardiac stress test to assess the likelihood of CAD
Lexiscan or regafenoson
Monoket
Isosorbide mononitrate
Beta blockers
What is the target dose?
Trick question! Titrate slow to a target HR od 55-60
Clopidogrel dosing and contraindication
75 mg
COntra; serious bleeding
Alcohol shoul dbe limited to?
1 drink per day
IHD patients should do what with their lifestyle?
Heart healthy
maintain BMI of 18.5- 24.9
All nitroglycerin contain products patient counseling
Dont use with sildenafil, tadalafil, avanafil, riociguat
Nitroglycerin Spray COunseling
Dont shake
spray on or under the tongue dont inhale
Ideally when should a PCI be performed?
Within 120 minutes of first medical contact
Ranolazine
Counseling
Not for chest pain when it occurs
can cause QT prolongation
MOA of Aspirin?
Irreversibly binds to COX 1 and 2
Which decreases prostaglandin and thromboxane A2 production
Nexium and Prilozec should not be used with what?
Plavix
What is first line therapy for antiangina in IHD?
Beta blockers
Brillinta
Ticagrelor
3 recs for IHD patients?
BB, CCBs all, or long acting nitrates
What are the preferred aspirin formulations?
Non-enteric chewable formulations
If not available shew enteric coating
Ranexa Contraindications? 2
Liver cirrhosis
CYP3A4 inhibitors or inducers 3A4
What type of CCBs are effective?
Slow release and long acting
short acting shouldnt be used: Nifedipine IR
What GIIb/IIIa antagonist is not recommneded for medical managment?
Abciximan Reopro
Integrillin?
Eptifibatide
COntraindications for GIIb/IIa? 5
- Thrombocytopenia plats<100,000
- Severe uncontrolled HTN
- Active bleed
- Recent surgery or trauma 4 wks tirofiban, 6 weeks others
- Hx of stroke within the past two years for Reopro
Contraindications for Abciximab? 4
- GI bleed in past 6 wks
- Increased prothrombin time
- Hypersens to murine proteins
- Intracranial neoplasm, aneurysm
Integrillin contra
Eptifibatide
Dependency on dialysis
3 SEs of GIIBs/IIas
- Thrombocytopenia (ezpecially abcix)
- Bleeding
- Hypotension
Administration note for GIIb/IIas
Abciximab must be filtered
What are fibrinolytics used for?
Only used for STEMI
PCI timing preferred 2 time frames
- 90 minutes door to needle
- 120 from first medical contact
If it is not possible to perform PCI within 120 minutes what should be done?
Give fibrinolytic
Given within 30 minutes door to needle
Cathflo activase?
Used to restore function of potentially clotted central lines
Activase?
Alteplase
Activase dosing?
>67 kgs 100 mg over 1.5 hours
What are the two fibrinolytics?
Activase: Alteplase
Tenecteplase: TNKase
SEs of fibrinolytics?
Bleeding including ICH, hypotension
What 3 things should be monitored with fibrinolytics?
Hgb, Hct, s/sx bleeding
Protease activated receptor 1 antagonist? 1
Warnings 1
SEs 2
Varapaxar
Do not use in severe liver impairment
SEs: Anemia, Bleeding
Vorapaxar DIs?
Substrate of 3A4 and P-gP
Dont use with strong 3A4s
Secondary prevention in ACS
7 drugs
- Aspirin
- P2Y12s
- Nitro
- BBs
- ACE
- Aldosterone antagonists
- Statin
Secondary prevention after ACS:
Aspirin and P2Y12 notes
- Aspirin 81 mg forever
- Medical therapy pt: Ticagrelor or Clopdogrel with ASA for 1 year
- PCI treated DAPT
Secondary ACS prevention
Nitro and BBs timing
- Nitro indef with linguakl
- BBs: 3 years indef if HF pt or if needed for HTN management
Secondary ACS prevention ACE
Aldosterone antagonist
- Indef if EF < 40%, HTN, CKD, or DM, consider for all patients
- Aldosterone antagonist: Indef if EF<=40% and either symptomatic HF or DM receiving target doses of ACE and BB
- Contraindications: sig renal imparimetn SCr>2.5 in men, 2 for women or hyperkalemia K>5
Statin therapy ACS secondary prev
- <= 75 high intensigty
- > 75 mod
Pts with Chronic pain and ACS what is the DOC?
Naproxen lowest CV risk
If patient has to be on Warfarin and has ACS?
Lower warfarin INR goal if on triple therapy 2-2.5 nd for the shortest possible time
What is rec’d for ACS patients if they are getting triple anticoag?
PPIs if they have a hx of GI bleed while taking triple therapy
What is a cardioembolic stroke?
Embolus forms in the heart and travels to the nrain
SIgns and Symptoms of Stroke
- Face: one sided droop
- A Arms one drops
- S: slurred speech
- T: Time call 911 fast
What do you need to quickly indentify when lookling ar a stroke?
Ichemic versus hemorrhagic
What is performed to find what stroke is there?
Brain imaging CT scan
What is the immediate goal during a stroke?
Restore blood flow
Ischemic Stroke management?
What Agent is used?
What needs to be done?
- Alteplase (tPA), only fibrinolytic agent used for acute ischemic stroke
- Once a clot is confirmed use this
What criteria need to be met for alteplase use?
- Can be given 3 hours from symptom onset FDA approval
- Can be given within 4.5 hours in select patients
- It can be administered 60 minutes from hospital arrival door to needle
- BP is < 185/110: if this is the only contraindication then BP should be safely lowered and then admin
Activase dosing in ACS, and Stroke
Add pulmonary embolism when there
- ACS: If > 67 kg 100 mg over 1.5 hours
- Stroke 0.9 mg/kg max 90 mg
Absolute contraindications for Alteplase per package insert? 5
- Active bleed
- Recent within the past 3 months serious head injury
- Intracranial conditions that can increase bleed
- Intracranial or intraspinal surgery
- Severe uncontrolled BP > 185/110
Additional exclusion criteria for alteplase? 5
- Stroke within the past 3 months
- Previous ICH INR>1.7, aPTT > 40 plat <100,000
- Got Tx with LMWH within past 24 hours
- Use of Direct thrombin or direct factor Xa inhibitors with elevated anticoag tests or use within 48 hours
- BG < 50
Alteplase warnings? 2
- Major bleed ICH
- Angioedema
Alteplase notes?
Keep BP <180/105 for at least the first 24 hours after tx
All treatments for Stroke? 5
- Initial Alteplase
- Aspirin
- HTN management
- Hyperglycemia management
- DVT prevention
What dose and when should aspirin be given in stroke?
- 162-325 given 24-48 hours after stroke onset, dont give within 24 hours or Alteplase
HTN Managment in Stroke 3 rec drugs and BP target
- IV Labetalol, nicardipine, or clevedipine
- Lower to Bp <185/110 when alteplase is used maintain <180/105
- If they dont get alteplase may only need to treat in severe HTN BP>=220/120
Safe BP reduction?
15% in first 24 hours
Hyperglycemic managment in stroke?
keep BG in 140-180 range
DVT prevention is stroke? 2 things
- Compression socks pneumatic compression device
- If UFH or LMWH is used cannot be start until 24 hours after alteplase
Risk factors for stroke? 3
- HTN: Most important
- A. Fib
- Age >=55
Treating HTN in stroke?
2 drugs
- ACE
- HCTZ
- These have most evidence BP goal less than 130/80
A fib treatment in stroke
- Cardioembolic stroke due to a fib requires anticoag
Life style changes in Stroke? 2 bullets
- Sodium restriction < 2.4 grams/day or 1.5 for more BP reduction, mediterianian diet
- Wt reduction BMI goal 18.5-24.9 , waist in women < 35 inches, men < 40
What treatment is recommended in patients with noncardioembolic stroke or TIA?
Antiplatelet not anticoag
Antiplat reduces the risk of recurrence
Aspirin or aspirin + ER dipyridamole or clopidogrel
When should Plavix be used alone?
If pt has ASA allergy
When should combination ASA and Clopidogrel be intitiated and continued in STROKE?
within 24 hours and continued for at leat 21 days
Combo should not be used long term fro stroke or TIA due to increased hemorrhage risk
Dipyridamole MOA?
Inhibits the uptake of adenosine increases cAMP levels which inhibits plat ag
Aggrenox?
Dipyridamole
Warnings for Dipyridamole? SE?
Hypotension
SE: HA
Intracerebral Hemorrhage
Prevention treatments 2
Potentially reverse anticoag
and treat seizures when they happen not prophylaxticaly
What is the main treatment for ICH and what does it do?
Mannitol produces an osmotic diuresis, inhibits the tubular reabsorption of water and electrolytes, increases urinary output
BOTTOM LINE: Reduces intracranial pressure by withdrawing water from the brain
How is mannitol given for ICH?
IV
Mannitol Contraindications and Notes
Severe renal disease
Notes: Maintain serum osmolality <300-320 mOsm/kg
How does an acute subarachnoid hemorrhage present?
With a severe HA
Commonly cause by aneursym
What can occur in a subarachnoid hemmorhage and when?
Cerebral artery vasospasm
can happen 3-21 days after bleed
What is used to prevent cerebral vasospasms in SAH?
Oral Nimedipine
Nimedipine MOA?
DHP CCB: more selective for cerebral arteries
Boxed warning for nimodipine?
- NOT TO BE GIVEN IV death and threatening events have occured
Nimodipine DI?
Hypotension when used with CYP3A4s
- Avoid CYP3A4 inhibitors: clarithromycin, PIs, azoles
- Avoid grapefruit juice
- Avoid CYP inducers: rifampin, carbamazepine, phenytoin, at johns: can decrease levels
Nimodipine SE?
Hypotension
Nimodipine notes?
If contents cannot be swallowed the capsule can be withdrawn with a parenteral syringe and then transfered to oral syringe
Label syringe for ORAL USE ONLY
Bleomycin Max dose
And what toxicity?
Lifetime cumulative 400 units
Pulmonary Toxicity
What 4 drugs have maximum dosing recommendations due to toxicities?
Bleomycin, Doxorubicin, Cisplatin, VIncristine
Doxorubicin Maximum dose and why?
Lifetime cumulative: 450-550 mg/m2
Cardiotoxicity
Cisplatin maximum dose and why?
Dose per cycle: not to exceed 100 mg/m2
Nephrotoxicity
Vincristine Maximum dose and why?
Single dose capped at 2 mg
Neuropathy
What drugs cause myelosuppression?
3
Almost all cause myelosuppression except Asparginase, bleomycin, vincristine
How should myelosuppression be treated in chemotherapy patients?
If neutropenic give Colony stimulating factor
Anemia: RBC transfusion
Chemo drugs that cause N/V 3 main
- Cisplatin
- Cyclophosphamide
- ifosfamide
How is nausea and vomitting treated in chemo therapy patietns? 6
- Neurokinin-1 receptor antagonists (NKI-RA)
- Serotonin 3 receptor antagonists (5HT3-RA
- Dexamethasone
- Metoclopramide
- Prochlorperazine
- IV/PO fluid and hyfration
5 chemo drugs that cause Mucositis?
- Fluorouracil
- Capecitabine
- Irinotecan
- Methotrexate
- And many TKIs including the nibs
How is mucositis treated in chemo therapy patients?
Symptomatic tx , local anesthtics
4 chemo drugs that cause diarrhea?
- Fluorouracil
- Capectabine
- Irinotecan
- and many TKIs
How is Diarrhea treated in chemo therapy patients?
- IV/PO fluid hydration, antimotiliy agents (loperamide)
- Irinotecan: atropine for early onset
Main drug that causes consiptation in chemo
- Vincristine
How to treat constipation in chemo?
Stimulant laxatives
polyethylene glycol
Xerostomia?
Dry mouth
Artificial saliva substitutes caused by radiation
Cardiotoxicity In Chemo
Cardiomyopathy specifically 1
- Anthracyclines
Cardiotoxicity in chemo
QT prolongation? 2
- Arsenic trioxide
- TKIs, end in nib
How to treat cardiomyopathy in chemo patients?
Do not exceed cumulative dose of doxorubicin 450-550 mg/m2
and dexrazoxane can be given prophylactically
How to treat QT prolongation in cancer patient?
Maintain electrolyte balance consider holding therapy if QT interval is > 500 msec
4 chemo drugs that can cause pulmonary fibrosis
- Bleomycin
- Busulfran
- Carmustine
- Lomustine
Chemo drugs that cause hepatotox? 1 class?
- Antiandrogens
- Bicalutamide
- Flutamide
- Nilutamide
2 chemo drugs that cause Nephrotoxicity
- Cisplatin
- MTX
What can be given to treat nephro toxicity in chemo patients?
- Amifostine (ethyol) can be given prophylactically with cisplatin
- Ensure hydration
- DONT EXCEED MAX CISPLATIN DOSE OF 100 MG/m2/cycle
Two drugs in chemo that can cause hemorrhagic cystitis
Ifosfamide all doses
Cyclophosphamide higher doses > 1 g/m2
What can be given for hemorrhagic cystitis in chemo?
- Mesna (Mesnes) is ALWAYS given with ifosfamide and sometime cyclophos
3 classes of chemo drugs that cause peripheral sensory neuropathy
- Vinca alkaloids: Vincristine, vinblastine, vinorelibine
- Platinums: cisplatin, oxaloplatin
- Taxanes: Paclitaxel, docetaxel, cabazitaxel
Ways to reduce peripheral sensory neuropathy with vincristine?
limiting the dose to 2mg per wk
What does oxaliplatin cause?
Acute cold mediated sensory neuropathy avoid cold and cold drinks
Bortezomib SE treatmetn
SC admin is assoiciated with less peripheral neuropathy than IV
Chemo drugs that have thromboembolic risk? 2 classes
Aromatase inhibitors (anastrazole, letrozole)
SERMs (Tamoxifen)
What is amifostine (ethyol) for?
Given with cisplatin to prevent nephrotoxicity
What is Dexrazoxane used for?
With doxorubicin for cardiomyopathy prophylaxis
THis is Zinecard
Totect is used for extravacation
What is leucovorin or levoluecovorin (Fusilev) used for?
- Used with fluorouracil to enhance efficacy
What is Uridine triacetate used for? 2 things
Flourouracil and Capecitabine
As an antidote give within 96 hours
What is mesna used for?
Used with ifosfamide always to prevent hemmorhagic cycstis
What is atropine and loperamide used for>
Atropine: early onset diarrhea for Irinotecan
Loperamide: for delayed
Glucarpidase and Leucovorin or levoleucovorin used for?
given after methotrexate to prevent myelosuppresion and as a mucositis antidote
What hydration steps can you take with these drugs to reduce renal damage?
Mesna with Ifosfamide
Amifostene for cisplatin
When it damages the bladder and kidneys get it out with hypertonic solutions, these increase urine output and incluse mannitol and hypertonic saline
When are WBCs the lowest during chemo?
7-14 days
When do WBCs recover after treatment?
3-4 wks after
IOf someone has a low neutrophil count what can happen?
They are at increased risk of infection
Nuetropenia is classifies as an ANC of?
<1000 cells/mm3
What is severe neutropenia classified as?
ANC < 500 cells/mm3
What is used for the prevention of febrile neutropenia?
Filgrastim and Pegfilgrastim
Neupagen or Zarxio?
Filstastim G-CSF
Granix
Tbo-filgrastim
How is Neupagen, zarxio dosed?
Daily
Neulasta?
Pegfilgrastim
SEs for Filgrastim, pegfilgrastim and tbo-filgrastim?
Bone pain
Sargramostim SEs? 5
Fever, bone pain, arthralgias, myalgias, rash
How is Neulasta dosed?
Pegfilgrastim
Once per cycle
Pegylated filgrastim is longer acting and dosed less frequintly
How are CSFs stored?
Store in fridge protect vials from light
When should CSF be administered?
No sooner than 24 hours after chemo
What should pts report if on CSF?
Signs of enlarged spleen left upper ab pain
What is the potential only sign for neutropenia?
Fever can sometimes be the only sign of infection
How is febrile neutropenia defined?
What should be done?
Single oral temp of >38.3 or 101
ANC < 500
Oral temp >38 for greater than 1 hour
If the ANC is expected to drop below 500
EXTREMELY IMPORTANT TO GIVE EMPIRIC ABX
What infection type poses the highest sepsis risk in febrile neutropenia?
Gram negative
Inclusing Pseudomonas
Patients ANC is expected to drop below 500 for <= 7 days and has no comorbidities
What 3 Abx sets should be used?
- Anti-pseudomonal
- Cipro + amox/clav
- Or Cipro +/- clinda or
- Levofloxacin
Patietns ANC is expected to be < 500 for longer than 7 days and has comorbidities evidence of renal impairment CrCl<30 or LFTs > 5 x ULN
What 5 Abx are recommneded?
iv Antipseudomonas
- Cefepime or
- Ceftaz or
- Meropenem or
- Imepenem + cilstatin or
- Pip/tazo
What is not recommended in Chemo patients when you are trying to cure them and they have anemia?
ESAs they can increase tumor progression
What are the 4 criteria that need to be met if you are trying to use ESA in a cancer patient?
- Use ESA only in non myeloid malignancies where anemia is directly caused by the chemo
- If you use ESA you must have at least 2 more months of chemo
- Initiate ESA when Hgb is < 10
- Use the lowest dose needed to avoid the need for RBC infusions
Assess TBIC and TSAT to see if iron needs to be replaced because it will not work without it
When are platelet transfusions indicated in cancer patients or whenever?
WHen platelets are below 10,000 or 20,000 if active bleed
What are the 5 risk factors for chemotherapy induced Nausea and vomiting?
- Female
- < 50
- dehydrated
- Hx of motion sickness
- Hx of N/V with prior regimens
When should antiemetics be administered in CINV?
30 minutes before chemo
and provide take home meds
Acute N/V onset?
Within 24 hours after chemo
What is delayed nausea and vomiting onset?
1 to 7 days after
What is anticapatory N/V related to chemo therapy?
Before chemo
What is the treatment for acute N/V with chemo?
5HT3-RA
Treatment for delayed N/V associated with chemo? 3
1 to 7 days
NK1 receptor antagonists, corticosteroids, palonosetron (only 5HT-RA indicated for delayed)
Treatment of anticipatory N/V associated with chemo?
Benzos
What drug has very high chemo emetegenic risk?
Cisplatin
What drug is a combo NK1 /5HT3-RA?
Netupitant/palonasetron
Akynzeo
What NK1 is PO?
Arepitant
What NK1 is IV?
Fosaprepitant
What do NK1 end in?
Pitant
What do 5Ht3 RAs end in?
Setron
What are two other possible drugs for CINV?
Olanzapine
Dexamethasone
What drugs should a patient be put on if they are on a high emetic risk chemo regimen?
3 drugs
- NK1+5HT+Dexamethasone
- Netupitant/palonestron (Akynzeo) + dexamethasone
- Olanzapine + palonosetron + dexamethasone
What drug is included in all high or moderate emetic risk chemo regimens?
Dexamethasone
What drugs are commonly used for breakthrough CINV?
5HT3s, dopamine antagonists, cannabinoids
What do NK1s do?
Substance P/ neurokinin-1 receptor antagonists block these which augments the antiemetic activity of 5-HT3RA reeptor antagonists and corticosteroids
Emend?
Arepitant Oral
Fosarepitant injection
Contraindications to the Emends?
do not use with pimozide or cisopride: these are 3A4 substrates
What 3 NK1s are 3A4 inhibtiors and what should be doen?
Both emends and netupitant
Doses of dexamethasone should be decreased when used together
When are 5HT3s given?
1 day prior to chemo
Granisetron transdermal patch should be given prior to day 1
Zofran or Zuplenz film
Ondansetron
Sancuso?
pATCH FORMULATION OF GRANISETRON
Anzemet
Dolasetron
Aloxi
Palonosetron
Contraindication for 5HT3 RAs
Dont use with apomorphine (Apokyn) due to severe HTN and loss of consciousness
2 warnings for 5HT3s?
QT prolongation: dose dep more common with IV
Serotonin syndrome when given with other serotenergic agents
2 main SEs of 5HT3s?
HA, and constipation
What 5HT3 is not indicated for CINV and why?
Anzemet: IV Dolasetron: increase risk of QT prolongation
What 5HT3s are available both IV and PO?
All
Decadron
Dexamethasone
2 SEs of Dexamethasone?
Fluid retention and insomnia
3 dopamine receptor antagonists that are used in CINV?
Prochloperazine
Promethazine
Meclopramide
Compazine
Prochloperazine
Reglan
Meclopramide
Phenergen
Promethazine
Boxed warnings for Pherngen? 2
Dont give to kids < 2
Dont give intra-arterial or SC due to extravacation
Reglan black box?
Tardive dyskinesia that can be irreversible
Droperidol is what?
Dopamine antagonist
Droperidol Black box?
QT prolongation
What 4 key SEs of Dopamine receptor antagonists?
- Sedation
- Lethargy
- Decrease seizure threshold
- Actue EPS (common in children antidote is diphenhydramine or beztropine)
What dopamine antagonist is not used in CINV and why>
Droperidol due to high QT risk
Marinol?
Dranabinol