Managing side effects of chemotherapy and Palliative care Flashcards
What is the most succesful cancer treatment?
Surgery
What are the different options for systemic anti cancer therapy?
Cytotoxic, biological or hormonal chemo
What are the principles of chemotherapy?
Chemotherapy is given to sensitive tumour cells and causes cell death in a proportion of cells. Repeated administration results in proportional cell kill.
Tumour burden can be reduced to undetectable levels.
Targets rapidly dividing cells so normal body cells such as hair can be affceted
What is the difference between curative and palliative chemotherapy?
Curative: to cure the cancer, palliative: to improve and extend life
What is adjuvant chemotherapy?
Chemotherapy that is given after definitive treatment such as surgery or radiotherapy
What is neoadjuvant chemotherapy?
Chemo given pre treatment to facilitate the procedure and improve the chances of a cure
How is chemotherapy delivered?
IV is the most common route. Given via infusion
What is extravation?
Cytotoxic IV leakage
Why is chemotherapy given in cycles?
To achieve proportional cell kill but to allow patients some time to recover
How is efficacy achieved with chemotherapy?
Individualised dosages are given, based on body surface area. Response is measured and toxicity monitored, whilst also thinking about the intent of the treatment
What are the chemotherapy monitoring requirements?
RESPONSE: disease, treatment intentions, tumour markers, imaging
TOXICITY REVIEW: full blood count, U&E, renal/liver function, toxicity, side effects, weight
Decision on continuing/stopping/delaying/adjusting chemotherapy is made following monitoring
What are the advantages and disadvantages of oral delivery of chemotherapy drugs?
ADVANTAGES: more convenient for the patient, less expensive, lower toxicity, avoid complications with IV access
DISADVANTAGES: adherence, 100% bioavailability cannot be guaranteed like it can be with IV delivery, management of drug interactions, if the patient has diarrhoea or vomiting then it is not absorbed
What are biological therapies?
Using living organisms/substances derived from living organisms/laboratory based versions to target disease
Give some examples of biological therapies
- monoclonal antibodies
- cancer vaccines
- blood cell growth factors
- cancer growth factor blockers
- anti-angiogenics
- immunotherapy
- gene therapy
What are targeted therapies?
Therapies targeting the hallmarks of cancer, targeting changes in cancer cells that help them to grow, divide and metastasise. They can:
- induce immune response
- inhibit cancer cell growth
- inhibit angiogenesis
- release cytotoxic agents
- induce apoptosis
- inhibit hormone dependant growth
What are the different types of drug resistance?
- intrinsic: growth characteristics of tumour
- acquired: drug is deactivated, removed from cell
- cross resistance
When is glucose given to ‘ flush lines’?
Prior to giving carboplatin as it is not compatible with saline
What are the different types of chemotherapy induced nausea and vomitting?
Acute, delayed, anticipatory, breakthrough and refractory
What is acute CINV?
NV that occurs within 24 hours of treatment
What is delayed CINV?
NV that occurs more than 24 hours after chemo
What is anticipatory NV?
Hospital/sight associated NV
What is breakthrough CINV?
NV that occurs even with prophylactic anti-emetics
What is refractory CINV?
Repeat occurring NV
Which drugs are used to treat CINV?
- ondansertron and palonsertron (5ht3 antagonists, serotonin antagonists and should not be used at high doses)
- dexamethasone
- metoclopramide
- cyclizine
How do serotonin antagonists treat acute CINV?
The body thinks chemotherapy is a poison, as it damages cells in the GI tract, which leads to serotonin release
Discuss the use of ondansertron as anti-emetics
- it is a good all rounder and is incredibly effective
- can cause QT prolongation, which is dose dependant
- limited to 16mg OD or 8mg if over 75
- dilute and give over a longer period if over 65
- palonsertron is effective in small doses
What is the first step of the anti-emetic ladder?
No anti-emetics pre chemo, but metoclopramide is given to take home
What is the second step of the anti-emetic ladder?
IV dexamethasone is given pre chemo
metoclopramide given to take home
What is the third step of the anti-emetic ladder?
IV ondansertron and dexamethasone pre chemo
Ondansertron, dexamethasone and metoclopramide to take home
What is the fourth step of the anti-emetic ladder?
IV ondansertron and dexamthasone pre chemo
dexamethasone, ondansertron, metoclopramide to take home
PLUS
aprepriant
or palonsertron in place of ondansertron
What is the final step of the anti-emetic ladder?
IV palonsertron, IV dexamethasone pre chemo
Palonsertron, dexamethasone, metoclopramide to take home
aprepritant
What are common problems associated with chemotherapy?
Mucositis/stomatitis, hand/foot syndrome, chemo induced diarrhoea, myelosuppression, skin and hair problems with kinase inhibitors, neutropenic sepsis
What is mucositis/stomatitis and how is it treated/prevented?
Pain/inflammation of mucus membranes, a side effect of methotrexate. Can be prevented with good oral hygiene, using a soft toothbrush.
aciclovir/fluconazole can be given if infection
What is hand/foot syndrome and how is it treated?
Red/sore dry skin, patient can even lose their finger prints. Common side effect of antimetabolites and capecitabine. Can be prevented by intense moisturisation
How does capecitabine cause hand/foot syndrome?
Capecitabine has to be converted by thymidine phosphorylase to 5-fluorouracil. There is high levels of TP in the hands/feet, therefore capecitabine builds up in those areas and causes toxic effects
What is chemotherapy induced diarrhoea and how is it treated?
Diarrhoea common with irinotecan as it is metabolised in the liver. SN38 (metabolite of irinotecan) causes diarrhoea. Give subcutaneous atropine, if it still continues after 24 hours, give high dose loperamide/ciprofloxacin. It is dangerous as it can lead to dehydration
What is myelosuppression and how is it treated?
A condition in which bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, and platelets. Patients are myelosuppressed following chemotherapy. If cells are not back to normal before the next round of chemotherapy, do not give next cycle. Symptoms are bruising/bleeding, so filgrastin can be given to increase red blood cells. Common with FECT protocol
Which hair/skin problems can be associated with kinase inhibitors and how is it treated/prevented?
Common to get an acne like rash/brittle hair. Give topical corticosteroids/antibiotics, can be dehabilitating.
What is neutropenic sepsis and how should it be treated?
A medical emergency, associated with a low neutrophil count. Symptoms: increased temp. Give empirical beta lactams, pip taz
What are the different types of pain?
Somatic: bone/muscle ache
Visceral: organs, localised, throbbing pressure
Neuropathic: burning/stinging pain
How does advanced cancer cause pain?
Pain presses on organs
What is neuropathic pain and how is is treated?
Damage to nerves causes pins and needles feeling, with shooting and burning pain. Treated with tricyclic antidepressants. Start with low dose amitryptiline, then add gabapentin anticonvulsant. Can try alternative TCA if not effective, but make sure to titrate one down before starting a new one.
What is step 1 of the neuropathic pain ladder?
TCA or AC
What is step 2 of the neuropathic pain ladder?
TCA and AC
What is step 3 of the neuropathic pain ladder?
TCA + alternative AC
What is step 4 of the neuropathic pain ladder?
NMDA receptor blocker eg ketamine
What are key points for amitryptilline?
Usually has an effect within 3-7 days, can worsen constipation
What are key points for gabapentin?
Start low and go slow, has a fast effect and caution must be taken in renal impairment
What is step 1 of the pain ladder?
Non opioid eg paracetamol +/- adjuvants
What is step 2 of the pain ladder?
Weak opioid eg codeine and paracetamol +/- adjuvants
What is step 3 of the pain ladder?
Stop weak opioid
start strong opioid eg morphine and a laxative
paracetamol
+/- adjuvants
Discuss the use of morphine as a strong opioid in palliative care
Morphine is the gold standard strong opioid unless contraindicated or renal impairment (eGFR less than 30ml/min. Prescribed as a M/R dose plus IR liquid as 1/6th/1/10th of total daily dose for breakthrough pain
Why should morphine be avoided in the elderly or patients with renal impairment?
Because it is metabolised to produce an active metabolite (10%), which can accumulate and cause renal toxicity
How do you start a strong opioid in patients that have not previously been prescribed a weak opioid?
Start a I/R opioid every 4 hours and when required, add up what the patient has had in 24 hours and divide by 2 = new total daily dose of M/R opioid
How do you start a strong opioid in patients that have previously had a weak opioid?
Add up the codeine that they have had in the last 24 hours and divide by 10 to get the dose of morphine. Start a slow release opioid twice a day and immediate release when required at 1/6th of the total daily dose
Why should immediate release morphine be used to titrate dosages instead of modified release?
Because it will take longer to reach a steady state with MR
What are the adverse effects of strong opioids?
- nausea/vomitting
- drowsiness
- light headedness
- delirium
- constipation
- dry mouth
- respiratory depression
Why should you never give tramadol as a strong opioid?
- it has a similar structure to venlafaxine, so acts on various receptors
- needs good metabolism to be fully effective
- effects are not predictable
- high risk of serotonin syndrome when given alongside SSRIs
What are the key points for fentanyl?
Can have a lethal dose. Has no active metabolite, so is useful in renal impairment.
Matrix/reservoir patch can lead to dose dumping
Applying the patch to hot skin can cause OD
How is constipation managed in palliative care?
Common effect in advanced cancer as patients are immobile and taking lots of opioids. Give a stimulant/softener such as co-danthramer
How is breathlesness managed in palliative care?
oxygen for hypoxaemic patients
can also give low dose oral morphine as it has anxiolytic effects
How is nausea and vomiting treated in palliative care?
try to identify the cause and treat accordingly
can give benzodiazepenes if patients are anxious
metoclopramide then dexamethasone then ondansertron for anti-emesis
Which medications are given via syringe driver at the end of life?
- analgesia (morphine/oxycodone)
- anxiolytic (midazolam)
- antiemetic (cyclizine)
- anticholinergic (hyoscine butylbromide)
- water for injection as diluent
- check compatibility of agents in syringe driver
What are emergencies in palliative care?
- Hypercalcaemia
- superior vena cava obstruction
- spinal cord compression
What are the signs/symptoms of hypercalcaemia and how is it managed?
Symptoms: non-specific: drowsiness, coma, confusion, n&v, use a blood test to check (more than 1.3mmol/l then hyper)
rehydrate the patient and give a bisphosphonate
How is SVCO managed in palliative care patients?
Target and shrink tumour
What are the signs/symptoms of spinal cord compression and how is it managed?
Pins and needles, paralysis of lower limbs and neuropathic pain due to the tumour pressing on the spinal cord. Reduce the size of the tumour and treat symptoms.
