Managing Symptoms associated with Chemotherapy

Question 1

What are the 5 types of CINV?

Answer 1

Acute: within 24 hours
Delayed: after 24 hours
Anticipatory: conditioned response. difficult to treat
Breakthrough: anti-emetics before chemo but still vomit
Refractory: cycles of N+V

Question 2

Drugs used for CINV

Answer 2

•  Ondansetron and palonosetron	
(selective	5HT3	receptor	antagonists)	
• Aprepitant	
(a	neurokinin-1	[NK1]	receptor	antagonist)
• Dexamethasone	
(a	corticosteroid)		
• Metoclopramide	
(a	D2	receptor	antagonist)	
• Cyclizine	
(a	H1	receptor	antagonist)

Question 3

What monitors the blood for toxins which can cause CINV

Answer 3

The Chemoreceptor trigger zone (CTZ)

Question 4

Which neurotoxins are in the central pathway?

Answer 4

Seretonin, Dopamine, Acetylcholine, Histamine

Question 5

Which phase is the central pathway predominantly involved in?

Answer 5

Delayed phase of CINV

Primarily in the brain

Question 6

Which phase is the peripheral pathway predominantly involved in?

Answer 6

Acute phase of CINV

Primarily in the GIT

Question 7

Adverse effects of Ondansetron in chemo?

Answer 7

Increased QT interval hence cardiotoxic

Question 8

What are the 5 steps of the Anti-emetic Treatment Ladder

Answer 8

1. Metoclopramide to take home (+ nothing pre-chemo)
2. IV dexamethasone pre-chemo + Metoclopramide to take home
3. IV Ondansetron, IV dexamethasone pre-chemo + Ondansetron, Dexamethason, Metoclopramide, to take home
4. Same as above BUT Aprepitant OR Palonosetron instead of Ondansetron (both IV and oral)
5. Same as step 3 but aprepitant AND palonosetron instead of Ondansetron (both IV and oral)

Question 9

Key interaction between anti-emetics ?

Answer 9

Ondansetron and palonosetron (one or the other)

Question 10

Define: Mucositis

Answer 10

inflammation of mucous memebranes

Question 11

Define: Stomatitis

Answer 11

inflammation of lips and mouth area - sore mouth caused by rapid cell division in the mouth

Question 12

Treating mucositis / stomatitis

Answer 12

PREVENTION better than cure (oral hygiene)

• Chlorhexidine gluconate 0.2% w/v mouthwash
• Benzydamine hydrochloride 0.15% w/v mouthwash
• Sucralfate suspension
• Aciclovir 400mg five times daily
• Fluconazole 50 mg daily

Question 13

What is Palmar Plantar Erythrodysesthesia (PPE) ?

Answer 13

“Hand/foot syndrome” where the skin peels away

Mostly associated with capecitabine (chemo pro drug for breast, gastric, colorectal cancers)

Question 14

Describe the main adverse effect associated with capecitabine and how it occurs.

Answer 14

Capecitabine is a prodrug for 5-FU (leucovorin)
Uridine and/or thymine phosphorylase are in high concentrations in the feet and hands, hence, causes more “hand-foot syndrome”

Question 15

Describe the adverse effects of Kinase Inhibitors

Answer 15

Skin rashes:

• usually in first cycle (patients dont like bc of this)
• TKI dose reduction can prevent reoccurence
• use of hydrocortisone creams, topical clindomycin, tetracyclin Abx, prednisolone

Hair issues:
Eyelash Thricohmegaly - Long eyelashes (I would not complain)

Question 16

What is myelosuppression therapy

Answer 16

Chemo therapy that treats all 3: Anaemia, Neutropenia and thrombocytopenia.
involves common toxicity criteria (CTC) graded 1-5

Question 17

What is myelosuppression?

Answer 17

Side effect of many chemo drugs
Condition where bone marrow activity reduces, resulting in less RBCs, WBCs and platelets :(
When severe termed “myeloablation”

Question 18

What are the signs of myelosuppression?

Answer 18

Fatigue, breathless with spontaneous

bruising and bleeding

Question 19

What is neutropenic sepsis?

Answer 19

• Neutropenia with an infection
• Considered a medical EMERGENCY
• Signs include: tachycardia, high RR

Question 20

Diagnosis of neutropenic sepsis

Answer 20

1. neutrophil count ≤ 0.5 x 109/L

2. temperature higher than 38°C

Question 21

How do you treat neutropenic sepsis?

Answer 21

empirical beta-lactam antibiotic therapy in the form of piperacillin with tazobactam

Question 22

Chemo-induced diarrhoea (CID)

Answer 22

• look at notes -