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AAHPM > Mucositis, nausea, swollow dysfunction > Flashcards

Mucositis, nausea, swollow dysfunction Flashcards

1
Q

WHO staging

A
  1. Generalized erythema and pain, patient able to maintain normal diet
  2. Ulceration, patient able to eat solids
  3. Ulceration, patient restricted to liquid diet
  4. Ulceration, total parenteral nutrition, alimentation not possible because of oral pain or ulceration
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2
Q

RTOG stagings

A
  1. erythema
  2. Patchy, serosanguineous discharge
  3. confluent, fibrionus mucositis
  4. ulceration, hemorrhage, necrosis
  5. DEATH
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3
Q

Treatment

A
  • restricted to controlling pain and reducing infection
  • good oral hygiene and benzydamine mouthwash
  • Nutrition support: TPN, G-tube
  • Palifermin (keratinocyte growth factor) is now indicated for use in patients with hematological malignancies who are receiving high-dose chemotherapy and total body irradiation with autologous stem cell transplantation
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4
Q

Most common Chemotherapy commonly assoicated with mucositis

A
  • DNA cycle-specific > non-specific Cytarabine, Doxorubicin, Etoposide (high-dose) and -tecan, 5-FU (bolus administration schedules), Methotrexate (particularly low-dose), Taxal, alkylating (Cisplatin, Busulfan, mephalan,)
  • Antitumor antibody
         Bleo**mycin**
  • Molecularly targeted > eGF-targeted

sunitinib, sorafenib, Cetuximab, Temsirolimus, Erlotimib

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5
Q

Etiology

A
  1. Chemical abnormalities 33%
    * Metabolic, drugs, infections
  2. Imparied gastric emptying 44%
  3. Visceral and serosal causes 31%
  • Bowel obstrucation/ ileus, GI bleeding, enteritis, constipations
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6
Q

Mechanism-base approach Nausea/ vomitting

A
  1. Evaluation to determine the etiology
  2. Determine the pathophysiology, mechanism and, subsequently, receptors underlying the patient’s
    nausea and vomiting
  3. Choosing an antiemetic.
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7
Q

Pathophsyiology of nausea vomitting

A
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8
Q

Interrelationships Between Neural Pathways That Mediate Nausea and Vomiting

A
  1. VOMITTING CENTER (AchM, H1, 5HT2)
  2. Chemorecptor triggerzone (D2, 5HT3, NK-1)
  3. Cortex: via 5 senses, anxiety, menigeal, intracranial pressure
  4. Vestibular (AchM/ H1): MOTION trigger labyrinthine sents inputs into the vomiting center via the vestibulocochlear nerve
  5. Peripheral mechanoreceptors and
    chemoreceptors
  • GI tract, serosa, and viscera(5HT3, D2)
  • Transmit via the vagus and splanchnic nerves, sympathetic ganglia, and glossopharyngeal nerves (AchM)
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9
Q

Opioid induced nausea vomititng

A

Direct mechanisms

  1. Chemoreceptor trigger zone: D2 receptor OUTSIDE the blood-brain barrier
  2. Sensitization of the labyrinth. (H1, muscarinic acetylcholine receptor)
  3. Gastroparesis: D2

Indirect mechanisms: Constipation

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10
Q

Treatment for opioid induced N/V

A

D2 receptor blocker

Metoclopramide, haloperidol,
and prochlorperazine

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11
Q

Chemotherapy-Induced Nausea and Vomiting

A
  1. Chemoreceptor trigger zone: 5HT-3 and Nk-1 receptor
  2. Peripheral pathway: Damaged of the GI lining released 5HT-3
  3. Neurohomonal by alternating the arginin vasopressin and prostaglandin levels
  4. Cortex: Anxiety
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12
Q

Treatment of choice for Chemotherapy induced N/V

A
  1. 5HT3 antagonist: ondansetron,
  2. NK-1 antagonist: Aprepitite, Fosaprepitant (Emend)
  3. Dexamethasone
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13
Q

American Society of Clinical Oncology Guidelines for
Management of Chemotherapy-Induced Nausea and Vomiting

A
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14
Q

cytochrome P450 3A4

A
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15
Q

High Chemotherapy emetogenicity drugs

A
  • Cisplatin (Vlechlorethamine (nitrogen mustard)
  • Streptozocin
  • Cyclophosphamide >1500 mg/m2
  • Carmustine (BCNU)
  • Dacarbazine (DTIC)
  • Dactinomycin
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16
Q

Moderate Chemotherapy emetogenicity drugs

A
  • Oxaliplatin
  • Cytarabine (ara-C) >1000 mg/m2
  • Carboplatin
  • Ifosfamide
  • Cyclophosphamide
  • Doxorubicin
  • Daunorubicin
  • Epirubicin
  • Idarubicin
  • Irinotecan
17
Q

Low Chemotherapy emetogenicity drugs

A
  • Paclitaxel
  • Docetaxel
  • Mitoxantrone
  • Topotecan
  • Etoposide
  • Pemetrexed
  • Miethotrexate
  • Miitomycin
  • Gemcitabine
  • Cytarabine
  • 5-Flurouracil
  • Bortezomib
  • Cetuximab
  • Trastuzumab
18
Q

Minimal Chemotherapy emetogenicity drugs

A
  • Bevacizumab
  • Bleomycin
  • Busulfan
  • 2-Chlorodeoxyadenosine
  • Fludarabine
  • Rituximab
  • Vinblastine
  • Vincristine
  • Vinorelbine
19
Q

Malignant Bowel Obstruction

A
  • Peripheral pathways
  1. Steching, pain, and colic
  2. direct damage or irritation of the vagus nerver and released of the neuroendocrin
  • Chemoreceptor trigger zone: inflammatory mediators and bacterial toxins
20
Q

Treatment of choice for Bowel obstruction and Gastroparesis

A
  1. D2: Haloperidol, Metoclopramide (if incomplete obstruction)
  2. Muscarinic blocker: hyoscyamine.

Other options

  1. Dexamethasone
  2. Octreotide,nasogastric tube, venting
    gastrostomy tube
21
Q

Treatment of choice for other common etiology

A

Radiation-associated: 5HT3 antagonists (Zofran)

Uremia-associated: 5HT3 antagonists (Zofran)

Brain tumor/ ^ICP: Dexamethasone, D2 (Compazine)

Motion associated: Antimuscarinic acetylcholine receptor, H1: Scopolamine, diphenhydramine,
 and Thorazine (D2)
22
Q

Proved benifit Nonpharmacological Therapy

A

Behavior

avoiding strong smells or other nausea
triggers, eating small, frequent meals, and limiting oral in- take during periods of extreme emesis, and

Psychological techniques

23
Q

Pharmacological treatment by receptor

A
  1. CTZ D2: Haldol, Compazine, Thorazine
  2. GI D2: Metoclopamide (5HT3 at high dose)
  3. GI-5HT3: Ondansetron
  4. Central 5HT3: Mirtazapine
  5. Pure Anti-chl (M) antagonist/ : Scopolamine, Hyoscynamine
  6. H1: Diphenhydramine

Mixed:

  • Promethazine:H1, muscarinic and D2
  • Olanzapine: D2, muscalinic, H1 and 5HT3

Miss

  • Cannabinoid, dronabinol, AIDS and cancer

QUESTIONABLE systemic absorption and eff.

  • ABHR suppository: ativan/benadryl/haldol/reglan
  • BDR (Diphen, Decadron, Reglan
24
Q

Last resource USE only for EOL

A

Palliative sedation: Propofol: Sedation with 5HT3.

25
Q

Empirical treatment

A
  1. START with D2: Haldol, Compazine.
  2. Around-the-Clock NO PRN
  3. No head-to-head comparison
  4. 2nd agent act at DIFFERENT receptors

Personal Note

  • OLANZAPINE block every receptors which makes an ideal good 1st line empirical.
26
Q

Aspiration/ swollowing problem

A
  • Swallowing studies, such as videofluoroscopy, lack both sensitivity and specificity in predicting who will develop aspiration pneumonia. A sensitivity of 65% and specificity of 67% in predicting who would develop aspiration pneumonia within one year.
  • Swallowing studies may be helpful in providing guidance regarding swallowing techniques and optimal food consistencies for populations amenable to instruction.
  • In patients with advanced dementia and other terminal conditions,
    feeding tubes have not been found to reduce the incidence of aspiration and can significantly impair the dying patient’s quality of life
  • GOC: life prolongation via caloric support
27
Q

Contra-indications for swallowing evaluation

A
  • Imminent death—death expected within 2 weeks
  • Death expected within weeks from any progressive terminal illness.
  • Patients who lacks of ablity to cooperate and follow simple commands such as: decrease level of arousal (coma/obtundation).

AAHPM (21 decks)

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