Mucositis, nausea, swollow dysfunction Flashcards
WHO staging
- Generalized erythema and pain, patient able to maintain normal diet
- Ulceration, patient able to eat solids
- Ulceration, patient restricted to liquid diet
- Ulceration, total parenteral nutrition, alimentation not possible because of oral pain or ulceration
RTOG stagings
- erythema
- Patchy, serosanguineous discharge
- confluent, fibrionus mucositis
- ulceration, hemorrhage, necrosis
- DEATH
Treatment
- 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
Most common Chemotherapy commonly assoicated with mucositis
- 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
Etiology
- Chemical abnormalities 33%
* Metabolic, drugs, infections - Imparied gastric emptying 44%
- Visceral and serosal causes 31%
- Bowel obstrucation/ ileus, GI bleeding, enteritis, constipations
Mechanism-base approach Nausea/ vomitting
- Evaluation to determine the etiology
- Determine the pathophysiology, mechanism and, subsequently, receptors underlying the patient’s
nausea and vomiting - Choosing an antiemetic.
Pathophsyiology of nausea vomitting
Interrelationships Between Neural Pathways That Mediate Nausea and Vomiting
- VOMITTING CENTER (AchM, H1, 5HT2)
- Chemorecptor triggerzone (D2, 5HT3, NK-1)
- Cortex: via 5 senses, anxiety, menigeal, intracranial pressure
- Vestibular (AchM/ H1): MOTION trigger labyrinthine sents inputs into the vomiting center via the vestibulocochlear nerve
- Peripheral mechanoreceptors and
chemoreceptors
- GI tract, serosa, and viscera(5HT3, D2)
- Transmit via the vagus and splanchnic nerves, sympathetic ganglia, and glossopharyngeal nerves (AchM)
Opioid induced nausea vomititng
Direct mechanisms
- Chemoreceptor trigger zone: D2 receptor OUTSIDE the blood-brain barrier
- Sensitization of the labyrinth. (H1, muscarinic acetylcholine receptor)
- Gastroparesis: D2
Indirect mechanisms: Constipation
Treatment for opioid induced N/V
D2 receptor blocker
Metoclopramide, haloperidol,
and prochlorperazine
Chemotherapy-Induced Nausea and Vomiting
- Chemoreceptor trigger zone: 5HT-3 and Nk-1 receptor
- Peripheral pathway: Damaged of the GI lining released 5HT-3
- Neurohomonal by alternating the arginin vasopressin and prostaglandin levels
- Cortex: Anxiety
Treatment of choice for Chemotherapy induced N/V
- 5HT3 antagonist: ondansetron,
- NK-1 antagonist: Aprepitite, Fosaprepitant (Emend)
- Dexamethasone
American Society of Clinical Oncology Guidelines for
Management of Chemotherapy-Induced Nausea and Vomiting
cytochrome P450 3A4
High Chemotherapy emetogenicity drugs
- Cisplatin (Vlechlorethamine (nitrogen mustard)
- Streptozocin
- Cyclophosphamide >1500 mg/m2
- Carmustine (BCNU)
- Dacarbazine (DTIC)
- Dactinomycin
Moderate Chemotherapy emetogenicity drugs
- Oxaliplatin
- Cytarabine (ara-C) >1000 mg/m2
- Carboplatin
- Ifosfamide
- Cyclophosphamide
- Doxorubicin
- Daunorubicin
- Epirubicin
- Idarubicin
- Irinotecan
Low Chemotherapy emetogenicity drugs
- Paclitaxel
- Docetaxel
- Mitoxantrone
- Topotecan
- Etoposide
- Pemetrexed
- Miethotrexate
- Miitomycin
- Gemcitabine
- Cytarabine
- 5-Flurouracil
- Bortezomib
- Cetuximab
- Trastuzumab
Minimal Chemotherapy emetogenicity drugs
- Bevacizumab
- Bleomycin
- Busulfan
- 2-Chlorodeoxyadenosine
- Fludarabine
- Rituximab
- Vinblastine
- Vincristine
- Vinorelbine
Malignant Bowel Obstruction
- Peripheral pathways
- Steching, pain, and colic
- direct damage or irritation of the vagus nerver and released of the neuroendocrin
- Chemoreceptor trigger zone: inflammatory mediators and bacterial toxins
Treatment of choice for Bowel obstruction and Gastroparesis
- D2: Haloperidol, Metoclopramide (if incomplete obstruction)
- Muscarinic blocker: hyoscyamine.
Other options
- Dexamethasone
- Octreotide,nasogastric tube, venting
gastrostomy tube
Treatment of choice for other common etiology
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)
Proved benifit Nonpharmacological Therapy
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
Pharmacological treatment by receptor
- CTZ D2: Haldol, Compazine, Thorazine
- GI D2: Metoclopamide (5HT3 at high dose)
- GI-5HT3: Ondansetron
- Central 5HT3: Mirtazapine
- Pure Anti-chl (M) antagonist/ : Scopolamine, Hyoscynamine
- 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
Last resource USE only for EOL
Palliative sedation: Propofol: Sedation with 5HT3.
Empirical treatment
- START with D2: Haldol, Compazine.
- Around-the-Clock NO PRN
- No head-to-head comparison
- 2nd agent act at DIFFERENT receptors
Personal Note
- OLANZAPINE block every receptors which makes an ideal good 1st line empirical.
Aspiration/ swollowing problem
- 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
Contra-indications for swallowing evaluation
- 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).
