Onc Supportive Care Flashcards
know different cancer related conditions, what to do about them, and medications most likely to cause them
CINV Consequences and High Risk Offenders
- *Consequences**
- metabolic imbalances
- nutritional deficits
- general decline
** High Risk Offenders**
ACUTE
- patient factors: female, < 55yo, PMH motion/morning sickness
- radiation therapy
- chemo with busulfan, cytarabine, anthracyclines, methotrexate, irinotecan
DELAYED
- cisplatin, carboplatin, cyclophosphamide, doxorubicin
** Notes **
- Anticipatory, Acute and Delayed (>24 hrs after dose), Breakthrough, Refractory
(in that order)
Mucositis
- Consequences **
- nutritional deficiency requiring TPN
- mucosal inflammation and ulceration in the mouth and GI tract that is painful
- increased infection risk
- chemo dose reductions
- High Risk Offenders **
- intense, multicycle chemo
- HSCT
- patient factors: young, female, poor nutrition, comorbidities, poor dentition
- chemo agent: 5-FU/capecitabine, cytarabine, doxorubicin, etoposide, irinotecan, MTX
- Medications to Treat/Prevent **
- expensive palifermin (severity reduction)
- amifostine (if radiation induced)
- Non Pharm **
- good oral hygiene (soft toothbrushes/sponges)
- “oral cryotherapy”: swish ice chips (unless oxaliplatin)
- bland rinses (salt or baking soda), Magic Mouthwash
- NO alcohol mouthwash
- Notes **
- most people taking chemo will get mucositis
5HT3 antagonists
** Indication ** CINV Prophylaxis, low - high emetogenecity
- Agents **
- Dolasteron (PO)
- Ondansetron (PO/IV)
- Palonosetron (IV): very effective for delayed
- Granisetron (PO, SQ, IV, patch
AEs: QTc prolongation, constipation, headache, bradycardia
NK1 antagonists
Indication: High Emetogenicity CINV Prophylaxis
- *Agents**
- aprepitant
- fosaprepitant
- rolapitant
- netupitant
fosaprep is a prodrug of aprep, and both are CYP3A4 substrates inducers and inhibitors as well as CYP2C9 inducers
AEs: intractable hiccups, constipation, fatigue
Steroids
** Indications **
CINV Prophylaxis: moderate - high
Pre-medication for Paclitaxel hypersensitivity
Pre-medication for Docetaxel for fluid retention
Pre-medication for Pemetrexed for skin rash (starting 1 day prior to tx)
- Agents**
- Dexamethasone
AE: insomnia, hyperglycemia, GI upset
(多い!)
Drugs for Breakthrough CINV
ATC dosing
Cannabinoids:
-Dronabinol
-Nabilone
AEs: psychosis, hallucinations, (not great in elderly patients) increased appetite
DA antagonists: - Prochlorperazine
- Promethazine
AEs: EPS, akathisia, drowsiness
dystonia with prochloperazine
can tx EPS with diphenhydramine
Other:
- Haloperidol,
- Metoclopramide
- Olanzapine: good for acute and delayed
- scopolamine patch
AEs: extrapyramidal symptoms, metabolic effects
Scopolamine = xerostomia and drowsiness
CINV OTC
things to eat:
- NOT your favorite food
- small meals 5 - 6 times a day (don’t skip meals!)
- bland food
Drink lots
Drink clear liquids after vomiting
Palifermin
** Indication **
Severe mucositis
Usually HSCT patients
keratinocyte growth factor that leads to proliferation of tongue/mucosal epithelium
AEs: rash pruritis funny tastes "furry" tongue
Chemo Induced Diarrhea (CID)
- *Consequences**
- decreased quality of life
** High Risk Offenders** Irinotecan (acute and delayed) - weekly or infusion chemo - history of CID - abdominal-pelvic radiation - PO TKIs - patient specific: > 65 yo, female, bowel pathology, bowel tumor, biliary obstruction
- Medications to Treat/Prevent **
- pre-med irinotecan with atropine (reduces acute diarrhea from cholinergic mechanism)
- late irinotecan diarrhea caused by SN38: tx with loperamide
- tincture of opium
- octreotide
- steroids or immune checkpoint inhibitors for immune colitis
- Non-Pharm **
- Drink a lot, with electrolytes
- small meals
- foods with sodium and potassium and very little fiber
- avoid hot/cold, spicy, greasy, fatty, milk-y, or fake sugary foods. no caffeine.
** Notes **
Infections associated with Febrile Neutropenia
- Definition **
- fever (>38.3 C/101 F or 38.0/100.4 for >1 hr)
- high infection risk by bacteria
- enteric translocation
** High Risk Offenders**
high risk: > 10 days expected neutropenic (acute leukemia or allo HSCT)
intermediate risk: 7 - 10 days (lymphoma or auto HCST, multiple myeloma)
low risk: < 7 days (solid organ tumors)
** Medications for INFECTIONS **
Prophylaxis:
- high risk: FQ throughout neutropenic period, +/ azole
PJP prophylaxis: TMP/SMX (if dysfunctional lymphocytes)
HSV reaction: acyclovir and valacyclovir (for hematologic malignancies)
Treatment:
low risk: PO; FQ + amox-clav
High risk: IV; antipseudomonal beta lactam +/- vancomycin (if MRSA suspected or persistent infection), +/- antifungal
Loperamide
Indication
Uncomplicated CID
AEs:
constipation
abdominal cramps
Diphenoxylate/atropine (Lomotil)
Indication
Uncomplicated CID
controlled substance
AEs:
Drowsiness
urinary retention
Octreotide
Indication
Complicated CID
parenteral administration
decreases VIP secretion, increasing GI transit time
AEs: bradycardia chest pain fatigue headache
Tincture of Opium
Indication
Complicated CID
2nd line, alternative to octreotide
Controlled Substance
Increases GI smooth muscle tone to decrease propulsion
AEs:
drowsiness
constipation
Chemo induced Neutropenia
Low neutrophils
Function: fight bacteria and fungi
ANC < 500 cells/mm3
(ANC = WBC*(segs+bands))
“profound neutropenia”: ANC < 100 cells/mm3
- Risk **
- > 65 yo with full dose chemo
- certain treatment regimens
- previous chemo or radiation, previous neutropenia, recent surgery
- person isn’t doing so hot currently (poor renal/hepatic dysfunction, HIV)
** Prophylaxis **
G-CSF for high risk FN
** Treatment **
G-CSF: only give if risk factors are present: sepsis, pneumonia/infection, > 65yo, ANC <100, invasive fungal infection, hospitalization, prior FN, > 10 days expected neutropenia
CM-CSF
MOA: stimulate neutrophil growth, GM-CSF also stimulates monocytes and eosinophils
** Notes **
Nadir typically 1 -2 weeks after chemo
