Onco 1: Supportive care Flashcards
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consequences of chemo induced nausea and vomiting
- increased morbidity
- decreased qol
- nonadherehce
- dose redcution
- weakeness
- dehydration
- electrolyte imbalance
- decline in behavior and metnal health
- esophageal tears
acute CINV
occurs within 24 hours after chemo start
delayed CINV
occuring 24h to seeral days after start of chemo
breakthrough CINV
occurs depsite ppx
anticpatory CINV
before treatmetn dt anx or expected CINV
refractory CINV
recurring in subsequent cycles
relavent receptors in CINV
- 5-HT3
- susbtance p and NK1
- DA
peripheral pathway for CINV
- 5HT3 mediated
- orginates in GI
- usually acute
central pathway for CINV
- NK-1 mediated
- in brain
- predominately involved in dealyed
risk factors for CINV
- less than 50
- female
- hx of pregnancy vomiting
- hx of CINV
- prone to motion sickness
- little to no EtOH use
- anx/high expectaion for CINV
ppx for a parenteral chemo agent with high risk for CINV
- option 1 (preferred):
- day 1: olanzapine, dexamethasone, NK1, 5HT3
- day 2-4: olanzapine, dexamethasone - option 2:
- day 1: olanzapine, dexamethasone, palonosetron
- day 2-4: olanzapine - option 3:
- day 1: dexamethasone, NK1, 5HT3
- day 2-4: dexamethasone
options 1, 3: if aprepitant was the NK1 used, use it on days 2 and 3
ppx for a parenteral chemo agent with moderate risk for CINV
- option 1:
- day 1: olanzapine, dexamethasone
- day 2-3: olanzapine or dexamethasone - option 2:
- day 1: olanzapine, dexamethasone, palonosetron
- day 2-3: olanzapine - option 3:
- day 1: dexamethasone, NK1, 5HT3
- day 2-3: +/- dexamethasone
options 3: if aprepitant was the NK1 used, use it on days 2 and 3
ppx for a parenteral chemo agent with low risk for CINV
one of the followign 30 min before chemo
- dexamethasone
- metoclopramide
- prochlorperazine
- 5HT3
ppx for a parenteral chemo agent with minimal risk for CINV
no routeine ppx
ppx for a oral chemo agent with moderate-high risk for CINV
5-HT3
ppx for a po chemo agent with mnimal-low risk for CINV
prn
breakthrough treatment for CINV
- add an agent form a different class to curret regimen*
- consider around the clock vs pn
- consider antacid fi pt has dyspecia
*agents
- olanzapine
- ativan: useful for anticaptory
- prochlorperazine
- dexamethasone
- dronabinol (soln F > cap)
- metoclorpamide
- 5HT3
- scopolamine
non-pharm measures for CINV
- avoid strong smells
- acupuncture
- guided therapy
- relaxation
- hyponsis
- yoga
- biofeedback
- porgressive muscle relaxation
- cog disstraction guided imagery
dexamethasoe MOA in CINV
unknown, but though to interact with 5HT3 recceptors and GC receptors in medulla
Dexamethasone ADR
- isnomnia - admi in morning
- dyspepsia - take with food, consider H2RA or PPI
- hyperglycemia
- HTN
5HT3 RA MOA in CINV
block 5HT3:
- in peripheray (GI) on vagal nerve terminals
- centrally at chemo trigger zone (medulla)
5HT3 RA ADR
- Headache
- constipation
- QT prlongation
5HT3 RA 1st gen
- ondasentron
- granisetron
- more effective in acute ppx
- short acting
5HT3 RA second gen
- palonosetron
- effective in acute and delayed CINV ppx
- long acting
NK1 RA MOA in CINV
- inhibit P/NK1
- augment 5HT3 RA and dexamethasone antiemeti activity
NK1 RA use
only used in ppx (not treatment)
- especially useful in delayed CINV ppx
NK1 RA agents
- aprepitant
- fosaprepitant (also avalable in combo with palonsetron)
- rolapitant: must have at least 2 weeks betwee nadmin dt long t1/2 (7d)
- nitupitant/palonosetron
NK1 RA DDI
inhibition of CYP3A4 and 2C9 -> deccrease dexamethasone CINV ppx dose from 12 to 8mg on days 2-4
does NOT apply to rolapitant
olanzapien MOA in CINV
- blocks DA, 5HT3, muscarinic and histamine receptors
NK1 ADR
similar to placebo
- fatigue
- GI upset
- HA
- hiccups
olanzapien use in CINV
both ppx and breathrough
olanzaine ADR
- sedation: HS admin (unless premedication), lower dose in older adults
- hyperglycemia
- fatigue
- QT prolongation
DA antag MOA in CINV
- antag DA in chemoreceptor zone
DA antag use in CINV
most useful in breakthrough
DA antag ADR
- phenothiazines (prochlorprazine, promethazine)
- drowsiness
- constiaption - benzamine (metoclopramide)
- drowsiness
- diarrhea
- QT prolongation
- TD (avoid using > 12 weeks)
benzodiazepines (ativan) use in CINV
most useful for anticipatory CINV or breakthrough with an anx compoent
dt anxiolytic effet
give night before and/or morning of
benzodiazpine (lorazepam) ADR
- sedation
- dizziness
cannabinoids MOA in CINV
- CB1 agonism -> suppress vomiting
- indirect activation of 5-HT1a in raphe nucleus
cannabinods use in CINV
rarely used, onlly in refractory
cannabinods ADR
- sedation
- euphoria,, hallucinations
- palpitations
- flushing
- cough
scopolamine patch use in CINV
rarely used, only for breakthrough
it anticholinergic (that’s also it’s moa)
scopolamine ADR
- dry mouth
- somnolence
- blurred vision
consequences of chemo induced diarrhea
- depeltion of electrolytes
- malnutrition
- dehydration
- hospitalziaiotn
- chemo dose reduciton or delay
chemo induced diarrhea grading
- grade 1: < 4 stool/day over baseline
- grade 2: 4-6/day over baseline; limits ADL
- grade 3: >7 over baseline; requires hospitalzation
- grade 4: life threating
pt assessent of chemo induced diarrhea
- hx
- volume adn duration of diarrhea
- hdyraiton status
- pt risk factors
- fever
- orhtstatic symptoms
- abdominal pain
- weakness
offending agets for chemo induced diarrhea
- fluorouracil
- capecitabinne
- irinotecan
- pertuzumab
- abemaciclib
irinotecan and diarrhea
- acute:
- dt cholingeric stimulation
- usually responds to atropine - chronic
- dt GI mucosal damage
- 24h after admin
- dose independent
nonpharm treatmetn for chemo induced diarrhea
- avoid trigger foods
- aggressive PO rehydration
pharm treatment for chemo indcued diarrhea
not incudling refractory treatment
- loperamide: 4mg x1 followed by 2mg Q4H or after every unformed stool (MDD 16mg)
- diphenoxylate atropine: 1-2T Q6H until control achieved (MDD 8T)
pharm treatment for refractory chemo indcued diarrhea
- rule out c.diff and infective colitis
- octreotide
- tincutre of opium
- probiotics
mucositis
erythematous and ulcerative lesions of the musosa
- anhwere in GI tract
- onset is 5-14 days
stomatitis is mouth only
complications of mucositis
- decreased oral intake-> poor nutrition (grade 4 requires parenteral or enteral nutrition)
- increased infection risk
- pain (may require opioids or PCA)
pathophysiology of mucositis
- initiation: cellular damage, ROS formation
- primary damage response: acitavtion of p53 and NK-kB
- signal amplification: release of cytokines -> tissue damage, cell death
- ulceration: high risk of infeciton
- healing
pt risk factors for mucositis
- smoking
- poor oral hygiene
- preexisting oral lesions
- female
- existing nutritional status
offending agents for mucositis
- melphalan
- cisplatin + radiaiton
- high dose MTX
- doxorubicin
- busulfan
- 5-FU
mucositis ppx
- oral hygiene
- avoid acidic/spicy foods
- soft toothbrush
- soln or IV instead of tab
- nonalcoholic mouthwash QID - cryotherapy: ice cubes in mouth before and/or during chemo
- MOA: vasoconstriciotn -> less drug to oral mucosa
managemnet of mucositis
- PO decontamination: bland or onco outhwash (dexametasone if everlimus induced)
- pain: opioids, 2% lidocaine swish and spit
- dry mouth: artifical saliva or gum
- nutrition: liquid or soft diet; TPN
- throush: fluconazole 200mg x1 then 100mg QD 21D
profound neturopenia
ANC < 100
prolonged neutropenia
lasting > 10 days
consequneces of neutropenia
- dose reduciton or treatment delays
- compromised clincal outcomes
- long hospital stay
- increased treatment cost
- decreased qol
febrile neutropenia G-CSF primary ppx: when to give
- high risk: give
- intermediate risk and 1 pt risk factor: consider
- low risk adn 2+ pt risk factors: may be considered
G-CSF agents
- filgrastim
- pegfilgrastim
- eflapegrastim or efbemalenagrastim
do NOT give within 24h after chemo dt enhanced chance of chemo tox
filgrastim admin for priamry ppx of febrile neutropenia
- start 24h after chemo completion
- give QD until ANC recovery (~4 days)
short actig
pegfilgrastim admin for priamry ppx of febrile neutropenia
- give 1-4 days after compeltion
- single admin of 6mg
- wait 12+ dyas between admin and next cycle
long acting
eflapegrastim or efbemalengrastim admin for priamry ppx of febrile neutropenia
- start just after 24hs after completeion of chemo
- single dose
- 13.2 eflapegrastim
- 20mg efbemalengrastim - do NOT give 14d before next cycle
G-CSF use in treatment of febrile neutropenia in pts who had ppx with filgrastim
filgrastim
G-CSF use in treatment of febrile neutropenia in pts who had ppx with a G-CSF (not including filgrastim)
no need for further G-CSF
G-CSF use in treatment of febrile neutropenia in pts who did NOT have ppx
can give G-CSF if one of the following
- 65+
- sepsis
- ANC < 500
- expected to be prolonged neutropenia
- documented infection
- hospitalzation at time of fever
- hx of febrile neutropenia
secondary ppx with G-CSF for febrile neutropneia
pt had febrile neutropenia last cycle
- if prior use of growth factor for treatment/ppx of febrile neutropenia; consider chemo dose reducito or switch therapy
- no prior use: consdier starting
somatic cancer pain
- Tumor invades bone, muscle, or connective tissue
- Often presents as aching, stabbing, throbbing, or pressure
visceral cancer pain
- Tumor invades itnernal organs and blood vessels
- Often presents as gnawing, cramping, aching, or sharp pain
neuropathic cancer pain
- Pain from damage or dsfxn of nervous system
- Often presents as burning, tingling, shotting, or electric/shocking pain
non-opioid pain meds
APAP, NSAIDs
adjuvant analgesics
- antidepressatns
- anticonvulsants
- CS
- topicals
cance pain treatment
- Pain persisting or increasing: non opioid + adjuvant
- lowest possile dose
- start with IR and PRN, assess ad titrate as needed
- Pain perisisting or increasing: opioid for mild to moderate pain +/- non-opioid +/- adjuvant
- opioid for mod-severe pain +/- non-opioid +/- adjuvant
titrating an opioid
In general min dose increase is 25-50%
opioid rotation
offer to pts with pain that is refractory to dose titration or with poorly managed ADR, logisitic or cost concerns, or trouble with ROA or absorption
immune related ADR
increased immune system activity -> inflammation response
- increased T cell activit
- increased preexisting Ab
- increased inflamatrroy cytkines
mild-mod immune therapy related ADR treatment
grade 1-2
- sympotatic management (local therapies preferred)
- consdier delaying immunotherapy
- may need CS
severe immune therapy related ADR treatment
grade 3-4
- hold immunotherapy
- CS required
- possible additional immunosuppressant in steroid refractory ADR
- may need inpatient care and additional supportive care
corticosteroid ADR
with what she calls “suportive care”
- gastritis: consider PPI or H2RA in pt at high risk
- infection
- risk of PJP if pt going to get prednisone 20mg+ for 4+ weeks -> ppx bactrim (preferred), atovaquone, dapsone, pentamidine
- risk of fungal if prednisone 20mg+ for 6+ weeks -> ppx with fluconazole - OP
- VitD 400-1000 IU QD
- Ca 1000-1200mg QD
