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PHM 703: Crit Care/Heme/Onc > Onco 1: Supportive care > Flashcards

Onco 1: Supportive care Flashcards

i need emotional support cat

1
Q

consequences of chemo induced nausea and vomiting

A
  • increased morbidity
  • decreased qol
  • nonadherehce
  • dose redcution
  • weakeness
  • dehydration
  • electrolyte imbalance
  • decline in behavior and metnal health
  • esophageal tears
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2
Q

acute CINV

A

occurs within 24 hours after chemo start

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3
Q

delayed CINV

A

occuring 24h to seeral days after start of chemo

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4
Q

breakthrough CINV

A

occurs depsite ppx

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5
Q

anticpatory CINV

A

before treatmetn dt anx or expected CINV

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6
Q

refractory CINV

A

recurring in subsequent cycles

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7
Q

relavent receptors in CINV

A
  • 5-HT3
  • susbtance p and NK1
  • DA
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8
Q

peripheral pathway for CINV

A
  • 5HT3 mediated
  • orginates in GI
  • usually acute
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9
Q

central pathway for CINV

A
  • NK-1 mediated
  • in brain
  • predominately involved in dealyed
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10
Q

risk factors for CINV

A
  • 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
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11
Q

ppx for a parenteral chemo agent with high risk for CINV

A
  • 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

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12
Q

ppx for a parenteral chemo agent with moderate risk for CINV

A
  • 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

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13
Q

ppx for a parenteral chemo agent with low risk for CINV

A

one of the followign 30 min before chemo
- dexamethasone
- metoclopramide
- prochlorperazine
- 5HT3

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14
Q

ppx for a parenteral chemo agent with minimal risk for CINV

A

no routeine ppx

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15
Q

ppx for a oral chemo agent with moderate-high risk for CINV

A

5-HT3

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16
Q

ppx for a po chemo agent with mnimal-low risk for CINV

A

prn

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17
Q

breakthrough treatment for CINV

A
  • 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

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18
Q

non-pharm measures for CINV

A
  • avoid strong smells
  • acupuncture
  • guided therapy
  • relaxation
  • hyponsis
  • yoga
  • biofeedback
  • porgressive muscle relaxation
  • cog disstraction guided imagery
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19
Q

dexamethasoe MOA in CINV

A

unknown, but though to interact with 5HT3 recceptors and GC receptors in medulla

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20
Q

Dexamethasone ADR

A
  • isnomnia - admi in morning
  • dyspepsia - take with food, consider H2RA or PPI
  • hyperglycemia
  • HTN
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21
Q

5HT3 RA MOA in CINV

A

block 5HT3:
- in peripheray (GI) on vagal nerve terminals
- centrally at chemo trigger zone (medulla)

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22
Q

5HT3 RA ADR

A
  • Headache
  • constipation
  • QT prlongation
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23
Q

5HT3 RA 1st gen

A
  • ondasentron
  • granisetron

  • more effective in acute ppx
  • short acting
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24
Q

5HT3 RA second gen

A
  • palonosetron
  • effective in acute and delayed CINV ppx
  • long acting
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25
Q

NK1 RA MOA in CINV

A
  • inhibit P/NK1
  • augment 5HT3 RA and dexamethasone antiemeti activity
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26
Q

NK1 RA use

A

only used in ppx (not treatment)
- especially useful in delayed CINV ppx

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27
Q

NK1 RA agents

A
  • aprepitant
  • fosaprepitant (also avalable in combo with palonsetron)
  • rolapitant: must have at least 2 weeks betwee nadmin dt long t1/2 (7d)
  • nitupitant/palonosetron
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28
Q

NK1 RA DDI

A

inhibition of CYP3A4 and 2C9 -> deccrease dexamethasone CINV ppx dose from 12 to 8mg on days 2-4

does NOT apply to rolapitant

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29
Q

olanzapien MOA in CINV

A
  • blocks DA, 5HT3, muscarinic and histamine receptors
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29
Q

NK1 ADR

A

similar to placebo
- fatigue
- GI upset
- HA
- hiccups

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30
Q

olanzapien use in CINV

A

both ppx and breathrough

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31
Q

olanzaine ADR

A
  • sedation: HS admin (unless premedication), lower dose in older adults
  • hyperglycemia
  • fatigue
  • QT prolongation
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32
Q

DA antag MOA in CINV

A
  • antag DA in chemoreceptor zone
33
Q

DA antag use in CINV

A

most useful in breakthrough

34
Q

DA antag ADR

A
  • phenothiazines (prochlorprazine, promethazine)
    - drowsiness
    - constiaption
  • benzamine (metoclopramide)
    - drowsiness
    - diarrhea
    - QT prolongation
    - TD (avoid using > 12 weeks)
35
Q

benzodiazepines (ativan) use in CINV

A

most useful for anticipatory CINV or breakthrough with an anx compoent

dt anxiolytic effet

give night before and/or morning of

36
Q

benzodiazpine (lorazepam) ADR

A
  • sedation
  • dizziness
37
Q

cannabinoids MOA in CINV

A
  • CB1 agonism -> suppress vomiting
  • indirect activation of 5-HT1a in raphe nucleus
38
Q

cannabinods use in CINV

A

rarely used, onlly in refractory

39
Q

cannabinods ADR

A
  • sedation
  • euphoria,, hallucinations
  • palpitations
  • flushing
  • cough
40
Q

scopolamine patch use in CINV

A

rarely used, only for breakthrough

it anticholinergic (that’s also it’s moa)

41
Q

scopolamine ADR

A
  • dry mouth
  • somnolence
  • blurred vision
42
Q

consequences of chemo induced diarrhea

A
  • depeltion of electrolytes
  • malnutrition
  • dehydration
  • hospitalziaiotn
  • chemo dose reduciton or delay
43
Q

chemo induced diarrhea grading

A
  • 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
44
Q

pt assessent of chemo induced diarrhea

A
  • hx
  • volume adn duration of diarrhea
  • hdyraiton status
  • pt risk factors
    - fever
    - orhtstatic symptoms
    - abdominal pain
    - weakness
45
Q

offending agets for chemo induced diarrhea

A
  • fluorouracil
  • capecitabinne
  • irinotecan
  • pertuzumab
  • abemaciclib
46
Q

irinotecan and diarrhea

A
  • acute:
    - dt cholingeric stimulation
    - usually responds to atropine
  • chronic
    - dt GI mucosal damage
    - 24h after admin
    - dose independent
47
Q

nonpharm treatmetn for chemo induced diarrhea

A
  • avoid trigger foods
  • aggressive PO rehydration
48
Q

pharm treatment for chemo indcued diarrhea

not incudling refractory treatment

A
  • loperamide: 4mg x1 followed by 2mg Q4H or after every unformed stool (MDD 16mg)
  • diphenoxylate atropine: 1-2T Q6H until control achieved (MDD 8T)
49
Q

pharm treatment for refractory chemo indcued diarrhea

A
  • rule out c.diff and infective colitis
  • octreotide
  • tincutre of opium
  • probiotics
50
Q

mucositis

A

erythematous and ulcerative lesions of the musosa
- anhwere in GI tract
- onset is 5-14 days

stomatitis is mouth only

51
Q

complications of mucositis

A
  • decreased oral intake-> poor nutrition (grade 4 requires parenteral or enteral nutrition)
  • increased infection risk
  • pain (may require opioids or PCA)
52
Q

pathophysiology of mucositis

A
  1. initiation: cellular damage, ROS formation
  2. primary damage response: acitavtion of p53 and NK-kB
  3. signal amplification: release of cytokines -> tissue damage, cell death
  4. ulceration: high risk of infeciton
  5. healing
53
Q

pt risk factors for mucositis

A
  • smoking
  • poor oral hygiene
  • preexisting oral lesions
  • female
  • existing nutritional status
54
Q

offending agents for mucositis

A
  • melphalan
  • cisplatin + radiaiton
  • high dose MTX
  • doxorubicin
  • busulfan
  • 5-FU
55
Q

mucositis ppx

A
  • 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
56
Q

managemnet of mucositis

A
  • 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
57
Q

profound neturopenia

A

ANC < 100

58
Q

prolonged neutropenia

A

lasting > 10 days

59
Q

consequneces of neutropenia

A
  • dose reduciton or treatment delays
  • compromised clincal outcomes
  • long hospital stay
  • increased treatment cost
  • decreased qol
60
Q

febrile neutropenia G-CSF primary ppx: when to give

A
  • high risk: give
  • intermediate risk and 1 pt risk factor: consider
  • low risk adn 2+ pt risk factors: may be considered
61
Q

G-CSF agents

A
  • filgrastim
  • pegfilgrastim
  • eflapegrastim or efbemalenagrastim

do NOT give within 24h after chemo dt enhanced chance of chemo tox

62
Q

filgrastim admin for priamry ppx of febrile neutropenia

A
  • start 24h after chemo completion
  • give QD until ANC recovery (~4 days)

short actig

63
Q

pegfilgrastim admin for priamry ppx of febrile neutropenia

A
  • give 1-4 days after compeltion
  • single admin of 6mg
  • wait 12+ dyas between admin and next cycle

long acting

64
Q

eflapegrastim or efbemalengrastim admin for priamry ppx of febrile neutropenia

A
  • start just after 24hs after completeion of chemo
  • single dose
    - 13.2 eflapegrastim
    - 20mg efbemalengrastim
  • do NOT give 14d before next cycle
65
Q

G-CSF use in treatment of febrile neutropenia in pts who had ppx with filgrastim

A

filgrastim

66
Q

G-CSF use in treatment of febrile neutropenia in pts who had ppx with a G-CSF (not including filgrastim)

A

no need for further G-CSF

67
Q

G-CSF use in treatment of febrile neutropenia in pts who did NOT have ppx

A

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

68
Q

secondary ppx with G-CSF for febrile neutropneia

pt had febrile neutropenia last cycle

A
  • if prior use of growth factor for treatment/ppx of febrile neutropenia; consider chemo dose reducito or switch therapy
  • no prior use: consdier starting
69
Q

somatic cancer pain

A
  • Tumor invades bone, muscle, or connective tissue
  • Often presents as aching, stabbing, throbbing, or pressure
70
Q

visceral cancer pain

A
  • Tumor invades itnernal organs and blood vessels
  • Often presents as gnawing, cramping, aching, or sharp pain
71
Q

neuropathic cancer pain

A
  • Pain from damage or dsfxn of nervous system
  • Often presents as burning, tingling, shotting, or electric/shocking pain
72
Q

non-opioid pain meds

A

APAP, NSAIDs

73
Q

adjuvant analgesics

A
  • antidepressatns
  • anticonvulsants
  • CS
  • topicals
74
Q

cance pain treatment

A
  1. Pain persisting or increasing: non opioid + adjuvant
    • lowest possile dose
    • start with IR and PRN, assess ad titrate as needed
  2. Pain perisisting or increasing: opioid for mild to moderate pain +/- non-opioid +/- adjuvant
  3. opioid for mod-severe pain +/- non-opioid +/- adjuvant
75
Q

titrating an opioid

A

In general min dose increase is 25-50%

76
Q

opioid rotation

A

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

77
Q

immune related ADR

A

increased immune system activity -> inflammation response
- increased T cell activit
- increased preexisting Ab
- increased inflamatrroy cytkines

78
Q

mild-mod immune therapy related ADR treatment

grade 1-2

A
  • sympotatic management (local therapies preferred)
  • consdier delaying immunotherapy
  • may need CS
79
Q

severe immune therapy related ADR treatment

grade 3-4

A
  • hold immunotherapy
  • CS required
  • possible additional immunosuppressant in steroid refractory ADR
  • may need inpatient care and additional supportive care
80
Q

corticosteroid ADR

with what she calls “suportive care”

A
  • 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

PHM 703: Crit Care/Heme/Onc (16 decks)

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