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Therapeutics > Oncologic Emergencies > Flashcards

Oncologic Emergencies Flashcards

1
Q

Objectives of Hypercalcemia of malignancy

A

indentify characteristic signs and symptoms of HOM
categorize the severity of a ptietn’s HOM bsed on lab findings
explain the andvantage and diasdvantages bteween the various tx modalities for HOM
-formulate a treatemtn regimen based on severity of HOM as well as monitoring parameteros for assessing efficacy and/or side effects

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2
Q

what are the effects of increased PTH?

A

increased bone resorption
increased calcium reabsorption in kidney and decreased phosphate reabsorption
increased activation to active Vitamin D

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3
Q

what are the 3 types of cancers that can cause hypercalcemia?

A

release of parathyroid-related peptide by tumor (pTHrP)
local stimulaiton of osteoclasts by metastases to the bone
-systemic secretion of Vit D

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4
Q

signs and symptos of hypercalcemia?

A

kidney: polyuria, dehydration, nephrolithiasis, renal failure
GI ; N/V, constipation, anorexia, abdominal pain, polydipsia
Neuro: letheragiy, confusion, somnolence
-hypovolemia, cardiac arrhythmias

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5
Q

what is nephrolithiasis?

A

kidney stones

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6
Q

bones, stones, moans and groans?

A

bones: bone pain
stones: kidney stones
moans: abd pain
groans: neurologic

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7
Q

corrected calcium?

A

measured ca2+ plus 0.8(4-albumin)

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8
Q

why do you need to correct your calcium level?

A

40% of calcium is bound to albumin

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9
Q

Mild hypercalcemia range

A

10.4-11.9 mg/dl corrected calcium

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10
Q

moderate hypercalcimia range?

A

12-13.9 mg/dl corrected calcium

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11
Q

severe hypercalcemia?

A

> 14mg/dl corrected calcium

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12
Q

treatments for mild hypercalcemia?

A

<12mg/dL

  • hydration
  • prevention
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13
Q

treatment for hypercalcemia moderate?

A

-hydration
+/-diuresis
-IV bisphosphonate
+/- calcitonin

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14
Q

treatment for hypercalcemia severe?

A 
-hydration
\+/-diuresis
-IV bisphosphonate
\+/- calcitonin
\+/- dialysis
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15
Q

three main goals of treating hypercalcemia of malignancy?

A

increase renal elimination
decrease bone resorption
decrease GI absorption

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16
Q

advantages / disadvantages of hydration?

A

+helps reestablish euvolemia
+facilitate excretion of calcium
-caution with high risk patients

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17
Q

dose of hydration for hypercalcemia?

A

0.9% NaCl continuous infusion 300-500ml/hr

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18
Q

advantages / disadvantages of diuresis?

A

+facilitates elimiation of calcium by inhibiting reabsorption in loop of hence
+can prevent fuluid overload
+acts quickly
-must administer only after adequate hydration
-electrolyte abnormalities
-dehydration
-not routinely used

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19
Q

diuretic for hypercalcemia? dose?

A

furosemid 20-40mg IV q 12h

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20
Q

advantages / disadvantages of calcitonin?

A

+onset 2-4 hours

  • flushing, nausea, hypersensitivity
  • response only limited to first 48 hours-> tachyphylaxis
  • intranasal route is not effective
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21
Q

MOA calcitonin?

A

increase renal Ca2+ resorption

decreased bone resorption

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22
Q

dose of calcitonin for hypercalcemia?

A

4-8 IU/kg SQ or IM every 12 hours (max 8 IU/kg every 6 hours)

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23
Q

Who is at an increased risk of emesis with anticancer meds?

A

female more than males
younger more than older esp if < 30yo
less if high consumption of alcohol
if n/v w/ chemo, pregnancy or motion sickness

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24
Q

what ar ethe four types of emesis?

A

anticipatory
acute (withing 24 hrs of chemo)
delayed (> 24 hrs after chemo)
breakthrough (despite therapy)

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25
Q

non pharm treatment of emesis?

A

small frequent meals
bland room temperature food
use distractions like TV, music etc
maintain hydration

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26
Q

for minimal risk emetic regimen, what kind of emetic prophylaxis do you need to use?

A

none

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27
Q

for low risk emetic regimen, what kind of emetic prophylaxis do you need to use? for how long?

A

dexamethasone or dopamine agonist
+/- lorazepam, H2 blocker or PPI

Day 1, repeat daily for multiday regimens

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28
Q

for Moderate risk emetic regimen, what kind of emetic prophylaxis do you need to use? for how long?

A

selective serotonin antagonist on day 1, day 2-3 optional
AND
Dexamethasone Day 1, day 2-3 optional
+/- NK1 antagonist, lorazepam, h2 blocker or PPI

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29
Q

for High risk emetic regimen, what kind of emetic prophylaxis do you need to use? for how long?

A 
selective serotonin antagonist , day 1 optional day 2-3
AND 
dexamethaosne days 1-4
AND NK-1 Antagonist days 1-3
\+/- lorazepamp, h2 blocker or PPI
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30
Q

what do you do for breakthrough emesis?

A

add one agent form a different drug class to the current PRN regimen

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31
Q

what do you use for anticipatory emesis?

A

use a benzodiazepine & behavioral therapy

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32
Q

what is the difference between aprepitant and fosaprepitant?

A

aprepitant comes in an oral capsule while fosaprepitant is the injectible form of the drug

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33
Q

brand Emend?

A

aprepitant and fosaprepitant

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34
Q

what is the MOA of aprepitant?

A

competitive inhibitor or NK1 receptors in the CNS

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35
Q

adverse effects aprepitatn?

A

fatigue
constipation
hiccups

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36
Q

CYP interactions of apreptitant?

A

moderate cyp3a4 inducer

mild cpy 2c9 inducer

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37
Q

when should you use aprepitant (indication)

A

acute and delayed emesis with highly emetogenic regimens

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38
Q

dose aprepitant?

A

125mg po 1 hr before chemo

80mg po days 2 and 3 in the AM

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39
Q

fosaprepitant dose?

A

150mg IV on day 1 only

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40
Q

patient education for aprepitant?

A

SE of medication
take with or without food
inform physician if on warfarin

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41
Q

what is the the MOA of the “-setrons” ondansetron, palonosetron, granisetron, doasetron?

A

selective serotoning 3 antagonists

inhibtn serotning receptors on vagal afferent nerves

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42
Q

adverse effects of selective serotonin 3 antagonists?

A

Headache and drowsiness
constipation
fatigue
qt prolongation

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43
Q

patient education for selective serotonin 3 antagonists?

A

take at the first sign of nausea
may cause change in defecation pattern
HA and drowsiness

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44
Q

Zofran

A

ondansetron

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45
Q

ondansetorn dosing for prevention of CINV?

A

8-32mg IV 30 min prior to chemo
OR
8mg po BID/TID starting 30 min before chemo

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46
Q

ondansetorn dosing for breaktrough N/V?

A

4-8 mg po TID

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47
Q

what is the MOA for corticosteroids for emesis?

A

unknown

48
Q

adverse effects of corticosteroids?

A

agitation, insomnia,
hiccups, upset stomach
arrhythmia
hyperglycemia, transient leukocytosis

49
Q

patient education with corticosteroids?

A

take with food and in the morning

follow a taper is given one

50
Q

labs to monitor for corticosteroids?

A

serum potassium
glucose
WBC
occult blood loss

51
Q

dexamethasone

A

decadron

52
Q

dexamethosone dose for prevention of CINV?

A

12mg IV or PO 30 min before chemo on day 1

8mg po daily or bid on subsequent days of treatment

53
Q

dexamethasone dosing for delayed or breakthrough N/V

A

4-10mg IV or PO QD or BID x 2-4 days
OR
8mg IV /pPO q 12h x 2 days then 4mg IV/PO q 12h x 2 days

54
Q

MOA of lorazepam for antiemetic?

A

enhancement of inhibtoroy effect of GABA on neuronal excitability

55
Q

adverse effects of lorazepam

A

sedation
respiratory depression
confusion

56
Q

monitoring for lorazepam?

A

RR
blood pressure
HR
drowsiness (sedation score)

57
Q

patient educaiton for lorazepam?

A

causes sedation
do not drink alcohol or any other sedatives
do not drive when taking BZDs

58
Q

dosing of lorazepam for anticipatory emesis?

A

0.5-1mg po night before and morning before chemo

59
Q

dosing lorazepam ofr breakthrough N/V

A

0.5-2mg PO/SL/IV q 4-6hrs prn

60
Q

what is the MOA of prochlorperazine or promethazine ?

A

dopamine receptor antagonists

61
Q

compazine AND formulations

A

prochlorperazine

IV PO IM PR

62
Q

Phenergan AND formulations

A

IV PO IM PR

promethazine

63
Q

adverse effects of doapine receptor antagonists?

A 
sedation 
hypotension
akathesia 
dystonia 
extravasation with promethazine
64
Q

prochloperazine CINV prevention dose

A

5-10 mg po IV 1hr before chemo

65
Q

prochlorperazine doses

A

breakthrough N?V 5-10mg po/ IV q6h prone OR 25 mg PR q12h PRN

66
Q

promethazine CINV dosing

A

breakethrough 12.5-25mg po or IV (central line) q 4h prn

67
Q

metoclopramide MOA

A

dopamien receptor antagonist and serotonin receptor antagonist at higher doses

68
Q

AE of metoclopramide

A

drowsiness
dystonia + akathesia at higher doses
diarrhea

69
Q

formulations of metoclopramide?

A

PO
IV
IM

70
Q

patient educaiton of reglan?

A

may cause diarrhea
drowsiness or agitaiton
take at first sign of nausea or retching

71
Q

what is the MOA of scopolamine?

A

anticholinergic at parasympathetcis sites of smooth mucscle, secretory glands and CNS

72
Q

AE scopalamine?

A 
constipation 
tachycardia 
thirst 
urniary retention 
drowsiness
73
Q

indication scopalamine

A

breakthrough N/V

74
Q

patient education for scopalamine

A

apply clean hairless place behind ear
wash hands afterwards
Sid effects

75
Q

dosing for scopalamine patch?

A

1.5mg patch applied q 3 days prn nausea

76
Q

indicaiton of cannabinoids

A

breakthrough nausea and vomiting

77
Q

mOA cannabinoids?

A

agonism at cannabinoid-1 receptor

78
Q

adeverse effects of cannabinoids?

A 
dysphoria
tachycardia
flushing
withdrawal 
drowsiness, confusion, detachment 
increased appetitne
79
Q

Marinol

A

dronabinol classIII

80
Q

Cesamet

A

nabilone class II

81
Q

dronabinol dosingg for n/v

A

5mg/m2/dose 4-6 times daily

82
Q

nabilone dosing

A

1-2 mg bid prn

83
Q

what causes mucositis?

A

chemo kills rapidly dividing mucosal cells in the GI tract

84
Q

agents available for mucositis prophylaxis?

A

palifermin
cryotherapy
oral hygeine

85
Q

indication of palifermin?

A

for patients receiving intense chemotherapy regimens such as hemapoetic stem cell transplantation

86
Q

palifermin MOA

A

keratinocyte growth factor - 1

87
Q

adverse effects of palifermin?

A

rash, prurities

mouth /gongue discoloaration or scalloping

88
Q

dosing palifermin

A

60mcg/kg/day IV 3 consecutive days before and 3 days consecutieve after chemotherapy

89
Q

how long is palifermin stable for?

A

at room temperature 1 hour after reconstitution

90
Q

when to use cryotherapy for mucositis?

A

with short half life therapies (bolus 5-FU and melphalan)

91
Q

symptom treatment for mucositis?

A 
topical anesthetics (magic mouthwash)
systemic analgesics (avoid NSAIDs)
antidiarrheals
92
Q

what are the two options for anemia induced by cancer?

A

erythropoesis stimulating agents

red blood cell transfusion

93
Q

what are the risk with ESAs? benefits?

A

increased thrombolic events
decreased survival
time to tumor progression shortened

Benefits
transfusion avoidance
improvement in fatigue

94
Q

risks and benefits of red blood cell transfusion?

A 
transfusion reactions
CHF
viral or bacterail transmission 
iron overlaod 
increased thrombolic events 
decreased survival

benefits:
rapid increased of H/H
rapid improvement in fatigue

95
Q

what is the indication of ESA’s

A

for palliative intent not for use in curative intent therapy

96
Q

which two agents are indicated as ESA’s?

A

epoeitin alfa

darbopoeitin alfa

97
Q

when do you initiate the ESAs?

A

if the HbB is < 10g/dL

98
Q

how long will it take for you to see the hgb increase with ESAs?

A

> = 2 weeks

99
Q

what is the goal hgb for patients on ESA’s

A

“minimum necessary to avoid transfusions”

-In practice people dont give it if the pts hgb i >= 12g/dL

100
Q

adverse effects of ESAs?

A 
hyper or hypotension
arthralgias , mayalgia, back pain
injection site pain/reacitons
fatigue 
edema
headache
101
Q

black box warnings for ESAs?

A

increased risk of thromboembolic events
decreased sruvival and increased dtumor porgression in cancer patients
dvt prophylaxix prior to surgery

102
Q

contraindicaitons of ESAs?

A

curative intent
albumin hypersensitivty
uncontrolled hypertension

103
Q

when should you discontinue ESAs once started?

A

when chemotherapy is complete

if no HgB response at 8-12 weeks

104
Q

what should you do with ESAs in terms of iron management?

A

measure iron level before starting ESA and monitor during therapy
consider supplementation if transferin saturaiton is less than 50% AND ferritin is less than or equal to 800ng/mL
used thie common regiment : ferric gluconate (ferrlecit) 125mg IV q week x 8 weeks

105
Q

what is tumor lysis syndrome?

A

a rapid lysis of tumor cells and release of contents into the blood stream : nucleic acids, proteins, phosphorous, potassium

106
Q

signs and symptoms of TLS

A

hyeruriciemia
hyperkalmeima
hyperphosphatemia
hypocalcemia

107
Q

what are the complications of tumor lysis syndrome

A

the electrolyte imbalances can lead to acute renal failure, arrhythmias and neuromauscular irritability

108
Q

risk factors for developing tumor lysis syndrome?

A

Pre existing factors:
-renal impairment, hyperuricemia, hyperphosphatemia, dehydration, nephortoxic agents
Tumor type: highly proliferative rate cancers have many cells and can burst much content, different cancers respond to chemotherapy by bursting more than others
Tumor burden: the bulkier the disease the more TLS (> 10cm), increased WBC > 50, 000 , elevated LDH (> 2ULN)

109
Q

what are the signs and symptoms of hyperkalemia?

A

muscle twitching
weakness
EKG changes
cardia arrhythmias

110
Q

what are the signs and symptoms of hyperphophatemia

A

calcium -phosphate precipitatie
renal osteodystrophy
hypocalcemia (inverse relationshi)

111
Q

what are the signs and symptoms of hyperuricemia?

A

nausea/vomiting
confusion
nephropathy

112
Q

what are the signs and symptoms of hypocalcemia?

A 
tremor
numbness
muscle cramps/spasms
lethargy, psychosis, coma
hypotension
113
Q

why do patients have hyperuricemia?

A

the lysisl of the DNA leads to purines being convereted into uric acid and causing hyperuricemia

114
Q

by looking at labs how do you define TLS by cairo-bisops standards (also called the laboratory definition) ?

A 
Tow or more laboratory changes must occur within 3 days before or 7 days after cytotoxic therapy
Uric acid >= 8mg/dl
K>= 6mEq/L 
Phos >= 6.5 
Calcium 25%
115
Q

what is the clinical definition of TLS?

A

defined by having the laboratory definition of TLS + at least one clinical complication

116
Q

by looking at labs how do you define TLS by cairo-bisops standards (also called the laboratory definition) ?

A 
Tow or more laboratory changes must occur within 3 days before or 7 days after cytotoxic therapy
Uric acid >= 8mg/dl
K>= 6mEq/L 
Phos >= 6.5 
Calcium 25%
117
Q

what is the clinical definition of TLS?

A

defined by having the laboratory definition of TLS + at least one clinical complication

Therapeutics (23 decks)

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