Oncologic Emergencies Flashcards
Objectives of Hypercalcemia of malignancy
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
what are the effects of increased PTH?
increased bone resorption
increased calcium reabsorption in kidney and decreased phosphate reabsorption
increased activation to active Vitamin D
what are the 3 types of cancers that can cause hypercalcemia?
release of parathyroid-related peptide by tumor (pTHrP)
local stimulaiton of osteoclasts by metastases to the bone
-systemic secretion of Vit D
signs and symptos of hypercalcemia?
kidney: polyuria, dehydration, nephrolithiasis, renal failure
GI ; N/V, constipation, anorexia, abdominal pain, polydipsia
Neuro: letheragiy, confusion, somnolence
-hypovolemia, cardiac arrhythmias
what is nephrolithiasis?
kidney stones
bones, stones, moans and groans?
bones: bone pain
stones: kidney stones
moans: abd pain
groans: neurologic
corrected calcium?
measured ca2+ plus 0.8(4-albumin)
why do you need to correct your calcium level?
40% of calcium is bound to albumin
Mild hypercalcemia range
10.4-11.9 mg/dl corrected calcium
moderate hypercalcimia range?
12-13.9 mg/dl corrected calcium
severe hypercalcemia?
> 14mg/dl corrected calcium
treatments for mild hypercalcemia?
<12mg/dL
- hydration
- prevention
treatment for hypercalcemia moderate?
-hydration
+/-diuresis
-IV bisphosphonate
+/- calcitonin
treatment for hypercalcemia severe?
-hydration \+/-diuresis -IV bisphosphonate \+/- calcitonin \+/- dialysis
three main goals of treating hypercalcemia of malignancy?
increase renal elimination
decrease bone resorption
decrease GI absorption
advantages / disadvantages of hydration?
+helps reestablish euvolemia
+facilitate excretion of calcium
-caution with high risk patients
dose of hydration for hypercalcemia?
0.9% NaCl continuous infusion 300-500ml/hr
advantages / disadvantages of diuresis?
+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
diuretic for hypercalcemia? dose?
furosemid 20-40mg IV q 12h
advantages / disadvantages of calcitonin?
+onset 2-4 hours
- flushing, nausea, hypersensitivity
- response only limited to first 48 hours-> tachyphylaxis
- intranasal route is not effective
MOA calcitonin?
increase renal Ca2+ resorption
decreased bone resorption
dose of calcitonin for hypercalcemia?
4-8 IU/kg SQ or IM every 12 hours (max 8 IU/kg every 6 hours)
Who is at an increased risk of emesis with anticancer meds?
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
what ar ethe four types of emesis?
anticipatory
acute (withing 24 hrs of chemo)
delayed (> 24 hrs after chemo)
breakthrough (despite therapy)
non pharm treatment of emesis?
small frequent meals
bland room temperature food
use distractions like TV, music etc
maintain hydration
for minimal risk emetic regimen, what kind of emetic prophylaxis do you need to use?
none
for low risk emetic regimen, what kind of emetic prophylaxis do you need to use? for how long?
dexamethasone or dopamine agonist
+/- lorazepam, H2 blocker or PPI
Day 1, repeat daily for multiday regimens
for Moderate risk emetic regimen, what kind of emetic prophylaxis do you need to use? for how long?
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
for High risk emetic regimen, what kind of emetic prophylaxis do you need to use? for how long?
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
what do you do for breakthrough emesis?
add one agent form a different drug class to the current PRN regimen
what do you use for anticipatory emesis?
use a benzodiazepine & behavioral therapy
what is the difference between aprepitant and fosaprepitant?
aprepitant comes in an oral capsule while fosaprepitant is the injectible form of the drug
brand Emend?
aprepitant and fosaprepitant
what is the MOA of aprepitant?
competitive inhibitor or NK1 receptors in the CNS
adverse effects aprepitatn?
fatigue
constipation
hiccups
CYP interactions of apreptitant?
moderate cyp3a4 inducer
mild cpy 2c9 inducer
when should you use aprepitant (indication)
acute and delayed emesis with highly emetogenic regimens
dose aprepitant?
125mg po 1 hr before chemo
80mg po days 2 and 3 in the AM
fosaprepitant dose?
150mg IV on day 1 only
patient education for aprepitant?
SE of medication
take with or without food
inform physician if on warfarin
what is the the MOA of the “-setrons” ondansetron, palonosetron, granisetron, doasetron?
selective serotoning 3 antagonists
inhibtn serotning receptors on vagal afferent nerves
adverse effects of selective serotonin 3 antagonists?
Headache and drowsiness
constipation
fatigue
qt prolongation
patient education for selective serotonin 3 antagonists?
take at the first sign of nausea
may cause change in defecation pattern
HA and drowsiness
Zofran
ondansetron
ondansetorn dosing for prevention of CINV?
8-32mg IV 30 min prior to chemo
OR
8mg po BID/TID starting 30 min before chemo
ondansetorn dosing for breaktrough N/V?
4-8 mg po TID
what is the MOA for corticosteroids for emesis?
unknown
adverse effects of corticosteroids?
agitation, insomnia,
hiccups, upset stomach
arrhythmia
hyperglycemia, transient leukocytosis
patient education with corticosteroids?
take with food and in the morning
follow a taper is given one
labs to monitor for corticosteroids?
serum potassium
glucose
WBC
occult blood loss
dexamethasone
decadron
dexamethosone dose for prevention of CINV?
12mg IV or PO 30 min before chemo on day 1
8mg po daily or bid on subsequent days of treatment
dexamethasone dosing for delayed or breakthrough N/V
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
MOA of lorazepam for antiemetic?
enhancement of inhibtoroy effect of GABA on neuronal excitability
adverse effects of lorazepam
sedation
respiratory depression
confusion
monitoring for lorazepam?
RR
blood pressure
HR
drowsiness (sedation score)
patient educaiton for lorazepam?
causes sedation
do not drink alcohol or any other sedatives
do not drive when taking BZDs
dosing of lorazepam for anticipatory emesis?
0.5-1mg po night before and morning before chemo
dosing lorazepam ofr breakthrough N/V
0.5-2mg PO/SL/IV q 4-6hrs prn
what is the MOA of prochlorperazine or promethazine ?
dopamine receptor antagonists
compazine AND formulations
prochlorperazine
IV PO IM PR
Phenergan AND formulations
IV PO IM PR
promethazine
adverse effects of doapine receptor antagonists?
sedation hypotension akathesia dystonia extravasation with promethazine
prochloperazine CINV prevention dose
5-10 mg po IV 1hr before chemo
prochlorperazine doses
breakthrough N?V 5-10mg po/ IV q6h prone OR 25 mg PR q12h PRN
promethazine CINV dosing
breakethrough 12.5-25mg po or IV (central line) q 4h prn
metoclopramide MOA
dopamien receptor antagonist and serotonin receptor antagonist at higher doses
AE of metoclopramide
drowsiness
dystonia + akathesia at higher doses
diarrhea
formulations of metoclopramide?
PO
IV
IM
patient educaiton of reglan?
may cause diarrhea
drowsiness or agitaiton
take at first sign of nausea or retching
what is the MOA of scopolamine?
anticholinergic at parasympathetcis sites of smooth mucscle, secretory glands and CNS
AE scopalamine?
constipation tachycardia thirst urniary retention drowsiness
indication scopalamine
breakthrough N/V
patient education for scopalamine
apply clean hairless place behind ear
wash hands afterwards
Sid effects
dosing for scopalamine patch?
1.5mg patch applied q 3 days prn nausea
indicaiton of cannabinoids
breakthrough nausea and vomiting
mOA cannabinoids?
agonism at cannabinoid-1 receptor
adeverse effects of cannabinoids?
dysphoria tachycardia flushing withdrawal drowsiness, confusion, detachment increased appetitne
Marinol
dronabinol classIII
Cesamet
nabilone class II
dronabinol dosingg for n/v
5mg/m2/dose 4-6 times daily
nabilone dosing
1-2 mg bid prn
what causes mucositis?
chemo kills rapidly dividing mucosal cells in the GI tract
agents available for mucositis prophylaxis?
palifermin
cryotherapy
oral hygeine
indication of palifermin?
for patients receiving intense chemotherapy regimens such as hemapoetic stem cell transplantation
palifermin MOA
keratinocyte growth factor - 1
adverse effects of palifermin?
rash, prurities
mouth /gongue discoloaration or scalloping
dosing palifermin
60mcg/kg/day IV 3 consecutive days before and 3 days consecutieve after chemotherapy
how long is palifermin stable for?
at room temperature 1 hour after reconstitution
when to use cryotherapy for mucositis?
with short half life therapies (bolus 5-FU and melphalan)
symptom treatment for mucositis?
topical anesthetics (magic mouthwash) systemic analgesics (avoid NSAIDs) antidiarrheals
what are the two options for anemia induced by cancer?
erythropoesis stimulating agents
red blood cell transfusion
what are the risk with ESAs? benefits?
increased thrombolic events
decreased survival
time to tumor progression shortened
Benefits
transfusion avoidance
improvement in fatigue
risks and benefits of red blood cell transfusion?
transfusion reactions CHF viral or bacterail transmission iron overlaod increased thrombolic events decreased survival
benefits:
rapid increased of H/H
rapid improvement in fatigue
what is the indication of ESA’s
for palliative intent not for use in curative intent therapy
which two agents are indicated as ESA’s?
epoeitin alfa
darbopoeitin alfa
when do you initiate the ESAs?
if the HbB is < 10g/dL
how long will it take for you to see the hgb increase with ESAs?
> = 2 weeks
what is the goal hgb for patients on ESA’s
“minimum necessary to avoid transfusions”
-In practice people dont give it if the pts hgb i >= 12g/dL
adverse effects of ESAs?
hyper or hypotension arthralgias , mayalgia, back pain injection site pain/reacitons fatigue edema headache
black box warnings for ESAs?
increased risk of thromboembolic events
decreased sruvival and increased dtumor porgression in cancer patients
dvt prophylaxix prior to surgery
contraindicaitons of ESAs?
curative intent
albumin hypersensitivty
uncontrolled hypertension
when should you discontinue ESAs once started?
when chemotherapy is complete
if no HgB response at 8-12 weeks
what should you do with ESAs in terms of iron management?
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
what is tumor lysis syndrome?
a rapid lysis of tumor cells and release of contents into the blood stream : nucleic acids, proteins, phosphorous, potassium
signs and symptoms of TLS
hyeruriciemia
hyperkalmeima
hyperphosphatemia
hypocalcemia
what are the complications of tumor lysis syndrome
the electrolyte imbalances can lead to acute renal failure, arrhythmias and neuromauscular irritability
risk factors for developing tumor lysis syndrome?
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)
what are the signs and symptoms of hyperkalemia?
muscle twitching
weakness
EKG changes
cardia arrhythmias
what are the signs and symptoms of hyperphophatemia
calcium -phosphate precipitatie
renal osteodystrophy
hypocalcemia (inverse relationshi)
what are the signs and symptoms of hyperuricemia?
nausea/vomiting
confusion
nephropathy
what are the signs and symptoms of hypocalcemia?
tremor numbness muscle cramps/spasms lethargy, psychosis, coma hypotension
why do patients have hyperuricemia?
the lysisl of the DNA leads to purines being convereted into uric acid and causing hyperuricemia
by looking at labs how do you define TLS by cairo-bisops standards (also called the laboratory definition) ?
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%
what is the clinical definition of TLS?
defined by having the laboratory definition of TLS + at least one clinical complication
by looking at labs how do you define TLS by cairo-bisops standards (also called the laboratory definition) ?
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%
what is the clinical definition of TLS?
defined by having the laboratory definition of TLS + at least one clinical complication
