Oncology Flashcards
Acute onset emesis
occurs 0-24 hours after chemotherapy. usually resolves in 24 hours. intensity peaks at 5-6 hours
serotonin antagonists, steroids, NK1 antagonists help
Delayed onset emesis
Occurs more than 24 hours after chemo
Most common with cisplatin, may occur wth carboplatin or doxorubicin
Schedule antiemetics for DNV
NK1 receptor antagonists help
Mildly emetogenic radiation
head/neck or extremities
no prophylaxis needed
Moderately emetogenic radiation
upper abdomen or pelvis or craniospinal
Prophylactic antiemetics recommended
Highly emetogenic radiation
total body, total nodal, upper-half body
prophylactic antiemetics recommended
duration of antiemetics for highly emetogenic chemo
3 days
duration of antiemetics for moderately emetogenic chemo
2 days
Recommended antiemetic regimen for highly emetogenic chemo
Day 1:
NK1 receptor antagonist
Serotonin receptor antagonist
Dexamethasone
OR
Olanzapine + palonosetron + dex
Consider adding lorazepam, olanzapine, H2RA/PPI
Day 2-4:
Dexamethasone
If aprepitant PO used on day 1, continue schedule
If olanzapine used on day 1, continue schedule
Recommended antiemetic regimen for moderately emetogenic chemo
Day 1:
Serotonin receptor antagonist
Dexamethasone
+/-
NK1 antagonist, lorazepam, H2RA/PPI
OR
olanzapine + palonosetron + dex +/- lorazepam, H2Ra/PPI
Day 2-4:
Serotonin antagonist or dex monotherapy or olanzapine if used on day 1
Mild emetogenic chemo regimen
single agent
Phenothiazine, butyrophenone (haldol, droperidol), steroids for schedule or PRN
olanzapine for breakthrough
H2RA or PPI role in antiemetic regimen
prevent dyspepsia, which may mimic nausea
High emetic chemo IV agents
> 90% frequency of emesis
AC (doxorubicin, cyclophosphamide) or separate agents
Carboplatin, Cisplatin
Carmustine
Dacarbazine
Epirubicin
Fam-trastuzumab
Ifosfamide
Mechlorethamine
Melphalan
Sacitizumab
Streptozocin
Use NK1 receptor anagonist, serotonin receptor antagonist, dexamethasone, and olanzapine as prn
Some moderate emetogenic IV chemo
31-90% frequency of emesis
Bendamustine
Daunorubicin
Cytarabine/daunorubicin
Ifosfamide
Irinotecan
MTX
oxaliplatin
Emetogenic prophylaxis required for these oral anticancer agents
Azacitidine
Busulfan
Ceritinib
Cyclophosphamide
Fedratinib
Lomustine
Midostaurin
Mitotane
Mobocertinib
Selinexor
Tomozolomide
Is there a preferred serotonin receptor antagonist for emesis prevention
no, all equal, choose per contract
Dolasetron, granisetron, ondansetron, palonosetron
Serotonin receptor antagonist dosage forms
Oral tab:
Ondansetron (+ ODT)
Granisetron
Dolasetron
Palonosetron + netupitant
Parenteral:
Ondansetron
Granisetron
Palonosetron
Patch:
Granisetron
SC:
Granisetron
Can NK1 receptor antagonists be used alone?
NO – must be used with serotonin receptor antagonist and steroid.
NK1 receptor antagonists drug interactions
oral contraceptives: use another form of birth control
warfarin: significantly decrease INR. recheck INR in 7-10 days.
R-CHOP: may increase neuropathy due to aprepitant’s CYP3A4 inhibition
Low emetogenic chemo antiemetic regimen
dexamethasone
OR
Metoclopramide
OR
Prochlorperazine
OR
serotonin receptor antagonist, PO
+/- lorazepam, H2RA/PPI
Continue on days 2-4
Moderate-high emetogenic PO chemo regimen
Serotonin receptor antagonist (PO) +/- lorazepam, H2RA/PPI
Minimal to low emetogenic PO chemo regimen
Metoclopramide or prochlorperazine or serotonin antagonist
prn only
When to modify pain regimen
More than 2 prn doses needed in2 4 hour period
Maximize dose/schedule of current pain med first before adding another
Mild pain 1-3 first step
nonopioid - NSAID, aspirin, APAP
Can consider show titration of short acting opioids
moderate pain 4-7 persistent first step
weak opioid: hydrocodone or codeine
Severe persistent pain 8-10
Strong opioids: morphine, hydromorphone, oxycodone
Once stable on short acting, change to extended release at 50-100% of usual daily requirement
FDA definition of tolerance to opioids
fentanyl 25 mcg/hr
morphine 60mg/day
oxycodone 30mg/day
hydromorphone 8mg/day
for 1 week or longer
Metastatic bone pain nonopioid analgesic
NSAID
Opioids compared to morphine
Some may have different potency, duration, oral effectiveness, adverse event profiles
none is clinically superior to morphine.
fentanyl patch in cachectic pt
may not have enough subcutaneous fat for depot to form which results in inadequate pain relief
Bisphosphonates in cancer
recommended IV if breast cancer w/ bone mets (every 3-4 weeks)
recommended IV if lytic bone destruction with multiple myeloma (q3-4 weeks)
recommended in solid tumor mets (q4-12 w)
caution osteonecrosis of jaw
Denosumab in cancer
RANKL inhibitor that promotes bone removal
recommended q4w if bone mets from multiple myeloma
Nadir
lowest WBC will fall after chemo
usually occurs 10-14 days after chemo and recover by 3-4 weeks after chemo
Exceptions: mitomycin, decitabine, azacitidine, bleomyicn, vincristine, nitrosureas = nadirts 28-42 days
ANC calculation
ANC = WBC * % granulocytes or neutrophils (segmented + band)
General blood counts required for receive chemo
WBC >3000
ANC >1000
Plt >100,000
Chemo regimen to avoid CSFs in
ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) in Hodgkin lymphoma due to rare infections and increased bleomycin induced pulm toxicity
Febrile neutropenia definition
single oral temperature >101F or more
OR
100.4F for >1 hour
Neutropenia = ANC< 500
Cultures and signs/symptoms of infection are generally negative, besides fever.
Most common source of infection in febrile neutropenia
endogenous flora = gram negative or gram positive
More prolonged the neutropenia and more prolonged administration of antibiotics = greater risk for fungal
Empiric therapy for febrile neutropenia
broad spectrum monotherapy with antipseudomonal B lactam
reassess at 3-5 days
When to add vanco for febrile neutropenia
sepsis
pneumonia (xray confirmed)
positive blood culture for GPC
catheter related infection
SSTI
colonization of MRSA, VRE, or penicillin resistant strep
Severe mucositis
When to add antifungal to febrile neutropenia
persistent or recurring fever after 4-7 days of ABX and length of neutropenia expected to be more than 7 days
Prophylactic antibiotics for febrile neutropenia
FQ or Bactrim
consider if going to be profoundly neutropenic for >7 days
Pegfilgrastim
Longest acting CSF - only one dose needed
cannot give chemo for 10-14 days after
CSF for chemo & radiation?
not recommended due to potential for worse myelopsuppression
CSF during febrile neutropenia
only should be given in risk factors for complications – pneumonia, expected neutropenia >10 days, invasive fungal, anc<100
When to dose reduce chemo instead of CSF
After an episode of neutropenia & chemo is palliative, not curative.
GSF in secondary prophylaxis
CSF administration when previous chemo has been delayed or dose reduced due to prolonged neutropenia
GSF in primary prophylaxis
recommended if chemo regimen associated with 20% or greater risk of febrile neutropenia
lab values increased in microcytic anemia
TIBC and RBC distribution width
microcytic anemia treatment
iron replacement
macrocytic anemia cause
folate and b12 deficiency
B12 deficiency lab values that are increased
increase in MCV, MCH, methylmalonic acid, homocysteine
folate deficiency lab values that are increased
increase in MCV and MCH, b12 normal
folate and b12 deficiency treatment
replacement
b12 can be PO or IM weekly x1 month, then monthly
folate = 1mg folate daily x4 months. must take if pregnant to prevent neural tube defects
epoetin and darbepoetin role in chemo associated anemia
-to be given in CHEMO associated anemia only, not cancer-associated anemia
-only to be used in noncurative setting
Dexrazoxane
Chemoprotectant for anthracyclines (daunorubicin, doxorubicin, idarubicin, epirubicin) and anthracenedione (mitoxantrone)
Acts as iron chelator to reduce free radical damage and associated cardiomyopathy
consider when >=300mg/m2 of doxorubicin given
Also used for anthracycline extravasation
Amifostine
chemoprotectant that prevents nephrotoxicity from cisplatin and xerostomia in head/neck cancer
high risk for N/V and hypotension - not often used.
Mesna
chemoprotectant to prevent hemorrhagic cystitis from cyclophosphamide and ifosfamide
ALWAYS used with ifosfamide
Start before or with chemo agent and continue after the end of chemo agent
Leucovorin
chemoprotectant for methotrexate
MTX toxic reactions: mucous membrane toxicity, renal/hepatic toxicity, CNS, myelosuppression
Used with fluorouracil in colorectal cancer to improve activity (not as rescue)
Glucarpidase
chemoprotectact used for toxic methotrexate concentrations in patients with delayed MTX clearance d/t renal dysfunction
Continue leucovorin until MTX concentration is below leucovorin treatment threshold for 3 days.
ADMINISER LEUCOVORIN >2 HOURS BEFORE OR AFTER DOSE OF GLUCARPIDASE. GLUCARPIDASE CAN DECREASE LEUCOVORIN CONCENTRATIONS
Trilaciclib
chemoprotectant used to decrease myelosuppression from platinum/etoposide regiments OR topotecan-regimens for small cel lung cancer
Severe hypercalcemia treatment
corrected ca >14 or symptomatic
NS 3-6L in 24 hours
Loop diuretics to prevent fluid overload
Bisphosphonates - but onset is 3-4 days
Calcitonin (rapid onset but short lived)
DO NOT give thiazides
Tumor Lysis Syndrome
Hyperuricemia, hyperkalemia, hyperphosphatemia, secondary hypocalcemia
NS + allopurinol
Vesicant antineoplastics
Doxorubicin
Daunorubicin
Epirubicin
Mechloethamine
Mitomycin
Trabectedin
Vincristine
Vinblastine
Vinorelbine
Streptozocin
*why we give doxorubicin as injection other than infusion
Anthracycline extravasation management
Cold therapy
Topical dimethyl sulfoxie (but not that established)
Dexrazoxane
Vinca alkaloid extravasation management
Heat therapy
Hyaluronidase
Mechlorethamine extravasation management
sodium thiosulfate
