Oncology I: Part II

Question 1

What is myelosupression?

Answer 1

Decr in bone marrow activity, which leads to fever RBCs, WBCs, platelets

Question 2

How long does it take to see effects of myelosuppression?

Answer 2

7-14 days for decr in WBCs/platelets
usually recover 3-4 weeks post-treatment
RBCs: Several months

Question 3

Neutropenia

Answer 3

ANC < 1000
Severe < 500

ANC = WBC x [(% segs + % bands)/100]

Question 4

Whats meds are used to treat neutropenia?

Answer 4

Colony stimulating factors (CSF):
G-CSF - Filgrastim (Neupogen, Zarxio)
- Tbo-Filgrastim (Granix)
Pegylated G-CSF - Pegfilgrastim (Neulasta) - longer acting - give one per cycle
GM-CSF - Sargramostim (Leukine)

Does not improve overall mortality
Shorten time of pt being at risk for infection
reduces mortality from infections (when given prophylactically)

Question 5

Notes on colony stimulating factors

Answer 5

all can cause bone pain
stored in fridge
post chemo recovery = ANC 2000-3000
Administer 1st no sooner than 24 hrs after chemo (up to 72 hrs)

Question 6

Febrile neutropenia definition

Answer 6

Oral temp of > 38 C for 1 hr and ANC < 500 (or suspected to drop to < 500 in 48 hrs)

high risk for developing sepsis

Question 7

Febrile neutropenia treatment

Answer 7

empiric coverage against pseudomonas
Low risk: oral antibiotics
Cipro + Augmentin
Cipro +/- clindamycin
Levofloxacin
High Risk (ANC < 100): IV beta lactams:
Cefepime
Ceftazadime
meropenem
Imipenem-cilastatin
Zosyn

Question 8

Treatment options for anemia

Answer 8

recover on its own
RBC transfusions
erythropoiesis-stimulating agents (ESA) -rarely used
shown to shorten survival and incr tumor progression in studies for breast, non-SC lung, head and neck, lymphoid, cervical cancers
Only use ESAs if Hgb < 10
Also monitor levels of iron, folate and B12

Question 9

Treatment for thrombocytopenia

Answer 9

platelet transfusion

plt < 10,000 (or 20,000 if active bleed)

Question 10

Acute CINV

Answer 10

N/v w/in 24 hrs after chemo

usually caused by serotonin

Question 11

Delayed CINV

Answer 11

1 to 7 days after chemo

mainly caused by substance P

Question 12

Anticipatory CINV

Answer 12

Before chemo

given BZDs before chemo to help relax

Question 13

Available 5Ht-3 receptor antagonist and info

Answer 13

Ondansetron (Zofran) po/iv
Granisetron (Kytril Sancuso [patch], Sustol [sc}
Dolasetron (Anzemet) po
Palonosetron (aloxi) po
Warnings: 
dose-dependent incr in QT (more with IV)
Serotonin syndrome with other serotonergic drugs
SEs:
HA, fatigue, dizziness, constipation

Question 14

Available sub P/Neurokinin-1 antagonist and info

Answer 14

used to augment the effects of 5HT3 antagonist and/or steroids (don't use alone)
Aprepitant (Emend) PO
Fosaprepitant (Emend) IV
Netupitant + palonosetron (Akynzeo) PO
Rolapitant (Varubi) PO
SE's: 
Dizziness, fatigue, constipation, weakness, hiccups
Emend/ Akynzeo: CYP3A4 inhibitors
Varubi: Cyp2D6 inhibitor

Question 15

Which corticosteroid is commonly used for CINV?

Answer 15

Dexamethasone (Decadron)
off-label dosing 
High risk; given for 3-4 days
Mod risk: given for 3 days
Low risk: given on days of chemo
Short-term side effects:
Incr appetite/weight, fluid retention, mood swings, insomnia, GI upset, incr BP and BG

Question 16

Dopamine receptor antagonists used for CINV and notes

Answer 16

Prochlorperazine (Compazine, Compro) - po/iv/rectal
Promethazine (Phenergan) - po/iv/im/ rectal
Metoclopramide (reglan) - po/iv
SEs:
Sedation, lethargy, hypotension, QT prolongation, acute EPS (give benztropine or diphenhydramine), decr seizure threshold
antocholinergic side effects (Reglan can cause diarrhea)

Question 17

Recommended regimen for high emetic risk agents

Answer 17

3 drugs (in some cases 4 drugs)
NK1-RA + 5ht3-RA + dexamethasone
Olanzapine + palonosetron + dexamethasone

Question 18

Recommended regimen for moderate emetic risk agents

Answer 18

2 or 3 drugs

Low risk: only 1 drugs (not NK1-RA alone)

Question 19

2nd line agents used for CINV

Answer 19

Cannabinoids
Dronabinol (Marinol, Syndros): 
avail as caps, solution
refrigerated, schedule C-III
Nabilone (Cesamet):
oral 1-2 mg BID
non-refrig, schedule C-II
SEs:
somnolence, euphoria, incr appetite, orthostatic hypotension, lower seizure threshold

Question 20

Drugs used to treat chemotherapy- induced diarrhea

Answer 20

Loperamide:
normal max dose is 16 mg/day
can use 24 mg/day under direct supervision
Diphenoxylate + atropine (Lomotil)

incr risk of diarrhea when FU/capcitabine is used with leukovorin

Question 21

Oral mucositis

Answer 21

symptoms usually peak around 7 days after chemo
resolve 4- 8 days later
Treatments:
Mucosal Barrier Gel (Episil, MuGard, etc)
Lidocaine 2% solution
15 mL q 3h prn
Avoid ingestion of foof 60 mins after use due to impaired swallowing
Magic Mouthwash

Question 22

Drugs used to treat xerostomia

Answer 22

Usually caused by radiation near the neck/head
Artificial saliva subs (Biotene, etc)
Pilocarpine (Salagen)
5-10 mg TID (reduce dose if hepatic impairment)
SEs:
flushing, sweating, nausea, urinary frequency

Question 23

Hand-Foot syndrome

Answer 23

palmar-plantar erythrodysesthesia
redness, swelling, pain, blisters of the palms and soles
Treatment:
Reduce chemo dose
cold compresses
EMollients
Corticosteroids and pain meds

Question 24

Hypercalcemia of malignancy

Answer 24

common in breast, lung, muliple myelnoma cancers
Symptoms: n/v, fatigue, dehydration, renal failure, mental status changes
rehydration is usually always needed (with normal saline, then give loop diuretics)

Question 25

Treatment of hypercalcemia of malignancy

Answer 25

1st line: Bisphosphonates
Zoledronic acid (Zometa)
4 mg IV x 1, repeat in 7 days if needed
Pamidronate (Aredia) 60-90 mg IV over 2-24 hrs
onset: 24-72 hrs
for mild-severe hypercalcemia
2nd line: Denosumab (Xgeva)
120 mg SC on days 1, 8, 15, then monthly 
onset: 24-72 hrs
for mod-severe
Adjunct: Calcitonin (Miacalcin)
lowers serum Ca in 2-6 hrs
used in pts with symptomatic hypercalcemia

Question 26

Vaccines in cancer pts

Answer 26

Avoid vaccines due to inadequate immune response
Give 2 weeks prior to imitating of chemo, if possible.
No live vaccines
Annual flu shot can be given in between chemo cycles