Oncology I: Part II Flashcards
What is myelosupression?
Decr in bone marrow activity, which leads to fever RBCs, WBCs, platelets
How long does it take to see effects of myelosuppression?
7-14 days for decr in WBCs/platelets
usually recover 3-4 weeks post-treatment
RBCs: Several months
Neutropenia
ANC < 1000
Severe < 500
ANC = WBC x [(% segs + % bands)/100]
Whats meds are used to treat neutropenia?
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)
Notes on colony stimulating factors
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)
Febrile neutropenia definition
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
Febrile neutropenia treatment
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
Treatment options for anemia
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
Treatment for thrombocytopenia
platelet transfusion
plt < 10,000 (or 20,000 if active bleed)
Acute CINV
N/v w/in 24 hrs after chemo
usually caused by serotonin
Delayed CINV
1 to 7 days after chemo
mainly caused by substance P
Anticipatory CINV
Before chemo
given BZDs before chemo to help relax
Available 5Ht-3 receptor antagonist and info
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
Available sub P/Neurokinin-1 antagonist and info
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
Which corticosteroid is commonly used for CINV?
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
Dopamine receptor antagonists used for CINV and notes
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)
Recommended regimen for high emetic risk agents
3 drugs (in some cases 4 drugs)
NK1-RA + 5ht3-RA + dexamethasone
Olanzapine + palonosetron + dexamethasone
Recommended regimen for moderate emetic risk agents
2 or 3 drugs
Low risk: only 1 drugs (not NK1-RA alone)
2nd line agents used for CINV
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
Drugs used to treat chemotherapy- induced diarrhea
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
Oral mucositis
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
Drugs used to treat xerostomia
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
Hand-Foot syndrome
palmar-plantar erythrodysesthesia redness, swelling, pain, blisters of the palms and soles Treatment: Reduce chemo dose cold compresses EMollients Corticosteroids and pain meds
Hypercalcemia of malignancy
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)
Treatment of hypercalcemia of malignancy
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
Vaccines in cancer pts
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
