Oncology: side effect management Flashcards
Screening for breast cancer
Aged 20 to 40 clinical breast exam every one to three years
Age greater than 40: clinical breast exam and mammography yearly
Warning signs
CAUTION
C: change in bowel or bladder habits A: sore that does not heal U: unusual bleeding or discharge T: thickening or lump in breast or elsewhere I: indigestion or difficulty swallowing O: obvious change and worked on mole N: Megan cough or hoarseness
Colon Cancer screening
Age greater than 50: annual physical oculist blood test or SQL immuno chemical test and one of the following: every five years sigmoidoscopy, contrast enema, CT scan or colonoscopy (every 10 years)
Screening for cervical cancer
Age 21 to 29: Pap smear only every three years
Age 30 to 65: Pap every three years or pap plus HPV testing every five years
Screening for prostate cancer
Start discussion at age 40 to 50 for a PSA with or without digital rectal exam
Screening for a lung cancer
Age 55–74 with greater than or equal to 30 pack your smoking history and are either still smoking or have quit for less than 15 years (low-dose CT scan)
Things that can reduce the risk of cancer
Stay away from tobacco products, stay at a healthy weight, get regular physical activity, eat healthy with plenty of fruits and vegetables, limit alcohol, protect your skin, know yourself your family and your risk, have regular checkups and cancer screenings
myelosuppression: anemia, neutropenia, thrombocytopenia
The lowest point that the white blood cells and platelets for each, also referred as the nadir, occurs about 7 to 14 days after chemotherapy
The someone’s generally recovered 3 to 4 weeks post treatment
Anemia: erythropoietin stimulating agents are not used as routinely anymore as it shortened survival and increases tumor progression
ESA agents now follow a rems program
Iron levels must be obtained as ESA’s will not work well to correct anemia if iron levels are inadequate
Erythropoietin stimulating agent
Blackbox warning: shortened overall survival and/or increased risk of tumor progression or recurrence; must follow the ESA apprise oncology program; patient must receive med guide monthly; use the lowest dose necessary to avoid the need for red blood cell transfusions; should only be used if hemoglobin is less than 10 and at least two additional months of chemotherapy are planned
These agents are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is a cure
Drugs: Epoetin Alfa (Epogen, Procrit); Darbepoetin (Aranesp)
Contraindication: uncontrolled hypertension, pure red cell aplasia that begins after treatment, multidose vials containing benzyl alcohol contraindicated in neonates, infants, pregnancy and lactation
Side effects: hypertension, fever, headache, bone pain, rash, nausea, call my thrombosis, edema, chills, dizziness
Monitoring: Hgb, HCT, iron, blood pressure
Notes: store in the refrigerator
Management of neutropenia
Result: increase infection risk and inability to fight infection
ANC= WBC x (%segs + %bands)/100
Neutropenia = ANC < 1000 Severe neutropenia = ANC 20% chance of developing febrile neutropenia: myeloid growth factors 1. Sargramostin (leukine) 2. Filtration (Neupogen) 3. Pegfilgrastim (Neulasta)
Side effects (2,3): bone pain, fever, rash Side effects (1): fever, bone pain, arthralgia, myalgia, rash, dyspnea, peripheral Adema, pericardial effusion, cardiovascular edema, hypertension, chest pain
Notes: store in the refrigerator; Edminister first dose 24–72 hours after the end of chemotherapy
Thrombocytopenia management
A.k.a. low platelets (may result in spontaneous bleeding) chemotherapy should be held until the platelet count recovers
Platelet transfusions are generally indicated when the count falls below 10,000 per millimeter^3 or 20,000 if an active bleed is present
Chemotherapy induced nausea and vomiting
Prevention is essential
Risk factors which increase the risk: female gender, less than 50 years of age, dehydration, history of motion sickness, and history of nausea/vomiting with prior regimens
Give antiemetics at least 30 minutes prior to chemotherapy and provide take-home antimanic medications such as ondansetron, prochlorpromazine, or metoclopramide
Three drug regimen:
1. Aprepitant (Emend) AND
2. Dexamethasone AND
3. Ondansetron, Granisetron, Dolasetrom, palonosetron
4 . ± Lorazepam, ± H2 receptor antagonist or proton pump inhibitor
Alternative to three drug typical anti-emetic regimen
Alternative for highly or moderately emetogenic regimens
- Olanzapine AND
- Dexamethasone AND
- Palonosetron
Regimen for moderate emetic risk chemotherapy
Typically a two drug combination of a steroid and a five HT3 antagonists with or without a neurokinin one antagonist
Low emetic risk regimen
Typically a one drug regimen of either a five HT three antagonist, dexamethasone, prochlorperazine or metoclopramide
Anti-emetic drug considerations
Phenothiazines and metoclopramide are dopamine blocking agents and could cause or worsen movement disorders and cause sedation
Metoclopramide requires a dose reduction with renal dysfunction
Centrally acting antihistamines can cause central and peripheral anticholinergic side effects which are typically intolerable and elderly patients
Anti-emetic agents: 5-HT3 receptor antagonist
MOA: work by blocking serotonin, both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone
Drugs: ondansetron (Zofran, Zuplenz film), granisetron (Granisol solution, Sancuso transdermal patch), dolasetron (Anzemet), palonosetron (Aloxi)
Note ondansetron available: IV, PO, ODT, solution; dolasetron can only be given PO
Contraindications: use of April morphine or a broken; do not use dolasetron IV or acute CINV due to QT prolongation
Side effects: headache, fatigue, dizziness, constipation
Due to risk of QT interval prolongation with all 5- HT3 antagonists make sure that electrolytes are corrected and ECG is monitored
Phenothiazines
MOA: work by blocking dopamine receptors in the CMS, including the chemoreceptor trigger zone
Drugs: promethazine (Phenergan, Phenadoz, Promethegan), prochlorperazine (Compro), Chlorpromazine (thorazine)
Contraindications: children less than two years old. Do not administer Promethazine VIA SC route
WARNING: IV IS NOT THE PREFERRED ROUTE DUE TO SEVERE TISSUE DAMAGE AND IF GIVEN SHOULD BE GIVEN THROUGH A LARGE BORE VEIN NOT IN THE HAND OR WRIST
Side effects: sedation, lethargy, hypotension, narrow let malignant syndrome, QT prolongation, a cute EPS, lower seizure threshold, strong anticholinergic side effects
Corticosteroid for emetic control
Dexamethasone (Decadron)
Short-term side effects: increased appetite, weight gain, fluid retention, emotional instability, insomnia, G.I. upset
Higher dose side effects: increased BP and blood glucose
Cannabinoids
Dronabinol (Marinol):CIII MUST REFRIGERATE CAPSULES
Nabilone (Cesamet): CII, no refrigeration needed
Side effects: drowsiness, euphoria, increased appetite, orthostatic hypotension
Substance P/neurokinin – one receptor antagonist
Indication: for acute and delayed nausea
Drugs: Aprepitant (Emend), fosaprepitant (Emend for injection-per drug of Emend)
Side effects: dizziness, fatigue, constipation, hiccups
Drug interaction: reduced dose of dexamethasone by 50% if using together
Mucositis management
Magic mouthwash, chlorhexidine rinse are often used
Only FDA approved agent: Palifermin (Kepivance) is restricted to high-dose chemo partis stem cell transplant
Patient should be counseled to you saline rents several times daily and agents containing viscous lidocaine are effective at numbing the local affected area. Patient can swish and spit the suspension
Management of hand foot syndrome
Aka Palmar plantar erythrodysesthesia
Occurs when small amounts of the drug leak out of the capillaries and into the plasma of the hands and the soles of the feet (increases due to friction or heat)
Prevention is key and includes: limit daily activities to reduce friction and he exposure, avoid long exposure to hot water, do not wear dishware washing gloves as the rubber will hold in the heat, avoid increased pressure on the soles of feet meaning no jogging powerwalking jumping, avoid increased pressure on the palms of the hands such as gardening, use of screwdrivers and knives)
Hypercalcemia of malignancy
Can result in nausea/vomiting, fatigue, dehydration and mental status changes as well as bone pain that can be significant
Bisphosphonates or denosumab (Xgeva) are used early in metastatic disease to prevent skeletal related events
Denosumab
Prolia: q6months in osteoporosis
Xgeva: SC monthly in cancer
MOA: blocks the interaction between RANKL and RANK, a receptor located on osteoclast surfaces, preventing osteoclast formation and leading to decreased bone resorption
Is not require adjustment for renal insufficiency like bisphosphonates
Bisphosphonate: zoledronic acid
Two brand names
- Reclast: 5 mg per year injection for osteoporosis
- Zometa: 4 mg monthly injection for cancer
All bisphosphonates require adjustment for renal insufficiency
Hypercalcemia of malignancy treatment
- Hydration with normal saline: dilutional effect and increased renal calcium excretion
- Look diuretics: and decreased renal calcium excretion (must follow hydration)
- Calcitonin: inhibits bone resorption, increases renal calcium excretion but is not commonly used and is only indicated for moderate to severe hypercalcemia
- IV bisphosphonates: inhibits been resorption by stopping osteoclast formation (zoledronic acid and pamidronate (aredia)
- Denosumab (Xgeva)
Vaccinations with planned chemotherapy
Avoid administration during chemotherapy juju sub optimal antibody response rather vaccination should precede the initiation of chemotherapy by greater than or equal to two weeks. Note the administration of live vaccines immunosuppressed patient should always be avoided these include MMR Varicella and zoster
