Oncology Supportive Care

Question 1

When should prophylactic antiemetics be used? ie emetogenic class of chemo and radiation

Answer 1

moderately or highly emetogenic chemo agents and highly emetogenic radiation

Question 2

What chemo agents are best known for delayed N/V?

Answer 2

cisplatin
doxorubicin/cyclophosphamide

Question 3

How many days should patients be protected for full period of risk for NV?

Answer 3

3 days if highly emetogenic and 2 days if moderately

Question 4

What anti-emetogenic regimen is used for highly emetogenic chemo and radiation?

Answer 4

-Neurokinin (NK1) receptor antagonist
-Serotonin receptor antagonist
-Dexamethasone
+/- OLZ
+/- Lorazepam
+/- H2RA or PPI

Question 5

What anti-emetogenic regimen is used for moderately emetogenic chemo and radiation?

Answer 5

-Serotonin receptor antagonist
-Dexamethasone
+/-Neurokinin (NK1) receptor antagonist

Question 6

What are the most common serotonin-3 receptor antagonists?

Answer 6

dolasetron, granisetron, ondansetron, and palonosetron

Question 7

What are some special considerations to take into account when prescribing palonosetron?

Answer 7

Half-life is ~40 hours, generally just give one dose
-PO can be given as combo product with NK1 antagonist

Question 8

When should corticosteroid antiemetics be avoided?

Answer 8

-Immune checkpoint inhibitors when administered without cytotoxic chemo
-avoid for 3-5 days before and 90 days after CAR T-cell therapies

Question 9

What are the most common NK1 receptor antagonists?

Answer 9

-aprepitant
-fosapripant
-rolapitant

Question 10

When can NK1 receptor antagonists be used alone?

Answer 10

never, must be used in combo with serotonin receptor antagonists and dex

Question 11

Common NK1 DDI?

Answer 11

Metabolized by CYP 3A4 and minor metabolism by CYP1A2 and CYP2C19
-oral contraceptives
-warfarin
-caution with R-CHOP

Question 12

Common side effects of NK1 RAs?

Answer 12

Headachem asthenia, dyspepsia, constipation

Question 13

What emesis treatment should be used for highly emetogenic oral chemo?

Answer 13

-Serotonin antagonist
+/- Lorazepam
+/- H2RA or PPI

Question 14

What antiemetic should be used for low emetogenic risk oral chemos?

Answer 14

Metoclopramide OR prochlorperazine or serotonin RA

Question 15

What is the MOA of benzamide analogs? What is the most common benzamide analog?

Answer 15

MOA -blockage of Dopamine receptors, stimulation of cholinergic activity in gut, increase gut motility
Ex: metoclopramide

Question 16

What is the MOA of phenothiazines? What are the most common phenothiazines?

Answer 16

MOA: block dopamine receptors
Ex: prochlorperazine, chlorpromazine, promethazine

Question 17

When should bisphosphinates be started in patients with breast cancer?

Answer 17

Start in pts with evidence of bone metastases
-Give pamidronate or zolendronic acid every 3-4 weeks

Question 18

When does the nadir generally occur?

Answer 18

10-14 days after chemo administration

Question 19

How is the ANC calculated?
If the WBC is 4500 and 10% segmented neutrophils and 5% band neutorophils what is the ANC?

Answer 19

ANC= WBC x percentage of granulocytes or neutrophils
4500 (0.1+0.05)= 675

Question 20

What is the WBC, ANC, and platelet count cut off to determine if a PT should receive chemo?

Answer 20

WBC >3000, ANC >1500, platelet count >100,000

There are exceptions to these rules

Question 21

What is the definition of neutropenia?

Answer 21

ANC <500 or count of less than 1000 with a predicted decrease to less than 500 during the next 48 hours

Question 22

What ANC indicates a CSF should be used?

Answer 22

-As primary prophylaxis which chemo regs associated with 20% or greater risk of febrile neutropenia, continue until post-nadir ANC is >10,000
-Use as secondary prophy if post-nadir ANC is

Question 23

When should CSF be used for patients with established neutropenia?

Answer 23

PT who have febrile neutropenia and risk factors for complications

Question 24

How should macrocytic anemia be treated?

Answer 24

IM or PO vitamin B12 replacement

Question 25

What are common erythropoiesis-stimulating agents [ESAs]. When are they approved to be used?

Answer 25

Epstein and darbepoetin Alfa
-Can be used for chemo associated (not cancer associated) anemia once Hgb <10

Question 26

What is dexrazoxane?

Answer 26

Chelating agent to decrease anthracycline-induced free radical damage

Question 27

What are examples of anthracyclines?

Answer 27

-Suffix “rubicin”
Danorubicin, doxorubicin, idarubicin, epirubicin

Question 28

What is amifostine? Why is it not commonly used in clinical practice?

Answer 28

Prevents nephrotoxicity from cisplatin, can cause dangerous hypotension

Question 29

When is mesna used and why?

Answer 29

Used when acrolein is present in the bladder, Acrolein is a metabolite of cyclophosphamide and ifosfamide and mesna inactivates Acrolein and prevents its interaction with the bladder

Question 30

When does leucovorin need to be used?

Answer 30

may be used after methotrexate doses >100 mg/m2 and should be used in doses >500mg/m2,
-Continue until 24048 hour methotrexate level is <0.1mM

Question 31

What are factors that increase likelihood of methotrexate toxicity?

Answer 31

Renal dysfunction, third-space fluid

Question 32

What kind of toxicity does methotrexate cause?

Answer 32

Mucous membrane toxicity, renal and hepatic toxicity, CNS toxicity and myelosupprossion

Question 33

What is Glucarpidase?

Answer 33

Carboxypeptidase indicated for treating toxic methotrexate concentrations ( do not give leucovorin within 2 hours before or after a dose of glucarpidase)

Question 34

Should you use heat, cold, hyaluronidase, or sodium thiosulfate for doxorubicin, danorubicin, and epirubicin?

Answer 34

Cold

Question 35

Should you use heat, cold, hyaluronidase, or sodium thiosulfate for vincristine, vinblastine, and vinorelbine?

Answer 35

Heat

Question 36

Should you use heat, cold, hyaluronidase, or sodium thiosulfate for mecholrethamine?

Answer 36

Sodium thiosulfate

Question 37

Should you use heat, cold, hyaluronidase, or sodium thiosulfate for vinal alkaloids?

Answer 37

Hyaluronidase