Oncology Therapies and blood transfusions Flashcards
How do we decide what to use?
- Clinical trials for all cancer types
- Target specific molecular pathways when possible
- Old chemotherapy agents can be helpful but also toxic!
- Initial and acquired drug resistance continues to be challenging!
Impaired membrane transport of drugs
Enhanced drug metabolism
Mutated target proteins
Blockage of apoptosis due to mutations in cellular proteins
Antiemetic medications
- 5HT3 receptor antagonists IV/PO/Sublingual
Ondansetron (Zofran)
Palonosetron (Aloxi)
May cause QT prolongation - NK1 receptor antagonists (Preventative) IV/PO
Aprepitant (Emend)
Given with Dexamethasone to improved immediate and delayed effect
Can’t swallow?
Prochlorperazine (Compazine) rectally
GI Toxicity
Oral mucositis
Pretreatment dental care
Ice chips during infusion (5-FU)
Antifungal medication
Antiviral medication
Mouthwashes
Non alcohol rinses (Biotene)
Lidocaine
Pain control!
GI Toxicity
Diarrhea Tx
mild/moderate/severe
Diarrhea
Mild-moderate
Loperamide (Imodium)
Severe
IV hydration
Electrolyte replacement
Octreotide (Sandostatin) SC inj. up to TID
Inhibits multiple hormones (growth hormone, glucagon, insulin, LH, and VIP)
Skin toxicity
S/Sx
Hyperpigmentation
Alopecia
Photosensitivity
Nail changes
Acral erythema (hand foot syndrome)
Painful palms or soles with erythema progressing to blisters, desquamation, and ulceration
Cardiac toxicity
S/Sx
acute/subacute/delayed
Acute: During chemotherapy treatment
Subacute: Days to months after
Delayed: Years after treatment
Possible baseline testing
Echocardiogram to ensure EF > 50%
EKG
Arrhythmias
Cardiac ischemia
Myocarditis
Thrombosis
Heart failure risk
Total dose received
Age > 70
Chest irradiation
Preexisting cardiac disease
Multiple agents at risk for cardiac complications
Cisplatin
Nephrotoxicity
IV hydration before, during, and after chemotherapy administration
Monitor Cr+ and electrolytes
May also develop low mg+, K+, and Na+
Miscellaneous toxicity
Hemorrhagic cystitis
peeing blood
Drink lots of fluids!
Frequent urination
IV Mesna for prevention
Miscellaneous toxicity
Neuropathy S/Sx
Sensory
Motor
Autonomic
If toxicity occurs, what do we do?
Hold next cycle until symptoms resolve
Add supportive medications
Drug dose reduction
Palliation vs. cure
Change regimen
Intravesical therapy
general and Sx
Deliver medications directly into the bladder via a urethral catheter
Typically post transurethral resection to decrease likelihood of recurrence
Side effects
Irritative voiding symptoms
Hemorrhagic cystitis
targeted agents
most common types
Many medications treating many cancer subtypes
Most common
* Monoclonal antibodies
Rituximab (Rituxan)
* Kinase inhibitors
Ibrutinib (Imbruvica)
Side effects differ based on cell receptor acts on
immunotherapy
general and types
4
Using own immune system
Types
* Immune checkpoint therapy
Help T cells respond longer
Ipilimumab (Yervoy) for lung cancer
* Adoptive cell therapy
Chimeric antigen cell (CAR) T cell therapy- T cells that are all genetically engineered to find and fight the cancer are infused
Multiple types undergoing clinical trials!
* Cytokine therapy
Interferons and interleukins are infused/injected, trigger an immune response
May be combined with other immunotherapies
IL-2 therapy for renal cancer
* Vaccine therapy
Help the body recognize cancer cells and stimulate the immune system
Sipuleucel-T (Provenge)
Blood Transfusions
Blood Types
Four Major Groups
A
B
AB
O
Blood types are inherited
Antigen is present on the RBC
Typing is done w/rbc
Antibody is present in the plasma
Antibody screening done on plasma
43% of population are O, 42% A, 12% B and 3% AB
Blood Types
O negative
Universal donor
It carries no antigen
Blood types
AB positive
Universal recipient
It carries no antibodies in the plasma
Rh Factor
general
Found on the surface of an RBC
Can be phenotypically positive or negative
Positive is dominant over negative
Rh negative patients form antibodies against the Rh factor if they are exposed to Rh positive blood
Blood transfusion between incompatible groups causes an immune response against the cells carrying the antigen Resulting in transfusion reaction
Rh Incompatibility in Pregnancy
Occur when the mother is Rh- and the baby is Rh+
Treatment:
Give a series ofRhoGAMshots during pregnancy to all Rh- mothers
1st shot: around the 28th week of pregnancy
2nd shot: just after birth
RBC Transfusion
Indications
Acute Blood Loss
Symptomatic Anemia
Volume: 300mL
1 unit UP Hgb 1 g/dL
Consider transfusion for Hgb < 7g/dL
indications for whole, packed RBCs, and autologous
Whole blood
Used for cardiac surgery or massive hemorrhage (>10 units of blood are needed in 24-hours)
Packed red blood cells
Most commonly used
Recommended transfusion “trigger” - hemoglobin is 7-8 g/dL
Autologous red blood cells
Donate own blood for an elective procedure
Platelet Transfusions
indications and how much will it increase platelet count?
Risk of spontaneous bleeding
Platelet count < 80,000/mcL
Risk of life-threatening bleeding
Platelet count < 5,000/mcL
6 pack or 1 unit pheresed platelets
1 pheresed unit will increase count by 50,000-60,000/mcL
Lasts 2-3 days
Platelet Transfusion Goals
Fresh Frozen Plasma
200-250 ml of plasma containing
All clotting factors (1 unit/mL of each)
AT-III
Protein C & S
Indications:
Correct factor deficiencies
Thrombotic microangiopathies- TTP
Correct/prevent coagulopathy with massive transfusions- 1:2 FFP:PRBC
Cryoprecipitate
Cryoprecipitated antihemophilic factor (AHF)
Thaw FFP and precipitate refrozen
15-20 ml per unit (bag)
Fibrinogen >150 mg
Factor VIII > 80 IU
Factor XIII at least 50-75 IU
Von Willebrand Factor at least 100-150 IU
Indications
Acute DIC
Low fibrinogen with bleeding/risk
1 unit INCREASE fibrinogen 8mg/dL
Transfusion Complications
Volume overload
Transfusion reactions
Iron overload
Infections
Hyperkalemia
Massive transfusions
CKD
Transfusion Rxns
Acute Transfusion Reactions
minor and critical
Complication that occurs during or after a blood product is given
Range from clinically benign to life-threatening
Minor
Urticarial (simple allergic) transfusion reaction
Febrile non-hemolytic transfusion reaction
Critical
Transfusion-associated circulatory overload (TACO)
Transfusion-related acute lung injury (TRALI)
Acute hemolytic transfusion reaction (AHTR)
Transfusion-associated sepsis
Anaphylactic transfusion reaction
q
Minor transfusion rxn
Urticarial transfusion reaction (UTR)
Common reaction
Occurs during or up to 2 hours after the transfusion
Commonly due to an antigen-antibody interaction that occurs between the patient and the product given
Clinical features:
Hives or pruritus
Management:
Mild reaction – continue the transfusion
Antihistamines (H1 and H2 blockers)
Minor transfusion rxn
Febrile non-hemolytic transfusion reaction (FNHTR)
Febrile non-hemolytic transfusion reaction (FNHTR)
Occurs during and up to 4 hours after transfusion
Accumulation of cytokines in the donor blood → immune reaction
Type II hypersensitivity reaction in which the host antibodies target donor leukocytes
Prevention by giving leukoreduced blood products
Clinical features:
Low-grade fever with chills
Headache
Malaise
Management:
Hold the transfusion for 30 minutes (often can restart)
Acetaminophen for fever
Check CBC and bilirubin to rule out hemolytic reaction
critical transfusion rxn
Transfusion-associated circulatory overload (TACO)
Transfusion-associated circulatory overload (TACO)
Occurs during or within 6 hours after transfusion
Patient develops pulmonary edema due to volume overload or circulatory overload
< 1% of patients
At risk patients:
Receive a large volume of a transfused product over a short period of time
H/O renal or cardiovascular disease
Clinical features:
Sudden tachycardia
Hypertension
Overload symptoms: increased jugular venous pressure
CXR: bilateral infiltrates (pulmonary edema)
Management:
Stop the transfusion
Diuresis – furosemide (Lasix)
Supplemental oxygen or assisted ventilation
critical transfusion rxn
Transfusion-related acute lung injury (TRALI)
Transfusion-related acute lung injury
Occurs during or up to 6 hours after transfusion
Patients develop acute lung injury
HLA antibodies in the donor blood triggers the neutrophils and pulmonary endothelial cells of the recipient
Neutrophils secrete proteolytic enzymes that lead to tissue damage → hypoxemia
1 in 5,000 transfusions
Clinical features:
Fever and/or chills
Respiratory distress (tachypnea, frothy pink sputum)
Hypotension
CXR: bilateral infiltrates (pulmonary edema)
Management:
Stop the infusion
Assisted ventilation or oxygen administration
IV steroids to aid with inflammation
No diuresis
critical transfusion rxn
Acute hemolytic transfusion reaction (AHTR)
General
Acute hemolytic transfusion reaction (AHTR)
True EMERGENCY
Occurs during or within 1 hour after transfusion
Acute intravascular hemolysis of transfused RBCs
Usually due to ABO incompatibility
Mislabeling and administering to wrong person
1:76,000 transfusions
Acute hemolytic transfusion reaction (AHTR)
Clin man
High grade fever
Flank pain, hematuria
Tachycardia, Tachypnea, Hypotension
Oozing from the IV site (DIC)
Chills
Headache
Anxiety
Cardiovascular collapse
Response to Suspected Hemolytic Reaction
Stop Transfusion
Aggressive intravenous hydration
urine output to be 100-200 cc/hr
Prevent acute tubular necrosis
Confirm correct transfusion was initiated
Return blood, bag, tubing, labels, transfusion record to the blood bank
Retype and crossmatch
Check Coombs test → should be positive
Coagulation studies (PT, PTT, Fibrinogen)- Risk of DIC
DIC: Administer FFP and platelets
Transfusion-associated sepsis
Rare reaction
Usually occurs within 1 hour of transfusion
Bacterial infection from a transfusion product that contains a microorganism
Clinical features:
Fever and/or chills
Hypotension
Management:
Stop the infusion
Culture the recipient’s blood and the donor’s blood
Broad-spectrum antibiotics
Anaphylactic transfusion reaction
clin man and Tx
Usually occurs right after the start of the transfusion; can be delayed up to 4 hours
Clinical features:
Angioedema
Wheezing, respiratory distress (bronchospasm)
Hypotension
Nausea and/or vomiting
Cardiac arrest or shock
Management:
Stop the transfusion
Hemodynamic stabilization (IV fluids, vasopressors)
Airway management
Epinephrine, steroids, antihistamines
