Side effect management

Question 1

Interventions being investigated to prevent chemo induced peripheral neuropathy

Answer 1

Cryotherapy (some evidence but no proof)
Compression therapy (tight gloves, some evidence)
Exercise (some evidence)

Question 2

Interventions being investigated to treat chemo induced peripheral neuropathy

Answer 2

1) Stop chemo short (decide on risk/benefit of further chemo)
2) Duloxetine (cymbalta) (proven efficacy)
3) Some data for acupuncture

Question 3

Neuropathy caveat

Answer 3

Neuropathy can continue to worsen even after you stop chemo

Question 4

Management of cancer cachexia

Answer 4

• Refer to nutrition
• Shift from 3 meals a day, to frequent high calorie, nutrient dense snacks
• No parenteral or tube feeding

Question 5

Definition of cancer cachexia

Answer 5

Loss of appetite, weight, and skeletal muscle

Question 6

pharmacologic management of cancer cachexia supported by evidence

Answer 6

There are no FDA approved drugs to treat cancer cachexia but there is data for the following:

• progesterone analogs (megestrone acetate or megace). Associated with modest weight gain (but its fat, not skeletal muscle) and will increase QOL.
• corticosteroids (improved appetite + weight gain (fat, not muscle) wellbeing)
• Optimal dosing and timing unknown

Question 7

pharmacologic management of cancer cachexia NOT supported by evidence

Answer 7

dronabinol/cannabinoids (insufficient data per ASCO and high fall risk in elderly)

Question 8

Checkpoint inhibitors and emetogenic potential?

Answer 8

little to none

Question 9

Are steroids contraindicated with checkpoint inhibitors?

Answer 9

No, still have demonstrated efficacy (this is an issue in combination studies with emetogenic chemo)

Question 10

primary classes (mechanisms) of drugs used for chemo induced nausea

Answer 10

NK1, 5-Ht3 receptor antagonists, steroids

Question 11

pulmonary side effect now being associated with CPI’s

Answer 11

ILD

Question 12

Definition of GCSF for primary prophylaxis

Answer 12

Primary prophylaxis refers to the initiation of G-CSFs during the first cycle of myelosuppressive chemotherapy, with the goal of preventing neutropenic complications throughout all of the chemotherapy cycles.

Question 13

Neulasta formulation

Answer 13

One time injection

Question 14

neupegen vs neulasta in terms of MOA and formulation

Answer 14

neupegen – binds to GCSF receptor, which you continue until counts recover
neulasta – binds irreversibly to receptor until it leaves the marrow, so you only need to give it once. (either sc injection or on body injector that automatically gives injection).

Question 15

RF’s for severe emesis

Answer 15

Age and gender (young females get the worst, older men do better, especially alcoholics)

Question 16

Timeline of emesis with chemo

Answer 16

• typically within first few hours
• some highly emetogenic chemo, you can have delayed reaction
• some patients get anticipatory emesis but less common these days with better antiemetics

Question 17

risk stratification of chemo emetogenesis

Answer 17

low, medium, or high risk

Question 18

what is asthenia

Answer 18

decreased muscle strength

Question 19

2 major categories of drugs that can be used to treat neutropenia

Answer 19

1) recombinant human granulocyte colony stimulating factor (G-CSF; filgrastim and pegylated filgrastim)
2) granulocyte-macrophage colony stimulating factor (GM-CSF; sargramostim)

Question 20

next step after diagnosing mucositis

Answer 20

Ask patient if it interferes with eating/oral intake

Question 21

Management of immune therapy Grade III myocarditis

Answer 21

• permanently discontinue immunotherapy

- Start high dose steroids

Question 22

Cetuximab mechanism

Answer 22

EGFR inhibitor

Question 23

Steroid sparing agent for immunotherapy related hepatotoxicity

Answer 23

ATG or mycophenolate (depending on severity) (NOT INFLIXIMAB, which can cause LFT elevations)

Question 24

Antiemetics for patients receiving a highly emetogenic chemo

Answer 24

3 drug combination:
*NK-1 receptor antagonist
5-HT3 receptor antagonist
Dexamethasone
**Many also give olanzapine

Question 25

Aprepitant MOA

Answer 25

Neurokinin 1 receptor antagnist

Question 26

How antiemetics are determined

Answer 26

Emetogenic risk category of chemo:
High
Moderate
Low

Question 27

Antiemetics for moderately emetogenic chemo

Answer 27

Two-drug combination:
Palonosetron
Dexamethasone

Question 28

Antiemetics for low emetogenic chemo

Answer 28

5-HT3 receptor antagonist

Question 29

Chemo regimens and drugs with high emetic risk

Answer 29

• Adriamycin/cyclophosphamide
• Cisplatin
• Cyclophosphamide
• Dacarbazine
• Ifosfamide
• Streptozocin