Side effects of chemotherapy Flashcards
What are some of the GI side effects associated with chemotherapy?
Nausea
Vomiting
Appetite changes
Constipation
Diarrhoea
Changes in the taste of food
Throat and mouth sores- Mucositis
What is CINV?
Chemotherapy induced nausea and vomiting
- occurs in up to 80% of patients and is very distressing
What are the risk factors for developing CINV?
- Female
- non-smoker
- age
- hypotension
- obesity
- suffers from migraines
- previous N&V in pregnancy
- hypoxaemia- low o2 in the blood
- Use of opioids in surgery
What are the complications of CINV?
- Dehydration
- Nutrition deficiency- increased by lack of appetite
- Electrolyte disturbances
- Aspiration pneumonia- presence of sick in the lungs- can increase infections
- Oesophageal tears- retching can cause tears- allowing food, chemicals from the GI tract to enter the chest and cause infection and inflammation
- Decreased quality of life
- May cause delays in having chemo, dose reductions or even discontinuing of treatment
What is acute CINV and its treatments?
This is CINV that starts within 24 hours of having the chemo, most commonly within 1-2 hours
- can give 5-HT3 antagonists e.g. Ondansetron
- Dopamine antagonists e.g. Domperidone or metoclopramide
What is Delayed CINV and its treatments?
This is CINV that starts 24 hours after chemotherapy- usually 1-7 days following
- Can give NK1 antagonists e.g. Aprepitant
- Dexamethasone- corticosteroid
What is breakthrough CINV and its treatments?
This is CINV that occurs within 5 days of chemo administration despite taking prophylaxis- anti-emetic drugs
- Can give 5HT3 antagonists e.g. ondansetron
- NK1 antagonists e.g. aprepitant
What is anticipatory CINV and its treatments?
This is nausea and vomiting that occurs prior to chemotherapy- stress- induced due to CINV with previous chemo cycles
May be triggered by sights, sounds, smells of the treatment room
- Can give Lorazepam (a benzodiazepine)
What is refractory CINV and its treatments?
This is CINV that develops in a subsequent cycle after prophylaxis has not worked in treating CINV in previous cycles
- can give levomeprazine via an SC IV infusion
What is mucositis?
Mucositis is when the mouth or gut becomes sore, ulcerated and inflamed
- can lead to dry mouth and lips, redness and swelling which leads to white ulcers, pain in the mouth, difficulty swallowing/eating/talking,
What strategies can help prevent mucositis?
- Brush teeth with a soft toothbrush at least twice a day
- Avoid floss or electric tooth brushes
- Rinse mouth regularly
- Avoid spicy or acidic foods
- Eat soft, moist foods
- use lip balm to stop dry lips
- Avoid mouthwashes that contain alcohol- check with dr or pharmacist
- stay hydrated
- chew gum to keep the mouth moist
What causes Mucositis?
The mucosal cells of the go tract are very sensitive to chemotherapy and are damaged and become susceptible to infection and inflammation
What are the treatment options for Mucositis?
For pain:
- local anaesthetic mouthwashes or lozenges e.g. corsodyl (Chlorhexidine Digluconate) or difflam (benzydamine hydrochloride)
- Analgesics e.g. paracetamol
- ice
If is infected:
- Will treat based on clinical investigations or cultures,
- Most commonly fungal = give systemic fluconazole or nystatin mouthwash
- if viral= acyclovir
Which chemotherapy drugs commonly caused chemotherapy induced diarrhoea?
- 5-fluorouracil
- Capecitabine
- irinotecan
these drugs are often used in colorectal and breast cancers
What are the pharmacological and non-pharmacological interventions to help with chemotherapy induced diarrhoea?
Non-pharmaceutical:
- Stay hydrated- 8-10 glasses of water per day
- Dietary modifications
- Have small and frequent meals
Pharmaceutical:
- Loperamide (Immodium) - 1st line treatment
- Oral antibiotics- e.g. ciprofloxacin, only if for over 24 hours- used as prophylaxis
- if severe- may be hospitalised and given IV fluids and electrolytes, take stool cultures
What is irinotecan chemotherapy and what is its main symptom and treatment?
Used for the treatment of metastatic colorectal cancer
- Can cause diarrhoea:
Regular loperamide (4mg then 2mg every 2 hours until
diarrhoea free for 12 hours)
Ciprofloxacin 250mg bd for 7 days if diarrhoea lasts >24 hours
- Can also cause Anti-cholinergic syndrome- which can present symptoms such as sweating, increased saliva production ,stomach cramps diarrhoea
- can give subcutaneous atropine 300mcg
What can cause chemotherapy related constipation?
- Certain chemotherapy drugs e.g. Cisplatin, vincristine
- Supporting drugs e.g. ondansetron for N&V and opioids for pain relief
- Lifestlye- changes in diet, inactivity
What can be used to prevent and treat chemotherapy constipation?
Prevention:
Drink plenty of fluids- 6-8 glasses of water
Eat foods containing lots of fibre e.g. fruit, veg, beans
Exercise where possible
Treatment:
Review medication
Give laxatives such as Senna, Laxido sachets or Lactulose oral solution
What causes alopecia from chemotherapy?
Chemotherapy targets fast-growing cells in the body and the hair follicle cells grow and divide quickly meaning they are also destroyed, resulting in hair loss
What can be used to try and reduce hair loss?
Scalp cooling:
Cooling reduces the blood flow to the scalp and therefore, the amount of chemotherapy medication that reaches this area.
This helps to prevent hair loss
usually worn for 15 minutes before each chemotherapy treatment
What is myelosupression and what does it cause?
Myelosupression is when bone marrow activity is reduced by chemotherapy. This causes a decrease in production of Red blood cells, white blood cells and platelets:
- Red blood cells- can cause anaemia- tiredness and and fatigue
- White blood cells- Can cause increase risk of infection and sepsis, neutropenia (low levels of neutrophils in the blood- weakened immune system)
- Platelets- more easily bleeding and bruising, thrombocytopenia ( platelet deficiency)
What is febrile neutropenia?
The presence of a fever and low levels of neutrophils (WBCs) in the blood which causes an increase in infection
To be febrile neutropenia, the patient must have:
- Temperature greater than 38 degrees
- Absolute neutrophil count of less than 0.5 x10^9 per litre
What are the risk factors of febrile neutropenia?
- severe symptoms
- Hypotension
- COPD symptoms
- leukaemia treatment
- Dehydrated
- older than 60
- an inpatient
How can febrile neutropenia be prevented?
- Maintain good hygiene- e.g. hand washing
- Avoid crowded places and ‘sick’ people
- Avoid foods containing probiotics e.g. yoghurts
- prophylactic antibiotics
- Granulocyte colony stimulating factor (GCSF) prophylaxis- medication that stimulated production of neutrophils- given as a daily sc injection for 5-7 days following myelosupressive chemo e.g. filgrastim
Describe the use go granulate colony stimulating factor prophylaxis for prevention of febrile neutropenia?
Medication e.g. figrastim is given as a subcutaneous injection once a day for 5-7 days following myelosuppressive chemotherapy
indications for GCSF:
1. Chemotherapy with >20% risk of FN
2. Continuing chemotherapy following episode of
FN
What is the treatment for low and high risk neutropenic sepsis (Febrile neutropenia)?
Low risk
- Outpatient treatment, maybe a short admission
- Oral antibiotics - ciprofloxacin or co-amocxiclav
- May be given iv stat then oral
High tisk
- Urgent admssion
- Urgent emperical IV antibiotics e.g. Tazocin or Ceftazidime
- Review after 48 hours- may iv to oral switch
What is hand-foot syndrome?
This is a common side effect of chemotherapy with Capecitabine that effects the hands and feet
Causes red and sore feet and hands, tingling, pain, swelling, decreased grip. May lead to ulceration and blistering
What is the prevention and treatment of hand-foot syndrome?
Prevention:
- Avoid tight-fitting shoes
- Don’t rub them
- Avoid heat exposure- hot water, sun etc
- don’t put too much pressure on them
Treatment:
- Creams containing Lanolin
- corticosteroid containing creams e.g. clobetasol
What is the major side effects of EGFR inhibitors?
Dermatological skin reactions that cause papulopustular eruptions most commonly on the face, chest or back
e.g. cetuximab, erlotinib
What are the treatment options for EGFR inhibitor skin reactions?
Depends on the severity of the reaction
Mild:
Topical antibiotic cream e.g. Clindamcyin
Moderate:
Add topical steroid e.g. Hydrocortisone cream
Add oral antibiotics e.g. doxycycline
Severe:
Refer to specialist
May dose adjust or even have to stop the treatment
What are the common side effects of immunotherapy?
- Has a different side effect to chemotherapy- not likely to cause hair loss or sickness etc
can cause - collitis
- pneumonia
hepatitis
rashes
What are the common side effects of immunotherapy?
- Has a different side effect to chemotherapy- not likely to cause hair loss or sickness etc
can cause - collitis
- pneumonia
hepatitis
rashes
Is dose adjustment a good strategy to minimise side effects from immunotherapy?
-NO, immunotherapy can’t be dose reduced like chemo
- can halt and resume, but not lower the dose
What is extravasation and how is it caused?
occurs if a drug is injected but leaks out of the vein. This leads to chemotherapy drugs entering the surrounding tissues which will cause pain, inflammation, blistering
- This would require plastic surgery to resolve
What are the symptoms of the 5 grades of hypersensitivity reactions?
1= transient flushing or rash, fever 38’>
2= Rash, flushing, urticaria, breathlessness (dyspnoea), fever greater than 38’
3= symptomatic bronchospasm, urticaria, oedema, andiodeoma, hypotension
4= anaphylaxis
5= death
What medications can be given for hypersensitivity reactions?
Dexamethasone 20mg every 6 hours for 4 doses
Ranitidine 150mg po every 8 hours for 3 doses
Chlorphenamine 4mg po every 6 hours for 4 doses
What are the common chemotherapy toxicities: Methotrexate
Stomatitis- inflammation of the oral mucosa that causes ulcers and pain and difficulty when eating or drinking (mouth NOT stomach)
What are the common chemotherapy toxicities: Bleomycin
Pulmonary fibrosis- Thickening and scarring of the tissue in the air sacs of the lungs makes it hard for the lungs to work
What are the common chemotherapy toxicities: Doxorubucin
Cardiac toxicity- causes damage to the heart muscles and valves- heart becomes weaker and struggles to pump blood
What are the common chemotherapy toxicities: Cisplatin
Ototoxicity- hearing or balance problems due to damage in the inner ear
nephrotoxicity- damage to the kidneys causing decrease in kidney function
What are the common chemotherapy toxicities: cyclophosphamide
Hemorrhagic cystitis- where the lining of the bladder becomes inflamed and starts to bleed
What are the common chemotherapy toxicities: Vincristine/Vinblastine
Peripheral neuropathy- damage to the peripheral nerves causing damage to hands, feet, arms etc
