Supportive and Palliative Care Flashcards
CID:
Pathogenesis
Caused by direct damage and inflammation to mucosa of intestine → imbalance between malabsorption and secretion
- ↑ secretion of electrolytes
* Caused by luminal secretagogues or reduced absorptive capacity (due to surgery or epithelial damage), called secretory diarrhea - ↑ intraluminal osmotic substances
* Leading to osmotic diarrhea - Altered gastrointestinal (GI) motility
Direct ischemic mucosal damage is reported in patients treated with agents targeting the vascular endothelial growth factor (VEGF), while an immune-mediated colitis is responsible for diarrhea with immune checkpoint inhibitors.
CIC:
Pharmacological and Non-pharmacological management
Include remarks on when which treatments are not recommended and why
Refer to formulary
Drugs to be avoided during special conditions are bulk-forming agents and recal suppositories/ enemas
CINV:
NK-1 antagonist
* Uses
* MoA
* Dosing
* A/Es
* DDIs
* Other remarks
Refer to formulary
CINV:
Olanzapine
* Uses
* MoA
* Dosing
* A/Es
* DDIs
* Other remarks
Refer to formulary
CIOM:
List the 5 stages of the pathophysiology of oral mucositis plus its accompanying symptoms
Refer to formulary
CINV:
Benzodiazepines
* Uses
* MoA
* Dosing
* A/Es
* DDIs
* Other remarks
Refer to formulary
CINV:
Metoclopramide
* Uses
* MoA
* Dosing
* A/Es
* DDIs
* Other remarks
Refer to formulary
CID:
Treatment algorithm of uncomplicated and complicated CID
Refer to formulary for picture :)
CINV:
Phenothiazines (prochlorperazine, chlorpromazine, promethazine)
* Uses
* MoA
* Dosing
* A/Es
Refer to formulary
Nutritional support:
ENTERAL NUTRITION
List the possible drug-nutrient interaction and its prevention
CID:
Predictive factors
- 1st cycle of chemotherapy
- Cycle duration > 3 weeks
- Concomitant neutropenia
- Mucositis, vomiting, anorexia, anemia
Nutritional support:
ENTERAL NUTRITION
List the potential complications and thus monitoring parameters
CIOM:
Treatment of oral mucositis
Include treatments that are recommended, others, and against
Refer to formulary
Nutritional support:
What is the equation to calculating total energy expenditure?
TEE = REE X activity factor (x stress factor)
*TEE: total energy expenditure
REE: resting energy expenditure
*
CINV:
Breakthrough CINV treatment principles:
* Give additional agent from a ________, based on the assessment of the current prevention strategies used
* If PO not feasible, consider ____ route
* ________________ repletion for losses
* Reassess next cycle’s antiemetics to ensure appropriateness of regimen
- Give additional agent from a different drug class, based on the assessment of the current prevention strategies used
- If PO not feasible, consider IV route
- Hydration and fluid repletion for losses
- Reassess next cycle’s antiemetics to ensure appropriateness of regimen
CID:
Loperamide
* Uses
* MoA
* Dosing
* A/Es
* DDIs
Refer to formulary
CID:
Octreotide
* Uses
* MoA
* Dosing
* A/Es
* DDIs
Refer to formulary
Nutritional support:
Management of EN tolerance
CINV:
Patient related risk factors
- Younger age (< 50 y/o)
- Female gender
- History of low prior chronic alcohol intake (< 1 glass of alcohol/day)
- History of previous chemotherapy induced emesis
- History of motion sickness
- History of emesis during past pregnancy
- Anxiety (History/Present)
Nutritional Support:
What are the 4 steps to formulating a nutritional support therapy plan?
- Nutritional screening
- Referral to dietician/ nutritional specialist
- Nutritional assessment (anthropometric measurements, biochemical assessment, clinical assessment, dietary assessment)
- Formulation of nutritional regime
Refer to formulary for more in depth detail!
Nutritional Support:
ENTERAL NUTRITION
List the types of devices, modes of administration, and the types of enteral feeds
Refer to formulary for more details!
Devices: pre-pyloric (NG, PEG) and post-pyloric (JG, PEJ)
Modes of administration: bolus and continuous
Types of enteral feeds: modular, semi-elemental/ elemental, polymeric, disease specific
Nutritional Support:
PARENTERAL NUTRITION
List the types of devices and composition of parenteral feeds
CINV:
Pathophysiology of CINV in peripheral pathway
PLUS How many hours later does CINV start/peak and decrease?
- Chemotherapy damages enterochromaffin cells in the gut, leading to the release of serotonin (5-HT).
- Serotonin binds to 5-HT₃ receptors on vagal afferent neurons in the gut wall.
- This activates signals via the vagus nerve (cranial nerve X) to the nucleus tractus solitarius (NTS) and the vomiting center in the brainstem.
- The response triggers acute-phase vomiting (occurring within the first 24 hours after chemotherapy).
→ Starts after 1-2hrs, peak within 5-6hrs, ↓at 12-24hrs
Nutritional support:
Risk factors of high risk patients of refeeding syndrome
CINV:
Dexamethasone
* Uses
* MoA
* Dosing
* A/Es
* DDIs
* Other remarks
Refer to formulary
CID:
Non-pharmacological management:
* ________ with Lactobacillus
* Avoid ____________, foods that contain _______, _______ food, foods high in ________ or dietary supplements with ________
* ________-containing foods should be avoided for at least ________ after CID has resolved
* Eat ________ meals
* ________ diet (____________)
* More than ________ of clear (electrolyte-containing) fluids containing salt and sugar
- Probiotics with Lactobacillus
- Avoid caffeine, alcohol, fruit juice, foods that contain lactulose, spicy foods, foods high in fat or fibre or dietary supplements with high osmolarity
- Lactose-containing foods should be avoided for at least a week after CID has resolved
- Eat small frequent meals
- BRAT diet (bananas, rice, applesauce, toast)
- More than 3L of clear (electrolyte- containing) fluids containing salt and sugar
CID:
Treatment algorithm of irinotecan-associated diarrhoea – both acute onset and late onset
Refer to formulary
CID:
Risk factors
- Age > 65 y/o
- Female
- ECOG performance status ≥ 2
- Bowel inflammation or malabsorption
- Bowel malignancy
- Biliary obstruction
CIOM:
Patient related risk factors
- Autoimmune disorders
- DM
- Female (5-fluorouracil induced)
- Genetic predisposition to tissue damage (deficiency in genes that produce enzymes responsible for metabolising chemotherapy)
- Folic acid/ Vitamin B12 deficiency
CIC:
Patient related risk factors (10)
- ↓ Fluid intake and dehydration
- ↓ Appetite (anorexia)
- ↓ Fibre/ bulk-forming foods in diet
- Vitamins/ supplements (e.g. Fe, Ca)
- Overuse of laxatives
- Low physical activity, a lot of bed rest
- Hypothyroidism
- Depression
- High levels of Ca/ K in blood
- Cancer growing into large intestine or pressing on the spinal cord
Nutritional Support:
List 4 causes of malnutrition, and 6 of its outcomes:
Causes
* GI: N/V, diarrhoea, changes in appetite/ early satiety, malabsorption
* Nutrient losses (dialysis)
* Impaired metabolism, ↑energy expenditure, protein catabolism
* ↓volitional intake
Outcomes
* ↑complications
* Poor wound healing
* Compromised immune status
* Impairment of organ function
* ↑use of healthcare resources
* ↑mortality
Palliative care:
List the 9 End of Life Syndromes, and its management for 3 of them
- Dyspnea:
* Common in lung cancer pts
* Consider oxygen therapy, esp if had prev bleomycin chemotherapy
* Morphine PRN titrated to RR (depress RR, make pt feel more comfortable) - Secretions
* Glycopyrrolate given (but exempt in SG)
* Anticholinergics used, but carefully weigh toxicities and pt preferences - Agitation/ Delirium
* Identify medication related causes/ contributors
* Give alternatives or deprescribe
* Antipsychotics are last line, ∵questionable efficacy & undesirable AEs - Bowel obstructions (unclog feeding tube)
- Anorexia/ cachexia
- Persistent nausea
- Chronic diarrhoea/ constipation
- Insomnia/ over-sedation
- Wound care/ pressure ulcers
CIC:
Drugs that can cause constipation:
- Chemotherapy drugs e.g. vinca alkaloids (vincristine, vinblastine, vinorelbine)
- Pain relievers (esp opioids)
- Antinausea drugs (e.g. ondansetron)
- Anticonvulsant drugs
Nutritional support:
PARENTERAL NUTRITION
List the potential complications and thus monitoring parameters
CIOM:
Palifermin is a ________ produed by ________, and decreases ________ of severe oral mucositis associated with ________ in patients receiving ___________
Dosing:
_______________
Palifermin is a keratinocyte growth factor produced by E coli, and decreases incidence and severity of severe oral mucositis associated with haematological malignancies in patients receiving myelotoxic therapy requiring HSCT
Dosing:
Administer first 3 doses prior to myelotoxic therapy, with the 3rd dose given 24-48 hours before therapy begind. The last 3 doses should be administered after myelotoxic therapy, with the first of these doses after but on the same day as hematopoietic stem cell infusion and at least 4 days after the most recent dose of palifermin
Note that based on guideline, it is recommended but not routinely used
Is an exemption drug, $21,900 per box of 3 vials
Nutritional Support:
What is the recommended energy intake per person?
25-35kcal/kg body weight
CIOM:
Pathogenesis
Chemotherapy/ radiation causing direct damage to epithelial stem cells → damage to mucosa of oral cavity, pharynx, larynx, esophagus, and GI tract
- Tissue response varies by seasonal and circadian changes
- EGFR Inhibitor targeted therapies (e.g. mabs, small-molecule inhibitors)
- EGFR is found in the esophagus and plays a role in maintaining mucosal integrity. EGFR inhibitors cause ↑ EGFR levels and mucosa inflammation
CIC:
List 5 symptoms of CIC
- Bloating/ feeling of fullness
- Abdominal pain/ cramping
- Swollen/ distended abdomen
- Flatulence
- N/V
- Loss of appetite
- No regular bowel movement for ≥2d
- Straining to have bowel movement
- Small hard stools that are difficult to pass
- Rectal pressure
- Leakage of small amts of stool resembling diarrhoea
CIC:
Pathogenesis
Usually occurs due to a combi of poor oral intake and drugs that slow intestinal transit time (e.g. opioids, antimemetics, chemotherapy)
CIOM:
Prevention of oral mucositis
Include treatments that are recommended, recommended but not routinely used, and against
Refer to formulary
CINV:
Strategies for anticipatory CINV treatment:
* Optimal ________________
* Behavioural therapy: ____________
* ________________
* Consider ____________
- Optimal antiemetics
- Behavioural therapy: Relaxation/ systematic desensitization, Hypnosis/ guided imagery, Music therapy
- Acupuncture/ acupressure
- Consider benzodiazepines
CINV:
Non-pharmacological management:
* Take ________ meals. Avoid ________ meals
* Avoid ________ food and food with ________ flavours or smells
* Sip ____________ often instead of trying to drink a full glass at one time
* Avoid ________ beverages
* Avoid ____________ for ____ hours after eating
- Take small, frequent meals. Avoid heavy meals
- Avoid greasy, spicy, very sweet or salty food and food with strong flavours or smells
- Sip small amounts of fluid often instead of trying to drink a full glass at one time
- Avoid caffeinated beverages
- Avoid lying flat for 2 hours after eating
Nutritional support:
Pathophysiology of refeeding syndrome
CINV:
5HT3 antagonist
* Uses
* MoA
* Dosing
* A/Es
* DDIs
* Other remarks
Refer to formulary
Nutritional support:
Management strategies of refeeding syndrome
- Check serum electrolytes at baseline
- Correct deficiencies prior to feeding. Defer feeding if electrolytes are critically low
- Thiamine (vit B1) supplementation
- Start low and go slow! Gradually ↑over next few days to meet nutritional requirements
- Monitor electrolytes as feeding progresses, adjust amount of replacements as needed
CINV:
Pathophysiology of CINV in central pathway
PLUS How many hours later does CINV start/peak and decrease?
- Chemotherapy drugs cross the blood-brain barrier or induce inflammatory responses that activate the area postrema (chemoreceptor trigger zone, CTZ // vomiting center) in the medulla.
- The CTZ contains dopamine (D₂), serotonin (5-HT₃), and neurokinin-1 (NK₁) receptors that mediate emesis.
- The substance P–neurokinin-1 (NK₁) receptor system is particularly important in delayed-phase vomiting (occurring 24+ hours post-chemotherapy).
- The cerebral cortex and limbic system may also contribute to anticipatory nausea and vomiting through learned responses to chemotherapy.
→ peak onset 48-72hrs after chemo, ↓after 1-3d
CID:
Pathophysiology of irinotecan-associated diarrhoea
Refer to formulary for picture
Nutritional support:
PARENTERAL NUTRITION
List the possible drug-nutrient interaction and its prevention
CINV:
Butyrophenones (haloperidol)
* Uses
* MoA
* Dosing
* A/Es
Refer to formulary
CIOM:
Treatment related risk factors
**Chemotherapy **
* Depends on agent/ regimen, duration, dose intensity, and schedule
* S-phase specific agents have highest risk
Risk ↑ with:
* Prolonged/ repetitive lower doses (VS bolus doses)
* Number of cycles
* Delayed clearance of chemotherapy by renal/ hepatic impairment
* Previous therapies toxic to mucosa
* Previous episodes of mucositis
Radiation
* Risk is dependent on radiation source, dosage, dose intensity, and vol of mucosa irritated
Risk ↑:
* When radiation is added to chemotherapy
* Smoking, alcohol
* Presence of xerostomia and infection
CID:
Severity grading
PLUS uncomplicated VS complicated CID
Refer to formulary for picture :)
CINV:
What is the treatment regimen of antiemetics for high, moderate, low, and minimal emetogenic risk? Include doses + duration of tx
Refer to formulary for picture :)
Note that Akynzeo is a single dose on Day 1, costs $87, and higher delayed-phase CINV prevention
While Aprepitant + 5HT3 antagonist cost $55, is effective but requires multi-day dosing
Nutritional support:
Protein requirements of:
* Healthy adult
* Trauma/ surgery/ burn
* Sepsis/ critical illness
* CKD not on dialysis
* CKD on HD/ PD
* CKD on CRRT
- Healthy adult: 0.8g/kg/day
- Trauma/ surgery/ burn: 1.5-2g/kg/day
- Sepsis/ critical illness: 1.5-2, up to 2.5g/kg/day
- CKD not on dialysis: 0.6-0.8g/kg/day
- CKD on HD/ PD: 1.2g/kg/day
- CKD on CRRT: up to 2g/kg/day
