Supportive and Palliative Care (GI) Flashcards

Question

Dosing of dexamethasone

Answer 1

IV/PO 12mg OD D1, IV/PO 8mgOD D2 onwards for highly emetogenic regimens

Answer 2

- Most common: transient elevations in glucose, insomnia (counsel to take night dose early, 5pm), anxiety, and gastric upset - Less common: psychosis (esp paediatrics, they become hyperactive causing problems for parents), or reactivation of ulcers (take after or with food or take PPI before food)

Answer 3

Antagonist of Dopamine, Serotonin, Histamine, Cholinergic receptors involved in CINV

Answer 4

5mg–10mg OD, consider lower doses (2.5mg OD) for elderly

Answer 5

Fatigue, sedation, postural hypotension, anticholinergic side effects Note: as olanzapine prevents CINV at low doses, the risk of AE is also lower

Answer 6

PO/IV Metoclopramide 10mg TDS PRN Note: as it is given PRN, check with pt if they are still using before prescribing more.

Answer 7

Blockade of dopamine receptors in the chemoreceptor trigger zone; stimulation of cholinergic activity in the gut, increasing (forward) gut motility; and antagonism of peripheral serotonin receptors in the intestines

Answer 8

Dopamine antagonist (metoclopramide)

Answer 9

Mild sedation and diarrhea, extrapyramidal reactions (e.g.,dystonia,akathisia)

Answer 10

Avoid prescribing Metoclopramide with Olanzapine– increase risk of extrapyramidal reactions (tardive dyskinesias, neuroleptic malignant syndrome)

Answer 11

Benzodiazepines

Answer 12

- Binds to benzodiazepine receptors on the postsynaptic GABA neuron to enhance inhibitory effect of GABA - Leads to sedation, reduction in anxiety, and possibly depression of the vomiting centre

Answer 13

PO alprazolam 0.5-1mg/PO lorazepam 0.5-2mg on the night before treatment and then 1-2 hours before chemotherapy begins Note: do not give long acting benzo

Answer 14

- Drowsiness, dizziness, hypotension, anterograde amnesia, paradoxical reactions (hyperactive, aggressive behaviour) Note: Caution in elderly (risk of falls, prescribe lowest effective dose)

Answer 15

Butyrophenones (haloperidol): PO/IV 0.5-2mg q4-q6hr Phenothiazines (prochlorperazine, chlorpromazine, promethazine): Prochlorperazine PO 10mg TDS/QDS PRN

Answer 16

Sedation and extrapyramidal symptoms

Answer 17

Drowsiness, hypotension, akathisia, and dystonia, extrapyramidal symptoms

Answer 18

Block dopamine receptors in the chemoreceptor trigger zone

Answer 19

- General principle is to give an additional agent from a different drug class- diff MOA - Choice of agent should be based on assessment of the current prevention strategies used - Consider use of several agents utilizing different mechanism of actions if necessary - If PO route not feasible due to ongoing vomiting, consider IV route - Hydration and fluid repletion for losses (ORS, 100plus) - Reassess next cycle’s antiemetics to ensure anti-emetic regimen is appropriate

Answer 20

- Take small, frequent meals. Avoid heavy meals. - Avoid greasy, spicy, very sweet or salty food and food with strong flavors 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.

Answer 21

Can result in abnormal electrolytes, inappropriate fluid balance, malnutrition, renal failure, weight loss, fatigue, and dehydration

Answer 22

- Taxanes - MTX - 5FU - Irinotecan - Doxorubicin - Cyclosphosphamide - Cisplatin - Oral targeted therapy - Gemcitabine - Cytarabine

Answer 23

Tyrosine kinase inhibitor

Answer 24

1) Age greater than 65 years 2) Female 3) Eastern Cooperative Oncology Group (ECOG) performance status (PS) of at least 2 Shows how fit pt is: can do daily activities/walk ard/bedridden? 0: v. fit >2: not so fit 4) Bowel inflammation or malabsorption 5) Bowel malignancy 6) Biliary obstruction Other predictive factors may include first cycle of chemotherapy, cycle duration greater than 3 weeks, concomitant neutropenia, other symptoms such as mucositis, vomiting, anorexia, or anaemia

Answer 25

Grade 1: ↑ of <4 stools/day above baseline Grade 2: ↑ of 4-6 stools/day above baseline and limits daily activites Grade 3: ↑ of >=7 stools/day above baseline, hospitalisation needed, limiting self care Grade 4: life threatening, urgent intervention needed Grade 5: death

Answer 26

Grade 1 or 2 No complicating S&S

Answer 27

- Grade 3 or 4 - Grade 1 or 2 with >=1 of: Cramping >Grade 2 N/V Decreased performance status Fever Sepsis Neutropenia Frank bleeding Dehydration

Answer 28

- Decrease morbidity and mortality from CID - Improve quality of life and activities of daily living. - Improve recovery of intestinal mucosa. - Decrease hospitalization

Answer 29

- Withhold chemotherapy for grade 2 - Diet modifications - Oral hydration with 8-10 large glasses of clear liquids - Loperamide 4 mg by mouth, then 2 mg by mouth every 4 hours or after every episode of diarrhea. (max 16mg/day) Continue until 12 hours free of diarrhea, then stop. If diarrhea is improving after 12–24 hours, continue with diet modifications and begin to add solid food. If diarrhea persists after 12–24 hours: 1) Schedule loperamide 2 mg every 2 hours. 2) Start oral antibiotics. 3) For diarrhea that progresses to severe or complicated, treat as such. 4). For diarrhea that persists as uncomplicated 12– 24 hours after scheduled loperamide, begin octreotide or other second-line agent.

Answer 30

1) Withhold chemotherapy. Resume when all symptoms resolve. 2) Restart at decreased dosage. 3) Administer octreotide 100–150 mcg subcutaneously three times a day or IV with dose escalation up to 500 mcg three times a day. 4) Start IV fluid hydration. 5) Start IV antibiotics (e.g., ciprofloxacin × 7 days)

Answer 31

Opioid that inhibits smooth-muscle contraction of intestine to decrease motility (primary neurotransmitter is acetylcholine)

Answer 32

Constipation, abdominal pain, dizziness, rash, bloating, nausea and vomiting, dry mouth, drowsiness Note: high doses have been assoc w paralytic ileus

Answer 33

Causes decreased hormone secretion, which increases transit time within intestine, decreases secretion of fluid, and increases absorption of fluid and electrolytes

Answer 34

bradycardia, arrhythmias, constipation, abdominal pain, enlarged thyroid, nausea and vomiting, headache, dizziness

Answer 35

Most commonly recommended dosage is 100–150 mcg subcutaneously three times a day Because of the dose–response relationship, may increase dosage at 50-mcg increments after 24 hours to 500 mcg three times a day or as continuous IV infusion (25–50 mcg/hour)

Answer 36

5FU and irinotecan-induced CID

Answer 37

- Probiotics with Lactobacillus are suggested to prevent Chemotherapy-or radiation- induced diarrhea. Diet modification: - Avoid caffeine, alcohol, fruit juice, foods that contain lactose, foods that are spicy or high in fat or fiber, or dietary supplements with high osmolarity. - Eat small, frequent meals. - BRAT diet (bananas- bulk forming, rice, applesauce, toast) - More than 3L of clear fluids containing salt and sugar: Electrolyte-containing fluids are ideal. eg. ORS or 100plus

Answer 38

- Irinotecan is converted primarily in the liver to active metabolite SN-38, which is 100–1,000 times more cytotoxic than the parent drug and is responsible for diarrhea. - SN-38 is deactivated by glucuronidation via UDP-GT1A1 to SN38-G. - Increased toxicity in those homozygous for UGT1A1*28, which causes decreased expression of UGT1A1 - Bacteria found in the gut produce β-glucuronidase that reactivate SN38-G to SN-38 via deconjugation. Commensal bacteria in gut are altered in the presence of irinotecan. SN-38 damages gut mucosa during excretion. - Leads to ablation of crypts, villus blunting, and atrophy of the epithelium in small and large intestine

Answer 39

Atropine 0.25–1 mg (maximum 1.2 mg) subcutaneous or IV (usually SC) Mechanism of action: inhibits acetylcholine at muscarinic receptor as a competitive antagonist

Answer 40

- insomnia, dizziness, - tachycardia, blurred vision, dry mouth, - constipation - CI in glaucoma

Answer 41

Loperamide 4 mg after first loose bowel movement, then 2 mg every 2 hours (4 mg every 4 hours at night might be better) until 12 hours have passed without bowel movement

Answer 42

Early: - within 24hrs of administration - Dose dependent - Avg symptom duration: 30mins - most symptoms occur during infusion Late: - after 24hrs - occur at any dose or frequency - avg onset is 6days if given every 3wk dosing - avg onset is 11days if given weekly dosing

Answer 43

- Lowered fluid intake and dehydration - Loss of appetite (anorexia) - Lack of fibre or bulk-forming foods in the diet - Vitamin or mineral supplements such as iron or calcium pills - Overuse of laxatives - Low level of physical activity or a lot of bed rest - Thyroid problems - Depression - High levels of calcium or potassium in the blood - Cancer growing into the large intestine (bowel) or pressing on the spinal cord - Certain drugs that are used to treat cancer or the side effects of treatment can also cause constipation These include: Pain relievers, especially opioid narcotic medicines, such as morphine or codeine Chemotherapy drugs such as the vinca alkaloids, which include vincristine vinblastine or vinorelbine Antinausea drugs such as ondansetron, granisetron or anticonvulsant drugs Diarrhoea meds.

Answer 44

- Bloating or feeling of fullness - Cramping or pain - Gas, or flatulence - Belching - Loss of appetite - No regular bowel movement for 2 or more days - Straining to have a bowel movement - Small Hard Stools That Are Difficult To Pass - Rectal pressure - Leakage of small amounts of stool resembling diarrhea - Swollen, ordistended, abdomen - Nausea or vomiting

Answer 45

- Eat more fibre - add bulk to stools - Eat natural laxatives: veg, coffee, prunes- v. sweet, caution in diabetes - Increase physical activity - Sufficient food

Answer 46

- Stool softeners help the stool hold water to keep it soft. - Laxatives may be used to help promote,or stimulate, bowel activity eg. senna or sennosides, mineral oil and lactulose. - Laxatives may also be used to increase fibre or produce bulk eg. Psyllium - Laxatives may be given as a suppository placed in the rectum. Suppositories can help promote bowel activity. eg. glycerine and bisacodyl - Enemas maybe used to clean out the bowel or deliver laxatives eg. phosphate enema (Fleet) and tap water. - Sometimes a stool softener and a laxative are used together. - A suppository or enema may not be recommended when white blood cell or platelet counts are low because of the risk of infection or bleeding when these products are use.

Answer 47

Chemotherapy or radiation causes direct damage to epithelial stem cells: - Tissue response varies by seasonal and circadian changes. - Targeted therapies such as cetuximab, bevacizumab, rituximab, and a variety of small-molecule inhibitors have demonstrated the potential to cause a variety of GI toxicities, including mucositis. - Epidermal growth factor plays a role in maintaining mucosal integrity. - EGFR can be found in the esophagus, and levels are increased in inflamed mucosa

Answer 48

Stage 1 Initiation: - Direct toxicity to cells - Oxidative stress - Increased vascular permeability Stage 2 Upregulation: - DNA damage - Prdtn of pro-inflammatory cytokines Stage 3 Signaling and Amplification: - Pro-inflammatory cytokines released - Positive feedback Stage 4 Ulceration: - Atrophy and mucosal breakdown - Inflammatory infiltrates - Macrophages activated by colonizing bacteria Stage 5 Healing: - Proliferation of epithelial cells - Return of local flora

Answer 49

Day 0-5: - mostly asymptomatic - redness - swelling - burning - increased sensitivity Day 0-7: - desquamation - white patches - often mistaken for candidiasis Day 6-12: - contiguous pseudomembranes Day 7-16: - painful erosions - ulceration

Answer 50

Risk of mucosal injury is affected by patient- and treatment- related factors. - Patient-related factors: Autoimmune disorders Diabetes Female (5-FU induced) Caucasians > African Americans. Genetic predisposition to tissue damage Deficiency in genes that produce enzymes responsible for metabolizing chemotherapy Folic acid or vitamin B12 deficiency - Treatment related factors: Chemotherapy Radiation Smoking and alcohol Depends on radiation source, dosage, dose intensity and volume of mucosa irradiated Xerostomia and infection

Answer 51

Prevent or decrease severity of mucositis Manage pain and other associated symptoms Prevent chemotherapy delays or dosage reductions

Answer 52

- Palifermin - Benzydamine HCI mouthwash - Oral cryotherapy - LLLT (laser therapy)

Answer 53

- Oracare Suspension (Nystatin 125,000U, Tetracycline 62.5mg, hydrocortisone 5mg, diphenhydramine 11.5mg/10mL) - Mylocaine suspension (diphenhydramine 11.5mg, lignocaine 16.7mg/10mL) - Morphine sulfate solution 1mg/mL

Answer 54

After food to kill the germs

Answer 55

Before food to help with the pain during eating

Answer 56

Yes so that it covers the back of the throat and gut

Answer 57

Oracort-E Soragel Medigel

Answer 58

Oral 7 mouthwash BioXtra mouthwash

Answer 59

Alcohol based mouthwashes as it has drying effect and might cause more xerostomia resulting in mucositis

Answer 60

Oral7: uses natural enzymes at neutral pH so it acts as "fake saliva" to prevent dry mouth