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oncology > Supportive Care > Flashcards

Supportive Care Flashcards

1
Q

CINV

A

increases morbidity
negatively effects patients QOL
non-adherence to chemo +/- dose reductions
weakness, dehydration, electrolyte imbalance, esophageal tears, decline in behavioral & mental status

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2
Q

acute CINV

A

occurring within first 24 hours

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3
Q

delayed CINV

A

24 hours to several days (2-5 days) after chemo

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4
Q

breakthrough CINV

A

occurs despite prophylactic treatment

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5
Q

anticipatory CINV

A

before treatment as a conditioned response to the occurrence in previous cycles

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6
Q

refractory CINV

A

recurring in subsequent cycles of therapy, excluding anticipatory CINV

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7
Q

peripheral emetic response pathway

A

5HT3 mediated
originates in GI tract
activated in first 24 hours after chemo
associated with acute emesis

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8
Q

central emetic response pathway

A

NK1 receptor mediated
primarily in the brain
involved in delayed CINV

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9
Q

general principles of emesis control

A

prevention!
choosing antiemetic agents: emetic risk, prior experience with antiemetics, patient factors
prophylaxis based on agent with the highest emetogenic risk
lifestyle management: smaller more frequent meals, healthier meals, room temperature food

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10
Q

risk factors of CINV

A

<50 yo
emesis during pregnancy
history of CINV, prone to motion sickness
female sex
little/no previous alcohol use
anxiety/ high pretreatment expectations of nausea

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11
Q

high IV emetogenic potential

A

AC ( anthracycline + cyclophosphamide)
carboplatin >4
Carmustine
Cisplatin
Cyclophosphamide
Dacarbazine
Doxorubicin
Epirubicin
Fam-trastuzumab deruxtecan
Ifosfamide
Mechlorethamine
Melphalan
Sacituzumab
Streotozocin

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12
Q

oral agents prophylaxis required on days of chemo admin

A

azacitidine
busulfan
certinib
cyclophosphamide
fedratinib
lomustine
midostaurin
mitotane
selinexor
temozolomide

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13
Q

breakthrough emesis treatment

A

add one agent from a different drug class
consider routine admin vs PRN
antacid therapy if patient has dyspepsia
*olanzapine, lorazepam, dronabinol, 5HT3 RA, prochloperazine, dexamethasone, metoclopramide, scopolamine

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14
Q

anticipatory emesis treatment

A

prevention!
avoid strong smells
Lorazepam useful
acupuncture
behavioral therapy: guided imagery, relaxation, hypnosis, cognitive distraction, yoga, biofeedback, progressive muscle relaxation,

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15
Q

Dexamethasone

A

MOA unknown
ADEs:
Insomnia- admin in morning
dyspepsia: take with food, consider H2 antagonist or PPI
Hyperglycemia
Hypertension

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16
Q

5HT3 RA (ondansetron, palonosetron, granisetron)

A

MOA: blocks serotonin peripherally (GI tract) on vagal nerve terminals and centrally in the chemoreceptor trigger zone (medulla)
1st gen: ondansetron, granisetron
-most effective for acute
-short acting
2nd gen: palonosetron
-effective in acute & delayed
-long acting

ADES:
headache
constipation
QTc prolongation

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17
Q

NK1 RA (aprepitant, fosaprepitant, rolapitant, fosnetupitant/palonestron, netupitant/ palonestron)

A

MOA: inhibits the substance P/ neurokinin 1
-augments 5HT3 & dexamethasone antiemetic activity
Only for prevention not treatment
-most useful delayed CINV
Drug interactions (except rolapitant)
-inhibition of CYP3A4 and CYP2C9 (decrease dexamethasone dose on days 2-4)
ADEs: fatigue, GI upset, headache, hiccups

Rolapitant has extended half life should not admin <2 wk intervals

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18
Q

Olanzapine

A

MOA: blocks dopamine, 5HT3, muscarinic and histamine receptors
Useful in prevention and breakthrough

ADES;
sedation: admin at bedtime, consider low dose for elderly
Hyperglycemia
Fatigue
QTc prolongation

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19
Q

Dopamine antagonists (prochlorperazine, metoclopramide, promethazine)

A

MOA: antagonize dopamine in the chemoreceptor trigger zone
Breakthrough CINV

Prochlorperazine, Promethazine
-phenothiazines
-drowsiness
-constipation

Metoclopramide
-benzamines
-drowsiness
-diarrhea
-QTc prolongation
-tardive dyskinesia (avoid >12wks)

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20
Q

Benzodiazepines (lorazepam)

A

MOA: anxiolytic
Useful for anticipatory or breakthrough with anxiety component
ADMIN either night before, morning of or both
ADES;
sedation
dizziness

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21
Q

Cannabinoids

A

MOA: CB1 agonism suppresses vomiting
indirect activation of 5HT1a in raphe nucleus
Only for refractory disease
ADEs: sedation, euphoria, hallucinations, palpitations, flushing, cough

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22
Q

Scopolamine

A

MOA: anticholinergic
Breakthrough only
ADE: dry mouth, somnolence, blurred vision

23
Q

CTID

A

incidence as high as 50-80%
depletion of fluids and electrolytes, malnutrition, dehydration and hospitalization, death
dose delays or reductions
Offenders: flurouracil, capecitabine, irinotecan, pertuzumab, abemaciclib)

24
Q

assessment of CTID

A

history
volume and duration
hydration status
added risk factors: fever, orthostatic symptoms, abdominal pain/ cramping, weakness

25
Q

Irinotecan- induced diarrhea

A

irinotecan can cause acute or delayed diarrhea
acute:
-due to cholinergic stimulation
-mean duration ~30mind
-usually respond rapidly to atropine

delayed:
-due to GI mucosal damage secondary to SN-38
-usually occurs >24 hours after admin
-noncumulative and occurs at all dose levels

26
Q

management of CTID

A

Nonpharm:
-avoidance of foods that aggravate diarrhea
-aggressive oral rehydration with fluids that contain water, salt, and sugar

Pharm:
-loperamide: first line, 4mg followed by 2mg q 4hours or after every unformed stool (max 16mg)
-diphenoxylate-atropine: 1-2 tabs q 6hours until control achieved (max 8 tabs)

27
Q

refractory CTID

A

octreotide
tincture of opium
probiotics
rule out clostridiolides difficile and infection colitis

28
Q

mucositis

A

occurs in 20-40% of patients
Onset: 5-14 days
Complications:
decreased oral intake: poor nutritional status
Grade 3-severe oral pain
Grade 4- requires parenteral or enteral nutrition

Infection Risk: gram positive oral flora, candida or fungal infections

Pain: may require opioids and PCA admin

29
Q

mucositis definition

A

erythematous and ulcerative lesions of the mucosa observed in patients treated with chemo
can occur anywhere in the GI tract

30
Q

stomatitis definition

A

mucositis limited to the oral cavity

31
Q

5 stage model of oral mucositis

A

initiation: cellular damage induces, reactive oxygen species formation
primary damage response: activation of p53 & NF-kB
signal amplification: release of inflammatory cytokines, tissue damage and cell death
ulceration: high risk for bacterial colonization
healing: cessation from ongoing tissue damage

32
Q

Chemo risk factors for mucositis

A

melphalan
cisplatin + radiation
high dose methotraxate
doxorubicin
busulfan
5-FU

33
Q

patient risk factors for mucositis

A

smoking
poor oral hygiene
oral lesions at baseline
female sex
pretreatment nutritional status

34
Q

grade 1 mucositis

A

asymptomatic or mild symptoms
intervention not indicated

35
Q

grade 2 mucositis

A

moderate pain or ulcer that does not interfere with oral intake
modified diet indicated

36
Q

grade 3 mucositis

A

severe pain
interfering with oral intake

37
Q

grade 4 mucositis

A

life threatening consequences
urgent intervention indicated

38
Q

prevention of chemo induced mucositis

A

oral hygiene
cryotherapy

39
Q

management of mucositis

A

oral decontamination: bland or oncology mouthwash, dexamethasone for everlimus-induced
pain control: 2% lidocaine, systemic opioids
palliation of dry mouth: artificial saliva products or chewing gum
nutritional support: liquid or soft diet; TPN
oral candidiasis treatment: fluconazole 200mg x1, then 100mg x 21 days

40
Q

patient risk factors for febrile neutropenia

A

prior chemotherapy or radiation therapy
persistent neutropenia
bone marrow involvement by tumor
recent surgery and/or open wounds
liver dysfunction
renal dysfunction
>65 yo full dose chemo

41
Q

filgrastim

A

short acting GCSF
start next day or up to 3-4 days after completion of chemo (5mcg/kg)
given until ANC recovery

42
Q

Pegfilgrastim

A

long acting GCSF
can admin day after or up to 3-4 days after completion of chemo
single admin(6mg)
allow >12 days between dose of pegfilgrastim and next cycle of chemo

43
Q

eflapegrastim or efbemalengrastim

A

long acting GCSF
admin 24 hours after chemo
single admin
do not administer 14 days before and within 24 hours of chemo

44
Q

possible indications for GCSF use in established febrile neutropenia

A

sepsis syndrome
>65 yo
ANC <100
neutropenia expected to be >10 days in duration
pneumonia or other clinically documented infections
invasive fungal infection
hospitalization at time of fever
prior episode of febrile neutropenia

45
Q

somatic pain

A

tumor invades bone, muscle, or connective tissue
often presented as aching, stabbing, throbbing or pressure

46
Q

visceral pain

A

tumor invades internal organs and blood vessels
often presented as gnawing, cramping, aching, or sharp pain

47
Q

neuropathic pain

A

pain sustained by damage or dysfunction in the nervous system
often presented as burning tingling shooting or electric/shocking pain

48
Q

general principles of opioids

A

offer to patients with moderate to severe pain
lowest possible dose to achieve acceptable analgesia
start with immediate release and PRN with frequent assessment and titration

PRN
-breakthrough pain
-IR or short acting opioid

Around the clock
-treat chronic pain
-SR or long acting opioids

49
Q

immune related adverse events

A

increased immune system activity from ICI results in inflammatory side effects
-increased t cell activity, preexisting autoantibodies, inflammatory cytokines

can occure during or after discontinuation on ICI treatment
make note of history of autoimmune disease

50
Q

mild-moderate AEs of immune mediated

A

symptomatic management
local therapies preferred
consider delaying immunotherapy
corticosteroids may be required

51
Q

severe aes immune mediated

A

hold immunotherapy
corticosteroids required
possible additional immunosuppressant in steroid refractory AEs
inpatient managemnet and addition supportive care may be necessary

52
Q

corticosteroids Immune mediated AEs

A

dose varies based on severity
-prednisone 0.5-2mg/kg/day
-methylprednisolone 1-2 mg/kg/day
prolonged steroid taper (4-12 weeks) may be required
long term use associated with HTN, osteoporosis, weight gain, insomnia, mental status changes, metabolic dysfunction, increased infection risk

53
Q

corticosteroid supportive care

A

Gastritis:
-PPI or H2 blocker in high risk (NSAID use, anticoagulation) for duration of corticosteroids

Infection
-PJP prophy: prednisone equivilant >20mg for >4 weeks : trimethoprim/sulfamethoxazole preferred
-Fungal: prednisone equivalent >20mg for 6-8 weeks : fluconazole

Osteoporosis
-Vit D 400-1000 IU daily and calcium 1000-1200mg from food or supplementation

oncology (9 decks)

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