Supportive Care: I Flashcards
complications of N/V
- most feared complication of chemo despite ___ nature
- can result in the inability to deliver intended dose of chemo
limited
- dehydration
- electrolyte
- abnormalities
- fatigue
- depression
before 5-HT3 anti-emetics, it was expected to vomit 5-12 times per day
Types of N/V
anticipatory
- ___ response conditioned by severity and duration of previous emetic reactions from prior cycles of chemo
- non-PCOL like hypnosis helpful
- can be provoked by sight, sound, or smell
learned
cancer patients have hightened senses
Types of N/V
Acute
- emetic response correlating with the administration of chemo
- within __ hours of receiving chem
Delayed
- Related to chemotherapy occurring > ___ hours following completion of chemotherapy
– Mechanism is not fully understood, but there is ↑
evidence that substance P binding to ___ receptor may play a role
24
24
neurokinin 1
Types of N/V
Breakthrough
- occurs even if on scheduled anti-emetics ___ to chemotherapy
Refractory
- persists despite ___ anti-emetics
- Failed other therapies
- prior
- appropriate
Patho of CINV
- Chemo is toxic to GI tract inducing damage to the epithelial cells
- Enterochromaffin cells lining the GI tract contain large stores of ___ that are released in massive quantities after exposure to chemo
- chemoreceptor trigger zone (CTZ)
stimulates the vomiting center - Located in the nucleus tractus solitarii in the ___ which stimulates the emetic response
- Input to the vomiting center from the higher cortical centers, pharynx, and GI
tract can induce emesis
- serotonin
- medulla
Neurotransmitters implicated in CINV (5)
- dopamine
- histamine
- acetylcholine
- serotonin
- substance P
highly emetogenic chemo (level 5)
single agent
- Carboplatin
- Carmustine
- Cisplatin
- Cyclophosphamide
- Dacarbazine
- Doxorubicin
- Epirubicin
- Fam-trastuzumab-deruxtecan
- Ifosfamide
- Mechlorethamine
- Melphalan
- Sacituzumab govitecan-hziy
- Streptozocin
Combo Chemo
when considering combo chemo, need to consider emetogenicity
- level 1 or 2 agents do not contribute to the emetogenicity of the regimen
- adding level 3 or 4 ___ the emetogenicity of the combo by 1 level per agent
- add the different levels together to decide on which antiemetics to use
increasing
Oral Anticancer Agents
Moderate to high emetic risk:
(≥ 30% risk) Prophylaxis required on days of oral anticancer agent administration
- Azacitidine
- Busulfan
- Ceritinib
- Cyclophosphamide
- Fedratinib
- Lomustine
- Midostaurin
- Mitotane
- Selinexor
- Temozolomide
Oral Anticancer Agents
Moderate to high emetic risk:
(≥ 30% risk) As needed dosing is initially appropriate on days of oral anticancer agent administration
- Adagrasib
- Elacestrant
- Avapritinib
- Binimetinib
- Bosutinib
- Cabozantinib
- Crizotinib
- Dabrafenib
- Enasidenib
- Encorafenib
- Estramustine
- Etoposide
- Imatinib
- Lenvatinib
- Niraparib
- Olaparib
- Procarbazine
- Rucaparib
risk factors for CINV
- women __ men
- younger __ older
- prior history of ___ and ___ sickness
- previous CINV tend to do worse
- anxiety/high pretreatment ___ of nausea
- chronic ethanol can be ___
- >
- >
- motion, morning
- anticipation
- protective
treatment guidelines
___ for acute N/V is based on the emetogenic potential of chemo
- ___ receptor antagonists may be substituted for each other
- oral efficacy = IV efficacy
prophylaxis
- 5HT3
highly emetogenic regimens
A) 4 drug
B) 3 drug
C) 3 drug
A) NK-1 antagonist, steroid, 5-HT3 antagonist, atypical anti-psychotic
B) atypical antipsychotic, 5HT-3 antagonist, steroid
C) NK-1 antagonist, steroid, 5-HT3 antagonist
These 3 agents can be added with any regimen and any emetogenicity if patients are experiencing these toxicities
+/- Lorazepam 0.5 mg to 2 mg PO or IV or sublingual either every 4 or 6 hours as needed
+/- H2 blocker or proton pump inhibitor
moderately emetogenic
A) 2 drug
B) 3 drug
C) 3 drugs
- steroid, 5-HT3
- anti-psychotic, steroid, 5-HT3
- NK-1, steroid, 5-HT3 antagonist
low emetogenic regimens
only 1 needed
- steroid ( ___ )
- metoclopramide
- prochlorperazine
- 5-HT3 (3)
- dexamethasone
- dolasetron, granisetron, ondansetron
Breakthrough Nausea and Vomiting
give an additional agent from a different drug class as needed
- haloperidol or metoclopramide
- prochlorperazine or promethazine
- olanzapine
- lorazepam
- dronabinol or nabilone
- dolasetron, granisetron, or ondansetron
- dexamethazone
- scopolamine
Depending on the severity of the N/V, you can schedule these agents
Delayed Nausea and Vomiting
typically involves use of one of the following (3)
- dexamethasone
- NK-1 antagonist
- olanzapine
Anticipatory N/V
___ - Use optimal antiemetic therapy during
every cycle of treatment
___ - 0.5 to 1 mg orally beginning the night before treatment and then again 1 to 2 hours prior to beginning of
chemotherapy
- prevention
- lorazepam
other prevention guidelines
Oral chemotherapy - High to moderate emetogenic risk
- Start ___ chemotherapy and continue daily
- ___ antagonists
Low to minimal emetogenic risk
- Start ___ chemotherapy and maybe given daily or prn
– ___
– ___
– ___ antagonists
- before
- 5-HT3
- before
- Metoclopramide
- Prochlorperazine
- 5-HT3
Other Prevention Guidelines
Radiation Induced Emesis
- Start pretreatment for each day of radiation
therapy
- ___ PO +/- dexamethasone
- ___ PO +/- dexamethasone
Granisetron
Ondansetron
Radiopharmaceuticals
- Nausea is associated with the ___ infusion accompanying treatment
- Antiemetics should be given ___ minutes prior to start of infusion
Recommendations for antiemetics include:
- ___ or ___ antagonists
- NOT ___ due to down regulation of somatostatin receptors
- amino acid
- 30
- 5-HT3, NK-1
- steroids
Common Toxicities Across Classes
Serotonin (5-HT3) antagonists
- Ondansetron
- Granisetron
- Dolasetron
- Palonosetron single agent or combination products (+/- netupitant
or fosnetupitant)
- Headache
- asymptomatic and transient EKG changes (max doses)
- constipation
- increased transaminases
Common Toxicities Across Classes
Corticosteroids
- Dexamethasone
(Short term use):
- Anxiety
- euphoria
- insomnia
- hyperglycemia
- ↑’d appetite