Supportive Care I (Weddle) Flashcards
List the 5 types of nausea/vomiting.
- Anticipatory
- Acute
- Delayed
- Breakthrough
- Refractory
List the 5 neurotransmitters implicated in CINV.
- Dopamine
- Histamine
- Acetylcholine
- Serotonin
- Substance P
Level ___ and ___ agents do not contribute to the emetogenicity of a drug regimen.
1 and 2
Adding level ___ or ___ agents increases the emetogenicity of the regimen by 1 level per agent.
3 and 4
List some risk factors for CINV.
- Women
- Younger age
- History of motion sickness
- History of morning sickness
- History of CINV
- Anxiety/anticipation of nausea
What condition can actually be protective against CINV?
Chronic ethanol
Give some examples of serotonin (5-HT3) antagonists.
- Ondansetron
- Granisetron
- Dolasetron
- Palonosetron
What are some common toxicities associated with serotonin (5-HT3) antagonists?
- Headache
- EKG changes
- Constipation
- Increased transaminases
Give an example of a corticosteroid.
Dexamethasone
What are some common toxicities associated with corticosteroids?
With short-term use:
- Anxiety
- Euphoria
- Insomnia
- Hyperglycemia
- Increased appetite
Give some examples of substance P (NK-1) antagonists.
- Aprepitant (oral and injectable)
- Fosaprepitant
- Rolapitant
- Netupitant
- Fosnetupitant
What are some common toxicities associated with NK-1 antagonists?
- Hiccups
- Drug interactions
Give some examples of dopamine antagonists.
- Chlorpromazine
- Haloperidol
- Metoclopramide
Give some examples of common toxicities associated with dopamine antagonists.
- Extrapyramidal side effects
- Diarrhea
- Sedation
Give an example of an atypical antipsychotic.
Olanzapine
What are some comon toxicities associated with atypical antipsychotics?
- Dystonic reactions
- Sedation
Give some examples of phenothiazines.
- Prochlorperazine
- Promethazine
What are some common toxicities associated with phenothiazines?
- Sedation
- Akathisia
- Dystonia
- Tissue damage (IV promethazine)
Give an example of a cannabinoid.
Dronabinol
What are some common toxicities associated with cannabinoids?
- Drowsiness
- Dizziness
- Euphoria
- Mood changes
- Hallucinations
- Increased appetite
Give an example of a benzodiazepine.
Lorazepam
What are some common toxicities associated with benzodiazepines?
- Sedation
- Hypotension
- Urinary incontinence
- Hallucinations
Give an example of an anticholinergic drug.
Scopolamine (patch)
What are some common toxicities associated with anticholinergics?
Inhibits SLUD (salivation, lacrimation, urination, defecation)
Provide an appropriate regimen for a highly emetogenic drug combination.
A. NK-1 → dexamethasone → 5-HT3 → olanzapine
B. olanzapine → palonosetron → dexamethasone
C. NK-1 → dexamethasone → 5-HT3
Provide an appropriate regimen for a moderately emetogenic drug combination.
D. dexamethasone → 5-HT3
E. olanzapine → palonosetron → dexamethasone
F. NK-1 → dexamethasone → 5-HT3
Provide an appropriate regimen for a low emetogenic drug combination.
Any 1 of the following:
- Dexamethasone
- Metoclopramide
- Prochlorperazine
- Dolasetron
- Granisetron
- Ondansetron
What eight drug classes may be used for breakthrough nausea/vomiting?
- Dopamine antagonists
- Atypical antipsychotics
- Phenothiazines
- Benzodiazepines
- Cannabinoids
- Serotonin (5-HT3) antagonists
- Steroids
- Anticholinergics
Which agents are typically used for delayed nausea/vomiting?
- Dexamethasone
- NK-1 antagonist
- Olanzapine
How can you prevent CINV from an oral chemotherapy regimen that has moderate to high emetogenic risk?
Start a 5-HT3 antagonist before chemo and continue daily
How can you prevent CINV from an oral chemotherapy regimen that has minimal to low emetogenic risk?
Start either metoclopramide, prochlorperazine, or a 5-HT3 antagonist before chemotherapy and maybe give daily or PRN
How soon before chemotherapy should anti-emetics be given?
At least 5-30 minutes prior to chemotherapy
What are the hallmark signs and symptoms of mucositis?
Can range from mild inflammation to bleeding ulcerations
The course of mucositis progresses in a stepwise fashion, and parallels the __________________.
neutrophil nadir
When does mucositis typically begin?
Day 5-7 after chemotherapy
What two chemotherapy drugs are MOST associated with mucositis?
5-FU and doxorubicin
What are some risk factors associated with mucositis?
- Pre-existing oral lesions
- Poor dental hygiene or ill-fitting dentures
- Combined modality of treatment (patients getting chemo and radiation)
How can a patient adjust their diet to avoid/not exacerbate mucositis?
- Avoid rough food, spices, salt, and acidic food
- Avoid smoking and alcohol
Give some general mouth care strategies for mucositis.
- Baking soda (+/- salt) rinse
- Soft toothbrush
- Saliva substitute
Provide 4 pain management strategies for mucositis.
- Topical anesthetics (magic mouthwash)
- Oral cryotherapy (ice chips)
- Sucralfate
- Opioid analgesics
Although Mary’s Magic Mouthwash will often provide adequate relief, provide one drawback.
short-lived effect
Oral cryotherapy works to decrease mucositis by what mechanism?
vasoconstriction may decrease chemotherapy delivery to the oropharyngeal mucosa
Through what mechanism could oral sucralfate be effective in mucositis pain management?
forms a protective barrier, also increases local production of prostaglandin E2 (a mucosal protectant)
What is a potential drawback of using sucralfate for mucositis pain?
potentially nauseating taste/texture, not much good data to support use
Why should mucositis patients be weary of using oral analgesic solutions OTC?
many contain a high percentage of alcohol, which may burn
Neutropenia is the incidence of decreased ______________.
white blood cells
What WBC count qualifies as neutropenia?
< 0.5 x 103 /µL
Define nadir.
the lowest value the blood count falls to (described by ANC)
Neutropenic patients are at an increased risk of ____________.
infection
How do you calculate ANC?
WBC x % granulocytes (segs + bands)
What ANC level qualifies as severe neutropenia?
< 0.5 x 103 / µL
What ANC and temperature qualify as febrile neutropenia?
ANC < 0.5 x 103 /µL and a single oral temperature > 101°F (> 38.3°C) or > 100.4°F (> 38.0°C) for at least an hour
When would CSFs be used for primary prophylaxis of febrile neutropenia?
if the patient is to receive a chemotherapy regimen that is expected to cause ≥ 20% incidence of febrile neutropenia
When would CSFs be used for secondary prophylaxis of febrile neutropenia?
the patient experienced a neutropenic complication from a previous cycle of chemotherapy and now you want to prevent that again
True or false: CSFs are 1st line for the treatment of neutropenic fever.
false; lackluster outcomes and high cost
CSFs can be used to support patients through ___________ chemotherapy.
dose dense
What happens after filgrastim is discontinued?
rapid drop in WBCs and neutrophils (50% decrease in 24 hours)
Which has a longer half-life: filgrastim or pegfilgrastim?
pegfilgrastim (Neulasta)
Which is a biosimilar: tbo-filgrastim or filgrastim-sndz?
filgrastim-sndz
What are the most common adverse effects associated with filgrastim?
- flu-like symptoms
- bone/joint pain
- DVT
What rare adverse effect is associated with filgrastim?
splenic enlargement/rupture
How is thrombocytopenia traditionally defined?
platelet count < 100 x 103 /µL
At what platelet count does an increased risk of bleeding occur?
< 20 x 103 /µL
Most institutions will not tranfuse a thrombocytopenia patient until they are ____________.
symptomatic
At what platelet count does ASCO recommend transfusion?
10 x 103 /µL
What are the four general causes of anemia?
- decreassed RBC production
- decreased erythropoietin production
- decreased body stores of B12/iron/folic acid
- blood loss
What should be done if a chemotherapy-induced anemia patient is symptomatic (short of breath)?
- transfuse as indicated
- consider ESAs
- perform iron studies
Which patient groups should be considered for ESA use?
- cancer and CKD
- underdoing palliative chemo
- without other identifiable causes
Patients with previous risk factors of ___________ events may be at a higher risk with ESA use.
thrombotic
_______ will yield gradual improvement in anemia-related symptoms, while _________ will yield rapid improvement.
ESAs; RBC transfusions
Epoetin alfa is a glycoprotein that stimulates _______ production.
RBC
In what groups is epoetin alfa contraindicated?
- uncontrolled HTN
- albumin hypersensitivity
- mammalian cell-derived product hypersensitivity
Epoetin alfa increases the risk of ________ in patients on dialysis.
seizures
How does darbepoetin stimulate erythropoiesis?
binds to the epoetin receptor like erythropoietin
What makes darbepoetin biochemically distinct from epoetin alfa?
addition of a sialic acid
Which has a longer half-life: epoetin alfa or darbepoetin?
darbepoetin
In which groups is darbepoetin contraindicated?
- uncontrolled HTN
- epoetin alfa hypersensitivity
Why should we NOT increase Hgb by < 1 g/dL in a 2-week period?
associated with increased risk of cardiovascular events
All oncology patients prescribed ESA therapy should have baseline _______________ performed.
iron studies
True or false: patients with an active infection are allowed to receive iron therapy.
false
What chemo drugs are known to cause myalgias?
taxanes and aromatase inhibitors
What treatment options are available for chemotherapy-induced myalgias?
NSAIDs, maybe opioids
What chemotherapy drugs are known to cause hemorrhagic cystitis?
high-dose cyclophosphamides and ifosfamide
What drugs can be used to prevent chemotherapy-induced hemorrhagic cystitis?
mesna
What non-pharmacologic strategy can be employed to prevent hemorrhagic cystitis?
hydration
What chemotherapy agents are known to cause heart failure?
- anthracyclines
- high-dose cyclophosphamides
- trastuzumab
What drug is a chemoprotectant against chemotherapy-induced heart failure?
dexrazoxane
What chemotherapy agents are known to cause peripheral neuropathy?
taxanes, vinca alkaloids, and platinums
Provide two treatment strategies for chemotherapy-induced peripheral neuropathy.
- change infusion rates (i.e. paclitaxel)
- adjunctive pain meds (gabapentin, amitriptyline)
What chemotherapy drug is known to cause pulmonary toxicities?
bleomycin
