Supportive Care In Oncology Flashcards
What are the 5 classes of chemo-induced N/V? Define each
Acute: occurs <24 hrs after chemo
Delayed: occurs 1-5 days after chemo
Breakthrough: occurs even while on prophylaxis
Anticipatory: occurs BEFORE chemo from conditioned anxiety
Refractory: recurs in multiple subsequent cycles of chemo
What are the 3 receptor targets for CINV?
5-HT3 receptors
NK-1 receptors
Dopamine receptors
The peripheral pathway for CINV involves the _____A____ system and is associated with ___B___ emesis. The central pathway for CINV involves the _____C____ system and is associated with ___D___ emesis.
A = GI
B = acute
C = CNS
D = delayed
What are some risk factors of CINV?
Female
Age <50 yo (young)
N/V during pregnancy
Hx of CINV, motion sickness
No alcohol use
Anxiety/expectations of nausea
[NAUSEATING that FANs have a HISTORY of NO ANXIETY]
In patients with HIGH emetic risk after IV chemo, what is the prophylactic course over 4 days?
Day 1: olanzapine + dexamethasone + NK1 RA + 5-HT3 RA
Days 2-4: olanzapine + dexamethasone + aprepitant (NK1 RA) if used po on day 1
In patients with MODERATE emetic risk after IV chemo, what is the prophylactic course over 3 days? (3 options, just recognize)
Option 1
Day 1: Dexamethasone + 5-HT3 RA
Days 2-3: Dexamethasone OR 5-HT3 RA
Option 2
Day 1: Olanzapine + dexamethasone + palosetron
Days 2-3: Olanzapine
Option 3
Day 1: NK1 Ra + 5HT-3 RA + Dexamethasone
Days 2-3: Aprepitant (if given po on day 1, if IV ignore) +/- Dexamethasone
only use 1 agent on days 2-3 usually
In patients with LOW emetic risk after IV chemo, what are possible prophylactic treatments?
Dexamethasone
Metoclopramide
Prochloperazine
5-HT3 RA
What is the only prophylaxis for CINV caused by oral chemo agents? (Moderate-high risk of emesis only!)
5-HT3 RA
What are the treatments used in breakthrough CINV?
Approach: +1 agent w different MOA than current prophy regimen
Consider changing prn to scheduled antiemetics
Consider antacid therapy if dyspepsia
Drugs: olanzapine, lorazepam, dronabinol solution, 5-HT3 RA, dexamethasone, compazine, metoclopramide
What are the treatments used in anticipatory CINV?
Lorazepam - if anxiety-related
Avoid strong smells
Acupuncture
Behavioral therapy (relaxation, hypnosis, distraction, yoga, guided imagery)
What are some AEs of dexamethasone? (CINV)
Insomnia (give in AM)
Dyspepsia (take w food)
High BG
HTN
What are the 1st gen 5-HT3 RAs? They are effective in which type(s) of CINV?
Ondansetron, Granisetron
Effective in preventing acute CINV
Short-acting
What is the 2nd gen 5-HT3 RA? It is effective in which type(s) of CINV?
Palosetron
Effective in preventing acute and delayed CINV
Long-acting
What are some AEs of 5-HT3 RAs?
Headache
Constipation
QTc prolongation
Name the 3 NK1 RAs. What agent do they come in combo with?
Aprepitant
Fosaprepitant
Rolaprepitant
combo w palosetron available
Can NK1 RAs be used alone? Why or why not?
No, adjunctive to 5-HT3 RAs or Dexamethasone ONLY!
Augments their activity, has no activity on its own
NK1 RAs are used for ________ only, not _________
Prevention only (of CINV), not treatment!
If given with an NK1 RA, what antiemetic drug needs to be dose decreased and why?
Dexamethasone, since NK1 RAs are potent inhibitors of CYP3A4 and CYP2C9
What are some AEs of NK1 RAs?
Fatigue, GI upset, headache, hiccups
Olanzapine is useful in prevention and breakthrough CNIV. What are some notable AEs?
Sedation! (Antipsychotic, has fall risk in elderly)
High BG
Fatigue
QTc prolongation
Name 3 dopamine antagonists used in CINV. What type of CINV are they used for?
Prochlorperazine
Promethazine
Metoclopramide
Used for breakthrough CINV
What are some notable AEs of the dopamine antagonists used in CINV? Particularly metoclopramide?
Prochlorperazine/Promethazine:
Constipation
Drowsiness
Metoclopramide :
Diarrhea
Drowsiness
QTc prolongation
Tardive dyskinesia
(Avoid use for >12 weeks)
Lorazepam is most useful in what kinds of CINV?
Anticipatory (anxious patients) or breakthrough
Cannabinoids like dronabinol are rarely used in CINV, but when may it be considered? What are some AEs?
May be considered in refractory breakthrough disease
AEs: sedation, hallucination/“high”, palpitations, flushing, cough
Scopolamine is rarely used in CINV, but when may it be considered? What are some AEs?
Only for breakthrough CINV
AEs: anticholinergic (dry, red, mad, etc)
How is cancer treatment induced diarrhea assessed?
Volume + duration of diarrhea
Hydration status
(Fever, othostatsis [dehydration indicator], abdominal pain, weakness)
How many stools per day for CTID grades 1-3? Is a higher or lower grade worse?
Higher grade = worse!
Grade 1: increase of ≤ 3 stools/day from usual
Grade 2: increase of 4-6 stools/day
Grade 3: increase of ≥ 7 stools.day [HOSPITALIZE!]
Grade 4: life-threatening, urgent intervention indicated!
What chemo drug is infamous for causing diarrhea (acute and delayed)? Acute diarrhea from this drug can be controlled by what agent?
Irinotecan
(I run to the can)
Acute diarrhea controlled by atropine
What are two agents that can be used FIRST-LINE to manage CTID (diarrhea)?
Loperimide
Atropine-diphenoxylate
What are 3 agents that can be used to manage REFRACTORY CTID (diarrhea)?
Octreotide
Tincture of opium
Probiotics
(If refractory, make sure to rule out c. Diff and infectious colitis!)
What is the onset of mucositis after chemo? What are 3 effects it has on the body?
Onset: 5-14 days later
Decrease oral intake (from oral ulcers)
Increased infection risk (open sores!)
Increased pain
What is the main difference between mucositis and stomatitis?
Mucositis = ulcers/lesions ANYWHERE in GI (from mouth to anus)
Stomatitis = oral ulcers only 👄
What are the 5 stages of oral mucositis?
Initiation (cellular damage from chemo)
Primary damage response
Signal amplification (increased cytokines)
Ulceration (high infection risk)
Healing
What are some chemo drugs that may cause mucositis?
Melphalan
Cisplatin
Methotrexate
Doxorubicin
Busulfan
5-fluorouracil
What are patient factors that could contribute to mucositis?
Smoking
Poor oral hygiene
Preexisting oral lesions
Female
Nutritional status
Mucositis grading is very similar to CTID grading, in that grade __ is the least harm and grade __ is the most harm
Grade 1 = least harm
Grade 4 = most harm
What are two PREVENTION tactics for chemo-induced mucositis?
Improved oral hygiene
Cryotherapy (hold ice cube in mouth while chemo is infused)
What are some management tactics of current chemo-induced mucositis? (5)
Oral decontamination (dexamethasone mouthwash)
Pain control (lidocaine swish and spit, opioids)
Moisten mouth (artificial saliva, chewing gum)
Nutritional support (liquid diet or TPN)
Oral candidiasis treatment (fluconazole)q
When is primary prevention prophylaxis indicated for febrile neutropenia?
High risk (G-CSF recommended)
Intermediate risk + ≥1 risk factor (consider G-CSF)
Low risk + ≥2 risk factors (may consider G-CSF)
What agents are used for primary prevention prophylaxis of febrile neutropenia? What days can you administer? Are they a daily dose or single dose?
G-CSFs:
Filgrastim (start day 1-4 after chemo) (take DAILY until ANC recovery)
Pegfilgrastim (start day 1-4 after chemo) (single dose)
Eflapegrastim (start 24 hrs after chemo) (single dose)
What are some possible indications for use of filgrastim/pegfilgrastim in existing febrile neutropenia?
Sepsis
Age > 65
ANC < 100 (profound neutropenia)
Duration of neutropenia > 10 days
Pneumonia
Fungal infection
Hx of febrile neutropenia
What are the three TYPES of cancer pain?
Somatic (when tumor invades BONE, MUSCLE, TISSUE)
Visceral (when tumor invades ORGANS, BLOOD VESSELS)
Neuropathic (nerve related pain)
When initiating opioids for cancer-related pain, what dosing do we start with?
PRN IR opioids, titrating up 25-50% every 3-4 hrs
Consider scheduled opioids ER if needed
What kinds of opioids can be used in cancer pain?
Morphine (soln or IR)
Hydromorphone
Oxycodone +/- APAP
Hydrocodone w/ APAP
During chemo, immune-mediated adverse events (autoimmune events) may occur. How do you manage these? (Mild-mod AND severe)?
Mild-moderate: symptomatic management, local therapies. Consider delaying immunotherapies, consider adding corticosteroids
Severe: HOLD immunotherapies. Corticosteroids REQUIRED.
Corticosteroids: prednisone 0.5-2mg/kg/day or MPS 1-2 mg/kg/day
When using steroid supportive care, what should be considered to avoid gastritis/infection/OP?
Gastritis - consider PPIs or H2RAs
Infection - consider PJP or fungal prophy (Bactrim, fluconazole)
OP - supplement vitamin D + calcium for long-term steroids
