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Crit Care, Oncology & Hematology > Supportive Care In Oncology > Flashcards

Supportive Care In Oncology Flashcards

1
Q

What are the 5 classes of chemo-induced N/V? Define each

A

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

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2
Q

What are the 3 receptor targets for CINV?

A

5-HT3 receptors
NK-1 receptors
Dopamine receptors

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3
Q

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

A = GI
B = acute
C = CNS
D = delayed

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4
Q

What are some risk factors of CINV?

A

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]

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5
Q

In patients with HIGH emetic risk after IV chemo, what is the prophylactic course over 4 days?

A

Day 1: olanzapine + dexamethasone + NK1 RA + 5-HT3 RA
Days 2-4: olanzapine + dexamethasone + aprepitant (NK1 RA) if used po on day 1

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6
Q

In patients with MODERATE emetic risk after IV chemo, what is the prophylactic course over 3 days? (3 options, just recognize)

A

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

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7
Q

In patients with LOW emetic risk after IV chemo, what are possible prophylactic treatments?

A

Dexamethasone
Metoclopramide
Prochloperazine
5-HT3 RA

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8
Q

What is the only prophylaxis for CINV caused by oral chemo agents? (Moderate-high risk of emesis only!)

A

5-HT3 RA

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9
Q

What are the treatments used in breakthrough CINV?

A

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

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10
Q

What are the treatments used in anticipatory CINV?

A

Lorazepam - if anxiety-related
Avoid strong smells
Acupuncture
Behavioral therapy (relaxation, hypnosis, distraction, yoga, guided imagery)

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11
Q

What are some AEs of dexamethasone? (CINV)

A

Insomnia (give in AM)
Dyspepsia (take w food)
High BG
HTN

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12
Q

What are the 1st gen 5-HT3 RAs? They are effective in which type(s) of CINV?

A

Ondansetron, Granisetron
Effective in preventing acute CINV
Short-acting

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13
Q

What is the 2nd gen 5-HT3 RA? It is effective in which type(s) of CINV?

A

Palosetron
Effective in preventing acute and delayed CINV
Long-acting

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14
Q

What are some AEs of 5-HT3 RAs?

A

Headache
Constipation
QTc prolongation

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15
Q

Name the 3 NK1 RAs. What agent do they come in combo with?

A

Aprepitant
Fosaprepitant
Rolaprepitant

combo w palosetron available

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16
Q

Can NK1 RAs be used alone? Why or why not?

A

No, adjunctive to 5-HT3 RAs or Dexamethasone ONLY!
Augments their activity, has no activity on its own

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17
Q

NK1 RAs are used for ________ only, not _________

A

Prevention only (of CINV), not treatment!

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18
Q

If given with an NK1 RA, what antiemetic drug needs to be dose decreased and why?

A

Dexamethasone, since NK1 RAs are potent inhibitors of CYP3A4 and CYP2C9

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19
Q

What are some AEs of NK1 RAs?

A

Fatigue, GI upset, headache, hiccups

20
Q

Olanzapine is useful in prevention and breakthrough CNIV. What are some notable AEs?

A

Sedation! (Antipsychotic, has fall risk in elderly)
High BG
Fatigue
QTc prolongation

21
Q

Name 3 dopamine antagonists used in CINV. What type of CINV are they used for?

A

Prochlorperazine
Promethazine
Metoclopramide

Used for breakthrough CINV

22
Q

What are some notable AEs of the dopamine antagonists used in CINV? Particularly metoclopramide?

A

Prochlorperazine/Promethazine:
Constipation
Drowsiness

Metoclopramide :
Diarrhea
Drowsiness
QTc prolongation
Tardive dyskinesia
(Avoid use for >12 weeks)

23
Q

Lorazepam is most useful in what kinds of CINV?

A

Anticipatory (anxious patients) or breakthrough

24
Q

Cannabinoids like dronabinol are rarely used in CINV, but when may it be considered? What are some AEs?

A

May be considered in refractory breakthrough disease
AEs: sedation, hallucination/“high”, palpitations, flushing, cough

25
Q

Scopolamine is rarely used in CINV, but when may it be considered? What are some AEs?

A

Only for breakthrough CINV

AEs: anticholinergic (dry, red, mad, etc)

26
Q

How is cancer treatment induced diarrhea assessed?

A

Volume + duration of diarrhea
Hydration status
(Fever, othostatsis [dehydration indicator], abdominal pain, weakness)

27
Q

How many stools per day for CTID grades 1-3? Is a higher or lower grade worse?

A

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!

28
Q

What chemo drug is infamous for causing diarrhea (acute and delayed)? Acute diarrhea from this drug can be controlled by what agent?

A

Irinotecan
(I run to the can)
Acute diarrhea controlled by atropine

29
Q

What are two agents that can be used FIRST-LINE to manage CTID (diarrhea)?

A

Loperimide
Atropine-diphenoxylate

30
Q

What are 3 agents that can be used to manage REFRACTORY CTID (diarrhea)?

A

Octreotide
Tincture of opium
Probiotics
(If refractory, make sure to rule out c. Diff and infectious colitis!)

31
Q

What is the onset of mucositis after chemo? What are 3 effects it has on the body?

A

Onset: 5-14 days later

Decrease oral intake (from oral ulcers)
Increased infection risk (open sores!)
Increased pain

32
Q

What is the main difference between mucositis and stomatitis?

A

Mucositis = ulcers/lesions ANYWHERE in GI (from mouth to anus)
Stomatitis = oral ulcers only 👄

33
Q

What are the 5 stages of oral mucositis?

A

Initiation (cellular damage from chemo)
Primary damage response
Signal amplification (increased cytokines)
Ulceration (high infection risk)
Healing

34
Q

What are some chemo drugs that may cause mucositis?

A

Melphalan
Cisplatin
Methotrexate
Doxorubicin
Busulfan
5-fluorouracil

35
Q

What are patient factors that could contribute to mucositis?

A

Smoking
Poor oral hygiene
Preexisting oral lesions
Female
Nutritional status

36
Q

Mucositis grading is very similar to CTID grading, in that grade __ is the least harm and grade __ is the most harm

A

Grade 1 = least harm
Grade 4 = most harm

37
Q

What are two PREVENTION tactics for chemo-induced mucositis?

A

Improved oral hygiene
Cryotherapy (hold ice cube in mouth while chemo is infused)

38
Q

What are some management tactics of current chemo-induced mucositis? (5)

A

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

39
Q

When is primary prevention prophylaxis indicated for febrile neutropenia?

A

High risk (G-CSF recommended)
Intermediate risk + ≥1 risk factor (consider G-CSF)
Low risk + ≥2 risk factors (may consider G-CSF)

40
Q

What agents are used for primary prevention prophylaxis of febrile neutropenia? What days can you administer? Are they a daily dose or single dose?

A

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)

41
Q

What are some possible indications for use of filgrastim/pegfilgrastim in existing febrile neutropenia?

A

Sepsis
Age > 65
ANC < 100 (profound neutropenia)
Duration of neutropenia > 10 days
Pneumonia
Fungal infection
Hx of febrile neutropenia

42
Q

What are the three TYPES of cancer pain?

A

Somatic (when tumor invades BONE, MUSCLE, TISSUE)
Visceral (when tumor invades ORGANS, BLOOD VESSELS)
Neuropathic (nerve related pain)

43
Q

When initiating opioids for cancer-related pain, what dosing do we start with?

A

PRN IR opioids, titrating up 25-50% every 3-4 hrs
Consider scheduled opioids ER if needed

44
Q

What kinds of opioids can be used in cancer pain?

A

Morphine (soln or IR)
Hydromorphone
Oxycodone +/- APAP
Hydrocodone w/ APAP

45
Q

During chemo, immune-mediated adverse events (autoimmune events) may occur. How do you manage these? (Mild-mod AND severe)?

A

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

46
Q

When using steroid supportive care, what should be considered to avoid gastritis/infection/OP?

A

Gastritis - consider PPIs or H2RAs
Infection - consider PJP or fungal prophy (Bactrim, fluconazole)
OP - supplement vitamin D + calcium for long-term steroids

Crit Care, Oncology & Hematology (18 decks)

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