supportive care: mucositis, hypercalcemia of malignancy, extravastion

Question 1

risk factors for mucositis

Answer 1

patient factors: smoking, baseline oral hygiene, younger age, female sex, pretreatment nutritional status

disease factors: head/neck cancer, treatment plan (chemo vs radiation), duration of treatment, dose of therapy, frequency of therapy

Question 2

OLD chemo that promotes mucositis

Answer 2

antimetabolites: 5FU, MTX
anthracyclines: doxorubicin
platins: cisplatin, carboplatin
taxanes: docetaxel, paclitaxel
alkylating agents: cyclophosphamide
irinotecan

Question 3

NEW chemo that promotes mucositis

Answer 3

mTOR inhibitors: everolimus
EGFR inhibitors: cetuximab
TKIs: afatinib
multi kinase inhibitors: sunitinib
CTLA-4: ipilimumab

Question 4

how to prevent mucositis

Answer 4

prophylactic oral care
professional dental assessment if high risk
cryotherapy
mucoadhesive hydrogel rinses (MuGard)
supersaturated calcium phosphate rinses (BioSal)
AVOID PRODUCTS WITH ALCOHOL

Question 5

Algorithm for treating mucositis with increasing symptom burden

Answer 5

bland rinses (NS, baking soda)
2% lidocaine swish and spit
diet modification
2% morphine swish and spit
systemic opioids

Question 6

targeted agents that can be used for mucositis

Answer 6

dexamethasone mouthwash for everolimus
systemic steroids for refractory mTOR inhibitor mucositis

Question 7

define irritant

Answer 7

ability to cause transient burning, pain, redness

Question 8

define vesicant-like

Answer 8

usually categorized as irritant but has potential to cause localized blistering and necrosis

Question 9

define vesicant

Answer 9

capable of causing edema, pain, erythema, tissue ischemia, blister/vesicle formation

Question 10

signs and symptoms of extravasation injury

Answer 10

symptoms: tingling, burning, discomfort, pain
signs: swelling, redness/blanching, absence of blood return, resistance during IV bolus admin

Question 11

treatment steps for extravasation

Answer 11

stop and disconnect infusion, leave needle in place
identify extravasated drug
attempt to gently aspirate as much extravasated drug as possible; avoid manual pressure over area as needle is removed
draw an outline around injury area
notify prescriber and start treatment specific measures ASAP
elevate affected limb and administer analgesia if needed

Question 12

what are the 2 specific methods for extravasation

Answer 12

localize and neutralize
disperse and dilute

Question 13

describe what to do for localize and neutralize

Answer 13

cold compress (Vasoconstriction)
antidote: dexrazoxane, DMSO, sodium thiosulfate

Question 14

describe what to do for disperse and dilute

Answer 14

warm compress (vasodilation)
diluting agent: hyaluronidase

Question 15

patient specific risk factors for extravasation

Answer 15

circulatory issues (PVD, Raynaud’s, fragile vein)
obesity
multiple venipunctures
impaired communication (dementia, aphasia)

Question 16

iatrogenic risk factors for extravasation

Answer 16

inexperience
multiple cannulation attempts
unsuitable access site
infusion pump use
prolonged infusion

Question 17

contributing medications to hypercalcemia of malignancy

Answer 17

calcium supplements, TPN
HCTZ/chlorthalidone
lithium
vitamin D
sedatives/hypnotics
opioids

Question 18

contributing disease states to hypercalcemia of malignancy

Answer 18

renal impairment

Question 19

what is the first line treatment for hypercalcemia of malignancy

Answer 19

aggressive hydration to dilute serum calcium and increase its excretion.

0.9% sodium chloride, plasmalyte, or LR
1 L bolus followed by 150-200 mL/hr infusion

Question 20

when may antiresorptive therapies such as bisphosphonates or RANKL inhibitor be used for hypercalcemia of malignancy

Answer 20

for moderate or severe HCM

Question 21

when may calcitonin be used for hypercalcemia of malignancy

Answer 21

severe HCM

Question 22

onset/duration of bisphosphonates

Answer 22

onset 2-3 days
duration 1-4 weeks
can repeat dose in 7 days if poor response

Question 23

which bisphosphonates are used for HCM

Answer 23

pamidronate, zoledronic acid (preferred bc better response)

Question 24

monitoring for bisphosphonates

Answer 24

SCr (can cause ATN)
Ca level (May need to start Ca and Vit D for hypocalcemia)

Question 25

contraindications for bisphosphonates

Answer 25

Z: SCr>4.5
P: SCr>3 or CrCL<30

Question 26

when is denosumab (prolia) suggested in the guidelines

Answer 26

instead of bisphosphonate for moderate-severe HCM (low LOE)

Question 27

onset/duration of prolia

Answer 27

onset 10 days, duration 3 months

Question 28

monitoring for prolia

Answer 28

Ca (boxed warning, need calcium and vitamin d supplementation)

Question 29

onset/duration of calcitonin

Answer 29

onset 2 hours, duration 48-72 hrs (tachyphylaxis)

Question 30

monitoring for calcitonin

Answer 30

serum calcium, stop date