Systemic Effects of Chemo Flashcards
1
Q
What is the most common dose-limiting side effect of chemo? Why?
A
- Myelosuppression
- All types of blood cells divide rapidly regardless of development stage and are therefore very vulnerable
2
Q
What chemo agents are likely to cause myelosuppresion?
A
- Because AA’s and nitrosurea’s affect both cycling or non-cycling, they are most likely to destroy bone marrow stem cells
- Antimetabolites, vinca alkaloids and antitumor antibiotics are cell cycle specific and so cause less severe myelosuppresion
- Combination therapies tend to cause more severe suppression
- Anti-angiogenic agents and targeted therapies can also cause a more mild suppression
- High risk in tumor cells of the bone marrow and previous chemo/rad
3
Q
What are colony stimulating factors?
A
- Exogenous type stimulates stem cells in the bone marrow to grow and differentiate into different colonies of blood cells
- In Ca care most often refers to stimulating production of WBC’s, especially neutrophils
4
Q
Why is chemo induced anemia less frequent than neutropenia?
A
- RBC lifespan of 120 days, therefore the marrow has time to recover before the number of circulating RBC’s decreases
- If a stimulating factor (EPO) is given, it is typically after ~4 weeks post treatment, and primary purpose is to avoid transfusion
5
Q
Why does thrombocytopenia occur?
A
- Platelet life span is 7-10 days, and penia usually appears 8-14 days after chemo along with neutropenia
- Chemo may be temporarily stopped if platelets drop below 50,000 to 75,000 cells/mm
6
Q
What stimulating factors are given for chemo induced thrombocytopenia?
A
Interleukin-II (increases stem cell proliferation) and is given until cells >50,000 before next cycle
7
Q
What levels of WBC would chemo be withheld?
A
- WBC between 1000-3000 cells/mm or if absolute neutrophil count (ANC) is less than 1000 to 1500 cells/mm (under 1500 is the official definition for neutropenia)
- Life threatening ANC is <500 cells/mm
8
Q
Why might we not see the standard signs of infection in a patient with neutropenia?
A
- Major function of neutrophils is phagocytosis > invasion of pathogens can increase in frequency in severity while in a neutropenic state, particularly around days 7-10
- Typical signs of infection may be inhibited, making the only sign a fever
- Neutrophils usually cause the overt signs of infection like inflammation and redness
9
Q
What are the advantages of using colony stimulating factors to improve neutrophil counts?
A
- Doesn’t change the rate of decline but it does improve the recovery rate and shortens the duration of neuropenia, reducing risk of mortality and morbidity from infections
- Full doses of chemo can be used
10
Q
How do we manage myelosuppression?
A
- Monitor labs and alter chemo dose/schedule as needed
- Assessment and education for infection prevention and identification of febrile neutropenia
- Avoid dental care and other procedures if able to during periods of neutropenia
- Appropriate hygiene (hand washing, avoid touching face, oral care)
- Safe food handling (maintain appropriate temperatures, wash all foods, avoid food sources with high risk exposure to bacteria like street vendors)
- Colony stimulating factors, particularly for neutropenia (granulate-CSF)
- Monitor VS when indicated (eg. daily temperature)
11
Q
What causes diarrhea in chemo?
A
- causes necrosis of the cells lining the intestinal crypt, causing ++ wall inflammation
- Without crypt cells replacement of GI cells are hampered and the surface for absorption is reduced - therefore imbalance with absorption causes diarrhea
- Diarrhea can cause other problems like lethargy, weakness and electrolyte imbalance; without management can cause malnutrition, dehydration and CV collapse
12
Q
What is the difference between early onset and late onset diarrhea?
A
- Early onset is within 24 hours and late is >24 hours
- Early onset can be managed with atropine; usually cramping, watery eyes, rhinitis and salivation is also present
- Late can be prolonged and lead to potentially fatal dehydration and electrolyte imbalance if not managed
- Must be treated immediately with immodium
13
Q
What are the recommendations for immodium dosages?
A
Two tablets (4 mg) after 1st loose stool, then one tablet (2 mg) q2h until diarrhea free for 12 hours
14
Q
What special considerations must be made for immune-mediated adverse reactions and diarrhea?
A
- imAE’s can cause severe and fatal immune-mediated adverse reactions of the multiple systems, but especially GI (enterocolitis, perforations)
- Permanent d/c of treatment is recommended for severe reactions
- Onset usually occurs during beginning of treatment but may occur months after last dose
15
Q
What are prevention and management techniques for diarrhea?
A
- Encourage monitoring stool quality and frequency (will determine if severe and needs escalation of care to hospital)
- Encourage 10-12 cups fluids/day
- Increase soluble fiber (peeled fruits, bananas, white rice/pasta) and decrease insoluble fiber (skins of fruits and vegs, leafy greens, nuts/seeds)
- Small, frequent meals
- Avoid spicy foods, deep fried/greasy foods, alcohol
- Avoid meds that can cause or worsen diarrhea (eg. laxatives, maxeran) in collab c MRP
- Take immodium
- Protect skin integrity to perianal skin
- Hand hygiene
- If diarrhea not resolving in 24 hours, and/or S&S of fever/infection present, seek urgent care to r/o other causes (eg. cdiff) and to receive appropriate supports (eg. IV fluids, labs, etc.)
16
Q
What chemo drugs cause diarrhea?
A
- Capecitabine
- 5-FU
- Irinotecan
- Leucovorin
- TKI’s
- Checkpoint inhibitors (-mabs) and biotherapy (high dose interferon or interleukin-2)
17
Q
What is acute n/v?
A
- Occurs from a few minutes to 1-2 hours post treatment, resolving within 24 hours
- Primarily mediated by serotonin release
18
Q
What is delayed n/v?
A
- Develops 24 hours post chemo, typically days 2-3 at it’s worst
- If nausea is well controlled within first 24 hours delayed n/v is less likely to occur
19
Q
What is anticipatory n/v?
A
- Usually 12 hours prior
- Conditioned from stimuli associated with chemo, usually after a few sessions and when efforts to control emesis have failed
- Ativan is helpful
20
Q
What causes n/v with chemo?
A
- Emesis is coordinated by the vomiting center in medulla
- VC is rich in neurotransmitter receptors that are sensitive to chemical toxins in the blood and CSF
- Chemo can cause damage to tissues that then release messengers (eg. serotonin) that trigger the VC
21
Q
Which chemo drugs are considered highly emetic?
A
- Carmustine *
- Cisplatin **
- Cyclophosphamide
- Dacarbazine
- Catinomycin and streptozotocin
- Mechlorethamine
22
Q
What ending does anthracycline drugs end in?
A
- Type of antibiotic that tx many types of cancer by damaging Ca DNA cells
- -rubicin
23
Q
How can nausea and vomiting be managed, non-pharm?
A
- Eat small, bland meals served cool (eg. rice, crackers, toast)
- Sip water and other fluids, aim for 8-10 glasses/day
- Oral hygiene
- Restrict fluids with meals
- Try tea/smoothies made with ginger, lemon zest or mint leaves
- Ginger candies or flat ginger ale
- Avoid solid food for 30-60 min after emesis, then slowing start to eat again (CF > dry starchy food > protein rich foods > dairy foods)
- Avoid smoking and alcohol
- Sit upright 30-60 min after meals
- Breath in fresh air (open window or walk)
- If anticipatory, use distraction techniques
- Acupressure
24
Q
What are some pharm management strategies for n/v?
A
- Avoid or d/c meds that cause of worsen n/v (talk c MRP about this)
- Anti-emetics and appropriate scheduling/administration
- allow 30-60 min after anti-emetic before eating
- zofran, dex, maxeran and prochlorperazine common drugs
- If taking highly emetogenic chemo, may be given haldol, nozinan, and gravol suppository
- If nausea/vomiting is decreasing oral intake, weight, and emesis is not resolving or increasing (24 hours), the pt needs urgent care
25
Q
What are cancer related factors that contribute to n/v?
A
- Treatments such as chemo, immunotherapy, radiation and surgery/anesthesia
- Cancer of the GI tract
- Brain mets/increased ICP
- Constipation (bowel obstruction)
- Vestibular dysfunction
- Anxiety
- metabolic changes (hyperglycemia, hypercalcemia, hyponatremia)
- Infections
- Pain/HA
- Gastritis (if n/v present and on immunotherapy, consider an autoimmune reaction that may need immediate attention)
26
Q
What are the risk factors for mucositis? (Referring to inflammation throughout the entire GI tract):
A
- Chemo-induced is believed to be d/t inflammatory events medicated by cytokines, and direct toxic effects on the basal epithelium, connective tissue and condition of oral cavity
- Aggressive regime with more prolonged or repetitive exposures
- More likely in hematologic malignancies compared to solid tumors
- Younger and elderly patients at risk
- Pre-existing oral disease (eg. cavities), poor oral hygiene, and local irritants (eg. poor fitting dentures, smoking/alcohol)
- Infection/inflammation of the gums can increase in bacterial and fungal organisms drastically
- Malnutrition (esp low protein) increase risk of infection
27
Q
What is the potential serious complication from mucositis?
A
- For the oral cavity, it is susceptible to infection esp while in neutropenic states; gram-negative organisms can flourish in the oral cavity and overgrow (eg. oral thrush [candida], herpes simplex virus)
- Mucous in the oral cavity is a first line of defense, so when it is poor it can further contaminate the lungs and GI tract, possibly leading to systemic complications
- Reduced intake ** causing malnutrition and weight loss
- Decreased quality of life
- Pain
- Difficulty talking
- Depression
- Sleep disturbances
- Trouble swallowing (xerostomia)
- d/t risks for nutrition deficits and infection, it can also be a costly complication if hospitalized for tube feeds/TPN
28
Q
What is involved in the assessment of mucositis, specifically oral?
A
- Presence of dentures and if fit is appropriate
- Visual inspection of fall aspects of the oral cavity
- Assess oral habits both before treatment and during
- Assess for risk factors (eg. are they an active smoker)
- Have pt referred to a dental professional for exam before starting tx
- Assess for changes like:
- Bleeding or changes in color (white patches?)
- changes in cleanliness (odor, debris)
- Changes in integrity (ulcers, cracks, lesions, erosions)
- Changes in perception (hoarseness, difficulty swallowing, pain)
- Taste ability
29
Q
What are interventions for mucositis, specifically oral?
A
- Good oral care, including proper tooth brushing (soft brush), flossing, and rinsing oral cavity
- If unable to tolerate a brush, can use sponges or gauze
- Oral rinse 4x a day with water-baking sosa
- Moisturize lips with water-based products
- Smoking cessation
- Avoid alcohol and foods/liquids that are spicy, acidic, rough or hot)
- Try to maintain adequate fluid intake to keep mucous membranes moist
- Sugarless candies for xerostomia
- Education re: how to assess the oral cavity and what changes to report
30
Q
What are some integumentary changes that can occur with Ca treatment?
A
- All chemo agents have a tendency to cause some type of skin reaction and often affect QOL and can cause non-adherence to treatment
- Hyperpigmentation
- Dryness
- Nail changes
- Erythema, rash, hand-foot syndrome (can cause loss of fingerprints) **
- Pruritus
- Photosensivity
- Alopecia
31
Q
What are some interventions for integumentary changes?
A
- To prevent PPE, avoid pressure like tight-fighting clothing and to avoid excessive heat around time of tx
- Antihistamine therapy for pruritus
- Skin care and comfort for pruritus - medicated baths, anesethetic creams, steroid creams, and emollient creams
- Soaps for sensitive skin
- Avoid use of perfumes, cosmetics and deodorants for + sensitive and itchy skin
- Keep room humid and the temperature cool
- Gentle methods of itching - using a soft cloth
- Educate re: sun exposure and sun safety (have a SPF of at least 30, but higher amounts might be irritating)
- For irritated nail-beds, wear loose-fitting shoes and do good nail care hygiene
- Educate re: skin self-assessments
- Promote adequate hydration/nutrition
- Avoid exposure to hot water
- Gently pat skin dry
32
Q
How do we assess integ changes?
A
- Assess all aspects of face, torso, extremities, scalp, areas of pressure/friction
- Color - erythema (patchy or uniform), change in pigmentation
- Thickening (esp of soles and hands)
- Moisture
- Integrity (any peeling, rashes, ulcers or blisters)
- Desquamation/bleeding
- Swelling
- Sensory changes
- Assess timing of onset
- Assess for pain, infection, bleeding and if altered integrity may need wound care/dressings
- Take into consideration conditions that can affect skin care (eg. DM)
33
Q
What classifications of chemo drugs are responsible for alopecia?
A
- Antimetabolites
- AA’s (cyclophosphamide)
- Anthracycline antibiotics
- Vinka alkaloids, taxanes (paclitaxel)
