Therapeutics Exam 2 (Weddle/Scott) Flashcards
Etiology of N/V: GI Disorders (like a bunch) CNS Disorders (\_\_\_\_\_\_,\_\_\_\_\_\_\_,\_\_\_\_\_\_) Pain (acute or chronic) Pregnancy GI intake (excessive intake of \_\_\_\_\_ or\_\_\_\_\_)
CNS: anxiety, tumors, Headaches/migraines
Intake: intake of food or alcohol
Etiology of N/V: Pregnancy --- 80% of pregnant women begins \_\_\_\_th - \_\_\_\_th week after last menstrual period usually resolves by \_\_\_th week
4th - 7th;
20th week
what is hyperemesis gravidarum
continue to have issues with N/V and so much that the mom starts to lose weight (baby is at risk)
What are some treatment induced causes of nausea and vomiting \_\_\_\_\_ agents \_\_\_\_\_ therapy \_\_\_\_\_\_ \_\_\_\_\_\_ NV associated with \_\_\_\_\_\_\_
ANP agents (anti-neoplastic) Radiation therapy opioids anesthesia assoc. with procedures
Complications of N/V
PATIENT DISCOMFORT
dehydration
malnutrition
aspiration pneumonia (puke in the lungs –> infection)
Anxiety (anticipatory NV)
Compromise therapy (decrease chemo bc NV so bad)
DECREASED QOL
Ways to Assess N/V
of episodes
onset
duration
severity of nausea (like pain scale: 0 - 10)
what are the 4 inputs/influences of the vomiting center
coretx
CTZ/dorsal vagal complex
GI
Vestibular (motion!)
Diseases that can cause N/V? (5?)
Metabolic disease neurologic disease GI disease genitourinary related to pregnancy
Pathophys of N/V
site of drug actions?
dopamine receptors histamine receptors muscarinic receptors serotonin receptors neurokinin receptors
Non-PCOL management of N/V
determine cause and put the gut to rest (clear liquids and IV hydration) dietary physical
what are the dietary PCOL therapy options for N/V
avoid fatty, spicy, fried, sweet foods
odors could wreck them
what are some physical PCOL therapy options for N/V
fresh air avoid sudden movements dim lights acupressure 3 fingers above the wrist
drug therapy for N/V
what drugs are antihistamines/anticholinergics
meclizine
dimenhydramine
scopolamine
MOA of antihistamines/anticholinergics
blocking histamine and muscarinic receptors in CTZ and vomiting center
drug therapy for N/V
what drugs are phenothiazines
prochlorperazine
promethazine
chlorpromazine
drug therapy for N/V
what drugs are serotonin antagonists
"-setrons" ondansetron granisetron palonosetron dolasetron
ADEs of meclizine, dimenhydramine, scopolamine
antihistamines/anticholinergics
cause drowsiness and sedation and dry mouth and constipation and blurred vision and confusion
ADEs of ondansetron and other “-setrons”
are serotonin antagonists
mild HA, dizziness, fatigue, constipation, QT prolongation
MOA of phenothiazines
dopamine inhibition at CTZ
ADEs of promethazine, chlorpromazine, prochrorperazine
dizziness, sedation, dry mouth, hypotension, EPS!!!!
what serotonin antagonist has a long ass half life (40 hours)
palonosetron
what serotonin antagonists are super pricey vs which ones are cheap boys
cheap: ondansetron, granisteron
pricey: dolasteron, palonosetron
which serotonin antagonist has NO oral dosage form
palonosetron
biggest disadvantage with serotonin antagoinsts
no suppositories!!
what are the more odd types of serotonin antagonists dosage forms
sancuso (granisetron) - PATCH
Sustol (granisertron) ER injection
what drugs are butryophenones
haloperidol and droperidol
not used for N/V a lot
biggest ADEs of haloperidol and droperidol
EPS and QT prolongation!!
will also see sedation and hypotension
what is the MOA of olanzapine
blocks D2, 5-HT2C, and 5-HT3 receptors
main side effect of olanzapine
sedation
what drugs are neurokinin antagonists
“-pitants”
aprepitant
fosaprepitant
rolapitant
ADEs of aprepitant, fosaprepitant, rolapitant?
neurokinin 1 antagonists
fatigue, HICCUPS, constipation, decrease appetite
Neurokinin antagonists are indicated for what kind of nausea and is not indicated for?
indicated for BOTH acute and delayed
not indicated as monotherapy
*rolapitant is indicated only for delayed though
Sancuse (granisetron) patch:
apply when?
may be worn for how long?
avoid _____ to site for up to 10 days
apply 24 - 48 hours BEFORE chemo
wear for up to 7 days
avoid sun exposure to site!
dosing schedule for aprepitant
oral agent:
one dose on day 1; and
then doses on days 2 and 3
dosing schedule for fosaprepitant
one dose IV on day 1
dosing schedule for rolapitant
one dose 1 -2 hours prior to chemo
benzos are especially helpful for what kind of NV
anticipatory
MOA of metoclopramide?
dopamine inhibition and serotonin inhibition (at high doses!)
ADEs of metoclopramide
EPS!! drowsiness, sedation, diarrhea, restlessness, agitatin
how to prevent EPS?
benadryl
what s the hardest NV to treat?
delayed
Factors affecting CINV:
Females or males are more susceptible?
Females
Factors affecting CINV:
EtOH intake effect?
pts with chronic EtOH intake will have less N/V
Factors affecting CINV:
prior chemo?
if NV was not controlled well before — they will have increase NV risk
Factors affecting CINV:
personality?
anxious personality
Factors affecting CINV:
predisposed NV?
if previous motion sickness….
what chemo agent has high risk of single IV ANPs
cisplatin
For preventing acute CINV:
always treat when risk is _______
always use ____ therapy whenever possible
mod to high risk
PO therapy — it is cheaper
Dosing time if IV or oral in relation to ANP admin?
if IV - give 30 mins before
if PO - give 60 mins before
if high emetic risk: use how many drugs and what classes (per Scott)
4 drugs.... 5-ht3 antagonist NK 1 receptor antag Dexamethasone olanzapine
if moderate emetic risk: use how many drugs and what classes (per Scott)
2 or 3 drugs
5-ht3 antagonist
NK 1 receptor antag
Dexamethasone
or
5-ht3 antagonist (on day 1)
Dexamethasone (on day 1)
Treating motion sickness:
_______ is key
prevention
what are the three main options for treating motion sickness
Scopolamine
Dimenhydrinate
Meclizine
the scopolamine patch for motion sickness should be applied about _____ hours before and will last for _____ hours
24 hours before
last 72 hours
Take dimenhydrinate needs to be taken _____ before needed
30 - 60 mins
Take Meclizine needs to be taken _____ before needed
30 - 60 minutes
how long will meclizine last
4 hours
how to prevent low emetic risk CINV
single dose of
dexamethasone 8 mg PO
or
5-HT3 antag
how to prevent CINV with minimal emetic risk drugs
do not do a routine anti emetic therapy – just do PRN
CINV:
complications?
dehydration
electrolyte abnormalities (low K+)
fatigue
depression
CINV:
Acute vs Delayed N/V? (time frame)
acute < 24 hours of getting chemo
delayed > 24 hrs after getting chemo
CINV - Pathophys:
______ cells lining the GI tract contain large stores of ______ and is released in massive quantities after chemo
enterochromaffin; stores of serotonin
CINV - Pathophys:
when serotonin gets to the ______ it stimulates the ______ center
chemoreceptor trigger zone (CTZ);
vomiting center
what are the main neurotransmitters implicated in CINV?
dopamine, histamine, acetylcholine, serotonin, substance P
what neurotransmitters are not MAJOR targets for CINV but reserved more for refractory or breakthrough
histamine and acetylcholine
Combo chemo and CINV:
Levels ____ do not contribute to the emetogenicity of the combo
1 and 2 (minimal and low)
Combo chemo and CINV:
adding levels ______increases the level of emetogenicity by ____ level
levels 3 and 4 (moderately)
increase by 1 level
Common toxicities of CINV drugs:
Serotonin antagonists
HA
asymptomatic/transient EKG changes - QT
constipation
increased transaminases
Common toxicities of CINV drugs:
Corticosteroids
short term: anxiety, euphoria, insomnia, hyperglycemia, increased appetite
Common toxicities of CINV drugs:
Substance P antagonists
hiccups
DRUG INTERACTIONS
Common toxicities of CINV drugs:
dopamine antagonists
EPS, diarrhea, sedation
Common toxicities of CINV drugs:
phenothiazines
sedation
akathisia
dystonia
Common toxicities of CINV drugs:
cannabinoids
drowsiness dizziness euphoria - mood changes hallucinations increased appetite
what drugs can be used for breakthrough N/V (weddle)
Lorazepam Dronabinol/Nailone serotonin antagonists (dolas,granis, ondans) dexamethasone scopolamine haloperidol/metoclopramide olanzapine prochlorperazine/promethazine
drugs for delayed N/V (weddle)
Dexamethasone Aprepitant Metoclopramide lorazepam diphenhydramine
actions to do for anticipatory N/V
prevention
behavioral
alprazolam/lorazepam
what are some behavioral actions for anticipatory NV
relaxation
hypnosis/guided imagery
music therapy
acupuncture/acupressure
Mucositis:
can affect what part of the body?
entire length of the GI tract from top to bottom
Mucositis course parallels the _______
neutrophil nadir
Mucositis begins ~ on days ______ after ____
5 - 7; after chemo (max at 10 - 14 days…)
Mucositis will improve as __________ increases
neutrophil count
Risk factors for Mucositis?
pre-existing oral lesions
poor dental hygiene/ill fitting dentures
pts getting chemo and radiation
Diet recommendations of Mucositis?
Avoid rough foods: salt, spicy, acidic
eat soft or liquids foods
AVOIDING smoking and alcohol
General Mouth Care Strategies?
salt/soda rinses BID - QID
soft bristled toothbrush
saliva substitute for radiation induced xerostomia
Main ways to manage the pain of Mucositis?
topical anesthetics (marys magic -lidocaine/antacids..)
Oral cyrotherapy (ice chips!)
Sucralfate (soothing and coating agent)
oral or parenteral opioid analgesics
Neutropenia?
low WBCs (<0.5 x 10^9)
if WBCs are low - pts are at risk of what?
infections
if pt has thrombocytopenia - they are at risk of?
have low platelets therefore risk of bleeding!
if pt has low RBCS - the patient is at risk for?
hypoxia and fatigue and anemiaaaa
normal ranges of WBCs/platelets/RBCs?
WBC: 4.8 - 10.8 x10^9/L
Platelets: 140 - 400 x10^9/L
RBCs: 4.6 - 6.2 x10^6/uL
definition of Nadir?
the lowest value of blood counts fall to during a cycle of chemotherapy
(lowest ANC = absolute neutrophil count)
ANC = ? (what eq’n)
WBC x % granulocytes (segs +bands)
To give a pt chemo their levels must be what?
WBC:
OR
ANC and Platelet?
WBC: > 3 x10^9/L (WBC > “3000(
ANC > 1.5 x10^9/L AND Platelet > 100
ANC > 1500; Platelet > 100,000
Severe neutropenia defined as?
<0.5 x 10^9/L
Febrile Neutropenia defined as?
ANC < 0.5 x10^9/L
AND a single oral temp > 101 F or >100.4 for at least an hour
CSFs (colony stimulating factors) used prophylactic following chemo has demonstrated what benefits?
decreased incidence of febrile neutropenia
decreased length of hospitalization
decreased confirmed infections
decreased duration of abx
who should be treated with CSFs because of primary prophylaxis of febrile neutropenia
high risk pts!
those pts would be preexisting neutropenia due to disease
extensive prior chemo
previous irradiation to the pelvis/areas containing large amounts of bone
should you treat febrile neutropenia with CSFs?
Nooooo.only do it if they are very sick
Other uses for CSFs:
support pts getting ______ chemo
after a ______ transplant to reduce duration of severe neutropenia
dose dense chemo!!!
use after stem cell transplant!
Other uses for CSFs:
used alone or in combo, after chemo, with plerixafor to mobilize ____________
peripheral blood progenitor cells
what drugs are CSF
Filgrastim
Pegfilgrastim
Sargramostim
Filgrastimvs Pegfilgrasim:
which one has a longer 1/2 life
pegfilgrastim
Filgrastimvs Pegfilgrasim:
which one is 3 -5 days of doses and which one is 1 day
3-5 days: filgrastim
pegfilgrastim: 1 dose
Pegfilgrastim PK?
non -linear PK;
clearance increases w/ increasing neutrophil count
what is Neuplasta?
an on body injector that gives CSF’s the day after chemo
dosing of Filgrastimvs Pegfilgrasim:
Filgrastim WT BASED!!! booo
peg: 6 mg SQ x 1 dose
Filgrastim Dosing:
dosing conundrum?
vials come in only 300 or 480 mcg single vials
round to nearest vial size!!!
ADEs of filgrastim
flu-like sxs
bone and joint pain (give loratadine — histamine release based pain)
DVT
rare: spleen enlargement
Thrombocytopenia:
do not treat until the platelet count is below _____
<20 x10^9/L;
<10 x 10^9/L`
how is thrombocytopenia treated?
typically transfusions
but can also use oprelvekin (interleukin 11) — not used tho
General causes of anemia?
decreased RBC production (cancer therapy/tumor infiltration into bone marrow)
decrease EPO production
Decrease body stores of vit. B12, iron, folic acid
blood loss
Chemotherapy and Anemia:
pts with a Hgb < _____ or a drop > than ______ from baseline should undergo a work up
< 11
> 2
Chemotherapy and Anemia:
if a pt is symptomatic – do what?
transfuse as indicated
consider use of ESA
perform iron studies
Black box warnings of ESA?
short overall survival if the target Hgb is > 12
typically ESAs are not recommended but who would you consider it with?
if pt and CKD
if pt going under palliative chemo (aka like metastatic??)
pt w/out other identifiable causes
Chemotherapy and Anemia:
ESA vs transfusion
which one has faster onset
transfusion
what drugs are ESAs
Epoetin
darbepoetin
Epoetin vs darbepoetin:
which one has a longer half life
darbepoetin
Epoetin: typically given every ______
Darbepoetin: typically given every ______
E: every week (once a week)
D: every 3 weeks
to give an ESA: must do an _____ study
iron
ESAs won’t do shit if there is no iron present
iron absorption will DECREASE if food is eaten ____ hours before or _____ hours after ingestion
2 hours before
1 hour after ingestion
which IV iron has a required test dose
iron dextran
Classic Chemo Toxicities:
if they get myalgias/arthralgias - what to treat it with?
NSAIDs
Pts may require opioids
Classic Chemo Toxicities:
if they get hemorrhagic cystitis- what to treat it with?
MESNA!! (used to prevent)
Hydration (prevention)
Classic Chemo Toxicities:
if they get heart failure - what to treat it with?
monitor for cumulative dose
assess for risk factors
DEXRAZOXANE (chemoprotectant – more for anthracyclines)
Classic Chemo Toxicities:
if they get peripheral neuropathy - what to treat it with?
change infusion rates
adjunctive pain medications
Classic Chemo Toxicities:
if they get pulmonary toxicites- what to treat it with?
corticoidsteroids (no good tx once it happens :( )
Type I Chemo Related CARDIAC Dysfunction: ACUTE is seen with the \_\_\_\_\_\_ drug class is like a \_\_\_\_\_\_ not common occurs \_\_\_\_\_\_\_after a dose rarely is \_\_\_\_\_\_\_ observed
seen w/ anthracyclines
like a MI
occurs immediately after a dose
rarely is pericarditis/CHF seen
Type I Chemo Related CARDIAC Dysfunction: CHRONIC onset usually seen when? IS common related to \_\_\_\_\_ dose (reversible or irreversible?)
with a year of getting anthracycline therapy
cumulative
IRREVERSIBLE
Type I Chemo Related CARDIAC Dysfunction:
LATE ONSET
occurs more often in who?
seen more in childhood/adolescence cancer survivors who received anthracyclines
Type II Chemo Related CARDIAC Dysfunction:
is seen with that drug class?
HER 2 targeted therapies
ex: trastuzumab
Type II Chemo Related CARDIAC Dysfunction:
reversible or irreversible
reversible
Type II Chemo Related CARDIAC Dysfunction:
how to treat?
stop the HER2 target drug – give CHF drugs — restart HER2 drug and keep on CHF drugs!!
Classic Chemo Toxicities:
what drugs would cause myalgia/arthralgias (weddle - from table)
paclitaxel/docetaxel
anastrozole/eltrozole
exemestane
Classic Chemo Toxicities:
what drugs would cause hemorrhagic cystitis
(weddle - from table)
high dose cyclophosphamide
ifosfamide
Classic Chemo Toxicities:
what drugs can cause heart failure
(weddle - from table)
antracycylines
high dose corticosteroids
trastuzumab
Classic Chemo Toxicities:
what drugs can cause peripheral neuropathy
(weddle - from table)
taxanes
vinca alkaloids
(microtubule boys)
Classic Chemo Toxicities:
what drugs can cause pulmonary toxicity
(weddle - from table)
bleomycin
Breast Cancer Epidemiology:
Risk of breast cancer ______ with age
increases
Breast Cancer Epidemiology:
decreased in _______ therapy has contributed to the decrease in mortality based on results from the WHI
decrease HRT (hormonal replacement therapy)
Breast Cancer Risk Factors:
more than ____% of pts will NOT have any risk factors
60%
Breast Cancer Risk Factors:
family history?
of 1st and 2nd degree relatives with disease has increased risk
Breast Cancer Risk Factors:
estrogen?
endogenous exposure (aka early menstrual cycle start or late menopause)
or exogenous estrogen (oral contraceptives/HRT)
Breast Cancer Risk Factors:
Personal history of cancer or radiation are risk factors
usually what are the causes for radiation exposure?
prior tx for lymphoma w/ mediastinal?? or environmental radiation exposure
Breast Cancer Risk Factors:
_____ because mechanism thought to be due to decreased hepatic metab of estrogen
alcohol
Breast Cancer Risk Factors:
prior breast biopsies w/ __________
proliferative histology
atypical hyperplasia, fibroadenomas, previous breast cancer
Breast Cancer Risk Factors:
risk factor related to children?
if nulliparity (no kids) or if first childbirth is after 30 yrs = increased risk
Breast Cancer Risk Factors:
related to height and weight?
if increased height and weight
Breast Cancer Risk Factors:
diet?
asian based diet = less risk
Breast Cancer Genetics:
only a small part (5-10%) of breast cancers are familial but when the _____ gene has a mutation then there is a laaarge increased risk
BRCA1 or 2 gene (a tumor suppressor gene)
the _____ risk model is a risk assessment tool to determine ______ in % of developing breast cancer compared to an age matched control
GAIL risk;
RR (relative risk)
Breast cancer screening:
______ exams have been removed from the screening guidelines
*but _____ is exam is considered an important discussion w/ women starting age 20
breast self exams and clinical breast exams
women should know what is normal and what is not
Breast cancer screening: ACS recommendations for a mammogram
40 - 44 y.o: opportunity for annual exams
45 - 54 y.o: annual mammograms
> 55: every other year mammograms or the opportunity for annual exams (if good health and > 10 years life expectancy)
Breast Cancer Prvention:
High risk patients (ex: with ______ mutations) may get risk reduction surgeries
what are these risk reduction surgeries
BRCA mutations
prophylactic mastectomy; bilateral oophorectomy
The breast cancer risk reduction surgeries — are they 100% effective??
hell nah,
buut mastectomy can reduce risk by like 90% and oophorectomy can decrease risk by like 50%
what 3 drugs have been studied for prevention of breast cancer
tamoxifen (P1 trial)
raloxifene (MORE trial/P2 (aka STARtrial))
exemestane
The trial (P1) finding out if tamoxifen was effective in reducing breast cancer risk showed what positive or negative events
positive: decreased risk in invasive/noninvasive breast cancer!! AND decreased skeletal events
negative: increased endometrial cancer; increased stroke/PE/DVT
STAR trial P2 trial demonstrated that _______ was as effective in ______ in decreasing breast cancer reduction
raloxifene is as effective as tamoxifen in breast cancer reduction
Pros and Cons of raloxifene (compared to tamoxifen)
Pros: fewer uterine cancers and fewer blood clots
cons: there was an increased risk of non-invasive cancers compared to tamoxifen????
AIs (aromatase inhibitors) are they effective in reduction and are they reasonable options for breast cancer prevention in post menopausal
yes – seen to be effective
but not currently FDA approved for PREVENTION
may be used in high risk pts
breast is composed of what things?
ducts, lobules, fatty tissue, connective tissue, and lymph nodes!
(lots of lymph nodes aka lots of opportunities of where it can spread)
two main kinds of breast cancer
Invasive and non invasive (in situ) carcinoma
Invasive breast cancer has invaded beyond the _______ of the ____ or _____
beyond basement membrane
of duct or lobule
subtypes of invasive breast cancer
IDC and ILC
IDC = invasive ductal carcinoma
ILC = invasive lobular carcinoma
subtypes of non-invasive breast cancer
DCIS and LCIS
DCIS: ductal carcinoma in situ
LCIS: lobular carcinoma in situ
most common two types of breast cancer?
IDC and ILC!!
IDC ~ 750%
ILC ~ 15%
DCIS: seen as _______ in a mammogram
microcalcifications
there is invasive and non-invasive breast cancer – what is the 3rd type?
inflammatory
inflammatory breast cancer:
______ form of breast cancer with ____onset and _____ prognosis
aggressive;
rapid onset;
poor prognosis
what would the pts breast look like/present like?
“orange peel”/peau d’orange
edema/redness
warmth/inflammation
why usually a delayed in diagnosis in inflammatory breast cancer?
ppl think it is cellulitis
Typical Presentation of breast cancer pts most patients (90%) present with a \_\_\_\_\_\_\_\_ lump in the breast
(most women detect lesion by themselves with self exam)
a painLESS lump (less than 10% will have pain as 1st symptom)
Typical Presentation of breast cancer pts
what are some other presentations of breast cancer?
(other than a painless lump)
nipple discharge/rertaction/ or dimpling
diagnosis of breast cancer?
Clinical breast exam/mammogram (maybe ultrasound)
Hx and PE (physical exam)
Core biopsy!!! (gold standard)
surgical biopsy
fine needle aspiration
what are the qualities/results/pathyology do you see from a biopsy
tumor size invasiveness tissue type differentiation nodal involvement ER/PR+ (hormonal receptor status) HER2 Neu status
two ways to test for HER2?
FISH!! (fluor in situ hybridization)
immunohistochemistry (detects protein expression)
ways to stage a tumor?
TNM shiiit
Oncotype DX :
if high risk, medium risk, or low risk — what kind of therapy??
high risk: chemo + endocrine
medium: NO CHEMO! - just endocrine (decided after a trial )
low: hormonal therapy only
Adjuvant vs neoadjuvant
adjuvant: after surgery
neoadjuvant: before surgery
If pt has stage 0 breast cancer and it is LCIS what are the general treatment strategy options
1 - observe
or
2 - use tamoxifen or aromatase inhibitors
or
3 - consider bilateral masectomies (reconstruction?)
(not considered risk factor invasive disease)
If pt has stage 0 breast cancer and it is DCIS what are the general treatment strategy options
1 - lumpectomy followed by radiation therapy
or
2 - total mastectomy +/- reconstruction
or
3 - lumpectomy alone
4 - consider endocrine therapy if pt has ER/PR + disease
what is a lumpectomy ?
“breast conserving surgery” – just taking out the lump/tumor
the goal for all stages of breast cancer is to ______
except for the stage of _____ the goal is ________
goal is to cure! stages 0 - 3
stage 4 = stabilize the disease
If pt has stage I, II, or IIIA breast cancer - what are the general treatment strategy options
breast conserving surgery(aka lumpectomy) + radiation therapy
or MRM (modified radical mastectomy) +/- radiation therapy
*some stage II or IIIA may get NEOadjuvant (before surgery to shrink tumor)
MOST women get adjuvant therapy (after surgery) either chemo, hormonal +/- biologic therapy
If pt has stage IIIB and IIIC breast cancer - what are the general treatment strategy options
most women have neoadjuvant chemo follow by MRM or lumpectomy
adjuvant therapy as appropriate
morphine: renal or liver function need to be considered before use?
yes- both!!
hydromorphone: renal or liver function need to be considered before use?
yes! both!!
what pain med does not have an IV formulation
oxycodone
what pain med is good because there are no renal or liver issues
fentanyl
what drug should not be used in a opioid naive person
fentanyl!! (potent as hell)
Methadone should be avoided in pts because of what 4 reasons? Numerous \_\_\_\_\_\_\_\_ Risk for \_\_\_\_\_\_\_\_\_\_ History of \_\_\_\_\_\_\_\_ Poor \_\_\_\_\_\_\_\_
numerous drug interactions (QTc prolongation!!)
risks of syncope or arrhythmias
hx of unpredictable adherence
poor cognition
for methadone pts need a baseline ______
EKG because of QT prolongation
the half life of methadone is ______
unpredictable!!
Methadone:
typically ok in ______ dysfunction
but should be avoided in severe ______ dysfunction
ok in renal
avoid in liver
Toxicities and management of Opioids:
if constipation - what to do?
add a bowel regimen! (always do this!!)
mild stimulant laxative and stool softener!!
Toxicities and management of Opioids:
if sedation - what to do?
tolerance will develop within a few days
hold sedatives or anxiolytics
consider dose reduction
Toxicities and management of Opioids:
if N/V - what to do?
change opioid
consider adding scheduled anti-emetic therapy
(metoclopramide or prochlorperazine)
(this side effect can go away usually around 7 - 10 days)
T or F: patients will develop a tolerance for constipation when on pain meds
FALSE!! add a bowel regimen!
Pruritus is seen most with _______
what pain med
morphine
Toxicities and management of Opioids:
if pruritis - what to do?
seen most with morphine..
change opioid or decrease dose
consider adding an antihistamine (benadryl)
Toxicities and management of Opioids:
if hallucinations/confusion/ or delirium - what to do?
decrease dose or change opioid
consider adding a neruoleptic med
Toxicities and management of Opioids:
if myoclonic jerking - what to do?
may be a sign of toxicity
consider changing opioid or treating underlying cause
Toxicities and management of Opioids:
if respiratory depression - what to do?
hold the opioid!!!
(sedation will precede resp. depression)
give LOW DOSE naloxone!!!!!! (if on opioids for chronic pain)
(do not give large rescue amounts — do not want to take away all the pain)
what is the celiac plexus
group of nerves that supply organs in the abdomen
celiac plexus block is usually helpful in patients that have______ cancer
pancreatic
Intrathecal pain pumps are good for pts who??
pts who are refractory to other opioid therapy or increased toxicites
or pts that gave more toxicities than benefit from traditional opioid therapy
On-Q pump?
LOCAL pain relief
adjuvant pain therapy alternatives?
dexamethasone/NSAIDs
remember neuropathic pain!
T or F: it is ok for pts on opioids to use their opioids for anxiety and depression/for sleep
Falseeee
if patients has stage IV breast cancer
the goal is _________
therapy will primarily consist of _____ and _______
______ typically only used for symptomatic relief
Radiation is used sometimes for palliation
goal = stabilize the disease
therapy = chemo and hormonal therapy
surgery for symptom relief…
T or F: radical mastectomies are not really used anymore
TRUE!
surgery has increased morbidity assoc. with it
different between radical mastectomy and MRM (modified radical mastectomy)
radical: major and minor pectoralis
MRM: jus minor pect.
both will do nodes and breast
Lumpectomy is usually done with _____ therapy
*may not do that therapy in pts who are ______
radiation
over 70 y.o
breast cancer patients typically get neoadjuvant therapy have a _____
large tumor (> 1 cm)
Breast cancer pts will get chemo if they have what 2 characteristics?
large tumor (> 1 cm) or lymph node positive
adjuvant hormonal therapy options for breast cancer
Surgical ablation (oopherectomy)
SERMs
LHRH analogs
AI’s (aromatase inhibitors)
LHRH analogs will decrease the hormone levels in about _______ (how long)
2 - 4 weeks
AI’s or LHRH analogs are used only in postmenopausal women
AI’s!!!
i think you can give LHRH analogs in premenopausal women and “make” them post menopausual???
If a women with breast cancer is postmenopausal what is the first line/best option for hormonal adjuvant therapy
AI’s for 5 YEARS then another 5 years…
(best ADE profile!)
*dont forget the cancer must be ER+!!
If a women with breast cancer is premenopausal what is the first line/best options for hormonal adjuvant therapy
Tamoxifen for 5 years then another 5 year or
????
AI x5 then more Ai x5 or T x5 ???
adjuvant therapy of trastuzumab for adjuvant therapy in breast cancer is typically done for _______ (how long)
1 year (no benefit seen to do it longer)
Adjuvant chemo in breast cancer:
durations longer than ________ do not appear to improve survival
3 - 6 months
Breast cancer patients may get neoadjuvant therapy if ________
tumor is big > 1 cm
if giving dose dense anthracyclines (can be done in breast cancer pts) — you must give ________
CSFs!! (bc neutropenia risk is high af)
most common adjuvant chemo for breast cancer
doxorubicin (CARDIOTOX!!) and cyclophosphamide
aka the “AC” chemo
was seen that giving _____ after doxorubicin and cyclophosphomide has improved outcomes in pts with LN + disease (in breast cancer lecture)
paclitaxel
can give this dose dense! weekly but lower dose!
For treating metastatic breast cancer: if ER/PR + Bone Metastasis Asymptomatic Visceral
what to do?
Hormone therapy!!
since bone disease - do bisphosphonate or denosumab
(bone metastasis tend to have better prognosis - do not bed to be aggressive with chemo)
OR send them to a clinical trial
pre-treat pts getting paclitaxel with what?
reduce SENSITIVITY RXNS with:
bendaryl
dexamethasone
famotidine (H2 blocker)
doxorubicin or cyclophosphamide is a vesicant and can cause extreme damage when it gets extravasted
doxorubicin!!
anything to do about that?? no clue
For treating metastatic breast cancer: if ER/PR - Symptomatic Visceral or hormone refractory what to do?
if HER2+: anti- HER2 therapy and CHEMO
if HER2-: CHEMO
for metastatic breast cancer:
if pt is to get chemo:
single agent or combo therapy is best?
single
combo = more toxicities with not enough extra benefits
what is the first line option for HER2+ disease?
with doses!! (she said know these :( )
Trastuzumab:
8 mg/kg IV day 1 followed by 6 mg/kg IV
pertuzumab
840mg IV day 1 followed by 420 mg IV
docetaxel
75 mg/m^2 IV
CDKs have are activated in _____ breast cancer
ER+ !!!
using CDK 4/6 inhibitors in ER+ breast cancer can be beneficial how?
can actually reverse some acquired resistance to previous hormone therapy
which CDK 4/6 inhibitor is the “best” and why do the other ones stink
Palbociclib = “good one”
Ribociclib: hella monitoring (LFTs and QT prolongation/EKG)
Abemaciclib = BID (booooo)
what monitoring should be done with palbociclib
neutropenia: monitor CBC before therapy, and beginning of each cycle and day 14 of the first 2 cycles
then monthly
Pulmonary embolism: monitor for signs and sxs
Breast Cancer:
give pts radiation when?
if tumor > 5 cm
or 4 + positive lymph nodes
if pt has had lumpectomy
if positive margins after surgery
Breast cancer:
when would pts get neoadjuvant therapy
when the tumor is greater than 1 cm?
