Toxicities and Supportive Care - Block 4 Flashcards
What is scoring of CTCAE?
Grade 0: no toxicity
Grade 5: death
What is the most common dose-limiting ADR?
Myelosuppression
Lifespan of neutrophils?
6-12 hrs
* Nadir seen 10-14 days after chemotherapy
* Recovery in 3-4 weeks after chemotherapy
Lifespan and platelets? RBCs?
Platelets: 5-10 days
RBC: 120 days
What are the complications of neutropenia?
Increased risk for infection (fever is a primary indicator)
What lab constitutes neutropenia?
ANC <1000
* Severe: <500
How do you calculate ANC?
ANC = (%segs + % bands) x WBC x 1000
Describe the chemo cycle?
Chemo day -> Nadir 7-14 days after chemo -> Highest risk of infection that lasts 5-7 days -> recovery period -> chemo day
What is the treatment for the neutropenia?
Colony stimulating facotrs
MOA of CSFs?
Stimulate the production of WBCs in bone marrow
Factors that influence neutropenia prophylaxis?
Primary: %risk and risk factors
Secondary: neutropenia and tx intent
How qualifies for primary CSF prophylaxis?
What are the RF of neutropenia?
- ≥65 YO recieving chemo
- Hx of chemo or radiation
- Persistent neutropenia
- Bone marrow involvements of tumor cells
- Recent surgery and/or open wounds
- Liver and renal dysfunction
What are the CSF agents?
- Filgrastim
- Pegfilgrastim
- Sargrasmostim
Dosing of filgrastim?
QD
Dosing of pegfilgrastim?
6 mg once per chemo cycle
How should CSF be administered?
- Start 24-72 hrs after chemotherapy ends
- Continue until post-nadir recovery (DC if ANC surpasses 10,000 cells/mm3)
How do you manage the ADRs of CSF?
Severe bone pain:
* Pretreat with APAP, NSAIDs, Loratadine
* If more severe, contact doctor
What are the presentations of febrile neutropenia?
Neutropenic:
* ANC <500 OR
* ANC is expected to decrease to <500 during the next 48H
Fever:
* Single oral temp. Of≥38.3˚C (101˚F) OR
* A temp. of ≥38.0˚C (100.4˚F) for ≥1 hr
What are the low risk tx for febrile neutropenia?
- Home IV therapy
- PO ABX
* Ciprofloxacin + Augmentin
* Clindamycin for penicillin allergy
* Levofloxacin
* Moxifloxacin
What is the scoring tool used for assessing the severity of febrile neutropenia?
MASCC Risk-Index score
What are the high risk rx for febrile neutropenia? What do you need to assess?
Monotherapy must cover PA:
* Cefepime
* Imipenem
* Meropenem
* Zosyn
* Ceftazidine
Assess:
* Institution sensitivities
* Patient allergies
* Recent ABX use by patient
Indications for vancomycin use?
- Severe catheter infection
- Positive blood cultures with G+ bacteria
- MRSA/PCN or cephalosporin resistant S. pneumoniae
- Soft tissue infection
- hypotension or septic shock
What agents are used for vancomycin resistance?
- Linezolid
- Daptomycin
What is thrombocytopenia?
Low platelets <100,000 cells/mm3
What are the presentations for thromcytopenia?
- Bruising
- Petechiae
- Hematemesis
- Hematuria
- Nose bleeds
Tx for thrombocytopenia?
Transfusion:
* Indicated for those ≤10,000 cells/mm3
* Transfuse at higher levels <20000 if there is active bleeding, surgical procedure is needed, or infection
- Chemo may be reduced or held until resolution
What is the definition of anemia?
Hb <13 in males
Hb <12
What is the most common s/s of anemia?
fatigue
What is the tx for anemia?
Transfusion
ESA:
* Epoetin alfa (Epogen, Procrit)
* Darbepoetin alfa (Aranesp)
Benefits of using ESA?
- Shortens survival
- Increase tumor progression
Inidcations for ESA?
Not idicated if the goal is cure:
* Only for palliative or may consider in pts with underlying kidney dx
When and how do you initiate ESA?
Hb <10
Goal: Hg >12
* Need to address any underlying iron def
* Use lowest dose needed to avoid transfusion
How should you monitor EPO?
Hgb increases by > 1 gm/dL in 2 weeks: decrease dose by 25% (epoetin) or 40% (darbepoetin)
Hgb >12 g: Hold doses until Hgb falls below 11g/dL and restart at lower dose
What must be administered with ESA to prevent def?
Iron (IV (preferred) or PO)