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)
When should you consider iron supplementation for ESA?
% Transferrin saturation <50%
AND
Ferritin 30-500 ng/mL
What are the IV iron products?
- Iron Dextran
- Ferric gluconate
- Iron sucrose
Which of the IV irons require test dose?
Iron dextran
ADR of IV iron?
- Anaphylaxis
- Hypotension
- DZ
What are the clinical presentations of mucositis?
- Pain
- Erythema
- Lesions/ulcerations
- Local infection
- Inability to eat, drink, or swallow
When does mucositis present after chemo?
7-14 days
What are the most common meds that mucositis?
- Methotrexate
- 5-FU
- Doxorubicin
- Multikinase inhibitors
- mTOR inhibitors
Infections that can lead to mucositis?
Candida and HSV
Tx for mucositis infection?
Mild fungal infection: nystatin suspension, clotrimazole troches
More severe: Fluconazole IV or PO
Acyclovir for HSV
Methods for good oral hygiene?
- Rinse mouth with baking soda/saline rinse 4 times daily after eating and at bedtime
- Chlorhexidine (Peridex)
Supportive tx for mucositis?
- Viscous lidocaine 2%
- Magic mouthwash
- Analgesics
What are the counseling points for good oral hygiene?
- Keep mouth clean
- Can be painful
- Have topical rinses to help control pain
- Brush with soft nylon brush to prevent injury
- May need PO or IV pain medications to control the pain
- Contact MD if current therapy not effective
Complications of diarrhea?
Dehydration and electrolye imbalances
Drugs that commonly cause diarrhea?
5-FU, HD methotrexate, capecitabine,irinotecan (acute and delayed)
Sorafenib, sunitinib, cetuximab, neratinib
Tx for diarrhea?
- Hydration (Pedialyte)
- Loperamide or Lomotil once infection ruled out
- Octreotide SQ for refractory diarrhea
Dosing for loperamide or lomotil?
Max dose of loperamide is 16 mg/day, however, may be increased to 24 mg/day
Take 4mg once, then take 2mg every 2-4 hours or after each loose stool until 12 hours have passed without a loose stool
Counseling for diarrhea?
Increase fluid intake with electrolyte containing fluids:
* Powerade/Gatorade, pedialyte
* Bananas
Eat frequent small meals: avoid greasy foods, raw fruits and veggies, caffeine
How to take loperamide and when to start
When to call MD
Dermatologic complications of chemo?
- Alopecia
- Hand and foot syndrome
- Rash
- Extravasation
Medications that cause a loss of pigmentation in hair?
Kinase inhibitors (Pazopanib)
Presentations of alopecia?
Occurs within 1-2 weeks of treatment:
* Regrowth after chemo
* Loss in significant heat through the head
* Sensitive skin
Common medications associated with hand foot syndrome?
Capecitabine, 5-FU, cytarabine, liposomal doxorubicin, and some TKIs
Presentations of hand foot syndrome?
- Redness, tenderness on palms and soles of the feet
- Can cause peeling
- Impacts ADLs
How do you manage alopecia?
- Avoid tight fitting clothes/shoes
- Avoid activities that rub the skin in the affected area
- Apply moisturizer often (emollients)
- Avoid hot water
- Wear protective clothing and sunscreen
- Cold compresses
- Notify docotr at first s/s
Tx for dry skin?
Alcohol-perfume-free moisturizer/emollient
Tx for edematous rash?
Topical anti-inflammatory agents
Topical or oral antibiotics may be needed for infection
Tx for pruritus?
Topical or oral diphenhydramine
Oral steroids
Overall non pharm for derm complications?
Applysunscreen
What is the difference between irritants and vesicants?
Irritant: short-lived and limited irritation to the vein
Vesicant: injection site rx -> chemical cellulitis
Tx for irritation and potent vesicants?
- Need to manage immediately to limit damage
- Stop injection
- Leave needle in place
- Apply cold compress
- For vinca alkaloids- apply HEAT
How should you administer a potent vesicant?
- Withdraw 3-5mL of blood/fluid if possible
- Adminsiter antidote if available
- Mark and photograph the area
Tx for PN
- Antidepressants
- Anticonvulsants
- Can be used in combination with opioids
- May also consider topical analgesics and corticosteroids
Counseling for PN?
- Numbness and tingling in hands and feet
- Gait problems
- Loss of sensation of hot and cold
- When to tell physician
Lifetime dose for doxorubicin?
(> 450-550 mg/m2)
Lifetime dose for daunorubicin?
(>550 mg/m2)
Lifetime dose for Idarubicin?
(> 150 mg/m2)
Lifetime dose for epirubicin?
(>900 mg/m2)
Cause of chemo cardiotox?
Free radical formation during metabolism
RF for chemo-iduced cardiotox?
- Age (impacts elderly and the very young)
- Female
- HTN
- Pre-existing heart condition
- Mediastinal radiation
- Anthracycline dosing
1.
Drug classes that increases risk for cardiotoxicity?
Anthracycline
Prevention for cardiotoxicity?
- Must check ejection fraction before beginning therapy
- Use liposomal doxorubicin (decreased cardiotox)
- Dexrazoxane (Zinecard)
MOA and dosing of Dexrazoxane (Zinecard)?
MOA: Binds iron to prevent free radical formation
Dosing: Recommended after having received 300 mg/m2 due to it decreasing the effect
How can hypercalcemia occur in chemo?
Cancer can cause calcium to leach from the bones:
* hypercalcemia
* weak bones
* prone to fractures
Presentation of Calcium < 13?
Usually asymptomatic
Presentation of Calcium > 13-15?
- Anorexia
- N/V, constipation
- Polyuria/nocturia
- Polydipsia
Presentation of Calcium >15?
- AKI
- Inability to arose, coma
- Life threatening arrhythmias
Tx for mild hypercalcemia?
Normal saline and furosemide
Tx for moderate to severee?
- Bisphosphonates
- Calcitonin
- Dialysis for severe renal impairment
- CS
- Denosumab
ADR of bisphos?
ONJ
* Do not repeat within 7 days
MOA of bisphosphonates?
- Slow down the action of osteoclasts and stabilize the bone
- Decrease bone pain and damage to bone by cancer
- Decrease calcium levels
Drugs that can cause ONJ?
Denosumab and bisphos
Which bisphos causes bone metastases?
Pamidronate and zoledronic acid
Ibandronate does not
Mechanism of TLS?
Chemo causes cell to lyse open spilling intracellular contents in bloodstream
Outcomes of TLS?
- Hyperuricemia
- Hyperkalemia
- Hyperphos
- Secondary hypocalcemia
-> Organ dysfunction if electrolyte levels increase
* AKI
* Cardiac arrhythmia
* SZ
Prevention and tx TLS?
- Hydration
- Allopurinol
- Basburicase
