Flashcards in 09 Chemotherapy Induced Anemia (CIA) Pak Deck (48):
What is Grade 0 in the Anemia Grading Scale?
Males Hgb: 14-18, Females: 12-16
What is Grade 1 in the Anemia Grading Scale?
Mild. Hgb: 10-normal
What is Grade 2 in the Anemia Grading Scale?
Moderate. Hgb: 8-10
What is Grade 3 in the Anemia Grading Scale?
Severe. Hgb: 6.5-7.9
What is Grade 4 in the Anemia Grading Scale?
Life-Threatening. Hgb: < 6.5
What what Anemia Grade do symptoms usually start?
What are the symptoms associated with Grade 2 (moderate) anemia?
Fatigue. Dyspnea. HA. Palpitations. Chest pain
What is the result of chronic anemia?
Can result in severe organ damage affecting the kidneys, CNS, CVS, lungs, immune system, etc
What is a low baseline hemoglobin level?
Males < 13.5, Females < 13
What are the general steps in the management of CIA?
1) Treat underlying deficiencies (iron, folic acid, vitamin B12). 2) Packed red blood cells (PRBC) transfusion. 3) Erythropoietin-stimulating agents (ESA)
When is transfusion indicted?
ASYMPTOMATIC Grade 3 with comorbidities (CHF; CHD; CVD; chronic pulmonary disease, high risk: progressive decline in Hgb w/ recent chemo or radiation). SYMPTOMATIC Grade 2 (sustained tachycardia, tachypnea, chest pain, dyspnea on exertion, lightheadedness, syncope, severe fatigue preventing work and usual activity
What is the Hgb goal in Asymptomatic Grade 3 anemia w/ comorbidities?
What is the Hgb goal in Symptomatic Grade 2 anemia?
How much will 1 unit PRBC raise Hgb?
By 1g/dL and Hct by 3%
What are the benefits of RBC Transfusion?
Rapid increase in Hgb and Hct. Rapid improvement in fatigue
What are the risks with RBC Transfusion?
Transfusion reactions (hemolytic, febrile, non-hemolytic, lung injury, chest pain, uticaria, etc.). Congestive heart failure. Virus transmission. Bacterial contamination. Increased thrombotic events. IRON OVERLOAD (at risk ~100mL/kg PRBC in lifetime and serum ferritin > 1000 mcg/L)
What are the normal iron levels?
What are the normal ferritin levels?
12-300mcg/L in males. 12-150mcg/L in females
What are the symptoms of Iron Overload?
Non-specific: Lethargy, weight loss, abdominal pain, joint pain
What is the indication for Deferoxamine (Desferal)?
Acute iron intoxication. Chronic iron overload secondary to multiple transfusions
What is the MOA of Deferoxamine?
Complexes with trivalent ions (non-specific) that are removed by the kidneys
How is Deferoxamine (Desferal) administered?
Rate of IV infusion NTE 15mg/kg/hr (to prevent flushing, uticaria, hypotension, and shock)
When is Deferoxamine (Desferal) contraindicated?
Severe renal disease or anuria (renally eliminated)
What are some DDIs with Deferoxamine?
Vitamin C > 200mg/day --> risk of cardiac impairment (rare). Prochlorperazine --> may lead to temporary impairment of consciousness
When is Deferasirox (Exjade) indicated?
Chronic iron overload d/t blood transfusion. PO ONLY
What is the MOA of Deferasirox (Exjade)?
Selectively binds iron which is excreted primarily through the feces
What is the administration of Deferasirox (Exjade) like?
DO NOT chew or swallow whole tablets. Disperse tablet in water, orange juice, or apple juice into a suspension. Take on empty stomach ~30 mins AC
How is Deferasirox (Exjade) supplied?
125mg, 250mg, and 500mg tablets for suspension
What are some DDIs with Deferasirox (Exjade)?
Aluminum-containing antacid can decrease absorption (separate 1hr before 2hr after meals)
What is a BBW for Deferasirox (Exjade)?
May cause renal impairment/failure, hepatic impairment failure, and gastrointestinal hemorrhage
When is Deferiprone (Ferriprox) indicated?
Transfusional iron overload d/t THALASSEMIA syndromes with inadequate response to other chelation therapy. PO only
What is the MOA of Deferiprone (Ferriprox)?
Selectively binds iron that are removed by the kidneys
How is Deferiprone (Ferriprox) dosed?
25mg/kg PO TID, max 33mg/kg TID. Take with food
What are some DDIs with Deferiprone (Ferriprox)?
Antacids can decrease absorption (separate by 4 hours)
What is a BBW for Deferiprone (Ferriprox)?
May cause agranulocytosis
What is the MOA of Erythropoiesis?
Kidney senses hypoxia (anemia) and increases endogenous erythropoietin production. Erythropoietin acts on the E-progenitor cells in the bone marrow to produce new red blood cells. Kidney senses increased tissue oxygenation. Kidney decreases erythropoietin production
How is Epoetin alfa (Epogen, Procrit) dosed?
40,000 units subQ weekly
How is Darbepoetin alfa (Aranesp) dosed?
500mcg SubQ every three weeks
What is alternative dosing for Darbepoetin alfa (Aranesp)?
100mcg SubQ weekly. 200mcg SubQ every two weeks
What are contraindications to ESA?
Uncontrolled HTN. Hypersensitivity to human albumin
What are the boxed warnings for ESAs?
Cancer Patients (decrease OS and/or increase tumor progression or recurrence in clinical studies with breast, non-small cell lung, head and neck, lymphoid and cervical CA patients (studies targeted Hgb > 12g/dL)). Chronic Renal Failure patients (Increased risk of death, serious cardiovascular events, and stroke (studies targeted Hgb > 13), dosing should be individualized to achieve and maintain Hgb at 10-12 g/dL)
What can be done to decrease the boxed warnings of ESAs?
Use lowest dose needed to void RBC transfusion, do not initiate if Hgb > 10. Use only for treatment of myelosuppressive therapy-related anemia. Do not use if anticipated outcome for therapy is CURE. Discontinue following the completion of chemotherapy course (within 6 weeks)
What are the more common ADRs associated with ESA?
What is the iron monitoring and supplementation like before starting ESA?
Assess iron studies (serum, total iron binding capacity (TIBC), and serum ferritin). Periodic monitoring of iron studies may be necessary every 3 months if ESA therapy is to continue
What are the common ADRs associated with IV Iron Supplements?
Hypotension, N/V/D, pain, HTN, dyspnea, pruritus, HA, and dizziness
Which IV Iron Supplements have the most ADRs?
Iron Dextran > Ferric Gluconate > Iron Sucrose
What is the max dose of IV Iron Supplements like?
1,000mg max, except Iron Dextran (can be higher)