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Oncology Therapeutics > Chemotherapy Complications CINVD/Mucositis > Flashcards

Chemotherapy Complications CINVD/Mucositis Flashcards

1
Q

For each type of CINV describe it

  1. Anticipatory
  2. Acute (onset, peak and how long after chemo)
  3. Delayed (onset, occurs with, and risk)
  4. Breakthrough
A
  1. Due to a conditioned response from occurrence of CINV
  2. Onset 1-2 hrs, peak 4-6 hrs, < 24 hrs
  3. Onset > 24 hrs after chemo, occurs w/high emetic risk regimens and risk lasts for 3 days
  4. AFter appropriate prophylactic medication
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2
Q

CINV Risk factors Patient Specific :
1. gender
2. age?
3. history of ?
4. Alcohol consumption levels?
5. History of __ or ___

CINV Risk factors TX specific :
1. chemotx agent
2. dosage
3. schedule

A
  1. female
  2. younger age!
  3. motion sickness or nausea w/preg , prior hx of chemotx
  4. low alcohol consumption
  5. depression, anxiety
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3
Q

For each Grade, state the Nausea level and vomiting episodes

  1. Grade 1
    Grade 2
    Grade 3
    Grade 4
A
  1. Loss of appetite w/o changes in eating habits
    -1-2 episodes of vomiting in 24 hrs
  2. oral intake decr w/o signif weight loss, dehydration, malnutrition
    3-5 episodes vomiting in 24 hrs
  3. inadequate oral caloric or fluid intake ; tube feeding, TPN or hospitlization indicated
    ->=6 episodes in 24 hrs
  4. Life threatening consequences, urgent intervention needed
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4
Q

For the following High emetic risk agents (> 90% frequency of emesis), state the specific dose

  1. Carboplatin
  2. Cyclophosphamide
  3. Doxorubicin
  4. Ifosfamide
  5. Which combo of chemo is considered HEC?
A
  1. AUC >=4
  2. > 1500 mg / m^2
  3. > = 60 mg / m^2
  4. > = 2 g/m^2 per dose
  5. AC combo w/anthracycline and cyclophosphamide
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5
Q

What are our goals of therapy ? (6)

A

Prevent –>
malnutrition
Metabolic imbalance
anorexia
decline in performance status
esophageal tears
lack of adherence to potentially beneficial tx

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6
Q

Anti-Emetic Agents : 5-HT3 Antags
1. Granisetron (KYTRIL)
a. what dosage forms?
b. dose?

  1. Ondansetron (ZOFRAN)
    a. what dosage forms?
    b. Dose?
  2. Palonosetron (Aloxi)
    a. dosage forms?
    b. dose?
  3. What are the general AE’s for this class? (3)
  4. If Palonosetron (3 days) or granisetron SQ or patch (7 days) given, what should you consider for breakthrough nausea?
A
  1. IV , PO, SQ or patch
    b. 1 mg IV or 2mg PO once
    10 mg SQ (redose in 7 days)
    3.1 mg / 24hr patch (apply 24-48 hrs prior to first dose)
  2. IV, PO, SL, ODT
    b. 8-16 mg IV or 16-24 mg PO
    Max 32 mg/day PO or 16 mg IV single dose or 0.45 mg/kg/day !
  3. IV or PO
    b. 0.25 mg IV or 0.5 mg PO once (only redose after 3 days)
  4. HA, constipation , QTC prolongation (primarily with ZOFRAN 16 mg IV)
  5. Need to consider alt agent
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7
Q

What are the 2 combo therapy products (NK1 + 5HT3) ?

A

Netupitant 300 mg / Palonosetron 0.5 mg PO x 1 30 min prior to chemotx

Fosnetupitant 235 mg / palonosetron 0.25mg x 1 30 mins prior to chemotx

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8
Q

ANTI EMETIC AGENTS : NK1 RECEPTOR ANTAGS

  1. Fosaprepitant (EMEND) IV
    - Dose
    -AE’s
  2. Aprepitant (EMEND) PO
    -Dose
    -In future, what days will u require dosing on ?
  3. Aprepitant (Cinvanti) IV
    -Dose
  4. Rolapitant (Varubi) IV OR PO
    -Dosing for IV and PO
    -when would u redose?
    -What causes the hypersensitivity rxn in pt’s with this drug?
  5. General class AE’s
  6. It is indicated for?
  7. Which drugs do you have to consider a CYP3a4 interaction for?
A
  1. 150 mg IVPB once
    -infusion related reactions due to polysorbate 80
  2. 125 mg PO
    -Dosing required on days 2-3
  3. 130 mg IVPB once
  4. 166.5 mg IV or 180 mg PO
    -2 weeks
    -Soybean oil component
  5. Hypersensitivity, fatigue and DDI’s
  6. Only for PREVENTION of CINV, not tx
  7. Fosaprepitant and aprepritant (Early inhib and late inducer)
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9
Q

ANTIEMETIC AGENTS : Dexamethasone

  1. Dose
  2. AE’s ?
  3. Generaly avoid with ___ and ___
  4. COnsider extending if pt’s experiencing ___
  5. Caution in pt’s with ___
  6. When should u dose to avoid insomnia?
A
  1. 8-12 mg PO or IV once daily
  2. Insomnia, hyperglycemia, incr appetite, mood changes, dyspepsia (consider H2 blocker or PPI)
  3. Cellular therapies , immune checkpoint inhibs
  4. delayed nausea
  5. diabetes
  6. In morning
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10
Q

PROCHLORPERAZINE (Compazine )

  1. Dosage forms?
  2. Dose
  3. AE’s ? CI with ?

OLANZAPINE (Zyprexa)
1. Dosage forms?
2. Dosing ?
3. AE”s?
4. COnsider using if ur pt cant tolerate ___ but caution with use with ?
5. Since the elderly are more sensitive to this medication, which dose should u start with ?
6. when should this med be dosed ?

LORAZEPAM (Ativan)
1. Dosage forms?
2. Dose?
3. U can consider this drug for what kind of nausea?

A
  1. PO and IV
  2. 10 MG PO q6hrs
  3. Sedation, CI with metoclopramide
  4. PO and IV
  5. 2.5-10 mg PO QHS
  6. Sedation, EPS, ortho hypo, metabolic effects
  7. dexamethasone , BZD’s
  8. 2.5-5 mg total
  9. bedtime
  10. PO and IV
  11. 0.5-1 mg PO or IV q6hr prn
  12. anticipatory or breakthrough (1mg PO night before tx and repeat 1-2 hrs prior to chemotx)
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11
Q

Which 5HT3 agent is typically used for HEC ?

A

Palonosetron

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12
Q

Prevention of Acute and Delayed Emesis with HEC!

  1. Option 1 preferred !
    -state agents and dosing on day 1/day of chemo
    -state agents and dosing on days 2-4
  2. Option 2 (no Nk1ra)
  3. Option3 (no 2nd gen anti-psychotic)
  4. For any of the listed options, what medication + dose would you send your patient home with to begin on day 4?
A
  1. Olanzapine 5 mg PO x 1
    Fosaprepitant 150 mg IV x 1
    Palonosetron 0.25mg IV x 1
    Dexamethasone 12 mg PO/IV x 1

Olanzapine 5 mg PO Qhs
Dexamethasone 8mg PO qam

  1. Olanzapine 5 mg PO X1
    Palonosetron 0.25mg IV x 1
    Dexamethasone 12 mg PO/IV x 1

Olanzapine 5 mg PO Qhs
Dexamethasone 8mg PO qam

  1. Fosaprepitant 150 mg IV x 1
    Palonosetron 0.25mg IV x 1
    Dexamethasone 12 mg PO/IV x 1

Dexamethasone 8 mg PO QAM

  1. Ondansetron 8 mg PO q8hrs prn N/V to
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13
Q

Prevention of Acute and Delayed Emesis with MEC : State day 1 and days 2-3 dosing

  1. Option 1
  2. Option 2 (no NK1ra)
  3. Option 3 (no antipsych)
A
  1. Palonosetron 0.25mg IV x 1
    Dexamethasone 12 mg PO/IV x 1

Dexamethasone 8 mg PO QAM

  1. Olanzapine 5mg PO x 1
    Palonosetron 0.25mg IV x 1
    Dexamethasone 12 mg PO/IV x 1

Olanzapine 5mg PO QHS

  1. Fosaprepitant 150mg IV x 1
    Palonosetron 0.25mg IV x 1
    Dexamethasone 12 mg PO/IV x 1

+/- Dexamethasone 8mg PO Qam

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14
Q

Prevention of Emesis with Low emetic risk

  1. Start when ?
  2. Repeat how often ?
  3. What agents/doses can you use? (4)
A
  1. Start prior to anti cancer tx
  2. Repeat daily for multi day doses of anti cancer therapy
  3. Dexamethasone 8-12mg PO/IV once
    Metoclopramide 10-20 mg PO/IV once
    Prochlorperazine 10 mg PO/IV once
    5HTR3 RA PO once
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15
Q

What methods can u use for anticipatory CINV? (4)

See chart for other breakthrough therapy of CINV

A
  1. Prevention
  2. Behavioral therapy
  3. acupuncture/acupressure
  4. anxiolytic therapy –> lorazepam 0.5-2 mg PO the night before tx and repeat 1-2 hrs prior to anti cancer tx

SEE CHART

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16
Q

Chemo induced Diarrhea Grading : For each Grade describe the stool episodes

Grade 1
Grade 2
grade 3
Grade 4

A
  1. increase of < 4 stools per day above baseline
  2. incr of 4-6 stools per day above baseline which limit activities of daily living
  3. incr of >= 7 stools per day above baseline
    -hospitalization needed
    -limiting self care
  4. Life threatening
    urgent intervention needed
17
Q

Types of Diarrhea

  1. 5FU/Capecitabine what kind
  2. 2 types of diarrhea w/irinotecan?
A
  1. Watery or bloody –> variable severity
  2. Acute < 24 h after tx due to cholinergic properties of irinotecan

delayed > 24h after tx

18
Q

Risk factors for CID !!!!
1. Age
2. Sex
3. ECOG score?
4. B
5. B
6. Which cycle of chemotx?
7. Cycle duration
8. Concomitant ___
9. Concomitant _____,___,____ or ___

A
  1. > 65 yrs
  2. Female
  3. ECOG Performance status of >=2
  4. Bowel inflamm or malabsorption , malignancy
  5. Biliary obstruction
  6. 1st
  7. greater than 3 weeks
  8. concomitant neutropenia
  9. concomitant mucositis, vomiting, anorexia , anemia
19
Q

RF for 5FU induced Diarrhea :

  1. Sex
  2. Race
  3. age
  4. BMI?
  5. Hx of
  6. Deficiency in ?
  7. 5FU + ____
  8. Slightly incr risk with what admin method?
A

Female

caucasian

advanced age

normal BMI

diabetes

DPYD*2A (decr CL of 5FU)

Leucovorin

BOLUS

20
Q

RF for Irinotecan-Induced Diarrhea

  1. What kind of dosing ?
  2. Homozygous presence of ?
  3. Poor ___
  4. Elevated ___
  5. HIstory of ___
  6. Low ____
  7. What age
  8. G
  9. C
A

Weekly irinotecan dosing

UGT1A1*28 polymorphism (less glucoronidation of SN38)

Performance status

serum creatinine

radiation to abdomen or pelvis

white blood cell count

> 70 yo

Gilbert syndrome

Crigler Najjar syndrome type 1

21
Q

TX Options : Loperamide

  1. Loperamide
    dose?
    What have high doses been associated with ?
A
  1. 4 mg PO x 1 then 2 mg PO after each loose BM w/MAX of 24mg/day

paralytic ileus

22
Q

TX options : Octreotide

  1. Dose
  2. How and wen can u incr dose?
A
  1. 100-150 mcg SQ
  2. May incr dosage at 50mcg increments after 24 hrs to 500 mcg TID or as a continuous IV infusion (25-50 mcg/hr)
23
Q

Management : Uncomplicated Vs Complicated

  1. Uncomplicated is defined as which stages? describe sx’s
  2. Complicated is which stages?
    -It can be grade 1 or 2 with >=1 of the following (List the following )
A
  1. Grade 1 or 2
    –> No complicating signs or sx’s
  2. grade 3 or 4
    -Cramping
    -Grade 2 N/V
    -Fever
    -Sepsis
    -Neutropenia
    -Frank bleeding
    -Dehydration
24
Q

How would you manage uncomplicated?

Complicated?

A
  1. DIet modifications
    Oral hydration
    Loperamide
  2. Admission to hospital
    Octreotide
    IV fluids
    ABX if warranted
25
Q

Initial management of Uncom Diarrhea

NON PHARM :

  1. What do u do with chemotherapy ?
  2. What kind of diet mods?
  3. State how u would orally hydrate them
  4. Name a pharm tx
A
  1. Withold chemo if grade 2 –> resume when sx’s resolve and consider dosage reduction
  2. Stop all lactose containing products, stop ALC, stop high osmolar supps, BRAT diet
  3. Oral hydration with 8-10 large glasses of clear liquids containing salt
    -diluted sports drinks , broth, decaff tea
  4. Loperamide 4 mg PO x 1 then 2 mg after each loose BM (max of 24 mg/day)
26
Q

Initial management of Complicated Diarrhea
1. admit where
2. What to do with chemo ?
3. Work up what ?
4. Complete __ and ___
5. admin ____
6. Octreotide at what dose?
7. admin of ___ prn if clinically indicated

A
  1. hospital
  2. DC, resume when sx’s resolve and consider restarting chemotx at decr dosage
  3. stool work up (blood, fecal leukocytes, Cdiff, Salmonella, E COli, Cbacter , infectious colitis)
  4. Blood counts (PLT, Hgb, Hct) and metab panel (K, Mg, Na)
  5. IV fluids
  6. Starting dose of 100-150 mcg SC TID or IV if pt is severly dehydrated
  7. IV antibiotics (fluoroquinolone)(if pt is febrile, hypotensive, peritoneal signs, neutropenia, bloody diarrhea)
27
Q

Irinotecan Induced Diarrhea

  1. Early phase begins when ?
    -__ dependent
    -Sx duration ?
    -Prevention using ?
    -TX using ?
  2. Late phase begins when ?
    -Can occur at any ____
    Median onset of ___ with ___ dosing
    Median onset of ___ w/weekly dosing
    TX is ?
A
  1. < 24 h after infusion
    dose
    30 mins
    Atropine 0.25-1mg SQ/IV 30 min prior to infusion
    Atropine 0.25-1mg SQ/IV
  2. > 24 hrs after irinotecan
    - dosage or frequency
    - 6 days, q3weekly
    11 days, weekly dosing
    Loperamide 4 mg PO after 1st loose BM then 2 mg PO q2H until 12h with no diarrhea
28
Q

Risk Factors for Mucositis :

  1. Patient related : S,B,A,F,P
  2. Tx related : C, D ,D , S, H/R, C, P, R + C
A
  1. Smoking , baseline oral hygiene , age , female, pre tx nutritional status
  2. Chemotherapy (s phase cycle specific have the highest risk) , Duration, dose intensity, schedule, hepatic/renal impairment, concomitant therapy, prior mucotoxic therapy, radiation + chemotherapy
29
Q

Which drugs have the highest risk for mucositis?

A

5FU (Bolus )
MTX
Cytarabine
Doxorubicin
Etoposide
Melphalan

Oncology Therapeutics (17 decks)

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