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Chemotherapy Induced N/V Flashcards

(78 cards)

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1
Q

Which phase is CNS pathway predominant?

A

Delayed

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2
Q

Which phase is peripheral pathway (gut) predominant?

A

Acute

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3
Q

Onset of acute phase

A

1-2 hours after administration

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4
Q

Peak intensity of acute phase

A

Within 5-6 hours

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5
Q

Resolution of acute phase

A

At 12-24 hours

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6
Q

Peak onset of delayed phase

A

48-72 hours after chemotherapy
Diminish in 1-3 days

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7
Q

What is breakthrough CINV?

A

N/V occurring despite preventive treatment

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8
Q

What is refractory CINV?

A

N/V occurring during subsequent cycles of chemotherapy when antiemetic prophylaxis or rescue therapy has failed in previous cycle

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9
Q

What are the 2 guidelines for CINV?

A
  • ASCO
  • NCCN
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10
Q

Frequency of HIGH emetic risk (IV)

A

> 90%

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11
Q

Frequency of MODERATE emetic risk (IV)

A

> 30-90%

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12
Q

Frequency of LOW emetic risk (IV)

A

10-30%

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13
Q

Frequency of MINIMAL emetic risk (IV)

A

<10%

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14
Q

Frequency of MODERATE to HIGH emetic risk (PO)

A

≥30%

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15
Q

Frequency of MINIMAL to LOW emetic risk (PO)

A

<30%

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16
Q

Patient risk factors for CINV - 7

A
  1. <50 years old
  2. Female
  3. Hx of low prior chronic alcohol intake (<1 glass)
  4. Hx of previous chemotherapy induced emesis
  5. Hx of motion sickness
  6. Hx of emesis during pregnancy
  7. Anxiety
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17
Q

Antiemetic combination for high risk

A

NK1+ 5HT3 + DEX +/- OLA
DEX D2-4 + OLA D2-4

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18
Q

Antiemetic combination for moderate risk

A

5HT3 + DEX
DEX D2-3

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19
Q

Antiemetic combination for low risk

A

5HT3 or DEX or DOPA

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20
Q

NK1 antagonist

A

Aprepitant (Emend)

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21
Q

Dose of Aprepitant

A

PO
Day 1: 125mg OD
Day 2-3: 80mg OD

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22
Q

5HT3 antagonist

A

Ondansetron
Granisetron

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23
Q

Dose of Ondansetron

A

IV/PO
Day 1: 8-16mg OD
Day 2 onwards: 8mg BD

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24
Q

Dose of Granisetron

A

Day 1: 1mg OD
Day 2 onwards: 1mg OM

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25
Combination of NK1 + 5HT3
Akynzeo - Netupitant 300mg + Palonosetron 0.5mg
26
Dose of Akynzeo
PO Day 1: 1 capsule OD
27
Dose of Dexamethasone
IV/PO Day 1: 12mg OD Day 2 onwards: 8mg OD
28
Dopamine antagonist
Metoclopramide
29
Dose of Metoclopramide
IV/PO 10mg OD-TDS
30
NK1 place in therapy
Prevents acute and delayed CINV
31
MOA of NK1 antagonist
1. Binds to NK1 receptors, which prevents substance P (nociceptive neurotransmitter) from binding 2. Attenuates vagal afferent signals
32
Which NK1 antagonist requires 3 day course?
Aprepitant
33
Common AE of NK1 antagonist
Low frequency of fatigue, weakness, nausea, hiccups
34
DDI with NK1 antagonist - 4
1. Steroids 2. Warfarin 3. BZDs 4. Certain chemotherapy e.g. ifosfamide
35
MOA of ifosfamide - NK1 antagonist DDI
Decreases metabolism of ifosfamide
36
MOA of steroids - NK1 antagonist DDI
Increased plasma concentration of steroids
37
MOA of warfarin - NK1 antagonist DDI
Decrease plasma concentration of warfarin (decrease INR)
38
MOA of BZD - NK1 antagonist DDI
Increase BZD concentration due to reduced metabolism
39
5HT3 antagonist place in therapy
Prevents acute CINV
40
MOA of 5HT3 antagonist
Blocks 5HT3 receptors peripherally in GIT and centrally in medulla
41
Between Ondanstetron and Granisetron, which is longer acting?
Granisetron
42
Adverse effects of 5HT3 antagonist
1. Headache 2. Constipation 3. QTc prolongation !!!!
43
Dexamethasone place in therapy
Prevents acute and delayed CINV
44
Most common AEs of Dexamethasone
1. Transient elevations in glucose 2. Insomnia 3. Anxiety 4. Gastric upset
45
Less common AEs of Dexamethasone
1. Psychosis (paediatric patients) 2. Reactivation of ulcers (take with or after food)
46
What class of medication is Olanzapine?
Atypical antipsychotic
47
Olanzapine place in therapy
Prevents acute and delayed CINV
48
MOA of Olanzapine
Antagonists of multiple receptors involved in CINV - dopamine, serotonin, histamine, cholinergic
49
Dose of Olanzapine
5-10mg OD 2.5mg OD for elderly
50
Adverse effects of Olanzapine
1. Fatigue 2. Sedation 3. Postural hypotension 4. Anticholinergic SEs
51
Metoclopramide place in therapy
Prevents acute CINV in low emetogenic regimens Useful for breakthrough CINV
52
Which agent is useful for breakthrough CINV?
Metoclopramide
53
Adverse effects of Metoclopramide
Mild sedation & diarrhoea Extrapyramidal reactions (e.g. dystonia, akathisia)
54
What drug should be avoided with Metoclopramide?
Olanzapine
55
Why should Metoclopramide and Olanzapine combination be avoided?
Increases risk of extrapyramidal reactions (tardive dyskinesias, neuroleptic malignant syndrome)
56
BZD place in therapy
Useful for anticipatory CINV
57
What agents are useful for anticipatory CINV?
BZDs - alprazolam or lorazepam
58
MOA of BZDs
Binds to BZD receptors on postsynaptic GABA of neuron to enhance inhibitory effect of GABA Leads to sedation, reduction in anxiety and possible depression of the vomiting centre
59
Dose of Alprazolam
PO 0.5-1mg on the night before treatment and 1-2 hours before chemotherapy
60
Dose of Lorazepam
PO 0.5-2mg on the night before treatment and 1-2 hours before chemotherapy
61
Adverse effects of BZDs
1. Drowsiness 2. Dizziness 3. Hypotention 4. Anterograde amnesia 5. Paradoxical reactions (hyperactive, aggressive behaviour)
62
Caution of BZDs
In elderly (risk of falls - prescribe lowest effective dose)
63
Adjunctive agents for CINV
Butyrophenones (haloperidol) Phenothiazines (prochlorperazine, chlorpromazine, promethazine)
64
Adjunctive agents place in therapy
May be considered in refractory CINV
65
Haloperidol MOA
Block dopamine receptors in the chemoreceptor trigger zone
66
Dose of Haloperidol
PO/IV 0.5-2mg q4-6hr
67
Adverse effects of Haloperidol
Sedation, extrapyramidal symptoms
68
MOA of phenothiazines
Block dopamine receptors in the chemoreceptor trigger zone
69
Dose of prochlorperazine
PO 10mg TDS/QDS PRN
70
Adverse effects of phenothiazines
Drowsiness, hypotension, akathisia, dystonia, extrapyramidal symptoms
71
General principle of breakthrough CINV
Additional agent from different drug class (different MOA)
72
Non-pharmacological for CINV (no. 1)
Small, frequent meals Avoid heavy meals
73
Non-pharmacological for CINV (no. 2)
Avoid greasy, spicy, very sweet or salty food, and food with strong flavours or smells
74
Non-pharmacological for CINV (no. 3)
Sip small amount of fluid often instead of a full glass at once
75
Non-pharmacological for CINV (no. 4)
Avoid caffeinated beverages
76
Non-pharmacological for CINV (no. 5)
Avoid lying flat for 2 hours after eating
77
Anticipatory CINV
1. Prevention 2. Behavioural therapy 3. Acupuncture/acupressure 4. Consider use of BZDs before treatment
78
Behavioural therapy for anticipatory CINV
a. Relaxation/systematic desensitisation b. Hypnosis/guided imagery c. Music therapy

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