CINV

Question 1

What is the MOA of serotonin antagonists?

Answer 1

These block serotonin receptors in the:

CNS: CTZ and vagal afferents (5-HT3-receptors)

Periphery: inhibits serotonin release from gastrointestinal tract

Question 2

What are the generic/brand names of 5-HT3 RAs?

Answer 2

Dolasetron (Anzemet)
Granisetron (Kytril)
Ondansetron (Zolfran)
Palonosetron (Aloxil)

Question 3

Zolfran doses for CINV treatment are:

Answer 3

High emotogienticity:
16-24 mg prior to chemo

Moderate: 8 mg PO Q8-12 hrs.

IV: 0.15 mg/kg/dose (MAX 16 mg/dose). Subsequent doses may be repeated 4 and 8 hrs after the 1st dose

Question 4

When should 5-HT3 RAs be used in CINV?

Answer 4

These are standard therapy for highly and moderately emetogenic chemo.
They are used synergistically with corticosteroids.
Oral and IV dosage forms are equally efficacious.
Antiemetic effect > anti-nausea effect

Question 5

What ADRs are associated with 5-HT3 RA use?

Answer 5

Generally well tolerated.
Common: HA, constipation
Severe: QTc prolongation

Question 6

When should dexamethasone (Decadron) be used for CINV?

Answer 6

Not effective as monotherapy for highly or moderately emetogenic regimens.
Very effective in preventing delayed CINV due to synergistic effects.

Question 7

ADRs associated with Decadron are:

Answer 7

Insomnia
Anxiety
Increased appetite
Rise in blood glucose levels
Many many more

Question 8

What is the MOA is NK1 antagonists?

Answer 8

Substance P is a neuropeptide which binds to NK1 receptor in abdominal afferent vagal nerves and CTZ resulting in emesis.

NK1 antagonists have high-affinity for human substance P/NK1 receptors.

Question 9

NK1 antagonists cause which ADRs?

Answer 9

Hiccups
Dyspepsia
Constipation
Diarrhea
HA
Fatigue

Question 10

What agents are NK1 antagonists?

Answer 10

Aprepitant (Emend)
Fosaprepitant (Emend for injection)
Netupitant/palonosetron (Akynzeo)
Rolapitant (Varubi)

Question 11

When are BZDs used in CINV?

Answer 11

Anticipatory and breakthrough CINV

Question 12

Which BZD is commonly used in CINV?

Answer 12

Lorazepam (Ativan)
0.5-2 mg PO/IV/SL Q4-6H PRN
Max 2 mg/dose

Question 13

ADRs caused by BZD use are:

Answer 13

Sedation
Amnesia
Dizziness
Unsteadiness

Question 14

What is the MOA of phenothiazines?

Answer 14

Blockade of dopamine receptors in the CTZ

Question 15

When are phenothiazines used?

Answer 15

Breakthrough treatment of delayed CINV.

Has rapid onset

Question 16

Which agents are classified as phenothiazines?

Answer 16

Prochlorperazine (Compazine)

Promethazine (Phenergan)

Question 17

ADRs of phenothiazines are:

Answer 17

Sedation

EPS

Question 18

What is the MOA of metoclopamide (Reglan)?

Answer 18

It’s antiemetic MOA is via inhibition of central and peripheral dopamine receptors.

Question 19

When is Reglan used?

Answer 19

Delayed CINV

For higher doses, co-administered with diphenhydramine and lorazepam to prevent EPS

Question 20

ADRs of Reglan are:

Answer 20

EPS
Drowsiness
Restlessness
Fatigue
Diarrhea

Question 21

What is the MOA of olanzapine (Zyprexa)?

Answer 21

Blocks dopamine, serotonin, histamine, and acetylcholine.

Question 22

What is the MOA of haloperidol (Haldol)?

Answer 22

It is a dopamine receptor antagonist

Question 23

When are antipsychotics used in CINV?

Answer 23

Prophylaxis for highly and moderately emetogenic regimens (olanzapine)

As a rescue med for breakthrough CINV

Question 24

What are the ADRs for olanzapine?

Answer 24

Disturbed sleep
Fatigue
Drowsiness
Dry mouth

Question 25

ADRs of Haldol include:

Answer 25

EPS Dystonic reactions HA QT prolongation (rare)

Question 26

BBW associated with antipsychotics are:

Answer 26

Use in caution with elderly patients and dementia: antipsychotics increase risk of mortality

Question 27

Which 2 agents are used to treat EPS?

Answer 27

Diphenhydramine and Benztropine

Question 28

What is the MOA of cannabinoids?

Answer 28

Direct inhibition of neurotransmitters via agonist of CB1 CNS receptor

Question 29

When are cannabinoids used in CINV?

Answer 29

In refractory cases

Question 30

Which agents are cannabinoids?

Answer 30

Nabilone (Cesamet) | Dronabinol (Marinol)

Question 31

ADRs associated with cannabinoids are:

Answer 31

Sedation Dysphoria or euphoria Concentration difficulties Paranoia

Question 32

What is the MOA of scopolamine transdermal patch (Transdermal Scop)?

Answer 32

It is an anticholinergic/antimuscarinic agent. It works in the CNS by blocking cholinergic transmission to the vomiting center.

Question 33

When is scopolamine used in CINV?

Answer 33

Refractory CINV associated with motion or dizziness

Question 34

ADRs caused by Transderm Scop used are?

Answer 34

Dry mouth Somnolence Blurred vision

Question 35

High emetic risk IV agents (>90%) are:

Answer 35

``` AC (doxorubicin/epirubicin with cyclophosphamide Cisplatin Cyclophosphamide > 1500 mg/m2 Doxorubicin > 60 mg/m2 Ifosfamide >= 2 g/m2 ```

Question 36

Mod emetic risk IV agents (30-90%) are:

Answer 36

``` Busulfan Carboplatin Cyclophosphamide = 1500 mg/m2 Doxorubicin < 60 mg/m2 Irinotecan Methotrexate >= 250 mg/m2 ```

Question 37

Low emetic risk agents (10-30%) are:

Answer 37

Docetaxel Doxorubicin liposomal 5-FU Paclitaxel (including albumin bound)

Question 38

Mod to high emetic risk oral agents are:

Answer 38

Busulfan >= 4 mg/d Ceritinib Crizotinib

Question 39

Min to low emetic risk oral agents are:

Answer 39

‘’Nib’’ | Capecitabine

Question 40

Patient specific risk factors for CINV are:

Answer 40

``` Female < 50 yo History of motion sickness Pregnancy-related nausea Lack of alcohol use History of anxiety or depression Prior chemo use ```