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IPFC 6 > Dermatologic toxicity + Hormonal > Flashcards

Dermatologic toxicity + Hormonal Flashcards

(42 cards)

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1
Q

What kind of dermatologic toxicity do cytotoxic chemotherapy cause (4)

A
  • Alopecia
  • Acral erythema/ hand-foot syndrome
  • Photosensitivity
  • Hyperpigmentation
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2
Q

What kind of dermatologic toxicity do targeted therapies cause (5)

A
  • Macular/papular rash
  • Acral erythema/ hand-foot syndrome
  • Acneinform EGFR rash
  • Photosensitivity
  • Keratocanthomas and squamous cell carcinoma
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3
Q

What kind of dermatologic toxicity do Immunotherapies cause (#)

A
  • Dermatitis
  • Alopecia areata
  • Bullous pemphigoid
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4
Q

When does alopecia occur?
Temporary/permanent

A

7-14 days after treatment
Usually temporary

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5
Q

What is used for prevention in alopecia? When can it be used

A

Cold caps during chemo
- can only use for curative intent

Wide tooth combs + satin pillowcases
- reduces friction/damage to hair

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6
Q

Differentiate between Hand-foot Syndrome (HFS) and Hand-foot skin reaction (HFSR)
Area it affects
Causative agent

A

HFS
- Generalized, affects entire palms and soles
- Capecitabine (cytotoxic 5-FU type agent)

HFSR
- Localized, thickened area
- Pain, blistering, desquamation
- Sorafenib (targeted agent)

BOTH
- dryness, redness, numbness and tingling of palms and soles

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7
Q

How treat the following grading of HFS and HFSR
Grade 1
Grade 2
Grade 3

A

Grade 1
- Maintain dose level

Grade 2
- 1st appearance: interrupt therapy until resolved (for HFSR, reduce dose too)
- 2nd appearance: interrupt therapy until resolved, reduce dose
- 3rd appearance: interrupt therapy until resolved, reduce dose
- 4th appearance: D/C therapy

Grade 3
- 1st appearance: interrupt therapy until resolved, reduce dose
- 2nd appearance: interrupt therapy until resolved, reduce dose
- 3rd appearance: D/C therapy

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8
Q

What to treat sunitinib with HSFR

A

Interrupt dose for grade 3
- consider reducing dose or stretching out frequency

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9
Q

What are prevention methods of HFS and HFSR (5)

A

Prevention:
- Frequent moisturizing
- Avoiding sources of heat (washing dishes)
- Avoid friction (tight shoes, gardening)
- Topical diclofenac for capecitabine HFS
- 10-20% urea cream for HFSR prevention (prevents thickening)

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10
Q

Treatment of HFS and HFSR

A

Withhold causative agent
Ice packs (not if Xelox use oxaliplatin + Capecitabine)
Oral and topical pain relievers

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11
Q

Which cancer agent causes the most maculopapular rash

A

TKIs

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12
Q

What is the treatment for maculopapular rash
Grade 1: <10% BSA
Grade 2: 10-30% BSA
Grade 3: 30%+ BSA

A

Grade 1: <10% BSA
- Oral antihistamine (loratadine)
- Menthol cream

Grade 2: 10-30% BSA
- Same as grade 1
- Add a topical corticosteroid (clobetasol 0.05%)

Grade 3: 30%+ BSA
- Refer to a dermatologist

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13
Q

What does the EGFR rash present as?
Correlates with?
Onset?

A
  • It is acneiform (acne mimicking)
  • Correlates with efficacy
  • Develops 8-10 days into treatment
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14
Q

What are the 4 rash phases of EGFR

A

Phase 1: Sensory disturbance with erythema (itch, redness) (week 0-1)

2 – papulopustular eruption (week 1-3)
3 – crusting (weeks 3-5)
4 – eythematotelangiectasias (weeks 5-8)
(red areas of blood vessels)
(lesions gone by 2 months)

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15
Q

Treatment for EGFR rash
Grade 1: <10% BSA
Grade 2: 10-30% BSA
Grade 3-4: 30%+ BSA

A

Grade 1
- continue same dose
- topical clindamycin 2% + HC 1% lotion for 4 weeks

Grade 2
- continue same dose
1. Topical clinda + HC lotion
2. AND minocycline/doxycycline 100mg BID for 4 weeks

Grade 3-4
- consider reducing dose
- Treat as grade 2
ADD 0.5mg/kg prednisone for 7-14 days
- if no improvement consider discontinuation
- rarely use isotretinoin in practice if does not work

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16
Q

What can be used for EGFR rash prophylaxis (2)

A

Monocycline/doxycyline 100-200mg daily

Topical hydrocortisone 1% once-BID

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17
Q

Nonpharm strategies for EGFR rash

Study These Flashcards
A
  • Thick, alcohol-free emollient cream on dry area
  • Non irritating and alcohol free cleanser
  • Sunscreen of SPF 15+ (with zinc oxide or titanium dioxide)
  • Adequately hydrate
  • Avoid HOT water
  • Avoid tight-fitting clothing

Anti-itch: cool compresses + antihitamines

Make-up: ok to use concealer, remove makeup with cetaphil or neutrogena (mild cleanser)

18
Q

What cancer agents is photosensitivity associated with (4)

Study These Flashcards
A

Noted with:
- Methotrexate
- 5-FU
- Dacarbazine
- BRAF-inhibitors (especially if monotherapy or with MEK inhibitors)

19
Q

Photosensitivitiy
Prevention (3)
Management (2)

Study These Flashcards
A

Prevention
- Avoid sun exposure
- High SPF sunblock
- Cover all areas (even if exposed for a short-time)

Management
- topical steroids
- Cool compresses

20
Q

Which class of cancer agent is associated with Keratoacanthomas (KA) and Squamous Cell Carcinoma (SCC)

Study These Flashcards
A

BRAF inhibitors

21
Q

Keratoacanthomas (KA) and Squamous Cell Carcinoma (SCC) treatment

22
Q

Which cancer class therapies cause immunotherapy rash (skin rash) (3)

Study These Flashcards
A
  • PD-1
  • PD-L1
  • CTLA-4
23
Q

Immunotherapy rash treatment
Grade 1: <10% BSA
Grade 2: 10-30% BSA
Grade 3: 30%+ BSA
Grade 4: Skin sloughing (dead skin)

Study These Flashcards
A

Grade 1
- Traimcinolone/Fluocinonide (mild steroids)
- Continue treatment

Grade 2
- Traimcinolone/Fluocinonide (mild steroids)
- Continue treatment

Grade 3
- HOLD agent
- Give PO or IV steroids (IV if severe)
- Derm consult

Grade 4
- D/C agent
- IV steroids
- Derm consult

24
Q

What are common toxicity symptoms with anti-estrogenic agents (5)

Study These Flashcards
A
  • Hot flashes
  • Arthralgias
  • Nausea
  • Fracture (with aromatase inhibitor)
  • Vaginal dryness
25
What drugs are used to manage hot flashes (4 classes)
Antidepressants (SSRIs/SNRIs): - Citalopram - Desvenlafaxine/Venlafaxine - Paroxetine (Paroxetine should not be use with Tamoxifen for hot flashes) Anticonvulsants: Gabapentin, Pregabalin Antihypertensive: Clonidine (possible efficacy) Alternative therapy: Relaxation training, hypnosis (possible efficacy)
26
Management of Arthralgias (4)
Duloxetine Other options (less evidence): Exercise, acupuncture Supplement: Omega-3 fatty acid (for obese patients) Short break/switching agents: - SWITCHING anastrozole -> letrozole has relieved arthralgia for some
27
Management of Vaginal dryness
Replens gel - topical estrogen safety debated
28
What ADRs are associated with Abiraterone (CYP17a inhibitor) (2)
Mineralcorticoid in nature - Hypertension - Hypokalemia - Edema Liver toxicity
29
How to treat the following abiraterone ADRs Mineralcorticoid ADR Liver toxicity
Mineralcorticoid ADR - Prednisone 10mg daily Liver toxicity - Grade 3 elevation in AST/ALT or Bilirubin: = HOLD + reduce to 500mg/day once LFTs return to baseline - Grade 4 elevation in AST/ALT or Bilirubin: = STOP Abiraterone
30
What are the ADRs of androgen deprivation therapy (4)
- Hot flashes - Loss of libido and ED - Fatigue - Mood changes
31
Androgen-deprivation management.. Hot flashes (3) Loss of libido and ED (2) Fatigue (2) Mood changes (1)
Hot flashes (3) - Venlafaxine - Gabapentin - Clonidine Loss of libido and ED (2) - Exercise and healthy lifestyle change - Medical therapies (caverject, vacuum pump) (VIAGARA does not work here) Fatigue (2) - Exercise (even a 10-min walk is important) - Methylphenidate Mood changes (1) - Depression screening
32
Differentiate between MOA of the checkpoint inhibitors CTLA-4i PD-1i PD-L1
CTLA-4i - T-cell primer PD-1i - Prevent T-cell inhibition - work on receptor PD-L1 - Prevent T-cell inhibition - work on ligand
33
ADRs of checkpoint inhibitors (5) Which drug is the worst?
- Rash/pruritis (managed with steroids) - Enterocolitis (both small and large intestine) - Hepatotoxicity - Pneumonitis (alevoli inflammation) - Endocrinopathy (in order of onset of presentation) Ipilimumab is more pronounced - CTLA-4i
34
Immune-related dermatitis (rash) treatment Grade 1-2 (30% or less) Grade 3: (30%+) Grade 4: (30%+ life-threatening)
Grade 1-2: - CONTINUE agent - Sun safety, moisturizer, mild soap, - Topical steroids - Diphenhydramine (benadryl) (antihistamine) Continue for 1-2 weeks - if no improvement, HOLD agent + start PO steroid-> taper Grade 3: - HOLD agent - PO or IV steroid -> taper Grade 4: STOP agent - PO or IV steroid -> taper
35
T/F immune-mediated colitis can present without diarrhea
True
36
Management of Enterocolitis Grade 1: <4 stools/day Grade 2: 4-6 stool/day Grade 3: 7+ stools/day Grade 4: Life-threatening colitis, perforation
Grade 1: - CONTINUE agent - antidiarrheal management Grade 2: - HOLD agent - Antidiarrheal management. - If persists past 3-5 days start PO steroid Grade 3: - HOLD agent - Prednisone PO (unless bowel perforation) - If no improvement in 5 days (or recurrence), intensify with infliximab Grade 4: STOP agent - Prednisone PO (unless bowel perforation) - If no improvement in 5 days (or recurrence), intensify with infliximab
37
How to manage immune-related hepatitis? Define Grade 2 Grade 3-4
Grade 2: - AST/ALT 3-5x ULN OR total bilirubin 1.5-3x ULN - HOLD agent, reassess in 5-7 days - If no improvement, Prednisone PO Grade 3-4: - AST/ALT >5x ULN OR total bilirubin >3x ULN OR significant increase with liver metastases - STOP therapy, start prednisone PO -> taper - If no improvement in 5-7 days, consider non-steroid immunosuppressive (mycophenolate)
38
What are the types of immune-related endocrinopathies (3)
Hypophysitis (inflammation of pituitary gland): - Headache at first - then confusion, hallucination, impaired vision, hypotension, impotence (altered mental state) Hypothyroidism: - (fatigue, cold feeling, etc..) Adrenal toxicity: - hypotension, hypoglycemia - vomiting, weight loss, pigmentation - hypokalemia, hyponatremia
39
Enddocrinopathy treatments - Asymptomatic TSH - Symptomatic endocrinopathy - Suspicion of adrenal crisis
Asymptomatic TSH elevation: - Continue therapy, monitor Symptomatic endocrinopathy: - HOLD (don't stop) treatment + PO steroids - Hormone replacement if needed (based on labs/pituitary scan) Suspicion of adrenal crisis: - HOLD (don't stop) treatment-> IV steroids + IV fluids
40
How does immune-related pneumonitis present?
- SOB - Dry cough - inc O2 requirements - can detect on imaging (can be asymptomatic)
41
What are risk factors for pneumonitis (5)
- NSCLC (lung cancer) with chronic lung inflammation - Heavily pretreated patients - Combination of CTLA-4 and PD-1 agents - Prior lung radiation - History of COPD
42
Treatment of immune related pneumonitis Grade 1: (radiographic changes only) Grade 2: (mild-mod sx) Grade 3-4: (severe)
Grade 1: - Consider HOLDING agent - monitor Q2-3 days Grade 2: - HOLD agent - PO prednisone + lung testing/scans Grade 3-4: - STOP agent - PO prednisone + Prophylactic ABX - If worsening after 2 days, consider non-steroid immunosuppressive agents (infliximab, cyclophosphamide, mycophenolate)

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