Drugs 4 Supportive Care in Oncology Flashcards
(45 cards)
1
Q
CA complications from the disease
A
- superior vena cava syndrome
- spinal cord compression
- brain metastases
2
Q
CA complications from chemo tx
A
- N/V
- mucositis
- hemorrhagic cystitis
- hypercalcemia
- Febrile Neutropenia
- tumor lysis syndrome
- extravasation
3
Q
Chemo-Induced N/V key receptors
A
-
5-HT3 receptors: located in the chemoreceptor trigger zone (near BBB)
- chemo agents → stimulate enterochromaffin cells in GI which release serotonin → binds to receptors → N/V
- Neurokinin-1 (NK1) receptors: in emetic center of medulla
- domapine receptors
- muscarinic receptors
- histamine receptors
- cannabinoid receptors
4
Q
Chemo-Induced N/V Risk Factors
A
- chemo-regimen
- radiation (esp total body) [+chemo? → more severe]
- female >male
- children > adults
- h/o motion sickness
- pregnancy-induced N/V
- poor emetic control in previous chemo tx
- ppl who drink more alcohol than usual tolerate it better or it is much worse
5
Q
Types of Chemotherapy-Induced N/V
A
-
Acute:
- occurs within 24 hours after chemo tx
-
Delayed:
- 24 hours to 5 days after chemo tx
-
Anticipatory
- occurs before chemo tx
- d/t previous experience of poor control
- risks: poor emetic control; female; young age; low chronic EtOH intake
- occurs before chemo tx
-
Breakthrough:
- occurs despite prophylaxis
6
Q
Antiemetic Drugs + Dosing
A
-
5-HT Serotonin Receptor Antagonists
-
“-setron”
- Dolasetron: 100 mg IV and PO
- Granisetron: 1-2mg PO, IV, Topical
-
Ondansetron: PO, IV 8-16 mg
- → >32mg = QT prolongation
- Palonosetron: highest potency; PO, IV 0.25-0.5mg
-
“-setron”
-
Others:
- Aprepitant: PO 125mg NK-1 antagonist
- Fosaprepitant: IV 150mg NK-1 antagonist
- Dexamethasone: PO 12mg Corticosteroid
7
Q
Mucositis
A
- degradation of mucosal lining in oral and GI systems by chemo or radiation → d/t lack of regeneration
-
Consequences:
- “White Patches”
- Pain, inadequate nutritional intake, risk of infx → bacterial, fungal, or viral
-
Tx:
- cryotherapy → ice chips
- Antimicrobial lozenges (i.e. Mycelex: clotrimazole troche)
- Sucralfate: GI med/antacid used to relieve pain and moisturize the mucus membrane
- Chlorhexidine rinses (Hibiclens)
- “Magic Mouthwash” → benadryl + Maalox (antacid) +/- Nystatin +/- TCN +/- lidocaine
- PO morphine for pain
8
Q
Palifermin (Keprivance)
A
- MOA: recombinant human keratinocyte growth factor → enhances epithelial cell proliferation
-
Indication: mucositis prophylaxis and Tx
- pts receiving high does chemo for stem cell transplant or leukemia induction
- Dosing: 60mcg/kg/IV 3 days before → wait 24-48hrs → chemo tx → wait 24-48 hours → and x 3 days after myelotoxic tx
-
Avoid within 24 hours before or after chemo → increases severity and duration of mucositis
- → chemo will target the rapidly growing new tissue
-
SEs:
- Rash, fever, pruritus, edema, tongue discoloration, thickening and taste change
- arthralgias
- HTN → monitor before and after drug therapy
9
Q
Definition of Febrile Neutropenia
A
- ANC < 500 cells/mcL OR ANC <1000 cells/mcL with predicted decrease to <500 cells/mcL
- T≥ 38C (100.4F) x 1 hour
- T≥ 38.3C (101F)
10
Q
ANC calculation
A
ANC = absolute neutrophil count
ANC = WBC x % neutrophils (both segs and bands)
11
Q
Risk factors for Febrile Neutropenia
A
-
Patient Related:
- age 60+
- poor performance status
- bone marrow involvement by tumor
- poor nutrition
- hematologic malignancy
- elevated LDH
- decreased hgb level
-
Therapy Related:
- hx of extensive chemo
- planned full dose intensity of chemo
- high dose chemo
12
Q
MASCC Risk Index for Febrile Neutropenia
A
Score ≥ 21 = low risk for complications and morbidity
- severity of sxs, hypotension, COPD, dehydration, outpt onset of fever, age <60, solid tumor or hematologic malignancy without fungal infx
13
Q
Colony Stimulating Factor
A
used to stimulate bone marrow to produce neutrophils
-
Stimulation of Neutrophils:
- Filgrastim (Neupogen): 5mcg/kg/day SC or IV but round to 300 or 480 vial size b/c vial is expensive
- Pegfilgrastim (Neulasta): 6 mg SC once per cycle
- SEs for both : bone pain approx 25% of pts
-
Stimulation of Neutrophils + Eosinophils + Macrophages:
-
Sargramostim (Leukine GM-CSF): 250mcg/m2/day ( based on body surface area)
- or round to 250-500mcg vial size
- SEs:
- hypotension, flushing
- low-grade fever
- bone pain
- injection site rxn
-
Sargramostim (Leukine GM-CSF): 250mcg/m2/day ( based on body surface area)
14
Q
Oral Tx for Low Risk Febrile Neutropenia
A
Cipro + Augmentin → if afebrile within 3-5 days of tx and etiology not identified continue with Cipro + Aug or switch from previous med to cipro +Aug
Children: Cefixime
Then discharge
15
Q
IV Tx for Low Risk Febrile Neutropenia
A
Vancomycin not needed
-
Monotherapy:
- cefepime
- ceftazidime or Carbapenem
-
Two Drugs:
-
Aminoglycoside and
- Antipseudomonal penicillin
- Cefepime
- ceftazidime or carbapenem
-
Aminoglycoside and
- Reassess after 3-5 days:
- if afebrile and no etiology switch to Cipro + Aug
- if afebrile + etiology → adjust to appropriate meds
16
Q
IV tx for high risk febrile neutropenia → no risk of MRSA
A
-
Monotherapy:
- cefepime
- ceftazidime or Carbapenem
-
Two Drugs:
-
Aminoglycoside and
- Antipseudomonal penicillin
- Cefepime
- ceftazidime or carbapenem
-
Aminoglycoside and
-
Reassess after 3-5 days:
- if afebrile and no etiology switch to Cipro + Aug
- if afebrile + etiology → adjust to appropriate meds
17
Q
IV tx for high risk febrile neutropenia → risk of MRSA
A
Vancomycin needed
-
Vancomycin and:
- cefepime, ceftazidime or carbapenem, meropenem with or without aminoglycoside (gentamicin or tobramycin)
-
if after 3-5 days still fever:
-
if no change in condition
- continue abx, consider d/c vanco
-
if worsening disease and if criteria for vanco are met:
- change abx
-
if febrile through days 5-7 and resolution of neutropenia not imminent:
- antifungal drug with or without abx change
-
if no change in condition
18
Q
Antifungals used for febrile neutropenia
A
amphotericin B (premedicate with acetaminophen and diphenhydramine), liposomal amphotericin B, caspofungin, voriconazole, posaconazole
19
Q
Chemo-Induced Hemorrhagic Cystitis Definition and Causes
A
- Definition: acute or insidious bleeding from the lining of the bladder
-
Causes:
-
High Dose Cyclophosphamide (Cytoxan) → used for non-hodgkin lymphoma
- cyclophosphamide = not toxic to bladder → metabolite acrolein (which is secreted in the urine) causes edema and bladder hemorrhage
-
Ifosfamide (Ifex) → used for germ cell testicular CA or soft tissue and bone sarcomas
- causes the release of tumor necrosis factors-alpha and interleukin -1-beta → releases nitric oxide → causes hemorrhagic cystitis
- → also releases acrolein
- Worse than cyclophosphamide
-
High Dose Cyclophosphamide (Cytoxan) → used for non-hodgkin lymphoma
20
Q
Prevention of Hemorrhagic Cystitis
A
-
Mesna (2-mercaptoethane sulfonate)
- binds to acrolein → eliminates it
- T ½ much shorter than Cytoxan (Cyclophosphamide) and Ifex (Ifosfamide) → need to give Mesna thorugh and after the chemo infusion
- PO Mesna dose = 2x IV dose (need to double PO dose due to 50% bioavailability)
-
Hyperhydration to dilute
- 2L 12-24 hours before chemo; 2L 24-48 hours after last dose of chemo + Lasix IV to maintain urine output >100mL/hr
-
bladder irrigation with catheterization
- NS 250mL -1L/hr to flush acrolein from bladder
- binds to acrolein → eliminates it
21
Q
Causes of hypercalcemia of malignancy
and review of Ca2+ balance
A
- occurs 10-30% → most common = breast cancer, squamous cell carcinomas of head and neck, renal CA, lung CA
- Ca2+ level balance:
- PTH:
- increased renal tubular resorption
- increased bone resorption (breakdown)
- 1,25-dihydroxyvitamin D
- increased Ca2+ absorption from gut
- calcitonin:
- decreased osteoclast activity
- stimulates ca2+ deposition in bone
- PTH:
22
Q
How to calculate corrected Calcium
A
serum Ca2+ + (0.8)(4- serum albumin)
23
Q
Hypercalcemia levels and s/sxs
A
- Levels:
- Normal = 8.5-10.5
- Mild = 10.5-11.9
- Mod = 12-13.9
- Severe = >14
- S/sxs
- anorexia, N/V, constipation
- bradycardia, ECG abn, arrhythmias
- muscle/bone: weakness, bone pain, fatigue, ataxia
- CNS: confusion, HA, seizure, coma
24
Q
Bisphosphonate drugs
A
used to tx hypercalcemia
deposits in bone matrix and inhibits osteoclast function
- Pamidronate 60-90mg IV over 2-24 hours
-
Zoledronic Acid 4mg IV over 15 minutes
- also used for osteoporosis
- SEs:
- fever, renal dysfunction
- pamidronate = less expensive
25
Tx of mild hypercalcemia of malignancy
mild = 10.5-11.9
tx the underlying malignancy
* asymptomatic:
* encourage ambulation and increase fluid intake
* if refractory → saline hydration + bisphosphonate +/- furosemide for fluid overload
* if refractory (5-7 days) → repeat bisphosphonate, continue hydration
* if refractory → calcitonin, gallium nitrate, steroids
* if refractory → dialysis
26
Tx of mod/severe hypercalcemia of malignancy
mod-severe = 12-13.9, or \>14
* triple therapy:
* saline hydration + bisphosphonate + calcitonin +/- furosemide for fluid overload
* if refractory → dialysis
27
Tumor Lysis Syndrome
occurs in high tumor burden malignancies or high proliferative rates
* _S/sxs_: uremia, visual disturbances, muscle cramping, edema, HTN, arrhythmias, seizure
* _Dx_: based on labs → occurs 3 days before or 7 days after chemo Tx
* Hyperuricemia \>8
* Hyperkalemia \> 6
* Hyperphos \>4.5
* Hypocalcemia \<7
* Renal dysfunction
* _S/sxs_: uremia, visual disturbances, muscle cramping, edema, HTN, arrhythmias, seizure
28
Risks for TLS
* High Risk:
* ALL, AML high grade non-hodgkin's lymphoma (Burkitt's Lymphoma)
* elevated Uric Acid Level (≥ 10)
* WBCs \>50K
* kidney tumor infiltration
* LDH greater than 2x normal
* Low Risk:
* CML, solid tumor, hodgkin's disease
* Normal uric acid levels (\<10)
* WBCs ≤ 50K
* no tumor infiltration in kidneys
* LDH ≤ 2x normal
29
TLS tx/ prophylaxis
Goals: prevent renal failure and electrolyte imbalance
* _Low Risk_:
* **oral _allopurinol_** (IV if unable to tolerate or take oral meds)
* daily monitoring of uric acid → _if normal then_ continue through cytotoxic therapy
* _if uric acid levels increase_ → switch to rasburicase daily
* _High Risk_:
* **_Rasburicase_ dose** *prior* to cytotoxic therapy
* monitoring uric acid every 6 hours
* _if uric acid levels are normal_ → do not continue
* _if uric acid levels increase_ → **administer daily until normalize**
30
Allopurinol
inhibits **xanthine oxidase:** prevents the creation of uric acid
use in _prophylaxis and tx of_ **_tumor lysis syndrome_** → *low risk patients*
31
Rasburicase
converts Uric Acid Levels to **allantoin**
used in the prophylaxis and tx of **_tumor lysis syndrome_** → high risk pts
\*\*\*Expensive\*\*\* $12,000/day
32
Sucralfate
used to tx **mucositis** → GI med (antacid) used to coat the mouth and form a protective barrier
33
Antiemetics used for high risk (\>90&) of CINV
* **5-HT3 serotonin receptor antagonist**: day 1
* **Dexamethasone**: days 1-4
* **Aprepitant**: days 1-3 or **fosaprepitant** (_IV formulaiton)_ day 1 only
34
Antiemetics used for Moderate risk (30-90%) with tx CINV
* without tx:
* **5HT3 serotonin receptor antagonist**: day 1
* **dexamethasone**: day 1
* With Tx (anthracycline, carboplatin, cisplatin, irinotecan cyclophosphamide, methotrexate)
* **5HT3 serotonin receptor antagonist**: day 1
* **dexamethasone:** days 1-3
* **_Aprepitant_:** days 1-3
35
Antiemetics used for low risk CINV pts
**dexamethasone**: day 1 PRN or **D2 antagonists** (compazine, reglan)
36
Aprepitant
NK-1 antagonist
PO: 125mg (PO formulation)
used to tx **chemo-induced N/V**
37
Fosaprepitant
NK-1 antagonist
IV: 150mg (IV formulation)
used to tx **chemo-induced N/V**
38
5-HT3 Serotonin Receptor Antagonists
“**D**on't **G**o **O**ut **P**uking”
* **Dolasetron**: 100mg (PO or IV)
* **Granisetron**: 2mg PO or 1 mg IV
* **Ondansetron**: 16-24 mg PO, 8mg IV
* dose \>32 mg = QT prolongation
* **Palonosetron**: 0.5mg PO, 0.25 IV
39
Filgrastim (Neupogen GCSF)
Colony Stimulating Factor for Neutropenia
Neutrophil = effector cells
* 5mcg/kg/day SC or vIV or round to 300 or 480 mcg vial size
* _SEs_: **bone pain**
* begin 1-3 days after chemo
40
Pegfilgrastim (Neulasta)
Colony stimulating Factor used in neutropenia
**longer half life than filgrastim**
* only stimulates neutrophils
* given 1-3 days after chemo, once per cycle dosing
* _SEs_: **bone painb**
41
Sargramostim (Leukine GM-CSF)
Colony stimulating Factor used **after induction of chemo in elderly AML (Acute myeloid leukemia) pts**
* effector cells = neutrophil, eosinophil, macrophage
* dosing: based on **body surface area**
* _SEs:_ first dose effects: flushing, hypotension
* low grade fever
* bone pain
* injection site rxn
42
Mesna (2-mercaptoethane-suflonate)
**prevents hemorrhagic cystitis**
* binds to _acrolein_ and eliminates it
* **PO dose = 2x IV dose**
* very high first pass effect → low bioavailability
* T½ = much shorter than **Cyclophosphamide** (Cytoxan) and **Ifosfamide** (Ifex)
43
Pamidronate
used to tx hypercalcemia
**bisphosphonate** drug → deposits in bone matrix and *inhibits osteoclast function*
* does not last as long as Zoledronic acid
* less expensive
* SEs:
* fever, renal dysfunction
44
Zoledronic Acid
used to tx hypercalcemia
**bisphosphonate** drug → deposits in bone matrix and *inhibits osteoclast function*
* lasts longer than pamidronate
* used for osteoporosis
* _SEs_: fever, renal dysfunction
* more expensive than pamidronate
45
Gallium Nitrate
used for refractory tx of Mild symptomatic hypercalcemia
**inhibits calcium resorption in bone**
* do not admin if Cr \>2.5mg/dL
