GI toxicities

Question 1

What is mucositis?

Answer 1

Inflammatory, ulcerative lesions of the oral and/or GI tract

Question 2

What is the cell turnover for the GI tract?

Answer 2

7-10 days

Question 3

What is the incidence of mucositis in HD chemotherapy and HSCT?

Answer 3

100%

Question 4

What are the sx of mucositis?

Answer 4

Pain
Ab bloating
NVD
Constipation

Question 5

What drugs cause mucositis?

Answer 5

Anthracyclines
Bleomycin
Cyclophosphamide
Taxanes
Vinca alkaloids
5-FU
Capecitabine
Cytarabine
Gemicitabine
Hydroxyurea
MTX
Pemetrexed

Question 6

What are the consequences of mucositis?

Answer 6

Delayed therapy
Reduction in chemo intensity
Increased hospital stays
Poor nutrition status
Increased risk of infection

Question 7

What are the WHO grade scale for oral mucositis?

Answer 7

Grade 0: no oral mucositis
Grade 1: Erythema and soreness
Grade 2: Ulcers, able to eat solids
Grade 3: Ulcers, requires liquid diet
Grade 4: Ulcers, unable to eat anything

Question 8

What is the prevention of cystitis?

Answer 8

Oral hygiene
Oral cryotherapy
Oral zinc supplementation
Treat dental issues
Nutrition and hydration

Question 9

What is used for sx control of mucositis?

Answer 9

Magic mouthwash
Pain control (opioids/PCA)

Question 10

What is treatment of mucositis?

Answer 10

Palifermin

Question 11

What is palifermin?

Answer 11

Keratinocyte growth factor

Question 12

How does palifermin work?

Answer 12

Promotes epithelial cell proliferation, differentiation and migration

Question 13

What are AEs of palifermin?

Answer 13

Rash
Edema
Taste disturbances
Arthralgias

Question 14

What is xerostomia?

Answer 14

Dry mouth

Question 15

What is amifostine used for?

Answer 15

Xerostomia in radiation of the head and neck

Question 16

What disease does amifostine reduce?

Answer 16

Esophagitis with chemo+radiation for NSCLC

Question 17

What drugs cause diarrhea?

Answer 17

Irinotecan
5-FU/capecitabine
Cytarabine
MTX
TKI
Anti-EGFR therapy
HD conditioning regimens for SCT

Question 18

What grade is classified as uncomplicated diarrhea?

Answer 18

Grades 1-2 w/no added RFs

Question 19

How many stools per day are in grades 1-2?

Answer 19

<4-6 per day

Question 20

What grade is classified as complicated diarrhea?

Answer 20

Grade 3-4 or Grade 1-2 w/presence of any added RF

Question 21

What are added RFs for diarrhea?

Answer 21

Mod-severe cramping
Sepsis
Grade 2+ N/V
Neutropenia
Decreased performance status
Blood in stool
Fever
Dehydration

Question 22

Where is uncomplicated diarrhea treated?

Answer 22

Outpatient

Question 23

What are ways to manage uncomplicated diarrhea?

Answer 23

D/C lactose-containing products and EtOH
Increase fluid intake (8-10 large glasses of clear liquid/day)
Small, frequent meals
BRAT diet
Lactobacillus for prevention
Loperamide

Question 24

If a patient has grade 2 diarrhea after chemo, what do we do?

Answer 24

Hold chemo until sx resolve and reduce dose w/next cycle

Question 25

What is the loperamide dose?

Answer 25

4mg, then 2mg every 4 hours

Question 26

What is the max daily dose of loperamide?

Answer 26

16mg/d (exception: irinotecan)

Question 27

When do we DC loperamide?

Answer 27

Diarrhea free for at least 12 hours | Diarrhea persists for more than 48 hours

Question 28

What is a 2nd line anti-diarrheal agent?

Answer 28

Octreotide Diphenoxylate/atropine Tincture of opium

Question 29

How do we adjust dose of loperamide if diarrhea persists for at least 24 hours?

Answer 29

Increase dose to 2mg every 2 hours

Question 30

Where do we treat complicated diarrhea?

Answer 30

Hospital admission

Question 31

What are the treatments of complicated diarrhea?

Answer 31

IV fluids, electrolyte replacement Octreotide Further work-up ABX

Question 32

How do we work-up complicated diarrhea?

Answer 32

CBC Electrolytes Stool: blood, C diff, other infections

Question 33

When does early onset diarrhea start with irinotecan administration?

Answer 33

During treatment or w/in 2-6 hours after administration

Question 34

What is the mechanism of early onset irinotecan induced diarrhea?

Answer 34

Reversible cholinesterase inhibition

Question 35

What are the effects of irinotecan?

Answer 35

``` Lacrimation Diaphoresis Ab cramping Flushing Diarrhea ```

Question 36

What drug is used to treat irinotecan induced diarrhea?

Answer 36

Atropine 0.25-1 mg IV/SC

Question 37

When does late onset diarrhea start with irinotecan administration?

Answer 37

1-12 days after administration

Question 38

How long can late onset diarrhea last with irinotecan induced diarrhea?

Answer 38

2-5 days; potentially fatal

Question 39

What is the mechanism of late onset irinotecan induced diarrhea?

Answer 39

Direct toxicity from irinotecan and SN-38 | Genetic polymorphism in UGT1A1 enzyme, responsible for inactivating SN-38 via glucoronidation

Question 40

What is the treatment of late onset irinotecan induced diarrhea?

Answer 40

HD loperamide: 4mg, then 2mg every 2 hours | No max dose