ic5 cinv Flashcards
What are the 2 pathways involved in emesis?
Peripheral (gut), involved in acute phase
Central (brain), involved in delayed phase
When does acute phase start? How long does it last?
onset: 1-2hrs, peak: 5-6hrs, resolve: 24hrs
What is breakthrough CINV?
How to treat
N/V despite preventive treatment
1) Give another agent from a different class
2) Consider IV route if PO not feasible due to ongoing vomiting
3) Hydrate and fluid repletion
4) Change the next antiemetic regimen for next cycle
How to explain emetic risk level to patients?
90% Risk level: if patient does not take the drugs for this medication, the chances they will experience N/V is 90%
Risk factors for CINV (7 points)
Young (< 50 yo)
Females
History of low prior chronic alcohol intake
< 1 glass of alcohol a day
History of previous chemotherapy induced emesis
History of motion sickness
History of emesis during past pregnancy
Anxiety
Antiemetic regimen for high, moderate and low risk
High risk
Acute (day 1)
NK1 + 5HT3 + DEXA, +/- OLA
Delayed (day 2)
DEXA (up to day 4)
OLA (up to day 4)
Moderate
Acute (no NK1)
5HT3 + DEXA
Delayed
DEXA day 2-3
Low
Acute (choose 1)
5HT3
DEXA
DOPA
Role of NK1 antagonist
Examples of NK1 and dose
For acute and delayed CINV
Aprepitant PO
3 day course
Day 1: 125mg, Day 2-3: 80mg
Netupitant PO 300mg (+ Palonosetron 0.5mg, in Akynzeo NEPA)
1 day course
5HT3 role
examples
Acute CINV only
In low, mod, severe risk
OGP (shortest to longest acting)
Ondansetron
Dose (Day 1): 8 - 16mg OD
Granisetron
Dose (Day 1): 1mg OD
Palonosetron 0.5mg (in Akynzeo)
Adverse effects of 5HT3
Headache
Constipation
- May worsen chemo induced constipation
QTc prolongation
- Black box warning
- Caution with use with other agents eg. Haloperidol
Role of Dexamethasone
Course of Dexa
Dose
Acute and delayed CINV
In low, mod, severe risk
D2-4 in high risk, D2-3 in moderate risk
Day 1: 12mg OD
Day 2: 8mg OD
Adverse effects of Dexamethasone (5 points)
Insomnia
Transient elevation in glucose (in DM patients)
Anxiety
Gastric upset (take with food)
Hyperactivity (in pediatric patients)
Role of Olanzapine
Dose
acute, delayed CINV, high emetic risk
5-10mg ON, 2.5mg if elderly
Role of Metoclopramide
Dose
Adverse effects
1) Acute CINV (in low risk)
2) Breakthrough CINV
10mg TDS prn
EPSE, space apart from Olanzapine
Benzodiazepines agents and dose
When to take
Alprazolam 0.5 - 1mg
Lorazepam 0.5 - 2mg
Take the night before treatment and 1-2hrs before chemo
Examples of adjunctive agents
when should adjunctive agents be used?
Haloperidol, Phenothiazines (proclorperazine, chlorpromazine, promethazine)
Use in refractory CINV
Non pharm for cinv
Take small, frequent meals. Avoid heavy meals
Avoid greasy, spicy, very sweet or salt food, food with strong flavour or smells
Sip small amounts of fluids
Avoid caffeinated drinks
Avoid lying flat for 2hrs after eating
Suck on candy, sour plum snack
why does chemo induce diarrhea
Chemo causes direct damage and inflammation to intestine mucosa
diarrhea severity grading
Grade 1
< 4 stools per day above baseline
Grade 2
4-6 stools per day above baseline
Limiting activities of daily living
Grade 3
≥ 7 stools per day above baseline
Hospitalisation needed
Limiting self-care
risk factors for chemo induced diarrhea (6 points)
> 65 yo
Female
ECOG performance status ≥ 2
Bowel inflammation or malabsorption
Bowel malignancy eg. colorectal cancer
Biliary obstruction
Definition of uncomplicated diarrhea
Management
grade 1 or 2
Withhold chemo if grade 2, resume when symptoms resolve by reducing chemo dose or changing chemo agent
Oral hydration of 8-10 glasses of water
Loperamide regimen
Add solid food after diarrhea improve in 1 day
Loperamide dosing
1) Loperamide 4mg, then 2mg every 4hrs or after every episode of diarrhea
(If diarrhea last for 12-24 hrs) → 2) Loperamide 2mg every 2hrs + start antibiotics
(if diarrhea still persist another 12-24hrs) → 3) Start Octreotide
Requirement for complicated diarrhea
Grade 3 or 4
Grade 1 or 2, +
Cramping
> Grade 2 nausea or vomiting
Decrease performance status
Sepsis
Neutropenia
Frank bleeding (obvious bleed)
Dehydration
Dose of Octreotide
100 - 150mcg SC 3x a day
Increase 50 mcg every 24hrs to 500 mcg TDS or as continuous IV infusion (25 - 50 mcg/hr)
Non pharm for CID
Avoid caffeine, alcohol, fruit juice, lactose containing food
Lactose-containing food should be avoided ≥ a week after CID resolved
Eat small, frequent meals
BRAT diet
Banana, Rice, Applesauce, Toast
Banana may not be accepted by patients as they perceive it to help with constipation instead
More than 3L of clear fluids containing electrolytes (salt and sugar)
