Myelosuppression? Talk about it
Myelosuppression from chemotherapy can lead to neutropenia, anemia and thrombocytopenia
Thrombocytopenia
- Can be a limiting factor for patients who require venous
thromboembolism (VTE) prophylaxis (i.e. hospitalized patients) - Can limit ability to continue therapeutic anticoagulation for patients who have an indication for anticoagulation
- Typically managed with platelet transfusions
- Important to keep in mind platelet count before administering any IM injections (sometimes patient’s require transfusions before IM injections, or other procedures)
Anemia
- Typically, asymptomatic patients without significant comorbidities are just being observed (Just monitor them)
- For other patients who require treatment RBC transfusions should be considered (safer than ESA -ESA is for a specific population)
- Use of erythropoiesis stimulating agents (ESAs) can considered for specific patient populations
Anemia - Use of erythropoiesis stimulating agents (ESAs)
…should be avoided in what patient group? can be used in what patient group? BBW?
Neutropenia… and it’s category
Neutropenia and Granulocyte-colony stimulating factor (G-CSF)
Duration and severity of neutropenia is improved with the use of granulocyte-colony stimulating factor (G-CSF) aka Neupogen.
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NOTE: The use of Neupogen has improved neutropenia by decreasing the duration and severity
G-CSF can be used to prevent or reduce
neutropenia… Risk assessment considerations when considering adding G-CSF
Risk assessment considerations when considering adding G-CSF
- Disease/ what type of cancer
- Chemotherapy regimen (high dose, dose-dense, standard dose)
- Patient risk factors
- Treatment intent (curative vs. Palliative)
-IMPORTANT: If overall risk of febrile neutropenia is >20% (high-risk) G-CSF is generally used!
Neutropenia
G-CSF considerations (the OG stuff)
Neutropenia
Pegylated G-CSF
Neutropenia
Adverse reactions with G-CSF and pegylated G-CSF
- Allergic reactions
- Injection site reactions
- Bone pain (10-30% of patients)
——- Preferred management: loratadine 10 mg daily for 5-7 days after G-CSF (why should we NOT opt for NSAID in patient with thrombocytopenia? it can increase risk of bleeding!) - Other: Splenic rupture, secondary malignancy (AML and MDS), fever, rash
Febrile Neutropenia (FN) and it’s requirements
NOTE: If the MASCC score is < 21 the patient is considered high risk!!!!
Outpatient management for Febrile Neutropenia (FN) in low-risk patients
Oral antibiotic regimens (pick one of the 3):
- Ciprofloxacin plus amoxicillin/clavulanate (Augmentin)
- Levofloxacin
- Moxifloxacin
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Continue to monitor patient daily for response and toxicity
Inpatient management for Febrile Neutropenia (FN) in high-risk patients
Empiric antibiotic therapy: monotherapy antipseudomonal beta-lactam
— Cefepime (2 grams q8h IV)
— Meropenem
— Piperacillin/tazobactam
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MRSA coverage is not typically added empirically unless there is a history or indication
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Concern for abdominal infection: favor piperacillin/tazobactam (Zosyn) empirically for anaerobe
coverage
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Consider fungal coverage if patient is persistently febrile after 4 days
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Consider history of previous antimicrobial prophylaxis regimens is applicable
Potential outcomes of treatment for Febrile Neutropenia (FN)
Which of the following is the biggest limiting factor which can impact a patient’s ability to receive anticoagulation while on active chemotherapy?
A. Thrombocytopenia
B. Anemia
C. Bleeding
D. Neutropenia
E. Infection
K.N. is a 70 YOM with newly diagnosed testicular cancer who is starting Cycle 1 of chemotherapy with VIP (etoposide, ifosfamide, and cisplatin, chemo on days 1-5, 21-day cycle) which has a high risk of febrile neutropenia (≥ 20%). The patient’s last standing weight was 81 kg on
C1D1. Which option for primary prophylaxis would be best for this patient?
A. Zarxio 300 mcg SubQ daily starting on day 5 until ANC recovery
B. Tbo-filgrastim 480 mcg SubQ daily starting on day 6 until ANC recovery
C. Udneyca 6 mg SubQ once on day 5
D. Neupogen 300 mcg IV daily starting on Day 6 until ANC recovery
K.L. is a 72 YOM with Non-Hodgkins Lymphoma on treatment with HyperCVAD. The patient presented to the ED overnight with a fever of 38.9°C and ANC of 400 cell/m3. Blood cultures were drawn before starting antibiotics and the results are still pending. The patient weight’s is 96 kg and his last CrCl was 65 mL/min. The
ER provider started the patient on empiric cefepime 1 gm q8h IV. The patient has now been admitted and transferred to the oncology unit. Would you like to make
any changes at this time?
A. Yes
B. No
C. Maybe?
A. Yes!!! Why?
empiric cefepime should be 2gm Q8h IV! Need highest dose possible!
Immune checkpoint-related toxicities and the timeline? Just know general
Principles of management of Immune checkpt toxicity
- Refer to guidelines for specific management of each toxicity (NCCN, ESMO)
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Steroids - Lower grades (1-2): Prednisone 1-2 mg/kg
- Higher grades (3-4) or serious toxicities: Methylprednisolone 1-2 mg/kg
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These patients with serious toxicities must continue a long steroid taper
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For some toxicities infliximab can be used
