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PHM 703: Crit Care/Heme/Onc > Onco 1: Supportive care > Flashcards

Onco 1: Supportive care Flashcards

i need emotional support cat (81 cards)

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1
Q

consequences of chemo induced nausea and vomiting

A
  • increased morbidity
  • decreased qol
  • nonadherehce
  • dose redcution
  • weakeness
  • dehydration
  • electrolyte imbalance
  • decline in behavior and metnal health
  • esophageal tears
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2
Q

acute CINV

A

occurs within 24 hours after chemo start

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3
Q

delayed CINV

A

occuring 24h to seeral days after start of chemo

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4
Q

breakthrough CINV

A

occurs depsite ppx

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5
Q

anticpatory CINV

A

before treatmetn dt anx or expected CINV

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6
Q

refractory CINV

A

recurring in subsequent cycles

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7
Q

relavent receptors in CINV

A
  • 5-HT3
  • susbtance p and NK1
  • DA
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8
Q

peripheral pathway for CINV

A
  • 5HT3 mediated
  • orginates in GI
  • usually acute
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9
Q

central pathway for CINV

A
  • NK-1 mediated
  • in brain
  • predominately involved in dealyed
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10
Q

risk factors for CINV

A
  • less than 50
  • female
  • hx of pregnancy vomiting
  • hx of CINV
  • prone to motion sickness
  • little to no EtOH use
  • anx/high expectaion for CINV
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11
Q

ppx for a parenteral chemo agent with high risk for CINV

A
  • option 1 (preferred):
    - day 1: olanzapine, dexamethasone, NK1, 5HT3
    - day 2-4: olanzapine, dexamethasone
  • option 2:
    - day 1: olanzapine, dexamethasone, palonosetron
    - day 2-4: olanzapine
  • option 3:
    - day 1: dexamethasone, NK1, 5HT3
    - day 2-4: dexamethasone

options 1, 3: if aprepitant was the NK1 used, use it on days 2 and 3

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12
Q

ppx for a parenteral chemo agent with moderate risk for CINV

A
  • option 1:
    - day 1: olanzapine, dexamethasone
    - day 2-3: olanzapine or dexamethasone
  • option 2:
    - day 1: olanzapine, dexamethasone, palonosetron
    - day 2-3: olanzapine
  • option 3:
    - day 1: dexamethasone, NK1, 5HT3
    - day 2-3: +/- dexamethasone

options 3: if aprepitant was the NK1 used, use it on days 2 and 3

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13
Q

ppx for a parenteral chemo agent with low risk for CINV

A

one of the followign 30 min before chemo
- dexamethasone
- metoclopramide
- prochlorperazine
- 5HT3

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14
Q

ppx for a parenteral chemo agent with minimal risk for CINV

A

no routeine ppx

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15
Q

ppx for a oral chemo agent with moderate-high risk for CINV

A

5-HT3

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16
Q

ppx for a po chemo agent with mnimal-low risk for CINV

A

prn

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17
Q

breakthrough treatment for CINV

A
  • add an agent form a different class to curret regimen*
  • consider around the clock vs pn
  • consider antacid fi pt has dyspecia

*agents
- olanzapine
- ativan: useful for anticaptory
- prochlorperazine
- dexamethasone
- dronabinol (soln F > cap)
- metoclorpamide
- 5HT3
- scopolamine

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18
Q

non-pharm measures for CINV

A
  • avoid strong smells
  • acupuncture
  • guided therapy
  • relaxation
  • hyponsis
  • yoga
  • biofeedback
  • porgressive muscle relaxation
  • cog disstraction guided imagery
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19
Q

dexamethasoe MOA in CINV

A

unknown, but though to interact with 5HT3 recceptors and GC receptors in medulla

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20
Q

Dexamethasone ADR

A
  • isnomnia - admi in morning
  • dyspepsia - take with food, consider H2RA or PPI
  • hyperglycemia
  • HTN
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21
Q

5HT3 RA MOA in CINV

A

block 5HT3:
- in peripheray (GI) on vagal nerve terminals
- centrally at chemo trigger zone (medulla)

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22
Q

5HT3 RA ADR

A
  • Headache
  • constipation
  • QT prlongation
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23
Q

5HT3 RA 1st gen

A
  • ondasentron
  • granisetron

  • more effective in acute ppx
  • short acting
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24
Q

5HT3 RA second gen

A
  • palonosetron
  • effective in acute and delayed CINV ppx
  • long acting
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25
NK1 RA MOA in CINV
- inhibit P/NK1 - augment 5HT3 RA and dexamethasone antiemeti activity
26
NK1 RA use
only used in ppx (not treatment) - especially useful in delayed CINV ppx
27
NK1 RA agents
- aprepitant - fosaprepitant (also avalable in combo with palonsetron) - rolapitant: must have at least 2 weeks betwee nadmin dt long t1/2 (7d) - nitupitant/palonosetron
28
NK1 RA DDI
inhibition of CYP3A4 and 2C9 -> deccrease dexamethasone CINV ppx dose from 12 to 8mg on days 2-4 | does NOT apply to rolapitant
29
olanzapien MOA in CINV
- blocks DA, 5HT3, muscarinic and histamine receptors
29
NK1 ADR
similar to placebo - fatigue - GI upset - HA - hiccups
30
olanzapien use in CINV
both ppx and breathrough
31
olanzaine ADR
- sedation: HS admin (unless premedication), lower dose in older adults - hyperglycemia - fatigue - QT prolongation
32
DA antag MOA in CINV
- antag DA in chemoreceptor zone
33
DA antag use in CINV
most useful in breakthrough
34
DA antag ADR
- phenothiazines (prochlorprazine, promethazine) - drowsiness - constiaption - benzamine (metoclopramide) - drowsiness - diarrhea - QT prolongation - TD (avoid using > 12 weeks)
35
benzodiazepines (ativan) use in CINV
most useful for anticipatory CINV or breakthrough with an anx compoent | dt anxiolytic effet ## Footnote give night before and/or morning of
36
benzodiazpine (lorazepam) ADR
- sedation - dizziness
37
cannabinoids MOA in CINV
- CB1 agonism -> suppress vomiting - indirect activation of 5-HT1a in raphe nucleus
38
cannabinods use in CINV
rarely used, onlly in refractory
39
cannabinods ADR
- sedation - euphoria,, hallucinations - palpitations - flushing - cough
40
scopolamine patch use in CINV
rarely used, only for breakthrough | it anticholinergic (that's also it's moa)
41
scopolamine ADR
- dry mouth - somnolence - blurred vision
42
consequences of chemo induced diarrhea
- depeltion of electrolytes - malnutrition - dehydration - hospitalziaiotn - chemo dose reduciton or delay
43
chemo induced diarrhea grading
- grade 1: < 4 stool/day over baseline - grade 2: 4-6/day over baseline; limits ADL - grade 3: >7 over baseline; requires hospitalzation - grade 4: life threating
44
pt assessent of chemo induced diarrhea
- hx - volume adn duration of diarrhea - hdyraiton status - pt risk factors - fever - orhtstatic symptoms - abdominal pain - weakness
45
offending agets for chemo induced diarrhea
- fluorouracil - capecitabinne - irinotecan - pertuzumab - abemaciclib
46
irinotecan and diarrhea
- acute: - dt cholingeric stimulation - usually responds to atropine - chronic - dt GI mucosal damage - 24h after admin - dose independent
47
nonpharm treatmetn for chemo induced diarrhea
- avoid trigger foods - aggressive PO rehydration
48
pharm treatment for chemo indcued diarrhea | not incudling refractory treatment
- loperamide: 4mg x1 followed by 2mg Q4H or after every unformed stool (MDD 16mg) - diphenoxylate atropine: 1-2T Q6H until control achieved (MDD 8T)
49
pharm treatment for *refractory* chemo indcued diarrhea
- rule out c.diff and infective colitis - octreotide - tincutre of opium - probiotics
50
mucositis
erythematous and ulcerative lesions of the musosa - anhwere in GI tract - onset is 5-14 days | stomatitis is mouth only
51
complications of mucositis
- decreased oral intake-> poor nutrition (grade 4 requires parenteral or enteral nutrition) - increased infection risk - pain (may require opioids or PCA)
52
pathophysiology of mucositis
1. initiation: cellular damage, ROS formation 2. primary damage response: acitavtion of p53 and NK-kB 3. signal amplification: release of cytokines -> tissue damage, cell death 4. ulceration: high risk of infeciton 5. healing
53
pt risk factors for mucositis
- smoking - poor oral hygiene - preexisting oral lesions - female - existing nutritional status
54
offending agents for mucositis
- melphalan - cisplatin + radiaiton - high dose MTX - doxorubicin - busulfan - 5-FU
55
mucositis ppx
- oral hygiene - avoid acidic/spicy foods - soft toothbrush - soln or IV instead of tab - nonalcoholic mouthwash QID - cryotherapy: ice cubes in mouth before and/or during chemo - MOA: vasoconstriciotn -> less drug to oral mucosa
56
managemnet of mucositis
- PO decontamination: bland or onco outhwash (dexametasone if everlimus induced) - pain: opioids, 2% lidocaine swish and spit - dry mouth: artifical saliva or gum - nutrition: liquid or soft diet; TPN - throush: fluconazole 200mg x1 then 100mg QD 21D
57
profound neturopenia
ANC < 100
58
prolonged neutropenia
lasting > 10 days
59
consequneces of neutropenia
- dose reduciton or treatment delays - compromised clincal outcomes - long hospital stay - increased treatment cost - decreased qol
60
febrile neutropenia G-CSF primary ppx: when to give
- high risk: give - intermediate risk and 1 pt risk factor: consider - low risk adn 2+ pt risk factors: may be considered
61
G-CSF agents
- filgrastim - pegfilgrastim - eflapegrastim or efbemalenagrastim ## Footnote do NOT give within 24h after chemo dt enhanced chance of chemo tox
62
filgrastim admin for priamry ppx of febrile neutropenia
- start 24h after chemo completion - give QD until ANC recovery (~4 days) | short actig
63
pegfilgrastim admin for priamry ppx of febrile neutropenia
- give 1-4 days after compeltion - single admin of 6mg - wait 12+ dyas between admin and next cycle | long acting
64
eflapegrastim or efbemalengrastim admin for priamry ppx of febrile neutropenia
- start just after 24hs after completeion of chemo - single dose - 13.2 eflapegrastim - 20mg efbemalengrastim - do NOT give 14d before next cycle
65
G-CSF use in **treatment** of febrile neutropenia in pts who had **ppx with filgrastim**
filgrastim
66
G-CSF use in **treatment** of febrile neutropenia in pts who had **ppx with a G-CSF** (not including filgrastim)
no need for further G-CSF
67
G-CSF use in **treatment** of febrile neutropenia in pts who **did NOT have ppx**
can give G-CSF if one of the following - 65+ - sepsis - ANC < 500 - expected to be prolonged neutropenia - documented infection - hospitalzation at time of fever - hx of febrile neutropenia
68
secondary ppx with G-CSF for febrile neutropneia | pt had febrile neutropenia last cycle
- if prior use of growth factor for treatment/ppx of febrile neutropenia; consider chemo dose reducito or switch therapy - no prior use: consdier starting
69
somatic cancer pain
- Tumor invades bone, muscle, or connective tissue - Often presents as aching, stabbing, throbbing, or pressure
70
visceral cancer pain
- Tumor invades itnernal organs and blood vessels - Often presents as gnawing, cramping, aching, or sharp pain
71
neuropathic cancer pain
- Pain from damage or dsfxn of nervous system - Often presents as burning, tingling, shotting, or electric/shocking pain
72
non-opioid pain meds
APAP, NSAIDs
73
adjuvant analgesics
- antidepressatns - anticonvulsants - CS - topicals
74
cance pain treatment
1. Pain persisting or increasing: non opioid + adjuvant - lowest possile dose - start with IR and PRN, assess ad titrate as needed 2. Pain perisisting or increasing: opioid for mild to moderate pain +/- non-opioid +/- adjuvant 3. opioid for mod-severe pain +/- non-opioid +/- adjuvant
75
titrating an opioid
In general min dose increase is 25-50%
76
opioid rotation
offer to pts with pain that is refractory to dose titration or with poorly managed ADR, logisitic or cost concerns, or trouble with ROA or absorption
77
immune related ADR
increased immune system activity -> inflammation response - increased T cell activit - increased preexisting Ab - increased inflamatrroy cytkines
78
mild-mod immune therapy related ADR treatment | grade 1-2
- sympotatic management (local therapies preferred) - consdier delaying immunotherapy - may need CS
79
severe immune therapy related ADR treatment | grade 3-4
- hold immunotherapy - CS required - possible additional immunosuppressant in steroid refractory ADR - may need inpatient care and additional supportive care
80
corticosteroid ADR | with what she calls "suportive care"
- gastritis: consider PPI or H2RA in pt at high risk - infection - risk of PJP if pt going to get prednisone 20mg+ for 4+ weeks -> ppx bactrim (preferred), atovaquone, dapsone, pentamidine - risk of fungal if prednisone 20mg+ for 6+ weeks -> ppx with fluconazole - OP - VitD 400-1000 IU QD - Ca 1000-1200mg QD

PHM 703: Crit Care/Heme/Onc (16 decks)

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