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Oncologic Emergencies Flashcards

1
Q

Objectives of Hypercalcemia of malignancy

A

indentify characteristic signs and symptoms of HOM
categorize the severity of a ptietn’s HOM bsed on lab findings
explain the andvantage and diasdvantages bteween the various tx modalities for HOM
-formulate a treatemtn regimen based on severity of HOM as well as monitoring parameteros for assessing efficacy and/or side effects

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2
Q

what are the effects of increased PTH?

A

increased bone resorption
increased calcium reabsorption in kidney and decreased phosphate reabsorption
increased activation to active Vitamin D

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3
Q

what are the 3 types of cancers that can cause hypercalcemia?

A

release of parathyroid-related peptide by tumor (pTHrP)
local stimulaiton of osteoclasts by metastases to the bone
-systemic secretion of Vit D

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4
Q

signs and symptos of hypercalcemia?

A

kidney: polyuria, dehydration, nephrolithiasis, renal failure
GI ; N/V, constipation, anorexia, abdominal pain, polydipsia
Neuro: letheragiy, confusion, somnolence
-hypovolemia, cardiac arrhythmias

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5
Q

what is nephrolithiasis?

A

kidney stones

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6
Q

bones, stones, moans and groans?

A

bones: bone pain
stones: kidney stones
moans: abd pain
groans: neurologic

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7
Q

corrected calcium?

A

measured ca2+ plus 0.8(4-albumin)

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8
Q

why do you need to correct your calcium level?

A

40% of calcium is bound to albumin

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9
Q

Mild hypercalcemia range

A

10.4-11.9 mg/dl corrected calcium

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10
Q

moderate hypercalcimia range?

A

12-13.9 mg/dl corrected calcium

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11
Q

severe hypercalcemia?

A

> 14mg/dl corrected calcium

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12
Q

treatments for mild hypercalcemia?

A

<12mg/dL

  • hydration
  • prevention
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13
Q

treatment for hypercalcemia moderate?

A

-hydration
+/-diuresis
-IV bisphosphonate
+/- calcitonin

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14
Q

treatment for hypercalcemia severe?

A 
-hydration
\+/-diuresis
-IV bisphosphonate
\+/- calcitonin
\+/- dialysis
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15
Q

three main goals of treating hypercalcemia of malignancy?

A

increase renal elimination
decrease bone resorption
decrease GI absorption

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16
Q

advantages / disadvantages of hydration?

A

+helps reestablish euvolemia
+facilitate excretion of calcium
-caution with high risk patients

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17
Q

dose of hydration for hypercalcemia?

A

0.9% NaCl continuous infusion 300-500ml/hr

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18
Q

advantages / disadvantages of diuresis?

A

+facilitates elimiation of calcium by inhibiting reabsorption in loop of hence
+can prevent fuluid overload
+acts quickly
-must administer only after adequate hydration
-electrolyte abnormalities
-dehydration
-not routinely used

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19
Q

diuretic for hypercalcemia? dose?

A

furosemid 20-40mg IV q 12h

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20
Q

advantages / disadvantages of calcitonin?

A

+onset 2-4 hours

  • flushing, nausea, hypersensitivity
  • response only limited to first 48 hours-> tachyphylaxis
  • intranasal route is not effective
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21
Q

MOA calcitonin?

A

increase renal Ca2+ resorption

decreased bone resorption

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22
Q

dose of calcitonin for hypercalcemia?

A

4-8 IU/kg SQ or IM every 12 hours (max 8 IU/kg every 6 hours)

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23
Q

Who is at an increased risk of emesis with anticancer meds?

A

female more than males
younger more than older esp if < 30yo
less if high consumption of alcohol
if n/v w/ chemo, pregnancy or motion sickness

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24
Q

what ar ethe four types of emesis?

A

anticipatory
acute (withing 24 hrs of chemo)
delayed (> 24 hrs after chemo)
breakthrough (despite therapy)

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25
non pharm treatment of emesis?
small frequent meals bland room temperature food use distractions like TV, music etc maintain hydration
26
for minimal risk emetic regimen, what kind of emetic prophylaxis do you need to use?
none
27
for low risk emetic regimen, what kind of emetic prophylaxis do you need to use? for how long?
dexamethasone or dopamine agonist +/- lorazepam, H2 blocker or PPI Day 1, repeat daily for multiday regimens
28
for Moderate risk emetic regimen, what kind of emetic prophylaxis do you need to use? for how long?
selective serotonin antagonist on day 1, day 2-3 optional AND Dexamethasone Day 1, day 2-3 optional +/- NK1 antagonist, lorazepam, h2 blocker or PPI
29
for High risk emetic regimen, what kind of emetic prophylaxis do you need to use? for how long?
``` selective serotonin antagonist , day 1 optional day 2-3 AND dexamethaosne days 1-4 AND NK-1 Antagonist days 1-3 +/- lorazepamp, h2 blocker or PPI ```
30
what do you do for breakthrough emesis?
add one agent form a different drug class to the current PRN regimen
31
what do you use for anticipatory emesis?
use a benzodiazepine & behavioral therapy
32
what is the difference between aprepitant and fosaprepitant?
aprepitant comes in an oral capsule while fosaprepitant is the injectible form of the drug
33
brand Emend?
aprepitant and fosaprepitant
34
what is the MOA of aprepitant?
competitive inhibitor or NK1 receptors in the CNS
35
adverse effects aprepitatn?
fatigue constipation hiccups
36
CYP interactions of apreptitant?
moderate cyp3a4 inducer | mild cpy 2c9 inducer
37
when should you use aprepitant (indication)
acute and delayed emesis with highly emetogenic regimens
38
dose aprepitant?
125mg po 1 hr before chemo | 80mg po days 2 and 3 in the AM
39
fosaprepitant dose?
150mg IV on day 1 only
40
patient education for aprepitant?
SE of medication take with or without food inform physician if on warfarin
41
what is the the MOA of the "-setrons" ondansetron, palonosetron, granisetron, doasetron?
selective serotoning 3 antagonists | inhibtn serotning receptors on vagal afferent nerves
42
adverse effects of selective serotonin 3 antagonists?
Headache and drowsiness constipation fatigue qt prolongation
43
patient education for selective serotonin 3 antagonists?
take at the first sign of nausea may cause change in defecation pattern HA and drowsiness
44
Zofran
ondansetron
45
ondansetorn dosing for prevention of CINV?
8-32mg IV 30 min prior to chemo OR 8mg po BID/TID starting 30 min before chemo
46
ondansetorn dosing for breaktrough N/V?
4-8 mg po TID
47
what is the MOA for corticosteroids for emesis?
unknown
48
adverse effects of corticosteroids?
agitation, insomnia, hiccups, upset stomach arrhythmia hyperglycemia, transient leukocytosis
49
patient education with corticosteroids?
take with food and in the morning | follow a taper is given one
50
labs to monitor for corticosteroids?
serum potassium glucose WBC occult blood loss
51
dexamethasone
decadron
52
dexamethosone dose for prevention of CINV?
12mg IV or PO 30 min before chemo on day 1 | 8mg po daily or bid on subsequent days of treatment
53
dexamethasone dosing for delayed or breakthrough N/V
4-10mg IV or PO QD or BID x 2-4 days OR 8mg IV /pPO q 12h x 2 days then 4mg IV/PO q 12h x 2 days
54
MOA of lorazepam for antiemetic?
enhancement of inhibtoroy effect of GABA on neuronal excitability
55
adverse effects of lorazepam
sedation respiratory depression confusion
56
monitoring for lorazepam?
RR blood pressure HR drowsiness (sedation score)
57
patient educaiton for lorazepam?
causes sedation do not drink alcohol or any other sedatives do not drive when taking BZDs
58
dosing of lorazepam for anticipatory emesis?
0.5-1mg po night before and morning before chemo
59
dosing lorazepam ofr breakthrough N/V
0.5-2mg PO/SL/IV q 4-6hrs prn
60
what is the MOA of prochlorperazine or promethazine ?
dopamine receptor antagonists
61
compazine AND formulations
prochlorperazine | IV PO IM PR
62
Phenergan AND formulations
IV PO IM PR | promethazine
63
adverse effects of doapine receptor antagonists?
``` sedation hypotension akathesia dystonia extravasation with promethazine ```
64
prochloperazine CINV prevention dose
5-10 mg po IV 1hr before chemo
65
prochlorperazine doses
breakthrough N?V 5-10mg po/ IV q6h prone OR 25 mg PR q12h PRN
66
promethazine CINV dosing
breakethrough 12.5-25mg po or IV (central line) q 4h prn
67
metoclopramide MOA
dopamien receptor antagonist and serotonin receptor antagonist at higher doses
68
AE of metoclopramide
drowsiness dystonia + akathesia at higher doses diarrhea
69
formulations of metoclopramide?
PO IV IM
70
patient educaiton of reglan?
may cause diarrhea drowsiness or agitaiton take at first sign of nausea or retching
71
what is the MOA of scopolamine?
anticholinergic at parasympathetcis sites of smooth mucscle, secretory glands and CNS
72
AE scopalamine?
``` constipation tachycardia thirst urniary retention drowsiness ```
73
indication scopalamine
breakthrough N/V
74
patient education for scopalamine
apply clean hairless place behind ear wash hands afterwards Sid effects
75
dosing for scopalamine patch?
1.5mg patch applied q 3 days prn nausea
76
indicaiton of cannabinoids
breakthrough nausea and vomiting
77
mOA cannabinoids?
agonism at cannabinoid-1 receptor
78
adeverse effects of cannabinoids?
``` dysphoria tachycardia flushing withdrawal drowsiness, confusion, detachment increased appetitne ```
79
Marinol
dronabinol classIII
80
Cesamet
nabilone class II
81
dronabinol dosingg for n/v
5mg/m2/dose 4-6 times daily
82
nabilone dosing
1-2 mg bid prn
83
what causes mucositis?
chemo kills rapidly dividing mucosal cells in the GI tract
84
agents available for mucositis prophylaxis?
palifermin cryotherapy oral hygeine
85
indication of palifermin?
for patients receiving intense chemotherapy regimens such as hemapoetic stem cell transplantation
86
palifermin MOA
keratinocyte growth factor - 1
87
adverse effects of palifermin?
rash, prurities | mouth /gongue discoloaration or scalloping
88
dosing palifermin
60mcg/kg/day IV 3 consecutive days before and 3 days consecutieve after chemotherapy
89
how long is palifermin stable for?
at room temperature 1 hour after reconstitution
90
when to use cryotherapy for mucositis?
with short half life therapies (bolus 5-FU and melphalan)
91
symptom treatment for mucositis?
``` topical anesthetics (magic mouthwash) systemic analgesics (avoid NSAIDs) antidiarrheals ```
92
what are the two options for anemia induced by cancer?
erythropoesis stimulating agents | red blood cell transfusion
93
what are the risk with ESAs? benefits?
increased thrombolic events decreased survival time to tumor progression shortened Benefits transfusion avoidance improvement in fatigue
94
risks and benefits of red blood cell transfusion?
``` transfusion reactions CHF viral or bacterail transmission iron overlaod increased thrombolic events decreased survival ``` benefits: rapid increased of H/H rapid improvement in fatigue
95
what is the indication of ESA's
for palliative intent not for use in curative intent therapy
96
which two agents are indicated as ESA's?
epoeitin alfa | darbopoeitin alfa
97
when do you initiate the ESAs?
if the HbB is < 10g/dL
98
how long will it take for you to see the hgb increase with ESAs?
>= 2 weeks
99
what is the goal hgb for patients on ESA's
"minimum necessary to avoid transfusions" | -In practice people dont give it if the pts hgb i >= 12g/dL
100
adverse effects of ESAs?
``` hyper or hypotension arthralgias , mayalgia, back pain injection site pain/reacitons fatigue edema headache ```
101
black box warnings for ESAs?
increased risk of thromboembolic events decreased sruvival and increased dtumor porgression in cancer patients dvt prophylaxix prior to surgery
102
contraindicaitons of ESAs?
curative intent albumin hypersensitivty uncontrolled hypertension
103
when should you discontinue ESAs once started?
when chemotherapy is complete | if no HgB response at 8-12 weeks
104
what should you do with ESAs in terms of iron management?
measure iron level before starting ESA and monitor during therapy consider supplementation if transferin saturaiton is less than 50% AND ferritin is less than or equal to 800ng/mL used thie common regiment : ferric gluconate (ferrlecit) 125mg IV q week x 8 weeks
105
what is tumor lysis syndrome?
a rapid lysis of tumor cells and release of contents into the blood stream : nucleic acids, proteins, phosphorous, potassium
106
signs and symptoms of TLS
hyeruriciemia hyperkalmeima hyperphosphatemia hypocalcemia
107
what are the complications of tumor lysis syndrome
the electrolyte imbalances can lead to acute renal failure, arrhythmias and neuromauscular irritability
108
risk factors for developing tumor lysis syndrome?
Pre existing factors: -renal impairment, hyperuricemia, hyperphosphatemia, dehydration, nephortoxic agents Tumor type: highly proliferative rate cancers have many cells and can burst much content, different cancers respond to chemotherapy by bursting more than others Tumor burden: the bulkier the disease the more TLS (> 10cm), increased WBC > 50, 000 , elevated LDH (> 2ULN)
109
what are the signs and symptoms of hyperkalemia?
muscle twitching weakness EKG changes cardia arrhythmias
110
what are the signs and symptoms of hyperphophatemia
calcium -phosphate precipitatie renal osteodystrophy hypocalcemia (inverse relationshi)
111
what are the signs and symptoms of hyperuricemia?
nausea/vomiting confusion nephropathy
112
what are the signs and symptoms of hypocalcemia?
``` tremor numbness muscle cramps/spasms lethargy, psychosis, coma hypotension ```
113
why do patients have hyperuricemia?
the lysisl of the DNA leads to purines being convereted into uric acid and causing hyperuricemia
114
by looking at labs how do you define TLS by cairo-bisops standards (also called the laboratory definition) ?
``` Tow or more laboratory changes must occur within 3 days before or 7 days after cytotoxic therapy Uric acid >= 8mg/dl K>= 6mEq/L Phos >= 6.5 Calcium 25% ```
115
what is the clinical definition of TLS?
defined by having the laboratory definition of TLS + at least one clinical complication
116
by looking at labs how do you define TLS by cairo-bisops standards (also called the laboratory definition) ?
``` Tow or more laboratory changes must occur within 3 days before or 7 days after cytotoxic therapy Uric acid >= 8mg/dl K>= 6mEq/L Phos >= 6.5 Calcium 25% ```
117
what is the clinical definition of TLS?
defined by having the laboratory definition of TLS + at least one clinical complication

Therapeutics (23 decks)

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