Symptom Management

Question 1

Difference between sarcopenia and cachexia?

Answer 1

Sarcopenia is AGE related loss of muscle mass and strength

Cachexia is ILLNESS related loss of skeletal muscle mass and weight

3 main differences for cachexia-
1) INCREASED basal metabolic rate
2) INCREASED inflammation
3) INCREASED muscle degradation

(not true in sarcopenia)

Question 2

Definition of cachexia?

Answer 2

1) Weight loss > 5% over past 6 months
2) Weight loss >2% in patients already having BMI <20 or with skeletal muscle mass
Is associated with increased mortality, decline and poor QOL

Question 3

Cachexia more common in what malignancies? Less common in what 2 malignancies?

Answer 3

1) More common in GI, pancreatic, lung, colorectal cancers
2) Less common in breast and prostate cancers

Question 4

Impact of cancer cachexia?

Answer 4

1) Decreased physical functioning
2) Decreased independence (increasing help needed with ADLs)
3) Increased risk of hospitalizations
4) Decreased response to cancer TX
5) Increased TX toxicity
6) Decreased QOL

Question 5

I say “anorexia + early satiety + bloating” you say….

Answer 5

Reglan
Maybe Erythromycin

Question 6

I say “anorexia + fatigue +nausea/pain” you say….

Answer 6

Dexamethasone

Or Marinol (for AIDS pts only… no efficacy in cancer)

Question 7

I say “anorexia + fatigue” you say…

Answer 7

Dexamethasone

Methyphenidate

Question 8

I say “anorexia + depression + insomnia/anxiety”

Answer 8

Mirtazapine

Olanzapine

Question 9

Treatment of refractory cachexia for cancer? What if LE < 6 weeks?

Answer 9

Megace (can cause DVT, muscle catabolism, adrenal suppression, hypogonadism)- on Beers List

Better if they have weeks to months prognosis

For SHORT life expectancy, can think about dexamethasone

Question 10

Drugs that are effective in RENAL pruritus? (3)

Answer 10

1) Gabapentin
2) Zofran
3) SSRIs

Question 11

Drugs that are effective in CHOLESTASTIC pruritis? (5)

Answer 11

1) Cholestyramine
2) Rifampin
3) Naloxone
4) SSRI (Sertraline)
5) Zofran

Question 12

Opioid Induced Constipation treatment

Answer 12

1) Start with stimulants and osmotics
2) NEVER use colace or bulk forming agents
3) Can try sodium chloride channel activators- lubiprostone (not good for methadone OIC), linaclotide
4) Naloxegol (not in cancer patients) or Methylnaltrexone great options

Question 13

Opioid Induced Constipation

Answer 13

Impacts 45-90% of opioid users
- Lengthens colonic time
- More reabsorption of water from GI tract (dry, hard stools)
- Inhibits peristalsis in bowels
- Inhibits defecation reflex
Starts happening MINUTES after taking it (5-25)
DURATION of opioid use relates to likelihood of constipation
ALWAYS offer ppx (no tolerance develops_
Can increase M+M, hospital visits, ER visits, QOL

Question 14

Double blind RCT for Octreotide outcomes?

Answer 14

No difference between Octreotide vs Placebo at 72 hours (any vomiting at 72 hours)
BUT you threw up less on octreotide

Question 15

Diarrhea caused by irinotecan or 5FU should be treated with what drug?

Answer 15

Irinotecan and 5FU chemotherapy can cause a secretory diarrhea that is best treated with octreotide.

Question 16

Risk factors for cancer related fatigue?

Answer 16

○ Unmarried, lower SES
○ Medical comorbidities
○ Poor nutrition
○ Mood disorders
○ Polypharmacy
○ High symptom burden
○ NOT ALWAYS CORRELATED with TYPE or treatment or DOSE intensity
Can be super tired even with short, brief chemo!

Question 17

Treatment for mucositis?

Answer 17

• Oral hygiene
• Mucosal coating agents
• Topical analgesics (lidocaine, morphine +doxepin)
• Topical dexamethasone

Question 18

Prevention of mucositis?

Answer 18

• Benzydamine (for ENT cancer)
• Chlorhexadine
• Zinc daily
• Ice/cold

Question 19

When will UV therapy help with pruritus?

Answer 19

Renal failure
ESLD
Hodgkin’s lymphoma
HIV
Breast carcinoma w/ skin infiltration

Question 20

Approach to management of opioid induced itching?

Answer 20

1) Rotate opioid
2) Sertraline/Paxil/Remeron
3) Naltrexone
4) Zofran

Question 21

Dressings for super WET wounds?

Answer 21

Alginates
Charcoal
Iodosorb

Question 22

Approach to TX hiccups

Answer 22

1) TX underlying cause (GERD- PPI!)
2) Stop hiccup causing meds (dexamethasone, opioids, benzos)
3) NON PHARM options! breath holding, eat sugar, fright
4) Drugs

Question 23

Drugs to TX hiccups

Answer 23

1) Thorazine
2) Haldol
3) Reglan (use this if also having gastric distention)
4) Baclofen
5) Gabapentin
6) Phenytoin (if CNS cause), depakote, carbamazepine

Question 24

For dysphagia- why should you NOT do thickened liquids?

Answer 24

No difference in risk of aspiration/pneumonia
INCREASED risk of pneumonia with honey thick liquids
INCREASED risk of dehydration

FT question–> answer is USUALLY careful hand feeding

Question 25

When to consider PleurX vs Pleurodesis?

Answer 25

Indwelling tunneled pleural catheter
-Better for intermediate PX (1-6 months)
-Indicated if any evidence of TRAPPED LUNG

Pleurodesis
-MAY be better for extended prognosis (» 6 months)
-Cannot use if patients have trapped lung

Overall- No real difference between PleurX vs Pleurodesis
- Pleurodesis spent more time in hospital (IP procedure), more painful
-20% ended up needing thoracentsis or PleurX
- PleurX needed fewer additional interventions
- BOTH highly effective for dyspnea 2/2 effusions (80% got symptom relief at 6 mos in RCT)

Question 26

TX options for chronic cough?

Answer 26

1) TX underlying cause
2) OPIOIDS (no opioid better than other)
3) Dextromethorphan better than placebo
4) Gabapentin MAY be helpful w/ chronic cough

Question 27

TX for XRT pneumonitis?

Answer 27

60 mg prednisone daily tapered slowly over months for RADIATION INDUCED pneumonitis