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Which drugs should not be given more than once every 6 weeks due to delayed recovery of the bone marrow?
- Lomustine (CCNU)
- Mitomycin C
- Ibritumomab tiuxetan – onset 4-7 weeks after admin and may persist to 3 months
- HD methotrexate – use leukovorin to prevent
What drug is used in conjunction with Methotrexate to prevent myelosupression?
You should expect onset of Neutropenia and Thrombocytopenia at what point with Alemtuzumab?
- Neutropenia: 4 weeks after admin
- Thrombocytopenia = 1 week after onset
For a patient who has not received CSF prophylactically, but has developed neutropenic fever, you should consider treatment if they are:
- > 65 years
- Have sepsis syndrome
- Severe ANC <100
- Anticipated prolonged neutropenia
When should you give CSF prophylaxis?
- >20% risk of Neutropenic fever (High risk) – all patients
- Intermediate risk of 10-20% - consider the option
Which chemotherapy drugs should never be accompanied by CSF and why?
- Bleomycin = ABVS or BEACOPP
- Enhances pulmonary toxicity
When should phrophylactic CSF be given?
24-72 hours after chemotherapy ends
How long should CSF be given for?
Until ANC is ~5000
What are the major SE of CSF?
- Bone pain – chest is common
- Splenic rupture – if WBC is too high
How can bone pain associated with CSF be ameliorated?
- Give APAP
- Opioids may be needed
- Claritin has been reported to help
What are the CSFs?
- Filgrastin (g-csf)
- Sargramostim (gm-csf)
Which CSF is a biosimilar like drug?
Which CSF is a true biosimilar?
How are CSFs administered?
- SQ – all drugs
- IV – only original Filgrastim and Sargramostim, but SQ preferred
What is a normal dose of CSF?
- Filgrastims: 5 mcg/kg-10 mcg/kg
- Neulasta: 6 mg x1 day after chemo
- Sargramostim: 250 mcg/m2
Filgrastim comes in what size vials?
300 and 480 mcg
Pegfilgrastim comes in what size of vials?
6 mg syringe
Sargramostim comes in what size vials?
250 and 500 mcg vials
When can you use Sargramostim?
- When Filgrastim fails
- Post-AML induction
When you treat neutropenic fever, what organism always need to be covered, due to exceptionally high risk of death?
What antibiotics cover pseudomonas and which ones are usually used for neutropenic fever monotherapy?
- Aminoglycosides – gent, tobra, amik
- Quinolones – cipro, levo
- Cefepime - USED
- Ceftazidime – USED
- Piperacillin-tazobactam (Zosyn) - USED
- Carbapenems – imipenem, meropenem, doripenem - USED
How should a patient with Neutropenic fever be treated?
Inpatient with IV antibiotics
What is used to evaluate risk of Neutropenic fever?
- MASCC Risk-Index
- < 21 = high risk
What should you know about the situation when evaluating treatment for neutropenic fever?
- Institution sensitivities
- Patient allergies
- Recent antibiotics used
What treatment regimens are used for Neutropenic fever for patients with a history of pseudomonas or G- infection and are clinically unstable?
- Dual QD therapy w/o Vancomycin
- Aminoglycoside (gent, tobra, amik) plus one of these:
Antipseudomonal penicillin: ticarcillin/clavulanate [Timentin®] or piperacillin/tazobactam [Zosyn®]
- Antipseudomonal cephalosporin: cefepime [Maxipime®] or ceftazidime [Fortaz®]
- Severe renal impairment: Use Cipro + an Antipseudomonal penicillin