Toxicities_Cancer

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Anonymous
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7570
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Toxicities_Cancer
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2010-02-21 19:06:07
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kkheal Cancer Toxicities
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Cancer Agent Toxicities
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  1. scales and criteria used by doctors and researchers to assess how a patient's disease is progressing, assess how the disease affectsthe daily
    living abilities of the patient, and determine appropriate treatment and prognosis
    • ECOG Common Toxicity Criteria
    • ECOG means: Eastern Cooperative Oncology Group
  2. Oral mucositis -
    Inflammation of oral (1) _________resulting from ___________ or ___________. Typically manifests as erythema (redness) or ulcerations
    Stomatitis - inflammatory condition of oral tissue, including mucosa, dentitionlperiapices and periodontium. - includes infections of oral tissues,
    as well as mucositis as defined above
    • (1) Mucosa
    • (2) chemotherapeutic agents or ionizing radiation
  3. Stage 4 mucositis comes with Symptoms associated with life-threatening consequences and clinical evaluation involves Tissue necrosis and spontaneous bleeding. What measure does it require?
    Parenteral or Enteral Support
  4. MOST COMMON AGENTS THAT CAUSE MUCOSITIS:
    • Most common agents:
    • (1) 5-FluoroUracil
    • (2) Doxorubicin
    • (3) Methotrexate
    • (4) Stem-cell transplant conditioning regimens
    • (5) Higher with combination regimens [docetaxel + 5-FU (58-74%)]
  5. Course of mucositis matches the "neutrophil nadir" and usually starts ___________ after therapy
    5 to 7 days
  6. Good mouth care for MUCOSITIS:
    Saline rinse: __________?
    Sodium bicarbonate rinse: ___________?
    • (1) HALF teaspoonful of sodium chloride in 8 oz of WATER
    • (2) 1 teaspoonful of sodium bicarbonate (baking soda) in 8 oz of WARM WATER
  7. MUCOSITIS higher with combination regimens ________________
    [docetaxel + 5-FU (58-74%)]
  8. 1. Soft-bristled toothbrush to decrease irritation
    2. Use of ________swabs or artificial saliva
    3. Avoid _________ containing mouth washes or rinses
    4. _________ mouthwashes not recommended
    • 2. lemon glycerin
    • 3. alcohol
    • 4. Chlorhexidine
  9. MUCOSITIS PREVENTION: Oral Cryotherapy

    (1) Use oral cryotherapy (ice chips) __________ PRIOR to ________
    (2) Contraindicated in:
    (1) 30 minutes prior to 5-fluorouracil

    (2) OXALOPLATIN- because painful and irritating.
  10. Severe Stage 4 Cases of Oral Mucositis:
    (1) Nutrition: use_____________
    (2) Infection:___________________
    • (1) Nutrition: use : Parenteral or Enteral Nutrition
    • (2) Infection use: Oral or IV therapy
  11. Pain Management: ORAL MUCOSITIS
    a. Topical anesthetics -limited use

    (1) _________2% solution: swish and spit 5 to 10m! Q 2-3 hrs pm
    (2) _________0.5 or 1% Solution: swish and spit 5 to 10m! Q 2-3 hrs pm
    • (1) Viscous lidocaine
    • (2) Dyclonine HCI
  12. b. Oral and parenteral analgesics for ORAL MUCOSITIS
    i. Administer around the clock
    ii. Consider PCA pumps
    iii. _____________ standard of care
    Morphine
  13. 5) Treatment of Infections from ORAL MUCOSITIS
    a) Antiviral agents eg Acyclovir
    b) Antifungal therapy
    most common fungus is ___________
    topical antifungals : _________ and __________ useful severe cases requires oral or IV therapy
    • (1) Candida
    • (2) Nystatin swishes and Clotrimazole troches
  14. c) Antibacterial therapy for ORAL MUCOSITIS
    most common bacteria: _________________?
    surveillance cultures useful:_______________?
    **good mouth care
    • (1) gram-positive
    • (2) not useful
  15. OTHER ADDITIONAL TREATMENT OPTIONS FOR MUCOSITIS:

    2 USEFUL and 2 NON_USEFUL
    • Other treatment options
    • Useful: (1) Sucralfate and (2) CSF (Colony Stimulating Factors)

    • Sucralfate 1 gram PO QID swish and swallow; local protective agent nauseating in some patients; has been shown to decrease pain
    • Colony stimulating factors lower incidence of mucositis in patients receiving these
    • Glutamine - amino acid and Allopurinol mouthwashes (1-16 mg/ml) -NOT USEFUL
  16. PREVENTING ORAL MUCOSITIS DURING STEM CELL TRANSPLANT CONDITIONING:
    Patients with hematologic malignancies undergoing hematopoietic stem cell transplantation to reduce the incidence and duration of severe oral
    mucositis.
    What is the Specific Agent o be USED?
    PALIFERMIN (Kepivance)- Keratinocyte Growth Factor-1
  17. __________ (Kepivance) 60 mcglkg/day IV bolus injection for three consecutive days immediately prior to and for three consecutive days, beginning the day of stem cell re-infusion, following the completion of myeloablative conditioning regimen
    NOTE: Should not be administered less than ______ prior to or less than ________ following myelotoxic therapy
    • (1) Palifermin
    • (2) 24 hours
  18. XEROSTOMIA (Dry Mouth) Risk Factors:
    i. _____________ for head and neck cancers
    ii. Concomitant medications eg __________
    • (1) Radiation therapy
    • (2) Anticholinergics eg Compazine
  19. XEROSTOMIA(dry mouth due to lack of saliva) Management:
    i. Frequent ___________ rinses
    ii. __________substitutes
    iii. __________swabs, sugar-free hard candy, ice chips
    iv. Pilocarpine
    v. Amifostine
    • (1) Saline Oral Rinses
    • (2) Saliva Substitutes
    • (3) Lemon Glycerine Swabs
  20. ___________Stimulates salivary secretion in patients with residual salivary function
    Pilocarpine (Salagen") 5mg tablets, 1-2 tablets PO TID to QID
  21. _____________ administered prior to radiation therapy for head and neck cancer involving parotid gland
    1. Decreases acute grade 2 xerostomia from 78% to 51 %
    2. Given slow IVP over 3 minutes, 15-30 minutes prior to radiation therapy
    Amifostine (Ethyol").........ChemoProtectant
  22. CONSTIPATION IN CHEMOTHERAPY
    3 Major Antineoplastic Treatments??
    • Antineoplastic drugs:
    • (1) Vinca alkaloids (Vincristine (MAX: 2mg), Vinblastine)
    • (2) Thalidomide
    • (3) Radiation Therapy
  23. Name 3 non-pharmacological Therapy for OPIOID or VINCA ALKALOIDS induced constipation
    Non-Pharmacological Therapy: Dietary modification and bulk laxatives

    • Diet - increased fiber
    • Oral fluids - adequate amounts
    • Light exercise
  24. VINCA/OPIOID INDUCED CONSTIPATION
    1st Line Drug Treatment for Preventing Vinca & Opioid Induced Constipation?
    • Emollient laxatives (stool softeners) + Stimulant Laxatives
    • (1) Docusate sodium (Colace) 50-500mg/ day in divided doses
    • (2) a. Bisacodyl (Ducolax) 5-15mg PO QD- TID OR 10mg rectally QD
    • b. Senna (Senokot)
  25. VINCA/OPIOID INDUCED CONSTIPATION
    2nd Line Drug Treatment for Vinca & Opioid Induced Constipation after using Colace and Bisacodyl?
    One time use (Saline Laxatives) or As Needed (HyperOsmotic Laxatives)?
    List 3 One Time use agents
    • Saline laxatives
    • a. Magnesium citrate
    • b. Sodium phosphate
    • c. Magnesium hydroxide (MOM)
  26. VINCA/OPIOID INDUCED CONSTIPATION
    2nd Line Drug Treatment for Vinca & Opioid Induced Constipation after using Colace and Bisacodyl?
    One time use (Saline Laxatives) or As Needed (HyperOsmotic Laxatives)?
    List 2 as needed use agents
    • Hyperosmotic laxatives
    • a. Lactulose 15-60ml PO QD to BID or 15-30ml PO Q 2 hrs until BM occurs
    • Very effective in preventing vinca and opioid induced constipation, titrate dosage, may be used periodically
    • as needed, unpalatable
    • b. Sorbitol
  27. VINCA/OPIOID INDUCED CONSTIPATION
    3rd Line Drug Treatment for Vinca & Opioid Induced Constipation after using One time use (Saline Laxatives) or As Needed (HyperOsmotic Laxatives)? eg Last Resort!!
    • Prokinetic Agents
    • a. Metoclopramide (Reglan) 10-20 mg PO QID
  28. Which Constipation Agents are good as one time treatments and NOT to be used Chronically?
    • (1) Lubricant laxatives
    • a. Mineral Oil
    • (2)Saline laxatives
    • a. Magnesium citrate
    • b. Sodium phosphate
    • c. Magnesium hydroxide (MOM)
  29. 5 Causes of Chemotherapy Induced Diarrhea?
    • Chemotherapy-induced DIARRHEA, also Caused by Radiation Therapy!!
    • (1) 5-Fluorouracil ± high dose leucovorin
    • (2) Camptosar (irinotecan)
    • (3) Methotrexate
    • (4) Cytarabine
    • (5) Graft versus host disease in BMT patients
  30. 3 Non-Pharmacological Therapy for Chemotherapy Induced Diarrhea?
    • Fluids & electrolytes
    • Nutrition
    • Avoid problem foods & drugs causing diarrhea
  31. Under what conditions do you use DOSE REDUCTION to manage DIARRHEA in Chemotherapy patients?
    Dose reductions - only if nothing else works or diarrhea life threatening
  32. Chemotherapy Diarrhea Management
    Absorbent & adsorbent agents, Opioid Agents and Somatostatin Analogue
    Name 2 Absorbent & adsorbent agents
    • Kaopectate
    • Metamucil
  33. Chemotherapy Diarrhea Management
    Absorbent & adsorbent agents, Opioid Agents and Somatostatin Analogue
    Name 2 Opioid Agents
    Opioid agents: loperamide, diphenoxylate/atropine

    (1) Loperamide (Imodium) 2mg po after each loose stool or 4mg load then 2mg PO Q 4hrs (max 16mg/day, unless patient receiving Irinotecan)

    (2) Diphenoxylate 2.5mg/atropine 0.025mg (Lomotil) 1-2 tablets Q 6 hrs or after each loose stool
  34. Chemotherapy Diarrhea Management: Absorbent & adsorbent agents, Opioid Agents and Somatostatin Analogue
    Name 1 Somatostatin Analogues
    Somatostatin analog: Octreotide 100-150 mcg SQ TID (up to 2000 mcg TID max)
  35. Specific Guidelines for Irinotecan
    a. Acute onset (during or within 24 hrs)
    i. Facial flushing, abdominal cramps, nasal congestion, or diaphoresis
    Which Anti-Diarrheal Agent?
    IV Atropine
  36. Specific Guidelines for Irinotecan
    Delayed Onset (> 24 hrs); Secretory diarrhea - may be life-threatening
    Which agent?
    • At first sign of diarrhea:
    • Loperamide 4mg PO stat, then 2mg PO Q 2 hrs until:
    • symptom-free for 12 hrs (4mg PO Q 4 hr)
  37. ________lowest value the blood counts fall to during a cycle of chemotherapy (usually described by absolute neutrophil count or WBC
    Nadir:
  38. _________approved for prevention of severe thrombocytopenia in patients undergoing chemotherapy for non-myeloid malignancies
    Oprelvekin (Neumega, Interluekin-ll)
  39. Dosage, Adverse Effects & Contraindications of Oprelvekin (Neumega)
    • (1) 50 mcg/kg daily
    • (2) Fluid Retention, Peripheral Edema, SOB
  40. _____________ leakage of drug into tissues surrounding the injection site and is accompanied by burning, erythema, and swelling
    • Chemotheraphy Induced Dermatological Side-Effect
    • -EXTRAVASATION
  41. List 4 Potential Vessicants
    *Potential Irritants (Cisplatin and Etoposide)
    • Potential Vesicants: V-I-M-P
    • (1) Vincristine, Vinblastine (Vinca Alkaloids)
    • (2) Daunorubicin, doxorubicin, Idarubicin (Topoisomerase 2, Intercalators, Anthracyclines)
    • (3) Mechlorethamine-mustard gas classic alkylating agent
    • (4) Plicamycin-Increases Ca
  42. In General Management of Extravasation of Vesicants
    Inject Antidote Subcutaneously around IV site
    Apply ICE/WARM compression to site and elevate extremity for 24-48 Hrs
    Which Vessicants get WARM?
    WARM COMPRESSIONS-(Hyaluronidase-Antidote)-Vinca Alkaloids, Etoposide (Non-Intercalator)
  43. In General Management of Extravasation of Vesicants
    Inject Antidote Subcutaneously around IV site
    Apply ICE/WARM compression to site and elevate extremity for 24-48 Hrs
    Which Vessicants get COLD compressions?
    Cold Compressions: (Antidote-DMSO-DimethylSulfoxide)-Intercalators, Methchlorethamine, Mytomycin
  44. In General Management of Extravasation of Vesicants
    Inject Antidote Subcutaneously around IV site
    Apply ICE/WARM compression to site and elevate extremity for 24-48 Hrs
    Which is the Antidote for Cisplatin?
    Sodium Thiosulfate
  45. How do you Prevent Extravasation during Chemotherapy?
    Put Chemotherapy Agent in a PIC line (Peripherally Inserted Catheter)
  46. What 3 Agents do you use for Severe Chemotherapy Induced RASH?
    • Continue EGFR
    • (1) Topical hydrocortisone Cream 2.5% OR Clindamycin 1 % Gel OR Pimecrolimus 1 % Cream
    • PLUS
    • (2) Doxycycline 100mg BID OR Minocycline IOOmg BID
    • PLUS
    • (3) Medrol Dosepak
  47. Reassess in 2 weeks - if reaction worsens, dose
  48. interruption or discontinuation may be needed.
  49. Which Agent can you give Radiation?
    5-Fluorouracil (Anti-Metabolite/antiPyrimidine Antagonist)
  50. You can give Radiation with 5-FU. Name 3 agents that cannot be given with Radiation?
    • Methotraxate
    • Doxorubicin
    • Bleomycin
  51. CHEMOTHERAPHY INDUCED HYPERSENSITIVITY RXNS-Be prepared to Premedicate Patient!!!

    Differentiate Between the Premedication for the TAXANES(Anti-MicroTubules)
    DoceTaxel-Premedication against fluid Retention/Edema
    PacliTaxel-Premedicate against Hypersensitivity
    • Similarity: Diphenhydramine(Bernadryl) and Corticosteroid (Dexamethasone)
    • Differences:
    • DA-Acetamenophen, Bernadryl, Corticosteroid (Edema)
    • PH-H2 Antagonist , Bernadryl, Corticosteroid (Hypersensitivity)
  52. Which Pretreatments do you use for
    Bleomycin
    Asparaginase
    Monoclonal Antibodies
    • Tylenol (Acetominophen)
    • Bernadryl (Diphenhydramine)

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