Term
|
Definition
| an inclincation to vomit or as a feeling in the throat or epigastric region alerting an individual that vomiting is imminent |
|
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Term
|
Definition
| ejection or expulsion of gastric contents through that mouth and is often a forceful event |
|
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Term
|
Definition
dehydration;
metabolic disturbances;
malnutrition;
esophageal tears;
wound dehiscence;
fractures;
aspiration pneumonia;
reduction of QOL of pt;
withdrawal from chemotherapy |
|
|
Term
| Risk Factors for Chemo-Induced N/V (CINV) |
|
Definition
Therapy Related:
- intrinsic emetogenicity of antineoplastic agent;
- dose, route, & administration rate of antineoplastic drug;
- concomitant radiation;
Patient Factors:
- poor contol with prior therapy;
- age <50;
- alcohol use history (<10 dirnks/week or 1.5 oz EtOH/day);
- female;
- history of motion sickness or morning sickness; |
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Term
|
Definition
| occurs during first 24 hr period following chemo administration |
|
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Term
|
Definition
occurs more than 24 hrs after chemo administration;
- high incidence with: cisplatin (#1), cyclophosphamide, doxorubicin, carboplatin; |
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Term
|
Definition
classically-conditioned response; a previously neutral stimulus elicits a conditioned response. Occurs prior to, or at other times without chemo agent being administered;
PREVENTION is best treatment;
Treatment of Choice: BENZODIAZEPINES |
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Term
| Prophylaxis of CINV in High Emetic Risk Pts on IV Antineoplastics |
|
Definition
Aprepitant/fosaprepitant (Emend)
+
5-HT3 antagonist (ondansetron, granisetron, dolasetron, palonosetron)
+
dexamethasone
+/- lorazepam
+/- H2 blocker/PPI |
|
|
Term
| Prophylaxis of CINV in Moderate Emetic Risk Pts on IV Antineoplastics |
|
Definition
Aprepitant/fosaprepitant (Emend)
+
5-HT3 antagonist (ondansetron, granisetron, dolasetron, palonosetron)
+
dexamethasone
+/- lorazepam
+/- H2 blocker/PPI |
|
|
Term
| Prophylaxis of CINV in Low Emetic Risk Pts on IV Antineoplastics |
|
Definition
dexamethasone
OR
metoclopramide
OR
prochlorperazine
+/- lorazepam
+/- H2 blocker/PPI |
|
|
Term
| Prophylaxis of CINV in Oral Chemo Agents |
|
Definition
5HT3 antagonist (ondansetron, granisetron, dolasetron, palonosetron)
+/- lorazepam
+/- H2 blocker/PPI |
|
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Term
| 5-HT3 Antagonists - ondansetron (Zofran, Zuplenz), granisetron (Kytril), dolasetron (Anzemet), palonosetron (Aloxi) |
|
Definition
MoA: blocks presynaptic serotonin receptors on sensory vagal fibers in gut wall, blocking acute phase CINV;
All are equally effective for ACUTE CINV;
P has activity in preventing delayed CINV;
**NOT FOR BREAKTHROUGH N/V** Prevention ONLY!!!
Available PO & IV
SEs: headache, constipation |
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Term
| ondansetron (Zofran, Zuplenz) |
|
Definition
5-HT3 antagonist;
Used to prevent acute CINV;
Dosing:
- single dose 16-24 mg PO or 8-12 mg IV prior to chemo;
- 24 mg dissolved ORALLY on tongue 30 min prior to start of a single-day chemo;
Side Effects:
- HA, constipation |
|
|
Term
| granisetron (Kytril, Sancuso) |
|
Definition
5-HT3 antagonist;
Used to prevent acute CINV;
Side Effects:
- HA, constipation;
Dosing:
- single dose 2 mg PO or 1 mg IV, or transdermal patch 34.3 mg prior to chemo |
|
|
Term
|
Definition
5-HT3 antagonist;
Used to prevent acute CINV;
Side Effects:
- HA, constipation;
Dosing:
- single dose of 100 mg IV/PO prior to chemo |
|
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Term
|
Definition
5-HT3 antagonist;
Used to prevent acute CINV and prevent DELAYED CINV;
Side Effects:
- HA, constipation;
Dosing:
- single dose 0.25 mg IV;
Higher receptor binding affinity & significantly longer T1/2 (40 hrs) |
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|
Term
| aprepitant/fosaprepitant (Emend) |
|
Definition
neurokinin-1 (Substance P) receptor antagonist;
Prevents acute & delayed CINV by inhibiting NK-1 receptor;
Always recommended for use as a 3-drug cocktail;
Dose: 125 mg PO or 115 mg IV 1 hr prior to chemo on Day 1, then 80 mg PO daily in AM on Days 2 & 3;
CYP3A4 Inducer & Inhibitor; CYP2C9 inducer;
SEs: asthenia, fatigue, diarrhea, hiccups, dizziness, dehydration;
Never give more than 12 mg Dexamethasone with this drug; |
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Term
|
Definition
Antiemetic MOA not fully understood;
Thought to potentiate antiemetic properties of 5-HT3 antagonists;
Administer IV, PO, or IM;
Most often used steriod for antiemesis;
TREATMENT OF CHOICE in tx N/V in pts receiving radiation to the brain, also reduces cerebral edema;
PO for delayed N/V;
Dose Range: 8-40 mg;
SEs: hyperglycemia, immunosuppression, insomnia, cataract formation, proximal muscle weakness, adrenal suppression, psychosis, mood changes, anxiety, GI irritation, weight gain, lethargy, aseptic necrosis of long bones; |
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Term
|
Definition
Dopamine-2 antagonist: competitive antagonist at D2 receptors in CTZ;
Uses: adjunctive therapy for prevention of delayed N or N due to constipation;
Dose: 10-20 mg PO or 1-2 mg/kg IV q2 hrs;
SEs: akathisia, dystonic rxns, sedation, fatigue |
|
|
Term
| prochlorperazine (Compazine), promethazine (Phenergan) |
|
Definition
Dopamine-2 Antagonist;
act on dopaminergic receptors at CTZ;
Uses: preventing N associated with radiation therapy & in Tx of N/V attributed to low & minimally emetogenic chemo drugs;
Administered PO, IV, IM, or PR;
SEs: EPS (dystonia, akathisia, NMS, dyskinesia), sedation, hypotension; |
|
|
Term
|
Definition
a group of metabolic disorders that usually occurs after the treatment of a neoplastic disorder, due to the destruction of cancer cells;
Manifestation:
- hyperphosphatemia;
- hypocalcemia;
- hyperuricemia;
- hyperkalemia;
- acute renal failure: acute uric acid nephropathy, acute hyperphosphatemia; |
|
|
Term
|
Definition
underlying malignancy: poorly differentiated lymphomas, acute lymphoblastic leukemia, acute myeloid leukemia;
hyperuricemia;
renal dysfunction;
increased tumor cell proliferation rate (WBC & LDH);
Tumor Burden;
Chemosensitivity of the malignancy; |
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Term
|
Definition
IV hydration: maintains renal blood flow & promotes urinary excretion of uric acid & phosphate;
Specifics:
- begin 24-48 hrs prior to chemo induction;
- 3-6 L/m^2/day or 125-250 mL/m^2/hr;
- maintain urine output at 100 mL/m^2/hr;
- monitor urine pH;
**DO NOT ADD POTASSIUM to the IV solution** |
|
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Term
|
Definition
Urate oxidase: metabolizes uric acid to allantoin;
Onset: hours;
C/I: G6PD deficiency;
Dose: 0.2 mg/kg IV over 30 min x 1 dose (may repeat dose in 24 hrs if inadequate response);
**ALTERNATIVE WEIGHT-BASED DOSING**
<70 kg: 4.5 mg x 1; 70-100 kg: 6.0 mg x 1; >100 kg: 7.5 mg x 1;
***NO INTERACTIONS W/ ALLOPURINOL***
ADRs: N/V, diarrhea, HA, fever;
Monitor: Collect blood 4 hrs post-transfusion in PRECHILLED heparinized tubes immersed in ice water; |
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|
Term
|
Definition
Inhibits xanthine oxidase;
Onset: 2-3 days;
C/I: allergy to med;
Dose: 300-800 mg/day in divided doses PO/IV (Start 1-2 days prior to chemo if possible);
Drug Interactions: azathioprine, 6-MP, ampicillin, warfarin, theophylline, cyclosporine;
ADRs: rash;
Monitor: routine tumor lysis labs;
Renal/Hepatic Dosing:
GFR 10-50: 50% of normal dose;
GFR <10: 25% of normal dose; |
|
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Term
|
Definition
| most common hematologic complication of cancer chemotherapy |
|
|
Term
| erythropoietin - epoetin alfa, EPO (Procrit, Epogen) |
|
Definition
Promotes proliferation & differentiation of erythroid precursors to stimulate RBC production;
Dose: 150 U/kg SQ 3x/wk up to 300 U/kg 3x/wk or 40,000-60,000 U qwk; Adjust to maintain target Hgb;
SEs: HTN, fatigue, HA, fever, edema, N/V, arthralgias, diarrhea;
BBW: Increased risk of thromboembolic events (stroke, MI, DVT, PE, TIAs), don't use in pts receiving CURATIVE myelosuppressive therapy;
**DO NOT START IF Hgb >=10** |
|
|
Term
| darbapoetin alfa (Aranesp) |
|
Definition
hyperglycosylated analogue of recombinant human EPO;
longer T1/2, dosed less frequently;
Dose: 2.25 mcg/kg SQ qweekly, adjust to maintain target Hgb - MAX: 4.5 mcg/kg;
SEs: HTN, fatigue, HA, fever, edema, N/V, arthralgias, diarrhea;
BBW: Increased risk of thromboembolic events (stroke, MI, DVT, PE, TIAs), don't use in pts receiving CURATIVE myelosuppressive therapy;
**DO NOT START IF Hgb >=10** |
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|
Term
| oprelvekin (IL-11, Neumega) |
|
Definition
Platelet growth factor - stimulates production of megakaryocytes & thrombopoiesis;
Indicated for Chemo-induced thrombocytopenia;
Dose: 50 mcg/kg SQ daily x 10-21 days;
RARELY USED (lack of bioavailability, lack of pharmacoeconomic advantage) |
|
|
Term
| Normal Range for Platelets |
|
Definition
| 140,000 - 440,000 cells/mm^3 |
|
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Term
|
Definition
| decreased platelet count, increased risk of bleeding |
|
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Term
|
Definition
morbid side effect of many anticancer treatments;
frequent site of GI mucosa inflammation --> extremely painful ulcerations, local infections, & inability to eat, drink, or swallow;
Usually FOLLOWS AFTER NEUTROPENIA;
Most severe manifestation: ulceration of mucosa; |
|
|
Term
|
Definition
| Mucositis to the the extent that alimentation is not possible --> no longer able to eat PO, start parenteral nutrtion; |
|
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Term
|
Definition
Ulcers with extensive erythema;
Pt cannot swallow solid food; |
|
|
Term
|
Definition
1) Radiation therapy;
2) Chemotherapy:
- methotrexate
- 5-fluorouracil
- irinotecan
- anthracyclines (doxorubicin, daunorubicin);
- etoposide;
- cyclophosphamide;
- melphalen |
|
|
Term
| Clinical Presentation of Mucositis |
|
Definition
erythema;
ulceration;
pain;
edema;
dysphagia;
diarrhea; |
|
|
Term
|
Definition
primary event: chemo or radiation;
generates reactive oxygen species (ROS);
causes acute tissue phase |
|
|
Term
| Upregulation with Generation of Messengers |
|
Definition
ROS leads to DNA damage & cell death in epithelial layer;
Activation of NF-kB;
Up-regulates TNF-alfa, IL-1beta, IL-6;
activation of COX-2 pathway & subsequent angiogenesis; |
|
|
Term
| Signaling & Amplification |
|
Definition
proinflammatory cytokines amplify mucosal injury;
tissue is altered biologically, but may appear normal; |
|
|
Term
| Ulceration with Amplification |
|
Definition
infiltrate triggered by oxidative stress & mediated by activated T-cells;
Bacterial colonization occurs;
Bacterial products can activate tissue macrophages & lead to more proinflammatory cytokines;
Changes in composition & amount of saliva; |
|
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Term
|
Definition
begins with signal from ECM;
leads to renewal of epithelial proliferation & differentiation, reestablishing local microbial flora;
phase marked by neutrophil recovery in HSCT;
oral mucosa appears normal: environment altered significantly, residual angiogenesis; |
|
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Term
|
Definition
| Mainstay of mucositis prevention & treatment |
|
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Term
|
Definition
| treatment of choice for oral mucositis pain in pts undergoing HSCT |
|
|
Term
| Magic Mouthwash, Hawaiian Punch, Stomatitis Cocktail, Magic Swizzle |
|
Definition
viscous lidocaine
+
diphenhydramine
+
Maalox;
not terribly efficacious |
|
|
Term
| Recommended Therapeutic Agents for Oral Mucositis |
|
Definition
Basic Oral Care (brushing, flossing, fluoride, etc) - MAINSTAY;
Benzydamine;
Pt-Controlled Analgesia (PCA);
Cryotherapy (sucking on ice chips) |
|
|
Term
| Agents with Insufficient Evidence for Recommendation in Tx of Mucositis |
|
Definition
bland rinses;
misoprostol;
flurbiprofen;
allopurinol ice balls;
amifostine; |
|
|
Term
| Agents NOT RECOMMENDED for Tx of Oral Mucositis |
|
Definition
Sucralfate;
Chlorhexidine;
Acyclovir;
Antimicrobial lozenges;
GM-CSF mouthwashes;
pentoxifylline; |
|
|
Term
| Recommended Agents for Use in GI Mucositis |
|
Definition
Octreotide >100 mcg SQ BID;
H2 blocker or PPI;
Sulfasalazine 500 mg PO BID;
Sucralfate enemas; |
|
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Term
|
Definition
recombinant keratinocyte growth factor;
Only FDA-approved drug for mucositis tx;
MoA: endogenous protein that binds to KGF receptor --> proliferation, differentiation, & migration of epithelial cells;
Indication: decrease incidence & duration of severe oral mucositis in pts w/ hematologic malignancies receiving myelotoxic therapy requiring hematopoietic stem cell support;
Guidelines: pts w/ hematologic malignancies receiving high dose chemo & TBI w/ autologous stem cell transplant --> use dose of 60 mcg/kg/day x 3 days prior to conditioning treatment & for 3 days post-transplant --> recommended for prevention of oral mucositis;
Precautions:
- stimulation of tumor growth;
- restore pH balance in oral cavitiy;
- FDA approved ajunct to standard oral care in treating mucositis that may be caused by radiation or high-dose chemo; |
|
|
Term
| Cryotherapy & Good Oral Hygiene |
|
Definition
| mainstay of current preventative measures against mucositis; |
|
|
Term
| Opioids & Total Parenteral Nutrition |
|
Definition
| mainstay of current treatment regimens for mucositis |
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