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85 Cards in this Set
- Front
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significance of infection when undergoing chemo
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Infection is a major cause of morbidity & mortality
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Fever during neutropenia may be the only sign of
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severe underlying infection- other signs of infection that normal people get might not happen because your wbc are fucked
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common sites for infection
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Areas of impaired or damaged host defenses are common sites of infection (mouth...and shit)
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high risk patients for febrile neutropenia (4)
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Prolonged (>7 days) & profound neutropenia (ANC <100 cells/mm3 post-chemo)
AND/OR Clinically unstable (fucked up vitals) Significant medical co-morbid conditions- contributing to current illness requires hospitalization (REQUIRES not...just got admitted) |
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Significant medical co-morbid conditions- contributing to current illness (4)
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Hypotension
Pneumonia, New-onset abdominal pain, Neurologic changes (altered mental status- old people-->get urine sample. wtf) |
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low risk patients for febrile neutropenia (2)
candidates for what type of treatment |
Anticipated brief (<7 days duration) neutropenic periods
No or few co-morbidities Candidates for oral empirical therapy in outpatient setting |
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most important bacteria you want to kill for febrile neutropenia
why? |
pseudomonas!!!!!
gram (-) kills you faster than gram (+), even though gram (+) more common |
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4 IV abx you want to give for high risk febrile neutropenia pt (IMPORTANT)
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cefapime
carbapenem (mirapenem) ceftazidime piperacillin/tazobactam (zosyn) |
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do not take what for febrile neutropenia
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don't take stupid otc for fever
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drugs for febrile neutropenia low risk pt (2)
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oral cipro + augmentin (amox/clav)
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when to throw in the vanc for febril neutropenia
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don't use vanc until gram + suspected as causing issue, or soft tissue infection
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granulocyte colony stimulating factor moa (2)
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stimulates production, maturation, and activation of neutrophils
also activates neutrophils to increase migration and cytotoxicity |
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pegfilgrastim vs. filgrastim
class of drug |
pegfilgrastim dosed once?? like...just once SQ after chemo i think
G-CSF |
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macrophage colony stimulating factor (GM-CSF)
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stimulates proliferation, differentiation, and functional activity of neutrophils, eosinophils, monocytes & macrophages
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GM-CSF
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sargramostim
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Palifermin (Kepivance): what is it
used for what |
keratinocyte growth factor
for mucositis |
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preferred route of admin for growth factors
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Subcutaneous administration is preferred route for G-CSF, ESA and Oprelvekin
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Reserve primary administration for
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pts with expected incidence (from literature regarding their chemo) of febrile neutropenia ≥ 20%
rare so usually just give chemo once then see what happens |
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Avoid primary admin of growth factors in patients...
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receiving chemo & radiotherapy (like…together)
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Consider dose reduction in lieu of CSFs when? (2)
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after neutropenic fever or severe or prolonged neutropenia after the previous cycle of treatment (usually not if curative intent though)
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clinical factors predispose to increased complications from prolonged neutropenia (7)
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patient age greater than 65 years
poor performance status and/or nutritional status previous episodes of FN extensive prior treatment including large radiation ports or administration of combined chemoradiotherapy (fried out marrow) cytopenias due to bone marrow involvement by tumor presence of open wounds or active infections more advanced cancer, as well as other serious comorbidities |
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growth factor use in hospitalized pt with febrile neutropenia- use?
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Not routinely used as adjunctive treatment with antibiotic therapy for patients with fever and neutropenia
DONT USE IT IN THE HOSPITAL I GUESS JUST FOR SECONDARY PPX OF WHATEVER |
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filgrastim- when to give
give until when |
Given 24 to 72 hours after chemotherapy & continued until reaching an absolute neutrophil count (ANC) of 2000 – 3000
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3 AE of filgrastim
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Bone pain (histamine mediated marrow swelling), pain at site of injection, fever or “flu-like” symptoms
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2 drugs that may help for filgrastim bone pain (anecdotal)
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NSAIDs & antihistamines have been used to decrease bone pain but have not been formally evaluated
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pegfilgrastim- not used for what
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mobilization of stem cells shit
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Fixed dose of pegfilgrastim should not be used in
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infants, children, and adolescents less than 45 kg
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sargramostim- used for what? not used for what?
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Usually used in BMT for stem cell mobilization, shorten time to neutrophil recovery, or myeloid reconstruction/marrow engraftment , not used really for febrile neutropenia ppx
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ESA used for whome?
DO NOT USE with what type of chemo? |
used for pt where intent of chemo is palliative. DO NOT USE if trying to cure or induce CR because ESAs can fuck up those people by helping with angiogenesis
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if you're using ESA you have to enroll in what?
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if you're using ESA you have to use REMS program
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palfermin- used for what? what is it?
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Synthetic version of keratinocyte growth factor aimed at decreasing horrible mucositis (prevention) (not used THAT much)
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why is prevention of mucositis important?
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in areas like the mouth mucositis can increase infective risk and that can spread to rest of body
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3 AE of palfermin
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skin toxicity (rash, edema, purities), oral toxicities (taste alterations), and pain
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EGFR-I “Rash”- pathophys
is it acne |
EGFR inhibition interferes with normal skin tissue function causing inflammation
NOT ACNE, but often called acneiform |
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EGFR-inhibitor rash- most commonly affected areas (2 main ones)
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More commonly affected areas include nose, nasolabial folds, cheeks, chin & forehead (“T-zone”); upper chest and/or back
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EGFR inhibitor rash- dose dependency, what increases severity??
usually occurs when and peaks when |
Dose dependent, increased severity w/antibodies
Usually occurs within 7 – 10 days, peaks in 2 weeks |
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non pharm options for EGFR inhibitor rash (2)
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MOISTURIZE! MOISTURIZE! MOISTURIZE!
Gentle cleansers, creams, low fragrance/alcohol Minimize sun exposure & use sunscreen |
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ppx for EGFR inhibitor rash (3)
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Begin prophylaxis with doxycycline 100 mg daily or minocycline 100 mg BID & low – potency topical steroid BID for first 6 weeks
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other options for EGFR inhibitor rash ppx (4)
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can also try retinoids, topical abx, oral steroids or dose reduction of chemo
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onset of hand/foot syndrome with traditional agents vs. tyrosine kinase inhibitors
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usu. develop from 2 – 12 days after starting traditional agents & 2 – 4 wks for multikinase inhibitors
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3 things in the pathophys of mucositis that are causing the dmg
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Process in which chemical cell damage, proinflammatory cytokines, and bacteria lead to mucosal cell damage & eventually ulceration
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mucositis 3 locations
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labial, buccal and soft‐palate mucosa; the floor of the mouth; & the ventral aspect of the tongue
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stepwise progression of mucositis (3)
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Asymptomatic erythema at 0 – 5 days post
Desquamation with white patches at 0 – 7 days post Contiguous pseudomembranes at 6 – 12 days post |
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mucositis- duration of therapy and effect on dmg
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Continuous infusions worse than short IV infusions (bolus better)
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4 non pharm for mucositis prevention/management
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Regular, systematic oral care hygiene, including brushing with a soft toothbrush, flossing, bland rinses, and moisturizers as part of a standardized oral protocol
Dental assessment & treatment prior to start of therapy for all patients, especially head & neck cancer patients Avoid rough food, spices, salt and acidic fruit; avoid smoking and alcohol Ice chips 30 minutes prior to therapy |
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2 drugs used for mucositis
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Palifermin for patients receiving high‐dose chemo & total body irradiation followed by stem cell transplant
Around-the-clock pain management is a must |
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2 causes of pathophys of hot flashes (affects men and women)
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Possibly due to dysfunction in the central thermoregulatory set point in hypothalamus as a result of decreased estrogen or gonadal steroid levels
Serotonin might also have an important role in thermoregulation |
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using HRT to treat hot flashes
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dumb...if you have cancer that is based on hormones
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professor's rec for treating hot flashes (2 main drugs to use, which one preferred best)
why not use the other stuff? |
venlafaxine
then gabapentin next other SSRI's not as robust, and DDI's that can fuck up endoxifen through CYP2C9 (go with SNRI before SSRI) |
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non pharm modifications for hot flashes (4)
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sipping cold drinks, lowering room temp, loose fitted clothing, avoiding alcohol & spices in diet
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3 hot flash drugs that interact with tamoxifen
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paroxetine
sertraline citalopram |
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downside to gabapentin (3)
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weight gain
sedation TID |
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downside to pregabalin for hot flashes (2)
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expensive
BID - TID |
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misc supplement for hot flashes
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vitamin E for mild
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what is an HSR? (2)
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Adverse rxn usually occurring within seconds to minutes of administration with features of an anaphylactic (antibody mediated) or anaphylactoid (not antibody mediated) reaction- usually anaphylactoid
Unexpected reaction not consistent with the drug’s known toxicities |
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HSRs usually what type
exception |
type I rxn (allergic/histamine mediated), unless you are using mabs/methotrex then could be the others
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2 drugs at very high risk for HSR
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asparaginase
paclitaxel- also excipient in drug called "cremifore??" that people react to (double whammy) |
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Only one drug class has never been reported to cause HSRs
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nitrosoureas (mustines)
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Overall reported incidence of HSR for all chemo (2) may be worse due to
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5 to 15% of patients
rates vary from drug to drug may be worse due to under-reporting |
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no proven risk factors but possible ones for HSR- (6)
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history of seasonal, food, general allergies
history of other drug allergies prior exposure to the drug dose of drug tumor burden or type patients receiving drugs with HSR history |
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2 drugs that react (HSR) completely differently and how
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carboplatin- delayed HSR- can take up to 8 doses
paclitaxel- immediate HSR within 1-2 doses- can re-treat usually |
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5 management strats for HSR
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Stop the infusion
Access and utilize support measures premedicate Multiple-day premeds(didn't discuss these much) Desensitization: serial dilution dose titration |
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drug of choice for HSR- other drug you can use to control rxn
can you restart chemo after rxn is managed? |
Diphenhydramine (drug of choice) or steroids for urticaria/rash- usually limited to one reaction and can restart drug
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4 other support meds/items for HSR
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Epinephrine, albuterol, O2 for shortness of breath
IV fluids or colloid replacement for hypotension |
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4 things to premed with for HSR
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diphenhydramine, H2RA, acetaminophen &/or steroid
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most common cancers for hypercalcemia (3)
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lung, breast & multiple myeloma most common- bone mets
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sx of hypercalcemia (7)
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lethargy, confusion, anorexia, nausea, constipation, polyuria & polydipsia
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3 pharm steps for managing hypercalcemia
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saline- lots of fluids- hydrate and increase urine loss of calcium (adjust based on cv status) 250-500 ml/h if depleted, then 100-150 mL
then furosemide after volume correction pamidronate or zoledronic acid (IV)- i'm pretty sure you put this in the saline |
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alternatives to managing hypercalcemia
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glucocorticoids- i think this is just for like...shrinking tumors
calcitonin- transient mithramycin gallium nitrate |
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eliminate what if hypercalcemic?
2 things to d/c |
Eliminate sources of calcium and discontinue medications that may increase calcium such as thiazides and Vitamin D
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tumor lysis syndrome due to...
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Due to massive release of intracellular contents after tumor cell death
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tumor lysis most commonly seen with...(2)
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hematologic & kinetically active solid tumors
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tumor lysis- treatable?
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NO. preventable only
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5 lab abnormalties that dx tumor lysis
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Labs show elevated uric acid (>8 mg/dL)
phosphorus (>1.45 mmol/L), potassium (>6 mg/dL)*** LDH (> 2x ULN) low calcium |
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clinical signs for tumor lysis (4)
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Scr ≥ 1.5x’s ULN, arrhythmia, seizure or sudden death (from potassium...)
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cancers at high risk for tumor lysis (3) and why
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agressive hematological malignancies (leukemia/lymphoma Burkitt (high grade), ALL, AMC- you have cancer cells EVERYWHERE and are highly chemosensitive)
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moderate risk for TLS (4)
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solid: SCLC- highly sensitive to chemo, some breast cancers
low grade lymphomas seminoma |
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thing that causes most of the problems with TLS and why
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uric acid (from DNA)- big deal- crystallizes in kidney and blocks elimination of all other elecrolytes and shit- so we target this for treatment
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2 drugs for TLS
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allopurinol-takes a while to work- give 2-3 days before chemo
rasburicase?- use if you want more immediate effects or "treatment" ; converts uric acid to allantoin |
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4 other things you have to watch with TLS
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hyperkalemia
low calcium hyperphos cardiac monitoring |
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6 things to manage hyperkalemia
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sodium polystyrene sulfonate, insulin, dextrose, sodium bicarb (if acidotic, but avoid because it fucks with rasburicase), albuterol, dialysis (if unresponsive to above)
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drug of choice for VTE and when to give when to stop
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GIVE TO EVERYONE HOSPITALIZED EVEN IF THEY ARE AMBULATORY in the absence of bleeding or other contraindications
then stop on discharge unless they had an event LMWH |
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cancer drug with very high rates of VTE
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bevacizumab (duh it fucks with VEGF)
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is route VTE ppx recommended for outpatients?
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Routine prophylaxis of ambulatory (not in hospital) cancer pts is not recommended, with the exception of pts receiving thalidomide or lenalidomide
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cancer pt undergoing what process should be considered for pharmacologic thromboppx?
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Pts undergoing major surgery for malignant disease should be considered for pharmacologic thromboprophylaxis
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