-
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
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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
-
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
-
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%)]
-
Course of mucositis matches the "neutrophil nadir" and usually starts ___________ after therapy
5 to 7 days
-
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
-
MUCOSITIS higher with combination regimens ________________
[docetaxel + 5-FU (58-74%)]
-
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
-
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.
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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
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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
-
b. Oral and parenteral analgesics for ORAL MUCOSITIS
i. Administer around the clock
ii. Consider PCA pumps
iii. _____________ standard of care
Morphine
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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
-
c) Antibacterial therapy for ORAL MUCOSITIS
most common bacteria: _________________?
surveillance cultures useful:_______________?
**good mouth care
- (1) gram-positive
- (2) not useful
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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
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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
-
__________ (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
-
XEROSTOMIA (Dry Mouth) Risk Factors:
i. _____________ for head and neck cancers
ii. Concomitant medications eg __________
- (1) Radiation therapy
- (2) Anticholinergics eg Compazine
-
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
-
___________Stimulates salivary secretion in patients with residual salivary function
Pilocarpine (Salagen") 5mg tablets, 1-2 tablets PO TID to QID
-
_____________ 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
-
CONSTIPATION IN CHEMOTHERAPY
3 Major Antineoplastic Treatments??
- Antineoplastic drugs:
- (1) Vinca alkaloids (Vincristine (MAX: 2mg), Vinblastine)
- (2) Thalidomide
- (3) Radiation Therapy
-
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
-
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)
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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)
-
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
-
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
-
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)
-
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
-
3 Non-Pharmacological Therapy for Chemotherapy Induced Diarrhea?
- Fluids & electrolytes
- Nutrition
- Avoid problem foods & drugs causing diarrhea
-
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
-
Chemotherapy Diarrhea Management
Absorbent & adsorbent agents, Opioid Agents and Somatostatin Analogue
Name 2 Absorbent & adsorbent agents
-
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
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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)
-
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
-
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)
-
________lowest value the blood counts fall to during a cycle of chemotherapy (usually described by absolute neutrophil count or WBC
Nadir:
-
_________approved for prevention of severe thrombocytopenia in patients undergoing chemotherapy for non-myeloid malignancies
Oprelvekin (Neumega, Interluekin-ll)
-
Dosage, Adverse Effects & Contraindications of Oprelvekin (Neumega)
- (1) 50 mcg/kg daily
- (2) Fluid Retention, Peripheral Edema, SOB
-
_____________ leakage of drug into tissues surrounding the injection site and is accompanied by burning, erythema, and swelling
- Chemotheraphy Induced Dermatological Side-Effect
- -EXTRAVASATION
-
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
-
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)
-
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
-
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
-
How do you Prevent Extravasation during Chemotherapy?
Put Chemotherapy Agent in a PIC line (Peripherally Inserted Catheter)
-
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
Reassess in 2 weeks - if reaction worsens, dose
interruption or discontinuation may be needed.
-
Which Agent can you give Radiation?
5-Fluorouracil (Anti-Metabolite/antiPyrimidine Antagonist)
-
You can give Radiation with 5-FU. Name 3 agents that cannot be given with Radiation?
- Methotraxate
- Doxorubicin
- Bleomycin
-
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)
-
Which Pretreatments do you use for
Bleomycin
Asparaginase
Monoclonal Antibodies
- Tylenol (Acetominophen)
- Bernadryl (Diphenhydramine)
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