Term
| What are the two phases of treating CINV? |
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Definition
Prevention:
- Select antiemetic based on regimen and patient factors
- Subsequent cycles may be altered based on response
Breakthrough:
- Treatment of CINV after it occurs, in spite of appropriate prevention regimen |
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Term
| What are the main principles of CINV prevention? |
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Definition
- Prevention is goal
- Risk of emesis is 4 days in high risk regimens and 3 days in moderate risk, protect throughout
- Correctly convert doses, and pay attention to antiemetic SE's
- Choice of agent depends on: emetic risk, prior antiemetic experience, patient factors
- Rule out other causes of emesis
- Consider PPI or H2 blocker for dyspepsia
- For multiple-drug regimens, treat against chemo agent with greatest emesis risk |
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Term
| What factors put a PATIENT at risk for emesis? |
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Definition
- Being a woman (LOL)
- Anxiety/expection of n/v
- roommate experiencing n/v (see them puking?)
- H/o emesis to prior chemo
- Prego
- Motion sickness
- Lack of sleep
- Poor food intake
- Basically, being an alcoholic PROTECTS YOU from emesis, weird. |
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Term
| What factors make a REGIMEN more likely to cause emesis? |
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Definition
- Combination regimens
- Rapid infusion
- >once daily administration
- Chemo > 1 day
- Pay attention to Grunberg levels |
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Term
| If a regimen's Grunberg Scale is <90%, what will we give them pre-chemo and post-chemo? |
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Definition
Pre-Chemo: Aprepitant + 5HT3 + Dex
Post-Chemo: Aprepitant x 2 days + Dex 12mg PO or IV |
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Term
| If a regimen's Grunberg Scale is 30-90%, what will we give them pre-chemo and post-chemo? |
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Definition
Pre-chemo: Same as high for some OR 5HT3 for most
Post-chemo: Same as high OR Dex alone OR 5HT3 alone |
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Term
| If a regimen's Grunberg Scale is 10-30%, what will we give them pre-chemo and post-chemo? |
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Definition
Pre-chemo: Dex only OR Prochlorperazine only OR metoclopramide
Post-Chemo: Nothing needed |
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Term
| If a regimen's Grunberg Scale is <10%, what will we give them pre-chemo and post-chemo? |
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Definition
Pre-chemo: Nothing needed
Post-chemo: Nothing needed |
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Term
| What is significant in regards to Emend (Aprepitant/Fosaprepitant)? |
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Definition
- NK1 and substance P inhibitor
- Approved for high and moderate risk
- Expensive and messes with P450 3A4 in EVERY way
- Give 125mg po pre-chemo, then 80mg/day x 2 days after
- Fosaprepitant 115mg IV pre-chemo, then aprepitant 80mg/day x 2 days |
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Term
| Give four examples of 5HT3 antagonists and their doses. What is a retarded pneumonic to remember the order of the doses? |
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Definition
- DOGP (Dogs pee?)
Dolasetron (Anzemet): 100mg IV pre-chemo x 1, 100mg po daily x 2-4 days
Ondansetron (Zofran): 8mg IV or 16mg PO x 1 dose pre-chemo, 8mg BID or 16mg IV x 2-4 days after
Granisetron (Kytril): 1mg IV x 1 dose pre-chemo, 1mg po BID or 2mg PO x 2-4 days after
Palonosetron (Aloxi): 0.25mg IV x 1 dose pre-chemo (lasts 3 days) or 0.5mg PO pre-chemo |
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Term
| What is significant regarding Dexamethasone for prevention of emesis? |
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Definition
- Unknown MOA
- 12mg IV/PO pre-chemo and for 2-4 days post chemo depending on risk
- Might mess with blood sugar, best if taken in morning to prevent insomnia |
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Term
| What are the principles of breakthrough CINV? |
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Definition
- *Add agent from different class*
- Schedule ATC doses instead of PRN
- Hydration/fluids, etc.
- Rule out other causes of N/V
- For next cycle, treat regimen as if ONE Grunberg level higher
- Consider changing regimen/doses if treatment is palliative
- Add H2-blocker or PPI if dyspepsic
- Add lorazepam +/- behavioral therapies if anxious |
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Term
| What are the agents and doses of drugs you could add to a regimen for breakthrough CINV? Pneumonic for remembering these?! |
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Definition
- Lorazepam 1mg IV/PO and then q8h prn
- Prochlorperazine 10mg q4-6hprn or 25mg PR q12h
- Promethazine 12.5mg-25mg PO/IV q4hprn
- Metoclopramide 10-40mg IV or PO q4-6h prn +/- Benadryl 25-50mg PO/IV q4-6h for dystonic reactions
- Haloperidol 1-2mg PO or IV q4-6h
- Olanzapine 2.5-5mg PO daily (Black box for diabetics and demented elderly)
**Medical Marijuana better for anorexia than N/V, elderly experience adverse events)**
- Dronabinol 5-10mg PO q3-6h
- Nabilone 1-2mg PO BID
*Other Hard Drugs Make Prevention Look Pretty Null*
LPPMHODN |
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Term
| What are the required components of pain management in oncology patients? |
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Definition
- Pain intensity must be quantified
- Formal pain assessment must be performed
- Reassess pain at specified intervals
- Psychosocial support must be available
- Specific educational material must be provided to patient |
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Term
| When assessing cancer pain using imaging studies and a physical exam, what are considered oncologic emergencies? |
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Definition
- Bone fracture or impending fracture
- Brain, epidural, leptomeningeal mets
- Infection
- Perforated viscera (acute abdomen)
**Needs to be distinguished if acute pain!
**Pain mgmt plus surgery, steroids, XRT, abx, etc. |
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Term
| What the the different cancer pain syndromes? |
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Definition
- pain from inflammation
- Bone pain w/o oncologic emergency
- Nerve compression or inflammation
- Neuropathic pain
- Severe refractory pain/imminent death |
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Term
| What are the general principles of opioid dosing, and how does this apply to the dosing seen in cancer pain? |
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Definition
- Appropriate dose which relieves pain with no SE's
- Depends on if pt is taking opioids or is opioid naive
- Calculate increase or decrease by TOTAL amount taken previous day
- Equillibrium reached in 5 T1/2
- If increasing, increase both ATC and PRN doses
- Never exceed 4g/APAP/Day
- If unmanageable SE's and pain <4, decrease total dose by 25%
- Always start bowel regimen at same time |
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Term
| What are the approximate doses of opioid-equivalents? |
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Definition
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Opioid
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PO
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IV
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Half-life
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Codeine
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200 mg
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130 mg
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2.9 h
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Hydrocodone
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30-200 mg
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n/a
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3.5-4 h
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Oxycodone
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15 – 20 mg
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n/a
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3.2 h
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Morphine
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30 mg
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10 mg
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1.5 – 2 h
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Hydromorphone
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7.5 mg
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1.5 mg
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2.5 h
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Fentanyl IV
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n/a
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100 mcg
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1-3h
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Fentanyl patch
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n/a
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50 mcg
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1-3 h
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Term
| How should we dose methadone in cancer patients? |
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Definition
- Tricky, has long half-life, accumulates after 2-5 days(side effects)
- High potency
- Dose q4h initially, then may need to increase to q6-8h after steady state (1-2 weeks)
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Term
| Which opioid agents are NOT recommended in cancer patients? |
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Definition
- Propoxyphene - renal, neuro
- Meperidine - renal, neuro
- Butorphanol
- Buprenorphine
- No morphine in renal failure
Pneumonic: BPBM (Bad Pharmacy Benefits Manager) |
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Term
| What are the principles of maintenance dosing for cancer patients on opiods? |
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Definition
- When patient is stable, convert to LA drugs
- Give rescue doses of short-acting opioids for breakthrough, should be 10-20% of 24h dose q1h prn
- Increase dose of LA form when prn dosing no longer effective
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Term
| What are the equivalent morphine IV and PO doses when a cancer patient is on each different strength of a fentanyl patch? |
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Definition
|
Morphine PO
(dose in 24 hours)
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Morphine IV
(dose in 24 hours)
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Fentanyl patch
(mcg /hr)
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25 - 65 mg
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8 – 22 mg
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25 mcg
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65 – 115 mg
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23 – 37 mg
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50 mcg
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116 – 150 mg
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38 – 52 mg
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75 mcg
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151 – 200 mg
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53 – 67 mg
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100 mcg
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201 – 225 mg
|
68 – 82 mg
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125 mcg
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226 – 300 mg
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83 – 100 mg
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150 mcg
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Term
| How do we manage patients on each level of the pain scale if they HAVEN'T taken opioids before? |
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Definition
1-3: consider NSAID or APAP; may start short-acting opioid
4-6: Titrate short-acting opioid like morphine 5-15mg
Reassess in 60 minutes, inc. by 50-100% if pain not resolved
Reevaluate in 24-48h once stable
7-10: Initiate opioid in same fashion, give same intial dose if still a 4-6 pain, continue same dose PRN if pain still 0-3
Reevaluate in 24h once stable, convert to long acting, calculate breakthrough pain dose (10-20% total dose q1h prn) |
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Term
| What are the most important points when considering whether or not to use an ESA to treat Chemotherapy-Induced Anemia? |
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Definition
- DO NOT use if NOT recieving chemo, Chemo and Procrit go hand-in-hand
- DO NOT use if patient may be cured
- DO NOT administer if Hgb > 12 --> VTE/Cardiac problems
- Shorter overall survival and TTP (Time to tumor progression) in several cancers when Hgb >12
- Risk of shorter survival cannot be excluded even if Hgb <12 |
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Term
| What is EPO and how does Procrit and Darbepoetin affect this? |
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Definition
- Hematopoietic growth factor made in the kidneys, helps make RBC's; patients with levels >200mU/mL may be refractory to treatment or need higher levels
- Procrit has same AA sequence as EPO, effective in 50-60% of patients
- Dose is 50-100units/kg TIW or 40,000/week, response may take 4 weeks, SE's are HTN or flu-like sx.
- Darbepoetin is glycosylated EPO, so half-life is longer
- FDA approved for cancer patients 2.2mcg/kg qweek or 500mcg/kg q3w (SQ)
- We almost always use 200mcg SQ QOW |
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Term
| When do we treat anemia in cancer patients? |
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Definition
Hgb <11 and ON chemo
Immediate correction: transfuse RBC's
Chemo is curative: transfuse RBC's
Asymptomatic and.........
no risks: Observe
If risks and AID: IV or PO Iron
If risks and FID: ESA after risk/benefit discussion
Symptomatic: Transfuse or ESA after discussion |
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Term
| What are the risks of developing symptomatic anemia that were discussed on the previous card? |
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Definition
nTransfusion in past 6 months
nH/o prior myelosuppressive chemo
nH/o XRT to >20% skeleton
nMyelosuppressive potential of current chemo
nCurrent Hgb level
nComorbidities
qCardiac, chronic pulmonary, cerebral vascular dz |
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