Complications of cancer therapy
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Created by:
megahnalthoff on August 21, 2011
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31 terms
English | Photos |
|---|---|
 Pathophysiology of nausea | -Triggered by impulses in vomiting center in the medulla near fourth ventricle -Vagal efferents to salivation center, abdominal muscles, stomach, diaphragm, and cranial nerves -Principle neuroreceptors are serotonin (5-HT3) and dopamine -Also acetylcholine, corticosteroid, histamine, cannabinoid, opiate and neurokinin-1 |
| Types of nausea and vomiting | -Chemotherapy-induced—occurs within minutes or hours of treatment (cisplatin) -Delayed onset—more than 24 hours after administration (cisplatin, cyclophosphamide, doxorubicin) -Anticipatory—prior to chemotherapy (cisplatin) -Breakthrough -Refractory |
| List the highly emetic agents | - Cisplatin - Adriamycin/cyclophosphamide - Ifosphamide |
| List agents with minimal emetic risks | - Cytarabine - Fludarabine - Rituximab - Trastuzumab |
| List the 5-HT3 antagonists | ondantsetron, granisetron, dolasetron, palonosetron |
| What steroid is commonly used as an anti-emetic? | dexamethosone |
| List the Neurokinin 1 antagonists | aprepitant, fosaprepitant |
| List adjuncts to anti-emetic treatment | Benzodiazepines—lorazepam H2 antagonists or proton pump inhibitors- omeprazole |
| Drug combos for low emetic risk therapies | - Steroids—dexamethasone - Antidopaminergics—metoclopramide, prochlorperazine, haloperidol - Benzodiazepines—lorazepam - H2 blockers or proton pump inhibitors |
| Drugs for breakthrough nausea | Always ADD agents rather than substitute - Antipsychotics—olanzapine - Cannibinoid—dronabinol, nabilone - Phenothiazine—prochlorperazine, promethazine - 5-HT3 antagonists - Steroids |
| Treatment for anticipatory nausea | - Benzodiazepines—lorazepam - Accupuncture/accupressure - Behavioral therapy—relaxation, hypnosis, music therapy |
| Chronic pain wheel |  |
| Somatic pain | - Most common--hitting thumb with hammer - Pain from bone metastasis - Well-localized - Prostaglandins sensitize nociceptors --NSAIDs work well for this pain |
| Visceral pain | - Deep, squeezing or colicky - Pain from bowel obstruction from tumor - Pain from liver metastasis - May be referred to cutaneous sites - Sometimes difficult to localize |
| Neuropathic pain | - Second most common type of cancer pain - Pain from tumor eroding into nerve root - Burning, electrical, paroxysmal |
| NSAIDs | - Work by inhibiting prostaglandins which sensitize nociceptors - 20-40% of cancer patients receive relief with these drugs - No tolerance or dependency - Ceiling effect - GI toxicity, liver toxicity |
| Examples of NSAIDs | - ASA, acetaminophen - Ibuprofen, naproxen - Salsalate (does not affect platelets) - Keterolac (can be given IV) - Cox-2 inhibitors--celecoxib |
| Opiates | - Interact with specific receptors in CNS (mu, kappa, delta) - All available agents are mu agonists - Oxycodone has some kappa agonist activity |
| Codeine | Weak optiate, relatively short acting - Converted to morphine in the liver by p450 system - Differences between ethnic groups - Overall, 10% not able to make this conversion - p450 inhibited by cimetidine, SSRIs, etc |
| List the strong optiates | - Morphine - Hydromorphone - Methadone - Fentanyl (available as a topical patch) |
| What drug should you NOT give? | Meperidine (Demerol) Significantly lowers the seizure threshold |
| RL is getting MSO4 at 10 mg/hr. What oral dose of MS Contin® is dose equivalent? | 10 mg/hr x 24 hours = 240 mg Factor of 3 =720 mg oral morphine =240 MS Contin® TID |
| Side effects of opiates | - Constipation—lactulose or senna - Itching—H1 antagonist - Somnolence--psychostimulants - Nausea - Respiratory depression |
| Drugs to treat neuropathic pain | Often the same as drugs use to treat seizures: - Tricyclics - Antidepressants - Anticonvulsants - Local anesthetics |
| Addiction and tolerance of opiates | Addiction: most patients are not addicted to optiates - Impaired control over drug use - Compulsive use - Use despite harm - Craving Tolerance: - Pharmacologic effect - Increasing doses needed to reach same effect over time - Doubling dose often required over time. |
| Withdrawal from opiates | - Anxiety, irritability, insomnia - Sweating, lacrimation, rhinorrhea - Hot flashes, chills - diarrhea, nausea, vomiting |
| Manage fatigue | Caffeine Methylphenidate Erythropoiesis Stimulating Agents DO NOT affect this symptom (erythropoietin, darbopoietin) |
| Particularly bad drugs for marrow suppression | - Docetaxel - Oxaliplain - Paclitaxel - Cisplatin - Irinotecan |
| GCSF | Myeloid stimulating agent Typically used in anticipation of febrile neutropenia, based on the regiment and on individual patient Not used once a patient ALREADY has febrile neutropenia GCSF with s-phase stimulating agents will cause PROFOUND neutropenia if given when the patient is already neutropenic |
| CSF toxicity | - Filgrastim—rash, urticaria, ARDS, bone pain, splenic rupture - Pegfilgrastim—splenic rupture, ARDS, allergy, bone pain |
| USMLE clinical pearls | - In treating nausea, agents are typically added and seldom removed - Cisplatin is HIGHLY emetogenic - Methylphenidate can help with fatigue, depression, and opiate-induced somnolence - Only senna and lactulose can mediate opiate induced constipation - Uncertain role of erythropoietic agents - CSFs are typically used to mediate anticipated neutropenia - Most cancer patients do not become addicted to opiates - Constipation is a common side effect of MSO4 that DOES NOT respond to docussate - 3:1 oral:parenteral morphine equivalency - AVOID meperidine - NSAIDs act by blocking the sensitizing effects of prostaglandins |
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