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Oncology Exam 2
Frei Thrombocytopenia (D)
| Question | Answer |
|---|---|
| Myeloid stem cells lead to the production of many cell divisions including _________ | platelets; *platelets differentiate from the myeloid stem cell lines |
| What is thrombocytopenia? | Condition in which there is a deficient number of circulating platelets; Defined as: < 150,000 cells/mm3 or 150 K 🌟 OR Relative thrombocytopenia – 50% decrease in platelet count on lab values (pt came in and had 450,000 a month ago and now at 100,000–> that would be both the absolute and the relative) 450K last month and 200K —> that would meet relative thrombocytopenia but “still doesn’t meet the criteria for true thrombocytopenia |
| What are s/sx of thrombocytopenia? | -Bleeding – main symptom -Purpura (big red splotches) and/or petechiae (tiny red freckles) -Epistaxis -Hemoptysis |
| Other symptoms of thrombocytopenia include: | -Menorrhagia -Hematuria -Intracranial hemorrhage, rare -Melena -Hematochezia *examples of all bleeding that we would see in a case *fatigue is a symptom of anemia, but not thrombocytopenia** |
| What are the major causes of Thrombocytopenia? | Deficits in production -Invasion of bone marrow by malignancy -Marrow destruction by: (Chemotherapy, Infection, Other Medications, Radiation); -Increased sequestration (Splenomegaly—> *platelets stuck in spleen and can't get the platelets out into circulation -Increased destruction (Immune thrombocytopenic purpura (ITP) (breaking down of platelets happens faster than its supposed to) -Disseminated intravascular coagulation (DIC) or sepsis) |
| Based on the chart "Algorithm for thrombocytopenia Evaluation", the most common cause of thrombocytopenia is? | Drug-induced thrombocytopenia; infection-induced thrombocytopenia; idiopathic immune thrombocytopenia; Congenital thrombocytopenia *look at blood cells, look for abnormalities, plts low? most common drug-induced thrmobocytopenia ⭐️ |
| Other common causes of thrombocytopenia include: | Medication induced; Heparin induced thrombocytopenia; immune thrombocytopenia purpura |
| ***What are medications that cause thrombocytopenia (medication-induced)? *medicines most associated with thrombocytopenia* | -Quinine/quinidine -Sulfonamide antibiotics (Bactrim) -Vancomycin -Penicillin -Carbamazepine -Rifampin -Heparin -Abciximab (GPIIb/IIIa inhibitors) -NSAIDs (Mobic, Ibuprofen) -H2 antagonists (ranitidine, cimetidine) -Chemotherapy -Valproic acid |
| ***What is the treatment for medication-induced thrombocytopenia? | -D/c offending med ***⭐️ -Monitor patient for s/s of toxicity -CBC monitored daily or more frequently depending on severity -Further steps are dependent on MOA -Transfuse plts if <10K (so even if they meet thrombocytopenia at <150,000, we would still wait to transfuse till 10K) |
| Why don’t we just give transfusions whenever platelets are low? | plt 1/2 life: 7-10 days; platelet transfusion last for about 2-3 days and thats how long it will increase platelet count; only reason to transfuse platelets is for a temporary fix to get people to some kind of goal. Most often: 1. About to have surgery, (get plt count high enough, do surgery and plts last for a couple of days while their wound heals and clots); plt transfusions not practical for chronic condition; ⭐️ real reason is the time frame (only works for a couple days) |
| What is immune thrombocytopenic Purpura (ITP)defined as: | Plt < 100K AND Unknown cause; Purpura means bruising *not the initial diagnosis of thrombocytopenia (not the answer on exam); answer would usually be drug-induced thrmobocytopenia; *ITP diagnosis would usually be a diagnosis of exclusion; NOT usually the FIRST diagnosis of thrombocytopenia |
| immune thrombocytopenic Purpura subcategories include? | -Newly diagnosed (diagnosis to 3 months) -Persistent (3 -12 months) -Chronic (lasting for more than 12 months) |
| Clinical presentations of Immune Thrombocytopenic Purpura are? | -Asymptomatic -Bruising or bleeding |
| Immune Thrombocytopenic Purpura epidemiology is? | -Related to autoimmune platelet destruction -Any age, affects both genders -Uncertain of cause |
| Immune Thrombocytopenic Purpura Goal of treatment is? | -Increasing platelet count to avoid bleeding episodes (usually >50K to keep pts out of spontaneous bleeding range (<10K)) -Not to “normalize” platelets (not trying to get to > 150K bc theres not much health consequences to having mildly low platelet level counts |
| ***Management of Immune Thrombocytopenic Purpura: ITP + (none or mild bleeding) + Plt >/= 20K --> Managed by? | -Observation alone bc they aren’t at spontaneous level or -1st line treatment |
| ***Management of Immune Thrombocytopenic Purpura: ITP + Plt <20K --> Managed by? | Should start 1st line treatment; if newly diagnosed consider hospitalization |
| ***Management of Immune Thrombocytopenic Purpura: Active Bleeding --> Managed by? | Can give all at same time: -Start Corticosteroids and IVIG -Transfuse platelets (plt count doesn’t matter) -Consider urgent splenectomy (if they have splenomegaly) *going to do everything |
| ***Management of an adult with Immune Thrombocytopenic Purpura: What is 1st line Therapy? | -Corticosteroids -IVIG -Anti-D immunoglobulin (not used as often) *one of these options is the answer, only in active bleed is when we give all* |
| Treatment for initial Immune Thrombocytopenic Purpura: 1st line. Tx options and dose are? | -Prednisone (0.5-2mg/kg) daily for 21 days; -Dexamethasone 40 mg PO daily for 4 days; -IVIG 1g/kg PRN; *remember that prednisone is for 21 days* vs Dexamethasone is only for 4 days of treatment. IVIG can be as needed by its gram/kg and usually over a couple of days |
| Treatment for initial Immune Thrombocytopenic Purpura: Active Bleeding or Platelets <10K. Tx option is? | Platelet transfusion *can be used as needed for procedures/surgery whether your bleeding or not |
| What are the treatment options for REFRACTORY Immune Thrombocytopenic Purpura? *refractory ITP-- failing steroids (failing 1st line) | -Rituximab (CD20 antibody) 375 mg/m^2 IV every week for 4 weeks (test for Hep B) (RR--> 60-75% and response for a year or 2) -Romiplostim 1 -10 mcg/kg SQ every week (rr--> 80%) -Eltrombopag 25-75 mg PO daily (rr--> 80%) -Avatrombopag 20 mg PO daily -Spenectomy (usually wait 1 year after diagnosis) -Platelet transfusion (active bleeding of platelets <10K *look at time frame and response rates; rituxumab get a long-term response; romiplostiim you have to stay on treatment throughout the process; |
| Why does Rituximab work in Immune Thrombocytopenic Purpura? | -It’s primary indication is for lymphoma -B cells are responsible for antibodies that destroy the platelets in ITP -Rituximab will target B cells decreasing the production of antibodies and limit destruction of platelets in ITP *Rituximab you come in every week; little more of risk for infusion rxns; test for Hep B; no response to Ritximab--> go to Romipolstim |
| Treatment for severe/refractory Immune Thrombocytopenic Purpura: Rituximab drug info? | -Chimeric monoclonal anti-CD20 antibody that depletes B lymphocytes -Sustained response rates -Well tolerated except for infusion reaction since its chimeric, HBV reactivation ⭐️ -Test for Hep B prior to treatment -Possibly retreat if had a good response |
| Romiplostim Drug info: *pt must continue to take TPO-RA to maintain platelet counts (plt counts are only affected while on treatment and expect to drop in a week or so) | -Ind: ITP not responding to other tx; -Route: SQ injection -Freq: Weekly ⭐️ -Warnings & Precaution: Thrombotic events (<2%) AML (4%) ⭐️ |
| Eltrombopag Drug info: *pt must continue to take TPO-RA to maintain platelet counts (plt counts are only affected while on treatment and expect to drop in a week or so) | -Ind: ITP not responding to other tx -Route: PO ⭐️ -Freq: Daily⭐️ -Warnings & Precautions: Hepatotoxicity BBW; Thrombotic events (<2%) ⭐️ |
| Avatrombopag Drug info: *pt must continue to take TPO-RA to maintain platelet counts (plt counts are only affected while on treatment and expect to drop in a week or so) | -Ind: Treat low platelets in chronic liver disease pts scheduled to undergo procedure; Chronic ITP -Route: PO ⭐️ -Freq: Daily ⭐️ -Warnings & Precautions: Thrombotic events (<2%) ⭐️ |
| Lusutrombopag Drug Info: *pt must continue to take TPO-RA to maintain platelet counts (plt counts are only affected while on treatment and expect to drop in a week or so) | -Ind: Treat low platelets in chronic liver disease pts scheduled to undergo procedure; no indication for ITP (NOT TESTABLE) -Route: PO ⭐️ -Freq: Daily for 7 days ⭐️ -Warnings & Precautions: Thrombotic events (<2%) ⭐️ |
| ***Can you get chemotherapy if platelets are low? | Platelets < 100K --> No chemo/call attending MD Normal Platelets (150K-400K or normal--> Give Chemo |
| Chemotherapy Induced Thrombocytopenia (CIT): Always evaulate pt for other causes of ________. Frequency varies among chemotherapy--> Most often associated with _____ and ________ ____ | thrombocytopenia; gemcitabine; platinum agents (Cisplatin, Carboplatin, Oxaliplatin) |
| Treatment for Chemotherapy Induced Thrombocytopenia (CIT) includes? | -Platelet transfusion (plt <10K or active bleed) -Other options (Chemotherapy dose reduction, Chemotherapy dose delay, Romiplostim or clinical trial with TPO-RA (when used for CIT there may be a small risk of thromboembolism)) *don't give chemo for less than 100K for platelets; 50K platelts and showed up for chemo--> hold and answer once platelts imprive, lower dose of chemo, dose delay; romiplostim while on chemo after developing thrombocytopenia; Romipolstim used mainly for curative chemo |
| Conclusions: Thrombocytopenia--> most common cause is ___-____. ITP usually requires tx from several different meds: 1st line for ITP is steroids. Refractory may require ______, ______, TRA to control platelet count. | drug-induced; splenectomy; rituximab |
| CIT (Chemotherapy induced Thrombocytopenia) is treated with dose ____, dose _____, or _______ | reduction; delay; romiplostim |
| The risk of spontaneous bleeding in thrombocytopenia doesn't occur until the pt is at? | platelet count of 20K or less *takeaway--> risk of spontaneous bleeding until your very low on your platelet count |
| Romiplostim is for _____ ________. for metastatic pts we consider dose reductions or dose-delay and may have less symptoms from other things | curable cancers |
| Erythropoietin is made where? Where does it act or its action? | Kidneys; Acts on the erythrocytes and the precursors of the erythrocytes of RBC |
| Risk of bleeding, according to Dr. Frei doesn’t occur until _____. So most of the time, when someone has thrombocytopenia, we don’t care because the risk of spontaneous bleeding really doesn’t occur until it’s below 20,000. | 20,000 |
| Treatment for refractory ITP—> options explained: | Rituximab-> get tx and respond long-term that could last a year or 2 but has a high risk for infusion rxn; Thrombopoietin receptor agonist (Romiplostim/Eltrombopag/Avatrombopag)—> plts only respond when you’re receiving tx, when you stop tx, plts go back down. |
| Treatment for refractory ITP: My PO options are? | Eltrombopag and Avatrombopag *both are taken daily |
| Treatment for refractory ITP: My injectable options are? | Rituximab (Q week for 4 weeks (test for Hep B); Romiplostim SQ every week |
Created by:
Xander635
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