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Oncology Exam 4
Frei Chemotherapy Induced NV (CINV) G
| Question | Answer |
|---|---|
| Definition: Nausea | an unpleasant subjective sensation involving the upper gastrointestinal tract usually associated with a feeling of the need to vomit |
| Definition: Retching | rhythmic spasmodic contractions of the diaphragm and abdominal muscles (dry heaving) |
| Definition: Vomiting | expulsion of the gastric content through the mouth caused by forceful and sustained contraction of the abdominal muscles and the diaphragm |
| Definition: Acute N/V? | Occurs in first 24 hours after chemotherapy administration |
| Definition: Delayed N/V? | Occurs AFTER first 24 hours after chemotherapy administration; can occur as late as 6 -7 days |
| Definition: Anticipatory N/V? | Often triggered by factors such as sight, smell, tastes, thoughts. |
| Definition: Breakthrough N/V? | Defined as an event occurring despite prophylactic treatment and/or requiring rescue with antiemetic agents |
| Nausea and Vomiting: occurs in about 50% of pts with advanced cancer at some time. Nausea was rated as a more ____ symptom than vomiting alone and can be as distressing as pain. Difficult to separate N/V. Nausea can be variably described by interchangeable symptoms such as? | unpleasant; -feeling sick, heartburn, bloated, touch of gastric, no appetite, indigestion |
| Basic Principles of CINV Management: Prevention is the ___ treatment. Risk of CINV includes? | BEST; -For high emetogenic chemotherapy is at least 3 days after chemo -For moderate emetogenic chemotherapy is at least 2 days after chemo *Oral and IV 5-HT3 antagonists have equivalent efficacy |
| Basic Principles of CINV Management: Choose agents based on? | -emetic risk -prior experience with antiemetics -patient risk factors *For multi-drug regimens, select antiemetic therapy based on drug with highest emetic risk |
| Risk Factors for CINV: Chemotherapy Related Risk factors: Emetogenicity of the prescribed regimen. Classified based on risk of emesis w/o predmedications: | -High > 90% (no nausea given) -Moderate 30 – 60% -Low 10 – 30% -Minimal < 10% |
| Emetic Risk of IV Administered Antineoplastic Agents | Mab (almost minimal). CPI (checkpoint) considrer minmal for emetic risk. *must know Cisplatin (highly emetic risk) -Dacarbazine, Carboplatin (highly emetic risk) -Carmustin (highly emetic risk) -AC combination (Anthracycline and cyclophosphamide is concidered (highly emetic risk) |
| Who is at risk for N/V--> Risk Factors for CINV: Pt related risk factors include? | -History of morning sickness with prior pregnancy -Poor control in previous chemotherapy treatments (anticipatory) -History of motion sickness -Children > Adults -Women > Men -Minimal or no EtOH > Long history of alcohol abuse -Anxiety/high pretreatment expectation of nausea |
| Assessment of Patient: Pt history is the key as well as Compliance Prior to chemo- exp. w/ N/V. Description of the pattern of vomiting may provide? | important diagnostic information, and there is often little to find on examination |
| Basic Principles of CINV Management include? | -Give breakthrough CINV antiemetics -Consider adverse effects of antiemetics -For multi-drug regimen, select antiemetic therapy based on the drug with the highest emetic risk |
| Other Causes of Nausea and Vomiting: Cause: Hypercalcemia: Tx? | Fluids, bisphosphonates |
| Other Causes of Nausea and Vomiting: Cause: Infection: Tx? | Antibiotics, Antifungals, Antivirals |
| Other Causes of Nausea and Vomiting: Cause: Raised intracranial Pressure: Tx? | Dexamethasone, mannitol |
| Other Causes of Nausea and Vomiting: Cause: Gastric Irritation or ulceration: Tx? | Stop offending agent; may given PPI, H2 antagonist |
| Other Causes of Nausea and Vomiting: Cause: Constipation: Tx? | Laxatives, Enemas, other measures |
| Other Causes of Nausea and Vomiting: Cause: Anxiety: Tx? | Reassurances and possibly anxiolytic drugs |
| Other causes of CINV include? *not always chemo causing nausea/vomiting | -Opioids ADR -Cytotoxic therapy -Renal failure -Functional gastric stasis (diabetes, vincristine) -Vestibular disturbance -Pancreatitis -Opioid withdrawal *not always chemo |
| Types of CINV: Classification based on ______ of nausea and/or emesis. | timing *radiation treated with serotonin inhibitors |
| CINV include what 3 types? | Anticipatory, Acute (24h), Delayed |
| Antiemetics that we can use for CINV include? | -Dopamine Antagonists (Prochlorperazine, metoclopramide, haloperidol, olanzapine) -Sero. receptor ant. (Ondansetron, dolasetron, granisetron, palonosetron) -Antihistamine (Promethazine) -Corticosteroids (Dexamethasone) (preferred) -BZDs (Lorazepam) -NK1 receptor antagonists and Substance P (Aprepitant, aprepitant emulsion for injection, fosprepitant, neupitant, fosneupitant, rolapitant) |
| Highly Emetogenic Regimen(HEC): Summary of regimen? | *no need to know doses. know drugs, recognize class. days 2-4--> day* (4 days of highly emetic) -Day 1 (day of chemo): 1. OLA, ANy 5HT3, Any NK1 RA, Dex; -Days 2-4*--> Aprepitant day 2-3; Olanzapine days 2-4; Dex days 2-4 |
| Highly Emetogenic Regimen(HEC): Typical/preferred regimen? How many days? | More neausea: givoing 3 or 4 drugs: Dex and 5HT3 inhibitor and NK1 or OLA or both Preferred regimn is the 4 drugs: Dex + 5HT3 + NK1 + OLA 0--> minimal; 1 med--> LOW; 2-3 drugs--> Moderate; 3-4--> High High: 4 days |
| Moderate Emetogenic Regimen (MEC) includes how many drugs? how many days? | give 2-3 drugs, and backbone include Dex and 5HT3 inhibitor. *moderate or high and possible to include NK1(pitant) or Olanzapine -Day 1: 5HT3 + Dex; -Day 2-3*: Dex or 5HT3 for days 2-3* Moderate: 3 days |
| Low Emetogenic Regimen | Dex or 5HT3 or DOPA *1 drug before chemo |
| Minimal has no routine ______ | prophylaxis (give PRN compazine but nothing before infusion) |
| Acute CINV Regimen: Emetic Risk Group: HEC: Antiemetics given on day of chemo include? | Dexamethasone and 5HT3 antagonists and NK1 and OLA (3-4 meds) (Ola--> olanzapine - atypical dopamine receptor antagonist) (NK1--> neurokinin1 antagonist *Highly (3-4 drugs), Moderate (2-3 drugs), Low emetic risk groups *always giving a Dex and a 5-HT3. Moderate, can add a 3rd drug, what's wrong is if you dont include dex or 5HT-3. Include NK1("pitant") or olanzapine |
| Example of Acute and Delayed N/V Regimen for HEC | DOPA: Olanzapine days 1-4 NK1 (pitant): Aprepitant days 1-3 Dex: days 1-4 5HT3: day 1 Palonsetron (long actinginjectible and works for a couple of days. |
| Drug-drug interactions: 5HT-3 inhibitors: Interactions include? | -Medications that prolong QTc interval -SSRI may increase risk of serotonin syndrome |
| Drug-drug interactions: NK1 inhibitors: interactions include? | -Dexamethasone levels are increased due to decreased metabolism# -Strong CYP3A4 Inducers should be avoided due to decreased NK1 levels -Strong CYP3A4 Inhibitors should be avoided due to increased NK1 levels^ -Decreased hormonal exposure with birth control during and for 28 days after^ -Serotonergic drugs can lead to serotonin syndrome ^- applies to aprepitant, netupitant, fosnetupitant, and fosaprepitant #- does not apply to rolapitant |
| Drug-drug interactions: Olanzapine: Interactions include? | -Medications that prolong QTc interval -CNS depressants |
| ADRs of Antiemetics: 5HT3 inhibitors: Interactions include? | -Constipation -Headache -QTc prolongation |
| ADRs of Antiemetics: NK1 inhibitors: interactions include? | -Fatigue -Eructation |
| ADRs of Antiemetics: Olanzapine: interactions include? | -QTc prolongation -Sedation |
| ADRs of Antiemetics: Dexamethasone: interactions include? | -Hyperglycemia -Insomnia -Dyspepsia |
| Additional Points for consideration for treating CINV: | -No corticosteroids are given prior to checkpoint inhibitors when administered without chemotherapy -Biosimilars have same risk as parent drug -Olanzapine: Dose can be decreased to 2.5 mg if too much sedation; Dose at night if possible unless a premedication to chemo |
| Breakthrough Nausea and Vomiting: What agents? | -Prochlorperazine; Promethazine; Metoclopramide; Ondansetron; Olanzapine; Dexamethasone; Lorazepam; 5-HT3 antagonist *add 1 agent from different drug class |
| Non Pharmacologic Methods Are Important: These include? | -Avoidance of food smells or unpleasant odors -Eat small frequent meals -Eating food at room temperature (less triggering) -Diversion -Relaxation -Acupuncture or acupressure bands: ↓ in proportion of acute vomiting; Did not reduce number of episodes (some benefit in decreasing severity of vomting) |
| Special Populations: N/V management: Severe and Persistent Nausea/Vomiting: Considerations? | -Outpatient vs Inpatient -Fluids/electrolytes -Begin with one agent and ADD -If patient nauseated, administer antiemetic ASAP -Patient has emesis, give IV antiemetic |
| Severe and Persistent Nausea and Vomiting: Need alternative administration routes (i.e. IV)? | Persistent nausea decrease gastric emptying with a resultant decrease in drug absorption -IV route may be suitable to control a single episode -Persistent problem--> Subcutaneous infusion using an infusion device such as a pocket sized syringe driver |
| Severe and Persistent Nausea and Vomiting: Alternative routes for medication include? *aside from IV/SQ | -Suppository or tablet form -Buccal administration of antiemetics is poorly tolerated -Transdermal route |
| Other Antiemetics that can be used are? | -Cannabanoids: Useful adjuncts to antiemetics and can be used for pts refractory for 5-HT3 ant, NK1 ant, and steroids; ADR: dizziness, euphoria, hallucinations -Metoclopramide: intravenous high dose; ADR: diarrhea -Olanzapine: refractory n/v; 2.5 – 5 mg daily on days 1 – 4; Weight gain, elevated glucose |
| Anticipatory Nausea/Vomiting risk factors include? | -Age < 50 years -N/V with last chemo -Feeling 'warm or hot all over' after last chemo -History of motion sickness -Experiencing ‘sweating’ or 'generalized weakness' after last chemo -Exp nausea after last chemo that was 'severe or intolerable' |
| Anticipatory Nausea/Vomiting: Prevention? Tx? | -Use optimal antiemetic therapy with every cycle -Tx: Lorazepam 0.5 – 2 mg po on the night before and morning of treatment 1-2 hours before chemo |
| Radiation-Induced Emesis Risk Factors: | -Overall incidence about 40% -Varies with the treatment administered -Treatment field is one of the major determinants of emetic risk -Only a minority of patients receive radiation therapy of high emetic risk. Emesis in this group can be difficult to prevent or control |
| Antiemetic Regimens for the Prevention of Radiation-Induced Emesis: Radiation Emetic risk: (High > 90%); Irradiated area (Total body (TBI): Recommended Antiemetics? | Prophylaxis with 5-HT3 serotonin receptor antagonist ± dexamethasone –Before each fraction and for at least 24 hours after |
| Antiemetic Regimens for the Prevention of Radiation-Induced Emesis: Radiation Emetic risk: (Moderate 60-90%); Irradiated area (Total body (TBI): Recommended Antiemetics? | Prophylaxis with 5-HT3 serotonin receptor antagonist ± dexamethasone –Before each fraction |
| Antiemetic Regimens for the Prevention of Radiation-Induced Emesis: Radiation Emetic risk: (low 30-60%); Irradiated area (1-lower thorax and Pelvis. 2- crandium and craniospinal): Recommended Antiemetics? | Rescue with 5-HT3 serotonin receptor antagonist –Before each fraction |
| Antiemetic Regimens for the Prevention of Radiation-Induced Emesis: Radiation Emetic risk: (minimal <30%); Irradiated area (H&N, extremities, cranium, breast): Recommended Antiemetics? | Rescue with dopamine receptor antagonist or 5-HT3 serotonin receptor antagonist (as needed) –Continue for each remaining radiation treatment day |
| OTC Role in CINV is? | -Minimal -If patient is receiving chemotherapy, make sure they have received appropriate antiemetics |
| Conclusions CINV? | -Nausea is the most distressing ADR of to cancer patients -Goal of treatment is prevention -3 types of nausea and vomiting -Prevention/treatment of n/v is based on severity and type of emesis |
Created by:
Xander635
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