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Oncology Exam 4
Chemotherapy Induced Diarrhea J
| Term | Definition |
|---|---|
| Chemotherapy-induced Diarrhea--> | -May be life-threatening -Complications: Electrolyte/fluid imbalances, Infection, Death -CID incidence if 50-80% of patients -CID related dehydration is linked to early death rates in roughly 5% of patients undergoing anti-cancer treatment |
| Types of Diarrhea include? | -Osmotic -Secretory (most common type) -Hypermotile |
| Grading Scale for Diarrhea: Common Terminology Criteria: 0, 1, 2, 3, 4, 5? *how often they go to the bathroom | 0: None 1: ⭐️Increase of < 4 ⭐️stools per day over baseline; mild increase in ostomy output compared to baseline 2: ⭐️Increase of 4 – 6⭐️ stools per day over baseline 3: ⭐️Increase of ≥ 7 ⭐️ stools per day over baseline 4: ⭐️Life-threatening consequences (arrhythmia) 5: Death *3-4 severe and hospitalization |
| Treatment related Causes of Chemotherapy-induced Diarrhea--> | -Chemotherapy Induced -Radiation Induced -Direct toxicity to epithelial cells -Clostridium difficle infection |
| Cancer therapy induced Diarrhea: any chemotherapy has the potential to cause it. What are the worst offenders (IN RED)? | -Fluorouracil (5-FU) ⭐️ -Irinotecan (CPT-11)⭐️ -Capecitabine -Neratinib -Abemaciclib -Tucatinib -Checkpoint Inhibitors |
| Incidence of Diarrhea for the agents in grades 3-4--> | Oxaliplatin/leucovorin/5-FU (11) Irinotecan/leucovorin/5-FU (12) Oxaliplatin/capecitabine/bevacizumab (29) Neratinib (40.1) *vinca alkaloids more associated with constipation, not diarrhea |
| Disease Related causes of diarrhea? | -Graft versus host disease ( -Surgical resection for GI tumors -Secretory tumors: Carcinoid, VIPomas, Gastrinomas, Medullary thyroid carcinomas (all associated with sig. diarrhea |
| Patient and Therapy Risk Factors (Main ones): | Elderly Associated bowel pathology (UC or malabsoprtion syndrome) Tumor in the bowel |
| How do we manage CID? | -Hold cancer treatment until grade 1 -Discontinue offending agents, if feasible -Avoid problem foods and meds -Metoclopramide -Misoprostol -Laxatives and antacids -Magnesium oxide |
| Management of CID: Grade 1-2. Use? | OTC dose Loperamide *"3 bowel movements or 3 watery loose stools per day--> grade of 1--> should use an OTC Loperamide (Imodium and use that when developing diarrhea) |
| Management of CID: No response? | -Escalate loperamide dose -Atropine/diphenoxylate |
| Management of CID: Refractory Loperamide? | Octreotide |
| Loperamide Drug info: FDA warning? OTC dosing? Escalated dose? | -FDA Warning of rare serious cardiac events, including QT prolongation, torsades de pointes, cardiac arrest and death -OTC Dosing Adult Dosing: 2 caps at onset, then 1 cap after every loose stool (8 mg daily max)⭐️ -Escalated dose: 2 caps at onset, then 1 cap every 2 – 4 hours until diarrhea stops for 12 hours (24 mg daily max) ⭐️ |
| Management of Diarrhea Grade 3 - 4: Manage via? | -Hold chemo -Supportive care: Fluids, Electrolytes -Rule out C. diff, if suspected (fever, hx of C.diff in past?) -Octreotide 100-150 mcg subcutaneous TID -Maybe antibiotics depending on situation *if you have C.diff, we won't stop the diarrhea |
| Agents for Treatment of Diarrhea include? | -Absorbents: Attapulgite (Donnagel), Polycarbophil -If infectious cause ruled out: Antimotility agents (OTC loperamide (Immodium) – 4 mg at onset, 2 mg after every loose stool until diarrhea resolves; Diphenoxylate/atropine (Lomotil)) -Pepto Bismol: Not in children under 12 years (risk of reye's syndrome) -Budesonide (not 1st line) -Tincture of opium |
| Treatment of Diarrhea: Octreotide: Dose? ADR? | -Octreotide 100-150 mcg ⭐️subcutaneous TID ⭐️ -ADR – Abd cramping; mild nausea; hypoglycemia Subcutaneous: 100 – 150 mcg (escalate) TID Intravenous: 50 – 100 mcg/hr, Continuous Depot - IM: 10 – 30 mg Q 28 days |
| For pts that had Irinotecan Induced Diarrhea (⭐️Early onset diarrhea) Treatment? | MOA: Cholinergic Presentation: ⭐️First 24 hours (sweating, n/v, flushing, abd cramping) Tx: Atropine 0.25 – 1 mg IV or SQ at onset |
| For pts that had Irinotecan Induced Diarrhea (⭐️Late onset diarrhea) Treatment? | MOA: ? (more common) Presentation: ⭐️24 hours after chemotherapy⭐️ Tx: Loperamide (diarrhea is secretory) 4 mg at onset of diarrhea, then 2 mg every 2 hours until diarrhea has resolved for ⭐️12 hours *timing is importnat; before 24h--> early(atropine); late after 24hr of chemo--> late (loperamide) |
| For pts that experienced Abemaciclib Induced Diarrhea. This occurs within the ______ cycle. Median onset between __-__ days. How do we manage? | first⭐️; 6-8; Manage with diet-> decrease other medications-> no resolve, dose reductions of Abemaciclib |
| Abemaciclib Induced Diarrhea: Incidence rates are? | -81% rate of diarrhea (in clinical trials) -9% rate of severe diarrhea -2% of trial permanently discontinued due to diarrhea |
| Abemaciclib Induced Diarrhea: Treatment with what agents and doses? | -Loperamide (OTC) - Take two caplets (4 mg) followed by one caplet (2 mg) every four hours until diarrhea-free for 12 hours (max 16 mg per day) ⭐️ -Diphenoxylate/atropine (Rx) -Tincture of opium (Rx) |
| Checkpoint Inhibitor Colitis has a __-__ % incidence rate. Hydrate affected pts is main tx. Manage immunotherapy based on grade--> | 20-40; (consider holding at grade 1, holding at grade 2 until resolve, d/c at grade ≥ 3) *stopping immune checkpoint inhibitor |
| Checkpoint Inhibitor Colitis what medications can we consider? | -Consider loperamide or diphenoxylate/atropine for 2–3 days -Steroids Prednisone/methylprednisolone 1-2 mg/kg/day for grade ≥ 2 until symptoms improve to grade ≤ 1, then taper over < 4-6 weeks -If no response to po steroids go to IV steroids -If no response after IV, consider infliximab or vedolizumab |
| Prevention of Chemotherapy Induced Diarrhea: Primary? | Atropine for Irinotecan Acute Diarrhea |
| Prevention of Chemotherapy Induced Diarrhea: Secondary prevention in curable cancer? | -Maybe, usually if had a grade 3 or 4 diarrhea that interrupted treatment -Octreotide sq tid |
| Summary of Chemotherapy Induced Diarrhea--> | -Diarrhea associated with cancer treatment can have severe consequences -Irinotecan and 5-FU are the chemotherapy agents most commonly assoc with diarrhea -Treatment can include antimotility agents and somatostatin analogs -Irinotecan induced diarrhea is treated differently than other chemotherapy induced diarrhea |
Created by:
Xander635
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