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49 Cards in this Set
- Front
- Back
What are the 2 classifications of nausea and vomiting?
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1. Simple - self-limiting
2. Complex - not relieved after administration of antiemetics; leads to secondary fluid and electrolyte imbalances |
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What are the sensory centers that send impulses related to nausea/vomiting?
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1. chemoreceptor trigger zone
2. cerebral cortex 3. visceral afferents from the pharynx and GI tract |
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What is anticipatory N/V and how is it treated?
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It is a conditioned response to previously experienced posttreatment N/V. The preferred agent is lorazepam 0.5-2 mg PO 4-12 hours prior to chemotherapy.
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What is acute phase N/V?
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Occurs within 24 hours of chemotherapy administration
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What is delayed phase N/V?
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24-72 hours after chemotherapy administration
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Which chemotherapy agents are considered high risk for N/V?
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carmustine
cisplatin cyclophosphamide (>1500mg/m2) dacarbazine dactinomycin mechlorethamine |
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Which chemotherapy agents are considered moderate risk for N/V?
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carboplatin
cytarabine (>1gm/m2) cyclophosphamide (<1500mg/m2) daunorubicin doxorubicin epirubicin idarubicin ifosfamide irinotecan oxalaplatin |
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Which chemotherapy agents are considered low risk for N/V?
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bortezomib
cetuximab cytarabine (<1gm/m2) docetaxel etoposide fluorouracil gemcitabine methotrexate paclitaxel topotecan trastuzumab |
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Which chemotherapy agents are considered minimal risk for N/V?
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bevacizumab
bleomycin busulfan fludarabine rituximab vinblastine vincristine vinorelbine |
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What is the percent chance of N/V for minimal, low, moderate and high risk agents?
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minimal - <10%
low - 10-30% moderate - 30-90% high - >90% |
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What rules do we follow when assigned N/V risk when using combination chemo therapy?
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low risk + low risk = moderate risk
low risk + moderate risk = high risk moderate risk + moderate risk = high risk |
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Which histamine H2 antagonists are used as chemotherapy antiemetics?
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famotidine
ranitidine |
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What is the MOA for histamine H2 antagonists used as chemotherapy antiemetics?
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they alleviate symptoms of simple N/V associated with heartburn or GI reflux
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Which antihistamine-anticholinergic agents are used as chemotherapy antiemetics?
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diphenhydramine
hydroxizine meclizine scopolamine |
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What is the MOA for antihistamine-anticholinergic agents used as chemotherapy antiemetics?
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they interupt visceral afferent pathways that stimulate N/V; useful in the treatment of simple N/V
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Which phenothiazines are used as chemotherapy antiemetics?
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prochlorperazine
promethazine chlorpromazine |
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What is the MOA for phenothiazines used as chemotherapy antiemetics?
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appear to block dopamine receptors in the CTZ; most useful in the treatment of simple N/V
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Which corticosteroids are used as chemotherapy antiemetics?
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dexamethasone
methylprednisolone |
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Which dopaminergic receptor antagonists are used as chemotherapy antiemetics?
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metoclopramide
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What is the MOA for dopaminergic receptor antagonists used as chemotherapy antiemetics?
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block dopaminergic receptors centrally in the CTZ; also accelerates gastric emptying and bowel transit time
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What substance P/neurokinin1 receptor inhibitor is used as a chemotherapy antiemetic?
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aprepitant (Emend)
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What is the MOA of aprepitant (Emend)? How is it given?
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It blocks substane P receptor. Substance P and serotonin are responsble for the acute phase of N/V, but substance P takes over as the primary mediator of delayed phase N/V. It must be started as a premed and continued for 3-4 days as it will not work PRN.
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Which SSRIs are used as chemotherapy antiemetics?
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dolasetron
granisetron ondansetron palonosetron |
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What is the MOA of SSRIs that are used as chemotherapy antiemetics?
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They block presynaptic serotonin receptors on sensory vagal fibers in the gut wall, effectively blocking the acute phase of CINV. These agents are less effective in the delayed phase.
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Which agents are used for simple N/V?
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Histamine H2 antagonists
Antihistamine-anticholinergic agents Phenothiazines |
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What is typically given for low emetic risk chemotherapy?
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dexamethasone
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What is typically given for moderate emetic risk chemotherapy?
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dexamethasone + SSRI
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What is typically given for high emetic risk chemotherapy?
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dexamethasone + SSRI + aprepitant (Emend)
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What steps can be to prevent mucositis?
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1. good oral hygeine
2. mouth rinses 3. oral cryotherapy (ice in mouth) 4. palifermin (Kepivance) which is a keratinocyte growth factor approved for use in patients receiving high-dose chemoradiotherapy prior to stem cell transplantation (very expensive) |
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What should we prophylax for when concerned about mucositis?
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herpes simplex virus (acyclovir)
oral candida (nystatin, clotrimazole, fluconazole) |
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What is considered fever in neutropenic patient?
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-a single temp of >38.3 C (101.3 F)
-a sustained temp of >38 C (100.4 F) |
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How do you calculate ANC (absolute neutrophil count)?
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WBC X [neutrophils(%) + bands(%)]
*bands are immature granulocytes |
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What is neutropenia?
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An abnormally reduced number of neutrophils circulating in peripheral blood. It is considered neutropenia when ANC is < 1000 cells/mm3.
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Facts about neutropenic patients and infection.
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At least 50% of febrile neutropenic patients have an established infection.
20% of profoundly neutropenic patients (ANC <100cells/mm3)experience bactermia. |
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Pseudomonas and neutropenic patients.
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There is significant morbidity and mortality in neutropenic patients with Pseudomonas aeruginosa. Empric therapy must provide coverage. If not covered, it can kill in 48 hours.
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Criteria for high-risk neutropenia in febrile patients
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Severe neutropenia (ANC <100 cells/mm3) lasting greater than 14 days
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Criteria for moderate-risk neutropenia in febrile patients
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Neutropenia with an ANC <500 cells/mm3 for a duration of 7-14 days
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Criteria for low-risk neutropenia in febrile patients
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Neutropenia with an ANC <500 cells/mm3 for up to 7 days
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Which drugs are good to use in cancer patients needing Pseduomonas coverage?
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ceftazidime
imipenem Zosyn Levaquin |
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Treatment of cancer patient with fever and neutropenia who is considered low risk
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Give 2 drugs
Levaquin + Augmentin |
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Treatment of cancer patient with fever and neutropenia who are considered moderate risk
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Start with IV therapy
Use cefepime, ceftazidime, or carbapenem (or any IV anti-Pseudomonal) Use monotherapy or add vancomycin depending on patient |
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Treatment of cancer patient with fever and neutropenia who are considered high risk
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Use vancomycin
with Levaquin, cefepime, ceftazidime, or carbapenem +/- aminoglycoside |
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What is tumor lysis syndrome?
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It is a spectrum of metabolic derangements usually associated with the initiation of cytotoxic therapy. TLS is an oncologic emergency that is caused by massive tumor cell lysis with the release of large amounts of potassium, phosphate, and nucleic acid into systemic circulation.
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What are the most common malignancies associated with Tumor Lysis Syndrome?
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1. Non-Hodgkin's lymphoma
2. Acute Lymphoid Leukemia |
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What are the characterisitics of a malignancy that leads to tumor lysis syndrome?
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1. high proliferative rate
2. sensitivity to treatment 3. bulky tumor 4. elevated LDH levels 5. some patients are dehydrated 6. renal insufficiency 7. Hyperuricemia, hypercalemia, hyperphosphatemia, and hyperkalemia are present before treatment |
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Laboratory classificatin of tumor lysis syndrome.
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Uric acid above 8 mg/dl
Potassium above 6 mEq/L Phosphorus above 4.5 mg/dl Calcium less than 7 mg/dl Patient needs to have 2 or more of these as well as being a 25% change from baseline for it to be considered TLS |
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What are the metabolic consequences of tumor lysis syndrome?
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1. hyperkalemia
2. hyperphosphatemia 3. secondary hypocalcemia 4. hyperuricemia 5. acute renal failure |
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What are the main treatment options for tumor lysis syndrome?
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1. Hydration fluids - (2000-3000 ml/m2/24 hours; minimizes uric acid precipitation; monitor for fluid overload)
2. Allopurinol (decreases uric acid production) 3. Rasburicase (enzyme that converts uric acid to a more soluble compound) 4. Phosphate binders (AlOH, PhosLo, sevelamer) |
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Monitoring parameter for tumor lysis syndrome
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1. Serum electrolytes (Na, K, CO2, Cl, Mg, PO4, calcium, uric acid) every 6-12 hours
2. Renal function and liver function tests |