Supportive care 2

when do you initiate ESA in anemia for cancer patients

Hgb <10

when do you hold ESA in anemia for cancer patients

Hgb > 11

what is the goal Hgb for anemia for cancer patients

10-11

should we initiate ESA in patients who are receiving curative intent chemotherapy

NO

dosing for ESA (erythropoietin)

150 units/kg SC tiw or 40k units once weekly until completion of therapy

how to dose adjust ESA (erythropoietin)

reduce dose by 25% if less than 1g/dL increase in 2 weeks

increase dose to 300 units/kg tiw or 60k units weekly if it does not increase by 1 or if still below 10

D/C after 8 weeks if RBC transfusions needed or no response

erythropoietin brand name

Epogen, Procrit, Retacrit

ESA pearls

CI in uncontrolled HTN

Risk of CV, thromboembolic events, tumor progression

monitor BP, CBC, start iron if ferritin <100 or TSAT <20

Neutropenia ANC value

<1500

Febrile Neutropenia value and temp

ANC<500 and temp >38.3 once or >38 for 1 hour

management of febrile neutropenia

Broad spectrum Abx

Consider G-CSF

Filgrastim dosing and route (granix is SubQ only)

weight > 75 = 480mcg daily iv or SubQ

weight < 75 = 300mcg daily iv or SubQ

filgrastim brands and routes

Neupogen - IV or SubQ

Granix - SubQ

Nivestym -

when do you start and stop filgrastim

start 24 hours after completion of chemo

treatment for up to 14 days until ANC reaches 10k, then d/c

difference between pegfilgrastim and filgrastim

pegfilgrastim is used once per cycle and is SubQ only

thrombocytopenia platelet count

<150k

thrombocytopenia treatment

platelet transfusion

which type of paraneoplastic syndrome causes SIADH or Cushings

small cell lung cancer (endocrine)

which type of paraneoplastic syndrome causes polycythemia (epo production)

Hematologic

lab values for Tumor Lysis Syndrome

Hyperkalemia >6

Hyperuricemia >8

Hyperphosphatemia >4.5

Hypocalcemia <7

risk factors for TLS

cancer more than 10cm

highly proliferative tumor

tumors senstive to chemo

dehydration, hypotension, acidosis, renal or cardiac disease

baseline uric acid >7.5

acidic urine

wbc >250k

elevated lactate dehydrogenase

clinical symptoms for TLS

renal impairment (SCr >1.5x UNL)

cardiac arrhythmias

Seizures

requires two lab values + any of the above

hyperkalemia management

Moderate and asymptomatic (K>6) - potassium binder

Severe (K>7) insulin, dextrose, sodium bicarb, albuterol

hyperuricemia management and their deficiencies

allopurinol - HLA-B *5801

rasburicase (uric acid >8) - G6PD

allopurinol dosing for TLS

600-800mg po in 2-3 doses

rasburicase dosing for TLS

treatment: 0.2mg/kg IV daily for 5 days

prevention: 6mg IV once before chemo

Hyperphosphatemia TLS management

Moderate (>6.5) - phosphate binders (calcium, sevelamer, lanthanum, aluminum)

Severe (>14) dialysis

Hypocalcemia TLS treatment

correct hyperphosphatemia

if symptomatic IV calcium

TLS prevention

Hydration (avoid LR)

most common vesicants

anthracyclines

cisplatin

mitomycin, mitoxantrone, mechlorethamine

vinca alkaloids

taxanes

oxaliplatin

anthracycline extravasation treatment

cold compress on day 1 only

dexrazoxane 100mg/m2 within 6 hours then again after 24 hours, then 500mg/m2 after 48 hours

DMSO - topical if dexrazoxane unavailable

Dexrazoxane brand names

Totect - for extravasation

Zinecard - for cardio

Mitomycin and mitoxantrone extravasation treatment

cold compress on day 1

DMSO - topical

Vinca extravasation treatment

hot compress

Hyaluronidase - 1ml as 5 separate injections SubQ

taxane extravasation treatment

cold compress

Hyaluronidase - SubQ

oxaliplatin and mechlorethamine extravasation treatment

sodium thiosulfate - SubQ

normal calcium leves

8.5-10.5

correct calcium formula

Calcium + [0.8x(4-albumin)]

Hypercalcemia of malignancy treatment

fluids

calcitonin - Im or SubQ, limit duration to 24-48 hours

Zoledronic acid

Pamidronate

Denosumab - 120mg SubQ every 4 weeks

How many doses is MESNA given in for hemorrhagic cystitis

3 doses

max dose of doxorubicin

450-550mg/m2

max dose of mitoxantrone

140mg/m2

what must the lvef be in order to start anthracyclines of trastuzumab

50

at what dose do we start dexrazoxane

>300mg/m2

what can cause cytokine release syndrome and what drug can be used

CAR T cell therapy

tocilizumab and then corticosteroid

which drugs require non-pvc bags

taxanes

etoposide

teniposide

ixabepilone

which drugs require a 0.22 filter

paclitaxel

etoposide

teniposide

bevacizumab

which drugs requires a 5 micron filter

amphotericin

which drugs are protect from light

dacarbazine

etoposide

anthracyclines

methotrexate

what iv solution can you put oxaliplatin in

D5W only