H/O Lecture 14: Bone Marrow Toxicity | Quizlet

Neutropenia

low WBCs

ANC <500

OR

<1000 w/ predicted decline to <500 in 48 hours

What are the s/sx of neutropenia?

Fever (may be the only sign)

Infection

Anemia

low RBCs (Hgb <10)

What are the s/sx of anemia?

Fatigue

Pallor

Dyspnea

Palpitations

Weakness

Dizziness

Thrombocytopenia

low platelets (plt <100)

Pancytopenia

decrease in ALL 3 cell lines

What are the s/sx of thrombocytopenia?

Petechiae

Nose bleeds

Gum bleeding

GI bleeds

Easy bruising

Hematuria

What ANC level is at highest risk for infection?

<500

Nadir

when ANC is at its lowest point after chemotherapy (~7-14 days)

What are the risk factors for neutropenia?

Type of chemo regimen

Previous treatments

>65 y/o

Poor performance status

Poor nutrition

Decreased immune function

Recent surgery

Prior chemo/radiation

COPD

CV disease

Liver or kidney disease

HIV

Heme malignancy

Bone marrow involvement

Which agents pose a HIGH risk of causing neutropenia?

Cyclophosphamide

Platinum agents

Anthracyclines

Taxanes

Cytarabine

Which agents pose a LOW risk of causing neutropenia?

Vincristine

Asparaginase

Bleomycin

Which agents pose a DELAYED risk of causing neutropenia?

Mitomycin

Busulfan

Melphalan

Thiotepa

Probarbazine

Carmustine

Which G-CSF agents are available for neutropenia?

Filgrastim

Pegfilgrastim

Which cells do G-CSFs affect?

Neutrophils only

Which G-CSF is dosed daily?

Filgrastim

What do G-CSFs NOT effect for patients with neutropenia?

Mortality

Tumor response rate

Overall survival

Reaching the nadir

What do G-CSFs effect for patients with neutropenia?

Decrease incidence of febrile neutropenia

Decrease duration of febrile neutropenia

Lessen nadir period

Fewer febrile days

Shorter duration of abx

Decreased number of infections

Fewer hospital days

When is primary G-CSF prophylaxis given?

for regimens with >20% incidence of febrile neutropenia

When is secondary G-CSF prophylaxis given?

after febrile neutropenia occurs

If a patient develops febrile neutropenia while using long-acting CSF primary prophylaxis with Pegfilgrastim, should they receive more G-CSF?

No

If a patient develops febrile neutropenia while using short-acting CSF primary prophylaxis with Filgrastim, should they receive more G-CSF?

Yes, Filgrastim is dosed daily during FN episodes

If a patient develops febrile neutropenia with no primary G-CSF prophylaxis, when would they recieve G-CSF treatment?

If they have risk factors present for infection associated complications

What factors put someone at risk for infection that warrant G-CSF treatment for febrile neutropenia?

Sepsis

>65 y/o

ANC <100

Neutropenia expected >10 days

Pneumonia for other documented infections

Invasive fungal infection

Hospitalization at time of fever

Prior episode of FN

Which G-CSF agent is indicated for the treatment of febrile neutropenia?

Filgrastim

Which G-CSF agent is only for prophylaxis of febrile neutropenia?

Pegfilgrastim

If a patient did NOT develop febrile neutropenia with their previous treatment cycle, should they receive G-CSF for their subsequent cycles?

Yes if they have been recieving primary prophylaxis

No if they have not been using primary prophylaxis

If a patient developed febrile neutropenia with their previous treatment cycle, should they receive G-CSF for their subsequent cycles?

Yes - doesn't matter if they have recieved primary G-CSF prophylaxis for not

How is Pegfilgrastim dosed?

once each cycle 24-72 hours after chemo

How is Filgrastim dosed?

Daily 24-72 hours after chemo

How long must patients wait between doses of Pegfilgrastim?

at least 12 days

Can patients get doses of Filgrastim if they have gotten Pegfilgrastim within the last 2 weeks?

No - need to be >12 days since Pegfilgrastim

What are the class effects of CSF?

Bone pain

Splenic rupture

Bruising

Inj site reactions

Generalized rash

Sickle cell crisis

What can be done for patients who experience bone pain with CSF?

Antihistamines (Loratadine)

NSAIDs if PLTs are okay

APAP

When are blood transfusions given to anemic cancer patients?

if Hgb <7-8 and symptomatic for rapid correction

What is considered moderate (grade 2) anemia in cancer patients?

Hgb 8-<10

What is considered severe (grade 3) anemia in cancer patients?

Hgb 6.5-<8

Why are ESAs controversial in cancer patients?

concern for progression of cancer

What are the risks of blood transfusions?

Iron overload w/ frequent infusions

Infusion reactions

What is used to treat iron overload?

Iron chelation agents

When should supplemental iron be given with ESAs?

Serum ferritin <500

AND

TSAT <50%

What are the ADRs of ESAs?

HTN

Pure red cell aplasia

Thrombosis

BBWs of ESAs

Risk of tumor progression

Increase risk of death from MI, stroke, VTE

Increase risk of CV associated death if given to CKD patients with a Hgb <11

What is the recommendation for ESA use in cancer patients

Must be on palliative chemotherapy

Use lowest dose needed

Hgb <10

Who is an ideal oncology candidate for an ESA?

Co-morbid CKD

Palliative chemo with frequent transfusions

Refuses blood products

Which formulation of iron is superior in cancer patients?

IV iron

What is the recommended dose of iron for cancer patients?

~1000mg IV iron

At what level of platelets are patients at high risk of bleeding?

Plt <20,000

When should patients recieve a platelet transfusion for thrombocytopenia?

Plts <10k

OR

Plts <20k AND symptomatic

1 unit of platelets would increase platelet levels by approximately how much?

~30K

What level of platelets is required for surgery?

>20-50k

TPO Receptor Agonists

Eltrombopag

Romiplostim (Nplate)

Are the TPO receptor agonists approved for use in cancer patients?

No - currently used off-label

ADRs of Eltrombopag

Hepatotoxicity

Thrombosis

ADRs of Romiplostim

HA

Arthralgia/myalgia

Thrombosis

Myelofibrosis

Should surgeries be delayed if a patient's platelet levels are below 20-50k?

No

What is the mainstay treatment of thrombocytopenia in cancer patients?

Platelet transfusions

When are TPO receptor agonists used in thrombocytopenic cancer patients?

If patients are refractory to platelet transfusions