6. Drug Induced Pulmonary Toxicity (SD)

What is the major cause of drug induced pulmonary toxicity

Iatrogenic Illness

What are the 3 chemo agents?

1. Bleomycin

2. Cylcyophosphalide

3. Methotraxate

What is bleomycin used for?

• Lymphomas

• ENT cancers

Where does bleomycin concentrate?

• skin & lungs

What are the risk factors for bleomycin

• O2

• radiation

• high dose regimin

• increased age

• decreased renal function

How does bleomycin present?

Insidious (slow) = weeks to month after trx

• dyspnea

• cough

• fever

What will we see on CXR for bleomycin pts?

bilateral nodule infiltrates

• basal prominence = lower lobes

What is the bleomycin patho?

1. type 1 destruction

2. type 2 dyplasia/hyperplasia

3. increase in fibroblasts and collagen deposition

4. fibrosis

What is the trx for bleomycin?

• stop

• IV corticosteroids

• supportive

What is the prognosis for bleomycin?

• most improve in weeks

• others 2 years

• others chronic fibrosis

What is cylcophosphamide used for?

• lymphomas

• breast

• ovarian

• autoimmune

What does cylcophosphamide do?

Causes depletion of glutathione = organism more susceptible for oxidative stress

How does cylcophosphamide present?

Insidious - years after trx

• cough

• dyspnea

• fever

cylcophosphamide CXR

• bilateral interstitial disease

• pleural thickening

Trx for cylcophosphamide

• stop

• steroids

• support

What is methotrexate used for?

• Chemo

• inflammatory diseases

  • rheumatoid

  • autoimmune

What drug group is a folate antaognist and what does the mean?

Methotrexate

• decreases in folate acid = no cell division

Methotrexate patho?

Unknown mechanism

• interstitial alveolar inflammation

• granulomas

• fibrosis

Lab findings for Methotrexate

• eosinophilia (increased WBC)

Why would I use a BAL for Methotrexate?

• lymphocytic alveolitis

CXR for Methotrexate

• bilateral infiltrates

• effusions

• adenopathy (hilar)

• pulmonary edema

Methotrexate TRX?

Stop

***can be restarted***

What are the 2 non-chemo agents?

1. Amiodarone

2. Talcum/ Talc

Non chemo mechanism of injury

• bronchioloitis obliterans organizing pneumonia

• ILD

• Vasculitis

• Pulmonary hemorrhage

• hypersensitivity

• reactive airway disorder

• P HTN

What is amiodarone?

• anti- arrythmatic

• lipid soluble = slow clearance

amiodarone method of injury

• Disrupts phospholipid break down

• Excess phospholipids accumulate = Cell injury

amiodarone risk factors

• Increased FiO2 = exacerbate ILD

• high dose

• preexisting lung disease

How does amiodarone present?

Like ARDS or symptomless. 1-2 years after trx or acute within weeks

• dyspnea

• cough

• fever

• chest pain

• maliase

amiodarone CXR

• patchy bilateral infiltrates

amiodarone CT

• ground glass

• pleural thickening

What is the earliest sign of amiodarone

Decreased DLCO

How do we diagnose for amiodarone

Use signs and symptoms

• exclude heart involvement

• exclude other pre-existing lung disease

What is Talcum/Talc?

Binding agent found in drugs

• crushing pills for IV drug users

• Ex) heroin, cocaine, meth

What is the patho of Talc?

1. Crush pills and talc will be released

2. Goes into pulmonary circulation

3. Fibrosis

Symptoms of Talc?

• dyspnea

• cough

• hypoxemia

Where do we see fibrosis in Talc?

Upper lobes

Where do we see emphysema in Talc?

Lower lobes

What are Talc users more at risk for getting

• pneumothorax

• PE

• P HTN

Talc trx

• Stop IV drug use

• Corticosteroids

• Bronchodilators

• O2

• Supportive = if irrevesrible