Supportive care 1

risk factors for CINV

younger age

female gender

anxiety

history of CINV

motion sickness

morning sickness during pregnancy

little or no alcohol use

the delayed phase is part of what pathway

central (substance P to NK1)

the acute phase is a part of which pathway

peripheral (5-HT3)

Granisetron class, route and dose

5-HT3 antagonist

oral , IV, patch, or subq

2mg oral / 1mg IV

Ondansetron class, route and dose

5-HT3 antagonist

oral and IV

24mg oral or 8mg IV (max dose 16mg IV)

Palonosetron class, route and dose

5-HT3 antagonist

IV

0.25mg IV

Dolasetron class, route and dose

5-HT3 antagonist

oral

100mg oral

class side effects of 5-HT3 antagonists

Qt prolongation

Serotonin syndrome

headache, constipation, fatigue

Granisetron patch brand name and which phase can it be used in

Sancuso

Acute phase only (apply 24-48 hours before)

is palonosetron recommended for delayed phase

NO

which 5-HT3 antagonist has the least risk for Qt prolongation

Palonosetron

Aprepitant class, route and dose

NK1 receptor antagonist

oral

125mg on day 1, 80mg daily on days 2 and 3

Fosaprepitant class, route and dose

NK1 receptor antagonist

IV

150mg IV

which NK1 receptor antagonist is not a CYP3A4 inhibitor and therefore has the least DDIs

Rolapitant

which chemo agents are 3A4 substrates

cyclophosphamide

docetaxel

etoposide

irinotecan

vinca alkaloids

on which agents do NK1 receptor antagonists act as an inducer on

hormonal contraceptives

which is the only NK1 receptor antagonist that is used in delayed phase

aprepitant

which drug needs a 50% dose reduction when used on the same day as NK1 receptor antagonists

dexamethasone

what is Akynzeo

a combo product of 5-HT3 antagonist and NK1 receptor antagonist

comes IV and PO

Dexamethasone dosing

12mg po on day 1, 8mg po on days 2 and 3

1:1 IV/PO dosing

recommended to be used with NK1 receptor antagonist

Antipsychotics used for CINV

Haloperidol (avoid in parkinsons)

Prochlorperazine (avoid in parkinsons)

Olanzapine (causes high blood sugar and excessive sedation)

Haloperidol dosing for CINV

0.5-2mg IV q 6 hours (only for breakthrough)

Prochlorperazine dosing for CINV

10mg PO or IV q6h prn

Olanzapine dosing for CINV

5-10mg PO prior to chemo on day 1

5-10mg PO days 2-4

Which drugs are at high emetic risk

Cisplatin

Anthracycline + cyclophosphamide

Carboplatin (AUC>4)

Cyclophosphamide (1500mg/m2 or greater)

Moderate emetic risk

oxaliplatin

irinotecan

carboplatin (AUC<4)

Cyclophosphamide (less than 1500mg/m2)

Low emetic risk

Docetaxel, Paclitaxel

Gemcitabine

Etoposide

Fluorouracil

what do we use for low emetic risk (only before chemo)

Dexamethasone

Metoclopramide

Prochlorperazine

5-HT3 antagonist

Moderate emetic risk treatment (Options D,E,F)

D : 5-HT3 + Dexamethasone on day 1, either or for monotherapy on day 2-3

E : Olanzapine + Palonosetron + Dexamethasone on day 1, Olanzapine day 2-3

F : NK1 + 5-HT3 + Dexamethasone on day 1, Aprepitant ± Dexamethasone on day 2-3

High emetic risk treatment (Options A,B,C)

A: Olanzapine + NK1 + 5-HT3 + Dexamethasone on day 1, Olanzapine + Aprepitant + Dexamethasone on days 2-4

B: Olanzapine + Palonosetron + Dexamethasone on day 1, Olanzapine on day 2-4

C: NK1 + 5-HT3 + Dexamethasone on day 1, Aprepitant (days 2-3 only) + Dexamethasone on day 2-4

which drugs are used for Anticipatory CINV

Lorazepam and Alprazolam

Lorazepam route and dosing

0.5-2mg PO,SL, or IV q6h

Alprazolam route and dosing

0.5-2mg PO q6h

CRD grading

Grade 1 - increase of less than 4 stools over baseline

Grade 2 - increase of 4-6 stools over baseline

Grade 3 - increase of 7 stools over baseline

Grade 4 - life threatening

Chemo agents at highest risk of CRD

Fluorouracil

Irniotecan

TKIs (nibs)

which foods should be avoided in CRD

Milk and dairy

spicy foods

alcohol

caffeine

high fiber and high fat

some fruit juices

in which grades can we continue chemo

1-2

in which grades should we withhold chemo

grade 3-4 until it reaches grade 1

resume with dose reduction

if does not resolve in 2 weeks d/c drug

pharm management of CRD

Loperamide - first line, 4mg then 2mg after every loose stool, max dose 16mg

Lomotil - max dose 20mg/0.2mg (8 tabs)

Octreotide - IV or SubQ

Irinotecan related diarrhea treatment

Atropine - if less than 24 hours, 0.25-1mg IV/SubQ

Loperamide - if longer than 24 hours, no max dose

what drugs cause CRC

Vinca alkaloids (vincristine is the highest risk)

Thalidomide

osmotic agents used in CRC

Miralax

Lactulose

Stimulant laxatives used in CRC

Senna - max dose 4 tabs bid

Bisacodyl

which agents should be avoided in CRC

docusate - not effective alone

Psyllium - avoid in patients with low fluid intake

agents at high risk for mucositis

5-FU

Methotrexate

Anthracyclines

prevention of mucositis

Good oral hygiene

mouth rinses

cryotherapy - ice chips

treatment for mucositits

avoid spicy or acidic foods

topical or systemic analgesics

magic mouthwash (lidocaine + Benadryl + Maalox)

treatment for mild cancer pain

non-opioid ± adjuvant

treatment for mild to moderate cancer pain

opioid - codeine, tramadol

non-opioid ± adjuvant

treatment for moderate to severe cancer pain

opioid - morphine, fentanyl

non-opioid ± adjuvant

tramadol pearls

dose adjust crcl < 30

can lower seizure threshold

metabolized by CYP2D6

can interact with serotonin agents

Morphine pearls

ER or IR

best avoided in patients with kidney disfunction - CrCl <60

fentanyl pearls

useful in patients with renal or hepatic dysfunction

avoid in opioid naive patients

patch effect delayed by 18-24 hours

change patch every 3 days

buprenorphine pearls

partial agonist and antagonist

full effect delayed by 72 hours

change patch every 7 days

morphine to hydromorphone conversion

30mg morphine = 7.5mg hydromorphone

reduce dose by 25-50% if old dose was effective

keep dose the same if dose was not effective

Osteoclast inhibitors: dosing and brand name for metastases

Dunosumab (Xgeva) 120 SubQ q 4 weeks

Zoledronic acid (Zometa) - 4mg over 15 or more minutes every 3-4 weeks

Pamidronate (Aredia) - 90mg over 2-4 hours every 3-4 weeks

VTE risk factors in cancer patients

cancer type - stomach, pancreas, lung, lymphoma, gynecologic

pre chemo platelet count 350k or more

hgb less than 10

pre chemo wbc greater than 11k

bmi 35 or higher

when to initiate VTE prophylaxis

hospitalized - all patients

ambulatory - only in high risk

inpatient VTE prophylaxis meds, dosing and pearls

Dalteparin - 5000 units SubQ daily (avoid if crcl <30)

Enoxaparin - 40mg SubQ daily (30mg if crcl <30)

Fondaparinux - 2.5mg SubQ daily (avoid if crcl<30, CI if weight <50kg)

UFH - 5000 units SubQ q8-12 hours (no dose adjust)

ambulatory VTE prophylaxis meds, dosing and pearls (avoid all if crcl<30)

apixaban - 2.5mg bid (avoid if weight <40kg)

rivaroxaban - 10mg po daily

Enoxaparin - 1mg/kg SubQ daily for 3 months, then 40mg SubQ daily

VTE management in cancer patients

apixaban - 10mg bid for 7 days then 5mg bid (normal vte dosing)

when should LMWH be used in VTE management

GI or GU cancer

increased bleed risk

severe renal impairment

when should VTE management be held

platelets <50k

when should vaccines be given in chemo patients

non live - at least 2 weeks before

live - at least 4 weeks before

any vaccine after chemo has been terminated for 3 months

what 3 vaccines are allowed during chemo

covid

flu

pneumonia

live vaccines (COZY IV RM)

Cholera

Oral typhoid

Zoster

Yellow fever

Intranasal flu

Varicella

Rotavirus

MMR