Myelosuppression/Supportive Care

Filgrastim (Neupogen)

G-CSF, MOA: Stimulate neutrophil progenitor cell proliferation and

differentiation

AE: bone pain, splenic rupture

5 mcg/kg/day subq until ANC 10,000/mm³

Pegfilgrastim (Neulasta)

G-CSF, MOA: Stimulate neutrophil progenitor cell proliferation and

differentiation

AE: bone pain, splenic rupture

6 mg subq as single dose, 12 days between injection & following chemo

Febrile Neutropenia

ANC <500 OR <1000 & expected <500 w/in 48hrs + fever

Require abx

Febrile Neutropenia PPX

-GCFF following 1st round of chemo

-GCSF after neutropenic complication

Febrile Neutropenia Treatment

-broad spectrum abx w/in 1 hr of presentation

Outpt: cipro + augmentin or levo/moxi

Inpt: IV abx, cefepime, zosyn, or carbapenems, ± Vanco

Erythropoiesis Stimulating Agents

Epoetin alfa (Epogen), Darbepoetin (Aranesp)

AE: thrombosis, HTN

BBW: death, MI, stroke, CV events, tumor progression

Diarrhea Grade 1

increase of <4 stools/day above BL

Diarrhea Grade 2

increase of 4-6 stools/day above BL

Diarrhea Grade 3

increase of 7+ stools/day above BL

Hospitalization, limiting self-care

Grade 4 Diarrhea

life threatening, urgent intervention needed

Grade 5 diarrhea

death

Diarrhea treatment

loperamide, Lomotil (diphenoxylate/atropine), ocreotide

Mucositis Grade 1

asymptomatic/mild - no intervention

Mucositis Grade 2

moderate pain; modified diet

Mucositis Grade 3

severe pain, interferes w/ oral intake

Mucositis Grade 4

Life threatening

Mucositis Grade 5

death

Mucositis treatment

Supportive care (avoid spice/acid)

Mouth washes (salt/baking soda, magic mouthwash)

Pain management (severe- PCA)

Rash

Prevention/Treatment: Avoiding skin irritants/keep skin hydrated/clean, Limit sun exposure/use sunscreen, topical corticosteroids

EGFR Inhibitor rash: Occur in up to 90% of patients, Correlated with positive response to therapy Pre-emptive therapy: prophylactic antibiotics with doxycycline or minocycline for 6 weeks

Hand-foot syndrome

Redness, swelling, pain, and numbness to hands and feet

Prevention: Avoidance of extreme temperatures, proper fitting footwear,

moisturizers

Peripheral Neuropathy

Numbness/tingling of fingers and toes, loss of sensation progressing

to pain

Common drugs: Taxanes, platinums, bortezomib vinca alkyloids

Treatment: Gabapentin, Duloxetine

CRS/ICANS

-Cytokine Release Syndrome (CRS)

-Immune Effector Cell Associated Neurotoxicity Syndrome (ICANS)

-IL-6 - large mediator

CRS Grade 1

Fever >100.4 w/o alt. cause, no HoTN, no hypoxia

CRS Grade 2

Fever >100.4 w/o alt. cause, HoTN responsive to fluids, hypoxia requiring low flow nasal cannula (<6L)

CRS Grade 3

Fever >100.4 w/o alt. cause, HoTN requiring 1 vasopressor, hypoxia requiring high flow nasal cannula

CRS Grade 4

Fever >100.4 w/o alt. cause, HoTN require multiple vasopressors, hypoxia require CPAP, BIPAP, or intubation

ICANS Grade 1

ICE Score 7-9, awakens spontaneously

ICANS Grade 2

ICE Score 3-6, awakens to voice

ICANS Grade 3

ICE Score 0-2, awakens to tactile stimulus, clinical/non convulsive seizure (resolves rapidly), local edema on imaging

ICANS Grade 4

ICE Score0, pt unarousable, life threatening seizure (>5 min), hemiparesis or paresis, diffuse edema, posturing, cranial nerve VI palsy, papilledema

CRS Treatment

• Supportive care (fluids, oxygen, acetaminophen)

• Grade II and above: tocilizumab

• Grade II and above can consider corticosteroids in

conjunction with tocilizumab

ICANS Treatment

• Supportive care (minimize anticholinergics)

• Steroids