Oncology Support

BCPS Oncology Support

 

Antiemetics

Acute onset: occurs within 24hr of chemotherapy, peaks 5-6hr, resolves within 24hr

Delayed onset: >24hr after chemo [cisplatin, carboplatin, cyclophosphamide, doxorubicin]

Anticipatory: conditioned response triggered by sights, smells; more likely to occur with delayed N/V is not controlled

Breakthrough: despite prophylaxis treatment and requires additional rescue meds

Refractory: occurs during treatment cycles when ppx and/or rescue has failed in previous cycles

 

Risk Factors: <50 yo, female, motion sickness, N/V pregnancy, N/V previous chemo [alcoholism decreases risk]

General Principles for Managing Chemo/Radiation N/V

1. PPx meds before moderate or high emetogenic agents

2. antiemetics should be scheduled for delayed N/V

3. most common: High- serotonin antag + dex (steroid increases efficacy by 10-20%)

4. may also add aprepitant to above regimen.  [metoclopramide + dex used to be the most common]

 

High (>90%): [doxorubicin/epirubicin + cyclophos], carmustine, cisplatin>50mg/m2, cyclophosphamide>1500mg/m2

Minimal (<10%): most ‘mabs, Vins, interferon alpha<5million/m2, methotrexate <50mg/m2

 

Treatment: Use ppx for all chemo high-low (not routine for minimal)

1. 5-HT3: all similar efficacy (except palonosetron)   AEs- HA, constipation

2. corticosteriods: dex more studied than methylpred   AEs- infrequent with short duration (insomnia, fluid retention)

3. neurokinin-1 antag: aprepitant (PO) fosaprepitant (IV)   DDI- CYP3A4(warfarin-decrease INR, oral dex- decrease dose 40%, OCs- another form)   AEs- asthenia, dizziness, hiccups

4. benzamide analogs (metoclopramide): AEs- mild sedation, EPS

5. phenothiazines (prochlorperazine, promethazine): AEs- EPS, drowsiness, HoTN

6. butyrophenones (haloperidol, droperidol): AEs- EPS, sedation, less HoTN than above

7. benzodiazepines (lorazepam): only in combo, can help manage EPS   AEs- amnesia (can be good with anticip)

8. Others: cannabinoids (dronabinol, nabilone); H2 blockers/PPI

 

Pain Management

General Principles for Cancer Pain Management

1.  oral route preferred- scheduled basis, not as needed (as needed for breakthrough pain); >2 doses may need modify

2. maximize one drug dose and schedule before adding another drug

3. provide medications for AEs: constipation, sedation

4. assess pain often- most important step!

 

Treatment

1. mild-mod (1-3): nonopiod- NSAIDs, ASA, APAP (platelets, SCr)

2. mod-severe (4-6): + weak opiod- codeine, hydrocodone (watch for APAP OD with combos)

3. persistent severe (7-10): change weak to strong opiod- morphine, oxycodone (constipation- stimulant laxatives, urinary retention, sedation- dextramphe, methylphen, N/V- meclizine, phenothiazines)

4. Bisphosphonates: Pamidronate or zoledronic acid for skeletal pain (spinal cord compression, fracture, bone mets) in breast CA and myeloma [SCr,elec]

5. Adjuvant: antidepressants, anticonvulsants, transdermal lidocaine, corticosteroids, benzos (spasms), strontium-89

 

Febrile Neutropenia: ANC<500, nadir usually day 10-14 [No chemo if WBC<3000, ANC<1500, or Plate<100]

Febrile= one temp 101 or 100.4 >1hr

Reassess all pts in 3-5 days after abx

CSFs may be given: similar in efficacy, should be initated in 24-72hr post-chemo, cont until post nadir ANC>10,000

 

Thrombocyotpenia (plate<100, no increased risk of bleeding until <20, transfuse plate when symptoms)

Oprelvekin (interleukin-11)- ppx, cont until post-nadir >50   AEs- edema, SOB, tachycardia, conjunctival redness

Anemia/Fatigue: epoetin/darbipoetin alfa

Chemoprotectants

1. Dexrazoxane: anthracyclines- cardiotox. May use in pts doxorubicin >300mg/m2 and may benefit from cont. use

2. Amifostine: cisplatin- nephrotox and head/neck radiation- xerostomia. AEs- HoTN, metallic taste, flush

3. Mesna: ifosfamide/cyclophosphamide- hemorrhagic cystitis (metabolite acrolein)

 

Oncology Emergency

1. hypercalcemia: thiazide and hormonal therapy can exacerbate

                Treat (cCa> 14):NS 3-4L in 24hr, loop (to prevent fluid overload), bisphosphonates, calcitonin, steroids

2. spinal cord compression- dexamethasone and radiation or surgery

3. tumor lysis syndrome (uric acid, K, P): hydration and allopurinol, rasburicase with uric acid> 10

 

Misc Pharmacotherapy

1. leucovorin rescue- MTX > 100mg/m2 [Also used in combo with 5-FU to enhance activity, NOT rescue]

2. Extravasation (vesicants): ACs (topical dimethyl sulfoxide, dexrazoxane, cold), Vins (hyaluronidase, heat),mechlorethamine (Na thiosulfate) oxaliplatin, paclitaxel

3. Diarrhea- loperamide (higher than usual doses)

4. Renal dose: MTX, carboplatin, cisplatin, etoposide, bleomycin, topotecan, lenalidomide

5. Hepatic dose: doxorubi, daunorubi, vincrist, vinblast, docetaxel, paclitaxel, sorafenib, pazopanib

6. Never administer Viscristine intrathecally

The Pharmacist's Manifesto

Cardiology Review