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Oncology I-II
Oncology Side Effects & Chemotherapy-Induced Nausea and Vomiting
| Term | Definition |
|---|---|
| What is the proposed MOA Of chemotherapy induced nausea and vomiting? | - chemotherapeutic agent target highly dividing cells - GI track is highly dividing norma cells - destruction of the inner lining/epithelium cells --> side effects |
| what are some factors that increases the risk of chemotherapy induced nausea and vomiting? | - female - <50 - dehydration - h/o of motion sickness - h/o of N/V |
| what are some of the recommendations to manage chemotherapy induced nausea and vomiting? | 1- give anti emetic drug 30 min prior to chemo cycle 2- give home med to manage breakthrough nausea and vomiting |
| what are the four types of nausea/vomiting induced chemotherapy? | 1- acute ( within 24hr post chemo) 2- delayed ( 1-7 days post chemo) 3- anticipatory ( prior to chemo) 4- breakthrough ( regardless of anti emetic tx) |
| Which major neurotransmitters are responsible for the following? 1- acute N/V 2- delayed N/V | 1- acute: serotonin 5-TH3 2- delayed: substance-P ( neurokinin-1) |
| which class of drugs is preferred to treat acute, delayed, breakthrough, and anticipatory N/V? | 1- Acute: 5-TH-3 blocker 2- Delayed: 5-TH-3 blocker + substance-P blocker ( NK-1) + steroid 3- anticipatory: benzodiazepines 4- breakthrough: - 5-HT-3 RAs - dopamine receptor blocker - cannabinoids |
| What is the drug of choice of 5-TH3 blocker to treat delayed N/V? | - the only FDA approved is palonosetron ( alone) |
| What are the three main classification of emetic risk potential groups? | 1- high emetic group ( >90% risk) 2- moderate emetic group ( 30-90%) 3- low emetic group ( <30-10%) 4- minimal risk group ( < 10%) |
| Which drugs are highly emetogenic chemotherapeutic agents? C2DEF | 1- Cisplatin 2- doxorubicin/ epirubicin 3- ifosfamide/ cyclophosphamide |
| which drugs are Minimal rISK ( <10) emetogenic chemotherapeutic agents? | - monoclonal Ab - TKIs |
| what is the goal of therapy for CINV? | - prevent N/V - schedule drugs prior to chemo and after chemo - FYI: N/V for high emetogenic drug: risk for 3 days post chemo FYI: N/V for moderate emetogemic drug : risk for 2 days post chemo |
| What is the difference in therapy between emetogenic agents? | - high emetogenic drugs: 3 drugs( can add one more if needed) - moderate emetogenic drugs: 2-3 drugs ( can add one more if needed ) - low emetogenic drugs: 1 drugs |
| What are some example of 5-HT-3 blocker? | - ondansetron - granisetron - dolasetron - palonosetron ( only FDA approved for moderate risk ) |
| What are some example of NK-1R blocker? | - aprepotant PO - Fosaprepitant IV - Rolaapitant |
| What is the approved steroid medication to prevent CINV? | - dexamethasone |
| What are some other drugs that can be added to CINV regimen? | - olanzapine - lorazepam |
| what is an example of a combination drug approved to prevent CINV? | - Akynzeo - consist of : 1- netupitant 2- palonosetron |
| What antiemetic regimen is appropriate for a patient receiving cisplatin chemo-based therapy? | ** first cisplatin is high emetogenic risk chemo - at least 3 drugs: 1- 5HT-3 blocker + NK-blocker + steroid 2- Akynzeo + steroid 3- Steroid + olanzapine + palonosetron |
| KEY point in antiemetic regimen in patient receiving high emetogenic chemo? | - steroid + 5-HT-3 blocker + other drug ( olnazapine, NK-1A) - steroid + combo drug - May add lorazepam - May use 4 drugs regimen ( steroid + 5-HT-3+ NK-1A+ olanzapine) |
| What antiemetic regimen is appropriate for patient receiving cytarabine 1gram ? | - moderate emetogenic drug - 2-3 drugs maybe used - same regimen as high emetogenic - steroid+ 5-HT-3+NK-1 - Steroid + 5-HT-3 only - Steroid + 5-HT-3 + olanzapine - steroid + combo |
| what antiemetic regimen is appropriate for patient receiving Paclitaxel? | - low risk - one drug is enough - steroid - 5-HT3 - dopamine receptor blocker: 1- prochlorperazine 2- metoclopramide |
| Which drug may used in patient experiencing anticipatory CINV? | - lorazepam ** benzodiazepines is indicated in anticipatory CINV |
| What is breakthrough N/V? | - N/V despite receiving antiemetic drug regimen |
| what are some drugs that can be used to in patient experiencing breakthrough N/V? | - 5-HT-3 RAs - dopamine receptor blocker - cannabinoids |
| what are some of the common side effect of 5-HT-3 blocker? | - migraine like headache - constipation |
| what are some example of dopamine receptor blocker? ( azine) | - prochlorperazine - promethazine - metoclopramide |
| what are the common side effect of dopamine receptor blocker? | - sedation - extrapyramidal symptoms ( EPS) such as acute dystonic rxn in younger pt |
| What is the recommended treatment for acute dystonic reactions? ( reversible EPS)? | - anticholinergic 1- benztropine 2- diphenhydramine |
| what are some other class of medication can be used as 2nd line ( they may/may not be legally approved in some states CI )? | - The cannabinoids 1- dronabinol (marinol, syndros) 2- nabilone ( cesamet) |
| What is the MOA of cannabinoids ( dronabinol and nabinol) in CINV? | - delta-9-tetrahydrocannabinol - naturally occurring compound - cannabis sative ( marijuana) |
| what are some of dronabinol or nabinol side effect? | cannabinoids drugs 1- sedation 2- dysphoria 3- euphoria |
| What is the MOA of substance P/Neurokinin-1 receptor blocker? | - Augmenting the antiemetic activity of 5-HT3 blocker and steroid - blocking substance P/neurokinin-1 receptor |
| what is substance P/Neurokinin-1 receptor blocker suffix? | epitant |
| Which antipsychotic drug the use of aprepitant and fosaprepitant is C/I? | - pimozide - cyp 3A4 substrate |
| Which gastroprokinetic drug the use of aprepitant and fosaprepitant is C/I? | cisapride cype 3A4 substrate and 5-HT4 agonist |
| which anti schizophrenic drug the use of rolapitant is C/I? | thioridazine cyp 2D6 substrate |
| What are some common side effect of substance P/ neurokinin1 receptor blocker? | - dizziness - weak/fatigue - constipation - hiccups ( involuntary diaphragm movements) |
| Which of the substance P/Neurokinin-1 receptor blocker are CYP 3A4 substrates? | - aprepitant - fosaprepitant - netupitant |
| which of the substance P/Neurokinin 1 receptor blocker are CYP 2D6 substrates? | rolapitant |
| The use of Substance P/Neurokinin-1 blocker concurrently with dexamethasone requires a reduction of dexamethasone except ? | except in rolapitant as it's CYP 2D6 substrate |
| Which drugs of substance P/neurokinin1 blocker require dexamethasone dose adjustment ( reduction) when used concurrently? | - aprepitant - netupitant |
| Which substance P/neurokinin 1 blocker requires dosing before ( day 1) and after chemotherapy for two days ( day II & III)? | aprepitant ( 3 DAYS DOSING) Day 1: 125 mg 1 h/r prior to chemo Day II, III: 80 mg |
| Which substance P/ Neurokinin 1 blocker drugs require one day dosing prior to chemotherapy ( DAY 1) ? | - fosaprepitant: 150 mg IV 30 min prior to chemo - Akynzeo: 300/0.5 mg orally 1 hr prior to chemo - rolapitant: 180 mg 1-2 hrs prior to chemo |
| What is the MOA of 5-HT3 receptor blocker? | - blocks serotonin receptor centrally ( chemoreceptor trigger zone) and peripherally ( vagal nerve terminals) |
| What is the recommended dosing of 5-TH-3 receptor blocker? | - ONCE on DAY 1 prior to chemo - patch is the only exception, start before DAY 1 |
| What are some examples of 5-TH-3 receptor blocker durgs? | - ondansetron - Granisetron - dolasetron - palonosetron |
| Which dopamine promoter is considered C/I in patient taking ondansetron? | - apomorphine ** the use of apomorphine with ondansetron increases the hypotensive effect of apomorphine |
| Which 5-HT-3 receptor blocker has CV effect in particular increases in QT interval ( torsade de pointes) ? | - dose dependent - IV 1- IV ondansetron ( zofran) 2- IV granisetron (kytril) 3- IV dolasetron ( anzemet) 4- IV palonosetron ( aloxi) |
| Which 5-HT-3 receptor blocker has the highest risk of inducing QT prolongation ( torsade de pointes)? | - IV dolasetron ( aznemet) highest risk of QT prolongation - NOT indicated for CINV tx |
| Which 5-HT3 blocker induces constipation, progressive ileum and gastric distension? | - granisetron SC injection ( sustol) |
| Which 5-HT3 drug is available only as IV? | palonosetron Aloxi |
| which 5-HT3 drug is available as oral combination with NK-1 blocker? | palonosetron+ netupitant = akynzeo |
| what are some of the common side effects of 5-HT3 blocker? | - headache - fatigue - dizziness - constipation - injection rxn ( sustol SC injection) |
| what are some considerations in using Sancuso ( granisetron patch)? | - prior to day 1 chemo - duration for 24 hr - apply Q 1-2 days prior to chemo - may leave it for a week |
| When is the use of dexamethasone in CINV is C/I ? | - systemic fungal infection - cerebral malaria |
| what are some of dexamethasone side effect ? | - short term use: 1- increases wt 2- fluid retention*** 3- insomnia 4- GI upset 4- emotional instability |
| What are the side effect of high dose dexamethasone? | - high blood pressure - increases blood glucose |
| what is the recommended dosing of dexamethasone in CINV on DAY 1 prior to chemo ? | - for high, moderate, low risk the first dose is fixed : 12 mg PO/IV on day 1 of chemo - FOR DAY 1 regardless of emetognicity, 12 mg PO/IV on day 1 except in high regimen, may start @ either 12 mg or 20 mg |
| What is the recommended dosing of dexamethasone with aprepitant or netupitant in high emetogenic chemo therapy? 4 days dosing | - Day 1: 12 mg PO/IV - Day 2, 3,4 : 8 mg PO |
| What is the recommended dosing of dexamethasone with fosaprepitant in high emetogeic chemo therapy? 4 days dosing | - Day1: 12 mg PO/IV - Day2: 8 mg/ day - Day 3and4: 8 mg BID |
| what is the recommended dosing of dexamethasone with rolapitant in high emetogenic chemo therapy? 4 days dosing | - Day 1: 12 mg PO/IV - Day 2-4: 8 mg BID |
| what is the recommended dosing of dexamethasone in moderate emetogenic chemo therapy? 3 days dosing | - Day1: 12 mg PO/IV - Day 2-3: 8 mg /day |
| what is the recommended dosing of dexamethasone in low risk emetogenic chemo therapy? | - ONLY at the day of chemo - 12 mg PO/IV |
| what is the MOA of dopamine receptor blocker? | blocks dopamine receptor and chemoreceptor trigger zone |
| What are the most common dopamine receptor blocker drugs are used in CINV? | 1- prochlorperazine 2- promethazine 3- metolopramide 4- droperidol |
| Which dopamine receptor blocker increases the risk of mortality in elderly patient with dementia related psychosis ( BBW)? | - prochlorperazine ( mortality) |
| Which dopamine receptor blocker is not indicated in patient less than 2 years due to the risk of respiratory depression ( BBW)? | - promethazine ( respiratory depression) |
| Which dopamine receptor blocker should not be given as SC or intra arterial? | - promethazine |
| What is the preferred route of administration of promethazine? | - DEEP IM injection - NEVER GIVE SC - IV can cause tissue injury if extravasation occurs |
| What is a complication of administering promethazine as IV? | - serious tissue injury if extravasation occurs |
| Which dopamine receptor blocker can cause tardive dyskinesia ( TD) which might be irreversible ( BBW) ? | Metoclopramide |
| What are some risk factors that increases the risk of developing tardive dyskinesia in patient receiving Metocopramide? | - increases duration - increases total cumulative dose ( avoid > 12 weeks use) |
| Which dopamine receptor blocker can cause QT prolongation and serious arrhythmias? | droperidol IV injection |
| What should be done prior to using droperidol IV ( dopamine receptor blocker)? | - Since the droperidol IV can induce QT prolongation + arrhythmias 1- 12 lead ECG prior to droperidol IV 2- 12 lead ECG 2-3 hours after droperidol IV |
| when is the use of droperidol IV C/I? | - if pt has a prolonged QT baseline |
| which patient population the use of dopamine receptor blocker should be avoided? | - pt with Parkinson ds as it exacerbate its sxs |
| which dopamine receptor blocker needs dose adjustment in patient with renal impairment eGFR < 40ml/min | metoclopramide - give 1/2 the dose |
| which dopamine receptor blocker is indicated only post operative n/v as it increases the risk of QT prolongation/ arrhythmias ? | droperidol IV |
| Which dopamine receptor blocker is available as suppository PR route of administration? | - prochlorperazine - promethazine |
| which dopamine receptor blocker is available as IM injection and considered the best ROD? | - promethazine |
| What is the difference in dosing metoclopramide in high emetic chemo regimen? | - usually dosed 10-40 mg every 6 hrs PRN- fixed - in high emetic : 0.5-2 mg/kg every 6 hrs prn -- PER Kg of the patient |
| What are the common side effect of dopamine receptor blockers? | - sedation - lethargy - QT prolongation - hypotension - constipation except methoclopramide and droperidol |
| What are some serious side effects of dopamine receptor blockers? | - neuroleptic malignant syndrome -acute EPS ( in children) - reduce the seizure threshold |
| which class of drug is used to treat dopamine receptor blockers induced acute EPS? | - anticholinergic 1- benztropine 2- diphenhydramine |
| What is the MOA of Cannabinoids in CINV? | - activating the cannabinoids receptor in CNS - inhibiting the vomiting center at medulla oblongata |
| What are the most common cannabinoid drugs used in CINV? | 1- dronabinol CIII 2- nabilone CII |
| what is the difference in class between DronaBINOL and DroPERIDOL? | cannabinoids vs dopamine receptor blocker |
| What are the dosage forms of dronabinol? | - capsule - solution ( 50% alcohol) |
| what are some side effects of cannabinoids? | 1- somnolence 2- euphoria/ dysphoria 3- increase appetite 4- hypotension 5- lowers seizure threshold |
| what are some common factors to consider prior to starting patients on cannabinoids? | - psychiatric disorders - substance abuse |
| what is the recommended dronabinol dosing in CINV? | - 5mg/m2 prior to chemo - Q2-4 hr PRN - max of 6 does/day |
| what is the recommended nabilone dosing in CINV? | - 1-2 mg BID/day - up to 48hrs |
Created by:
Smoham38
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