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137 Cards in this Set
- Front
- Back
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ZINECARD IS WHAT?
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DEXRAZOXANE
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What is ZINECARD used for?
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Doxorubicin-causing CARDIOMYOPATHY
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When Should ZINECARD be considered in women?
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Women who received > 300 mg/m2 of doxorubicin in the past & who benefit from doxorubicin continued therapy
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When should ZINECARD NOT be used?
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Do not use until 300 mg/m2 of doxorubicin has been given.
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What is TOTECT?
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DEXRAZOXANE
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What is Totect used for?
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Extravasation resulting from IV ANTHRACYCLINE chemotx
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What is the mechanism of the cardiomyopathy that Zinecard treats?
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Cardiac tissue has low level of ANTIOXIDANT enyzme activity, so they are susceptible to damage from IRON-ANTHRACYCLINE free radicals.
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What do anthracyclines create to cause toxicity?
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Oyxgen Radicals.
These bind to intracellular IRON to form IRON-ANTHRACYCLINE free radicals. |
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What does Dexrazoxane do to stop toxicity from anthracycline chemotx?
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It binds to IRON, preventing "radical" generation of the iron-chelation product.
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What is the PREVENTION DOSE (Dexrazoxane) for Cardioprotection?
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10:1 Ratio w Doxorubicin
Dexrazoxane 500 mg/m2 : Doxorubicin 50 mg/m2 |
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What is the PREVENTION DOSE (Dexrazoxane) for Cardioprotection + Patients w RENAL DYSFXN (CrCL < 40)?
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5:1
250 mg/m2 Dexrazoxane : 50 mg/m2 Doxorubicin |
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What is the PREVENTION DOSE (Dexrazoxane) for Cardioprotection + Patients w HEPATIC DYSFXN (CrCL < 40)?
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Still 10:1
Doxorubicin dose reduction is recommended in the presence of hyperbilirubinemia The dexa dose should be proportionately reduced |
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How is dexazoxane administered in these Prevention doses?
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Given by SLOW IV PUSH or RAPID IV INFUSION (~ 15 min) started 30 MIN prior to the dose of doxorubicin
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Dose & Administration for Extravasation (Treatment)
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Given Once Daily for 3 consecutive days
The first dose should be given ASAP and within the 1st 6 hours after Extravasation from antracyclines |
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What are the exact doses for the Extravasation Treatment with Dexazoxane?
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Day 1: 1000 mg/m2
Day 2: 1000 mg/m2 Day 3: 500 mg/m2 |
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What is the dose for Extravasation Treatment of Dexazoxane for someone with renal dysfunction? (CrCL < 40)?
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50% dose reduction
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What are the Side Effects of Dexazoxane? (3)
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1. Neutropenia & Thrombocytopenia
2. N/V/D 3. Mucositis *Possibly dec response rates of chemotx |
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What is the brand name of Amifostine?
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ETHYOL
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What is Amifostine used to prevent? (2)
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1. Cisplatin - induced nephrotoxicity (& neutropenia)
2. Xerostomia & Mucositis caused by Head and Neck Radiation |
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What is the mechanism of Amifostine?
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Selective Uptake in normal cells
Dephosphorylated into: WR-1065 WR-1065 = free thiol that is a free oxygen radical scavenger |
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What is the dose of Amifostine?
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910 mg/m2 IV
740 mg/m2 IV over 15 minutes, 30 minutes before chemotx. (740 dose is better tolerated & similar efficacy) |
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What is the dose of Amifostine prior to radiation therapy?
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200 mg/m2 IV over 3 minutes
Give 15 to 30 mins prior to radiation therapy |
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What is the unlabeled route for Amifostine dose before radiation therapy? What is the dose for that route?
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SQ
500 mg once daily |
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What are premedications for Amifostine? (2)
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(1) NS 1 L (up to 2 L) pre-Hydration
(2) 5HT3 Antagonist + Dexamethasone 20 mg IV |
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Which SE of Amifostine can be most severe?
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HYPOTENSION
* Reclining position during infusion * Anti-HTN meds held 24 h prior to amifostine * BP monitoring (0, 5, 10, 15 min) DURING INFUSION * BP monitoring 10 min AFTER INFUSION |
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What are the other 3 SE for Amifostine? Which 2 are more significant?
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* N/V Grade 4
* Hypersensitivity * HypoCalcemia *N/V and Hypersensitivity*** Hypersensitivity = could be fetal, erythema, or Stevens-Johnson Syndrome, or Toxic Epidermal Necrolysis!!!! |
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What is MESNA?
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Sodium 2- Mercaptoethane Sulfonate
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What is brand for MESNA?
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MESNEX
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What is MESNA used for?
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Uroprotectant (Prevention of hemorrhagic cystitis)
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Is MESNA compatible with ifosfamide?
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YES, data supports it
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Is MESNA Compatible with Cyclophosphamide?
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Not usually.
BUT! Used with high dose cyclophosphamide for HSCT regimens (BMT or PBSCT) |
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How is MESNA inactivated?
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It is a thiol that is inactivated in the Blood
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How is MESNA Re-activated?
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In the kidney where it binds ACROLEIN (which causes hemorrhagic cystitis) in the bladder & the pdt is eliminated in the urine
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How must MESNA be administered?
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Since it has short half life:
Multiple Doses, OR continuous infusion (CI) |
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What is the oral dose of MESNA compared to IV dose?
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PO - Double Dose of IV dose, since F is less
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What strength MESNA tablet is now available?
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400 mg
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Dose and Administration of MESNA (3 common): Ifosfamide doses < 2.5 g/m2/day
Ifosfamide IV Bolus (2 admin) |
(1) IV/IV: IV given 20% ifosfamide 15 min prior, at 4hr, and 8 hr after ifosfamide tx completion (60% total dose)
(2) IV/PO: 20% IV 15 min prior, 40% PO at 2 hrs, and 40% at 6 hrs |
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Ifosfamide Continuous infusion dosing with MESNA?
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IV CI: LD of 20% ifosfamide started 15 min before chemotx
followed by 40% during the ifosfamide infusion until 12 - 24 hrs after tx (ifosfamide) completion |
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What are MESNA SE? (2)
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(1) Bad smell & taste (mix in juice or cola!) ^_^
(2) N/V (usu from bad taste) |
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What is the role of Parathyroid hormone? Trigger
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decrease calcium
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What is the role of Parathyroid hormone? Gut
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Increase absorption of Ca and P
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What is the role of Parathyroid hormone? Kidney (2)
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(1) increase reabsorption of Ca
(2) increase excretion of P in urine |
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What is the role of Parathyroid hormone? Bone
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Increase osteoclastic activity (Bone resorption)
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What is the role of Parathyroid hormone? Overall
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Increase Ca and Increase P (in serum)
Decrease PTH |
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What is the role of 1,25-DihydroxyvitaminD3 (Calcitriol)? Trigger
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Decrease Ca
Increased PTH |
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What is the role of 1,25-DihydroxyvitaminD3 (Calcitriol)? Gut
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Increase absorption of Ca and P
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What is the role of 1,25-DihydroxyvitaminD3 (Calcitriol)? Bone
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Increase osteoclastic acitivity
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What is the role of 1,25-DihydroxyvitaminD3 (Calcitriol)? Parathyroid
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Decrease PTH (by inhibiting gene transcription)
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What is the role of 1,25-DihydroxyvitaminD3 (Calcitriol)? Overall
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Increase Ca
Increase P (in serum) Decrease PTH |
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What is the role of calcitonin? Trigger
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Increased Ca
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What is the role of calcitonin? Kidney
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Increase excretion of Ca, P, and Na in the urine
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What is the role of calcitonin? Bone
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Decrease osteoclastic activity
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What is the role of calcitonin? Overall
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Decrease Ca
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What do osteoclasts do?
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First break down bone to form a resorption cavity; they are bone resorption cells
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What do osteoblasts do?
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Bone-reabsorbing cells; resorption from osteoclasts stimulates osteoblasts to form new bone over the resorption cavity
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What can tumors cause in the pathophysiology of cancer-associated hypercalcemia?
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Osteolytic Hypercalcemia
From direct bone destruction |
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What do tumors secrete the resemble normal secretion in patients in the pathophysiology of cancer-associated hypercalcemia?
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tumors can secrete substance similar to PTH (PTH-like protein)
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What are immobile patients at risk of in the pathophysiology of cancer-associated hypercalcemia?
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They are at increased risk of hypercalcemia due to increased resorption
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What is the normal Calcium range?
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8.5 - 11 mg/dL
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What is corrected calcium formula?
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CorrCa = Meas Ca + [Normal ALB - Meas ALB]*0.8
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What do pts present with who have Corr Ca > 14 ?
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Symptomatic
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For Hypercalcemia, what is true with the signs and symptoms?
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The presenting sxs of hypercalcemia do not correlate well with the presenting Ca levels
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S/Sx of Hypercalcemia: Cardiovascular
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* increased myocardial contractility
* shortened QT wave * AC block and potentially asystole |
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S/Sx of Hypercalcemia: Central Nervous System
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* Delirium
* Confusion * Disorientation * Personality changes * Hallucinations & Delusions |
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S/Sx of Hypercalcemia: Renal
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* Polyuria
* Hypokalemia * Polydipsia * Hypomagnesemia * Dehydration * Hyponatremia |
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S/Sx of Hypercalcemia: Gatrointestinal
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* Anorexia
* Constipation * N/V * Abdominal Pain |
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Malignancy Hypercalcemia: Inpatient Treatment
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CorrCa > 14
Dehydration N/V Renal Dysfxn Cardiac Abnormalities Altered Mental Status Ltd Access to Medical Care and/or Lives Alone |
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Malignancy Hypercalcemia: Outpatient Treatment
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CorrCa < 12
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Malignancy Hypercalcemia: Management Overview (4)
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* Hydration (Risk pts drink 3 - 4L fluids/day)
* Remain Mobile * control N/V & other sx supportive care * Eliminate meds that interfere w elim of ca |
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Malignancy Hypercalcemia: Treatment
Mild Hypercalcemia (CorrCa < 12) |
* does not req aggressive tx
* Hydration w (salty) water followed by observation (in asx pts) * pharmacological intervention (sx pts) |
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Malignancy Hypercalcemia: Treatment
Moderate Hypercalcemia (CorrCa btwn 12 - 14) |
Base tx on Clincal symptoms
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Malignancy Hypercalcemia: Treatment
Severe Hypercalcemia (CorrCa < 14) |
* Requires aggressive tx
* Increase daily urinary calcium excretion * hydration w NS may req 3 - 6 L in 24 hr * Loop Diuretics may be administered after volume status has been corrected |
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Malignancy Hypercalcemia: Treatment
Severe Hypercalcemia (CorrCa < 14) --- LOOP DIURETICS |
* Furosemide 20 - 40 mg Q 12 h
* Bumetanide 0.5 - 1 mg QD * Induce hypercalciuria * Inhibit Ca reabsorptionin the loop of Henle * if given before volume repletion, can worsen fluid loss & exacerbate hypercalcemia * thiazide CI due to the inc in renal tubular Ca2+ absorption |
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What is Calcitonin?
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Salmon Calcitonin
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What are the different administration for Calcitonin?
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* IM
* SQ * Miacalcin(R) * Intranasal formulation is NOT used for hypercalcemia |
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Calcitonin has a more rapid effect of this compared to what other therapy for hypercalcemia?
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Calcitonin has more rapid hypocalcemic effect when compared to Pamidronate
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Calcitonin MOA
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Used in combination with bisphosphonates: Ca2+ lowering effect only lasts for 2 - 3 days, bc of tachyphylaxis
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Calcitonin dose
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*Initial = 4 IU/kg/dose SQ or IM q 12h
*Max dose of 8 IU/kg q 6 hr *Allergic potential check w 1 IU test dose |
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Side Effects Calcitonin
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Cutaneous Flushing
Erythematous rash Abdominal Pain Mild Nausea |
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Malignant Hypercalcemia: Bisphosphonates and Denosumab
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* not rapid correction
* only in hypercalcemia of malignancy, zolendronate demonstate superiority over pamidronate * refer to pain mgmt lecture |
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Malignant Hypercalcemia: Other tx choices (Not first line; CCS)
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* Use in pts w steroid-response tumors
* Phosphates are another treatment choice (not first line) |
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What is Cinacalcet?
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Sensipar
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When is Cinacalcet contraindicated?
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In low pts with CorrCa level less than 8.4. Make sure to check calcium prior to dispensing.
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Tumor Lysis Syndrome
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Occurs secondary to the rapid cell death that follows administration of chemotherapy in pt with leukemia, lymphoma, or in patients with high tumor burdens due to other malignancies, which are also highly chemosensitive
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Onset of TLS?
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Prior to chemotx or wihtin 1 - 5 days of receiving chemotx
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What does TLS cause? (4)
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Hyperuricemia
Hyperkalemia Hyperphosphatemia Secondary Hypocalcemia |
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TLS: 4 other complications from the electrolyte disturbance causes?
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* Acute renal failure (urate nephropathy, xanthine nephropathy or calcium phosphate precipitation)
* Cardiac dysrhythmias (from hyperkalemia & hypocalcemia) * Cramps (from hypocalcemia) * Sudden death (from hyperkalemia or hypocalcemia) |
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Laboratory TLS ?
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2 or more metabolic abnormalities must be present during the same 24 hr period iwthin 3 days beofre the start of tx or up to 7 days afterward
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Clinical TLS
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Lab TLS + an increased creatinine level, seizures, cardiac dysrhythmias, or death
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Uric Acid Production Diagram. What does Allopurinol do?
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blocks Xanthine Oxidase, stops conversion of hypoxanthine --> xanthine
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Uric Acid Production Diagram. What does rasburicase do? ???
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Blocks Urate Oxidase. Stops Uric Acid into allantoin
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TLS Prevention Management
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IV hydration + ORAL Allopurinol +/- diuretics +/- rasburicase
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TLS Prevention Management: How should you "hydrate"?
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NS
24 to 48 hours PRIOR to chemotx for 5 - 7 days |
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TLS Prevention Management: Why is NaHCO3 no longer recommended?
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While NaHCO3 increases solubility of uric acid, it also dec calcium phosphate solubility
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What is allopurinol?
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Xanthine Oxidase Inhibitor
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Dose and Administration of allopurinol?
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300 mg/day (higher doses, BID or TID) also used; varies
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How shoudl allopurinol be given, knowing that there is no effect on pre existing uric acid?
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Give 1 - 2 days before chemotox (bc allopurinol has no effect on preexisting uric acid, it is not used as tx after TL has developed.
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What is IV Allopurinol?
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Aloprim
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Why is IV allopurinol used?
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If patients cannot swallow.
But, compareed with rasburicase, same cost, just rasburicase may be slightly more effective. |
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Allopurinol ADR
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Dermatologic: Rash (Inc w ampicillin or amoxicillin use)
Close monitoring every 6 - 8 hours of uric acid, serum chemistries, and serum Cr and rapid response |
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What is brand of Rasburicase?
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Elitek
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What is Rasburicase?
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Recombinant urate oxidase that converts uric acid into a more soluble form (allantoin)
*Allantoin is 5-10x more soluble in urine than uric acid * shown to promptly correct serum uric acid levels & dec SCr |
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What patients should Rasburicase be indicated?
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* high risk pts for developing TLS, those with a serum uric acid concentration > 10, large tumor burdens, or existing renal dysfxn
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What are the two downfalls to Elitek?
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1. Expensive
2. Not recommended as a preventive in all patients |
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Elitek Dosing in Peds
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0.15 or 0.2 mg/kg daily x 5 days beginning 4 - 24 hrs prior to chemotx
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What is the more "practical" dosing for Elitek?
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3 - 7.5 mg IV once, recheck uric acid levels @ 4 hours, and RE-DOSE if necessary
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Elitek SE? (2)
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1. Anaphylaxis (chest pain, dyspnea, HoTN, urticaria)
2. Methemoglobinemia = AKA "Blue Baby Syndrome" and Ferrius state --> Ferric State |
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Rasburicase Contraindications
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G6P Dehydrogenase (G5PD) Deficiency: can't break down H2O2, a pdt of hte urate oxidase rxn.
Thus, hemolysis risk increases |
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Elitek Drug - Lab Interaction
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Ex vivo uric acid degradation
*Blood must be collected into prechilled tubes containing heparin anticoagulant *DIALYSIS (Last option) |
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What is Chemotherapy EXTRAVASATION?
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Leakage of vesicant materials inot the SQ tissue during administration
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What is Chemotx INFILTRATION?
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Inadvertent administration of non-vesciant or irritant or med into the surrounding tissues
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What is Chemotx VESICANTS?
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Drugs cause pain, inflammation and blistering local skin, underyling fash and ctrubute
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What is Chemotx IRRITANT?
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Drugs which are capable of causing inflammation, irritation, or pain at site of extravasation, but rarely cause tissue breakdown
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EXTRAVASATION Pathophysiology
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Extent of tissue damage depend on type of agent, DNA-binding or non-DNA binding
* DNA-binding agents cause lethal DNA crosslinking or strand breaks, leading to cell necrosis, * Non-DNA-binding agents are easier to be removed and cause less tissue damage |
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S/SX of EXTRAVASATION
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* Burning, stinging, or any discomfort/pain at the injection site
* Swelling, redness, or blistering at the injection site * No blood return is obtained * A resistance is felt on the plunger of the syringe of a bolus drug * Absence of free flow of the infusion * If in any doubt, treat as extravasation |
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Prevention of Extravasation? (4)
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* Careful and continual assessment of the cannulation site for swelling, redness, and pain
* Vesicant drugs in a chemotherapy regimen must be given before the other cytotoxic agents * Flush IV lines before and after administration * Consider the central venous route when possible to minimize the extravasation risk |
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What do nurses recommend for these drugs in the treatment of Extravasations?
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* Anthracyclines and other vesicants are usually recommended to be given as IV push by nurses.
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How should Vesicants be given if they are given peripherally?
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• When given peripherally, bolus doses (in syringes) of vesicants must be given via a fast running infusion of a compatible fluid
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What are the only 3 drug classes to be given vesicant cytotoxics in peripheral infusion (BAGS) ?
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• Only the following vesicant cytotoxics may be given by peripheral infusion (in bags): PACLITAXEL,
VINCA ALKALOIDS, DACARBAZINE |
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Management of Extravasation? (3)
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* Stop the injection/infusion. Disconnect the intravenous tubing
* Withdraw as much of the drug as possible * Mark area of skin |
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How would you manage extravasation in VINCA ALKALOIDS?
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* Apply local heat for 20 minutes 4 times daily for 1 for 2 days
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How would you manage extravasation in other Vesicants?
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* Apply cold compresses for 20 minutes 4 times daily for 1 to 2 days
* Limiting the cellular uptake of these agents |
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Drugs for treating Extravasation: DMSO (MOA?)
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* MOA: free radical scavenging/antioxidant properties, may sperad up the removal of extravasated drug
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Drugs for treating Extravasation: DMSO (Indicated for?)
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* Used for Anthracyclines
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Drugs for treating Extravasation: Hyaluronidase (MOA?)
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* Breaks down extracellular matrix to increase fluid to the site and dilute the actual concentration in the skin
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Drugs for treating Extravasation: Hyaluronidase (Indicated for?)
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VINCA ALKALOIDS
or TAXANES |
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Drugs for treating Extravasation: Sodium Thiosulfate (MOA ?)
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Prevents alkylation and tissue destruction by providing a substrate for alkylation in the subcutaneous tissue
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Drugs for treating Extravasation: Sodium Thiosulfate (Indicated for?)
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Mechlorethamine
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Drugs for treating Extravasation: Dexazoxane (Indicated for?)
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Tx of extravasation from IV anthracyclines.
****However, do not use DMSO in patients on dexrazoxane. |
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The majority of catheter occlusions are what type?
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THROMBOTIC
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How do you detect catheter occlusions? How do you get them?
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* Interrupt the delivery of infusion of chemotherapy, intravenous medication, nutritional support, blood products and acquisition of venous blood samples for testing
* Can result in discomfort, DVT, hospitalization, need for invasive procedures, and increased cost |
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Catheter Occlusion Prophylaxis: NaCl Flush
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Prior to and after administration of the medication, the IV injection device must be flushed in its entirety
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Catheter Occlusion Prophylaxis: Heparin Flush
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o 100 units/mL is used for older infants, children, and adults
o 10 units/mL is commonly used for younger infants (eg, <10 kg) |
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Volume of heparin flush is usually similar to what volume?
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Volume of catheter (or slightly greater).
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TX OF CATHETER OCCLUSIONS
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I. Thromolytics
a. Alteplase: (Cathflo®, Activase®) |
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TX CATHETER OCCLUSIONS
How to dose to dissolve the clot? |
* Patients ≥30 kg: 2 mg (2 mL); retain in catheter for 0.5-2 hours; may instill a second dose if catheter remains occluded
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What is the last possible therapy for catheter replacement?
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* Surgery
**** Catheter Replacement ******** |
