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51 Cards in this Set
- Front
- Back
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True or False: IV Serotonin antagonists are more effective than oral serotonin antagonists at controlling CINV.
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False. Oral and IV serotonin antagonists have equivalent efficacy when dosed at equal levels. We prefere oral over IV bc it is less invasive and less expensive.
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A chemotherapeutic regimen inlcuding 2 drugs that are "moderately" emetogenic is considered to have a ________ risk of emetogenicity.
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High.
Emetogenicity is additve |
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A chemo regimen which includes 2 drugs that have low risk of emetogennicity together is considered to have a ________ risk of emetogenecity.
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Low.
Emetogenicity is additive however, several low regimens do not get bumped up to moderate. |
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What are the chemo related risk factors for CINV?
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Chemotherapy related risks:
Emetogenicity of the prescribed regimen Combination chemotherapy >>> single agent |
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List the IV drugs with high emetic risk.
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Cisplatin (HIGHEST)
Carmustine Cyclophosphamide > 1500 mg/m2 |
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List the IV drugs with a moderate emetic risk.
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Carboplatin
Cyclophosphamide <1500 mg/m2 Cytarabine > 1gm/m2 Daunorubicin Doxorubicin Epirubicin Idarubicin Ifosfamide Irinotecan Oxaliplatin |
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High emetic risk = ?% risk
Moderate? Low? Minimal? |
High: >90%
Moderate: 30% to 90% Low: 10% to 30% Minimal: <10% |
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List the oral drugs with high emetic risk.
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Procarbazine
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List the oral drugs with moderate emetic risk.
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Cyclophosphamide
Temozolomide Vinorelbine Imatinib |
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True or False: Most oral meds are in the low/minimal risk category for CINV
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True
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List the patient related risk factors for CINV.
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History of depression
History of morning sickness with prior pregnancy Poor control in previous chemo treatments (anticipatory) History of motion sickness Children > Adults Women > Men NO ALCOHOL USE (Avg EtOH > Long history of alcohol abuse) |
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What are the basic principles of CINV management?
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Give breakthrough CINV antiemetics
Consider adverse effects of antiemetics Consider other causes of nausea or emesis |
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What are some other causes of N/V?
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Hypercalcemia
Infection Raised intracranial pressure Gastric irritation or ulceration Constipation Anxiety Opioids Cytotoxicity Renal failure Functional gastric stasis Vestibular disturbance |
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What can u give a patient with hypercalcemia to decrease their calcium and their risk of N/V
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fluids
bisphosphonates |
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What do you give a patient if you suspect raised intracranial pressure as the cause of N/V
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Dexamethasone
Mannitol |
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What are the three types of CINV?
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Anticipatory
Acute Delayed |
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Describe anticipatory CINV and how you might treate it.
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Nausea that occurs before chemo is given.
Related to anxiety Mediated by GABA Treat with Benzodiazepines |
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Describe acute CINV
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Occurs during the first 24 hours after chemo is given.
Mediated by Serotonin, DA, histamine |
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Describe Delayed CINV
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Can range up to several days after chemo is completed
Mediated by Serotonin, DA, histamine Serotonin plays a lesser role |
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Below are causes of CINV. What are possible treatments?
Anxiety Motion sickness Intracranial pressure |
Anxiety: use benzos
Motion sickness: use scopolamine Intracranial pressure: steroids, diuretics |
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List the antiemetic DA antagonists
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Prochlorperazine
Metoclopramide Haloperidol |
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List the antiemetic Serotonin receptor antagonists
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Ondansetrol
Dolasetron Granisetron |
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List the antiemetic antihistamines
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Promethazine
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List the antiemetic corticosteroids
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Dexamethasone
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List the antiemetic benzodiazepines
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Lorazepam
Oxazepam |
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List the antiemetic NK1 receptoer antagonist and substance P
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Aprepitant
Fosprepitant |
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If your pt had N/V caused by anxiety what drugs could u give them?
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Lorazepam or oxazepam
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What is the dose used for Dexamethasone? How do you dose adjust when given with Aprepitant?
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Dexamethasone (Oral/IV) 20 mg acute
+ Aprepitant then Dexamethasone 12mg for acute and 8mg on days 2 and 3 for delayed |
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What antiemetic regimen would you chose for a patient with parkinsons?
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Zofran (ondansetron)
Not metoclopramide or prochlorperazine since these are DA antagonists which could worsen or cause parkinson's symptoms Promethazine is an antihistamine that can cause sedation and put the patient at a greater risk for falss |
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What agents could you use for breakthrough N/V?
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Prochlorperazine
Promethazine Metoclopramide Ondansetron All PO route |
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List non pharmacologic ways to combat CINV
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Avoid food smells or unpleasant odors
Diversion Relaxation Acupuncture/acupressure bands Add these on top of pharmacologic methods not in place of them |
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What do you do if you have a patient who receives normal anti-emetic therapy and will not respond?
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1st interview pt to make sure they are taking meds correctly.
Assess fluids/electrolytes (renal failure, hypo/hyperkalemia) Begin with one agent and then add on If patient is nauseated administer anti-emetic ASAP If patietn is dehydrated/has low BP then give IV meds then switch to PO once under control If patient has emesis then give IV antiemetic Do not use aprepitant in these situations. Use Serotonin antagonist, prochlorperazine, or steroids |
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If non-responsive severe and persistent N/V then consider using:
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SubQ infusion
Usually with Serotonin antagonist |
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What are some alternative routes used for severe and persistent N/V
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IV
Suppository Buccal (poorly tolerated) Transdermal Sancuso (Serotonin antagonist) |
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True or false: Patients that have a history of marijuana use do not respond well to marinol
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True
Cannabanoids can be useful adjuncts to antiemetics and can be used for patients refractory for serotonin atnagonists, NK1 antagonists and steroids Marinol ADR: dizziness, euphoria, hallucinations |
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What are the ADR of Metoclopramide used IV as an antiemetic?
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diarrhea
EPS (distonia) |
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What are the ADR of Olanzapine used as an antiemetic for refractory N/V?
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Weight gain
Elevated glucose (watch out for diabetics, also true for steroids) |
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What are the risk factors for anticipatory N/V?
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Women
Age <50 yo N/V with last chemo Feeling warm or "hot all over" after last chemo History of motion sickness Experiencing sweating or generalized weakness after last chemo Exp nausea after last chemo that was 'severe or intolerable' |
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What do we give a patient who feels they have anticipatory n/v?
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Alprazolam 0.5 – 2 mg po q8h night before treatment
Lorazepam 0.5 – 2 mg po on the night before and morning of treatment |
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Name a major determinant of emetic risk for radiation-induced emesis?
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Treatment field
Total body: 100% risk Local radiation: mild-moderate risk |
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What treatment can you give pts with antiemetic risk associated with radiation?
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Prophylaxis with serotonin antagonist
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List ADR of Prochlorperazine
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sedation
dystonia eps |
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List ADR of Phenergan
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sedation
urine retention dry mouth sleepiness risk of falls |
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List ADR of serotonin antagonists
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HA
constipation |
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List ADR of Reglan (Metoclopramide)
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sedation
dystonia EPS diarrhea Same as prochlorperazine + diarrhea |
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List ADR of Dronabinol
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sedation
confusion dizziness hallucinations |
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List ADR of steroids
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increase blood glucose
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What is the medication related risk of CINV of a patient prescribed carboplatin and paclitaxel?
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Moderate
Carbo is moderate + Paclitaxel is low = Moderate |
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If a patient is on a moderate emetogenicity regimen and has multiple pt specific risk factors for CINV what is their risk?
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Moderate
Do not change to high |
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When do we use Aprepitant in an acute antiemetic regimen?
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In highly emetogenic regimes
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What is the emetogenicity of a regimen inlcuding Ifphosphamide and Doxorubicin?
How do you treate it? |
High
Acute: Dexamethoasone, ondansetron, aprepitant decrease dexamethasone daose to 12 mg |
