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55 Cards in this Set

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Normal RBC count
4.6-6.2 x 10^6/mm3
Normal WBC count
4,800-10,800/mm3
Normal platelet count
140,000-440,000/mm3
What is the absolute neutrophil count equation?
ANC = WBC x %granulocytes (Segs + Bands)
Definition of neutropenia
ANC <500/mm3
Definition of thrombocytopenia
Platelet count <100,000/mm3
What does NADIR mean? When does it occur? When does it recover?
Nadir is a term used to describe the lowest value of the ANC that the blood count falls to during a cycle of chemo.
Usually occurs about 10-14 days after chemo.
Counts recover by 2-4 weeks after chemo.
To administer chemo, a patient should have these values...
ANC >1500/mm3 or WBC >3000/mm3
AND
Platelets >100,000/mm3
Definition of febrile neutropenia
ANC ≤ 500/mm3 + Temp. ≥ 101˚F (≥38.3˚C) of a single oral temperature OR
ANC ≤ 500/mm3 + Temp. > 100.4˚F (≥38.0˚C) for at least 1 hour.
Patients with febrile neutropenia are considered high risk if they have these features... (5 things)
ANC <100/mm3
Abnormal chest x-ray
Severe renal or hepatic dysfunction
Malignancy in remission
Any cormorbid conditions which require hospitalization
Low-risk patients with febrile neutropenia should receive
Ciprofloxacin + Augmentin (amoxicillin-clavulanate)
If patients with febrile neutropenia have persistent fever, consider adding...
Broader spectrum antibiotics
Antifungals
Antivirals
High Risk Patients with Febrile Neutropenia (No vanco required)
Antibiotic Monotherapy
Carbapenem OR
Antipseudomonal penicillin
High Risk Patients with Febrile Neutropenia (No vanco required)
Antibiotic Dual Therapy
Aminoglycoside PLUS
Carbapenem OR
Antipseudomonal penicillin
High Risk Patients with Febrile Neutropenia (Vanco Required) Antibiotic therapy
Vancomycin PLUS
Carbapenem +/- Aminoglycoside
Antipseudomonal penicillin +/- Aminoglycoside
If overal infection risk is high and patient is taking Alemtuzumab, they should prophylax with...
Septra
If chemotherapy regimen has a incidence of febrile neutropenia of >20%, use this agent for prophylaxis
Colony Stimulating Factors (CSF)
Which agents have been proven to reduce the incidence, magnitude and duration of neutropenia following chemotherapy and bone marrow transplantation?
G-CSF (filgrastim/Neupogen)
GM-CSF (sargramostim/Leukine)
Avoid concomitant use of CSF during which therapies
Chemotherapy AND Radiotherapy
When should CSF be started after completion of chemotherapy administration?
CSF should be started 24 hours after completion of chemotherapy administration
Which CSF has evidence for reduction in infection related mortality?
G-CSF (filgrastim/Neupogen)
Filgrastim and sargramostim should not be administered in the period _____before til ____ after administration of chemotherapy
24 hours
24 hours
Pegfilgrastim should not be administered in the period ____ before til ____ after the administration of chemotherapy
14 days before
24 hours after
Most centers treat with CSF until ANC levels are
ANC ≥ 2000-3000/μl
G-CSF brand and generic names
Neupogen
filgrastim
GM-CSF brand and generic names
Leukine
sargramostim
PEG-G-CSF brand and generic names
Neulasta
pegfilgrastim
Neupogen dose
5mcg/kg SC inj. QD
Leukine dose
250mcg/m2 SQ inj. QD (approx. 5mcg/kg)
Neulasta dose
single 6mg SC dose administered 24 hours post chemotherapy
How should you decide whether pegfilgrastim or filgrastim should be used?
Expected duration of neutropenia
(one dose of pegfilgrastim lasts longer than filgrastim)
What is the main adverse effect of filgrastim?
Medullary bone pain
What are some of the patient risk factors for developing febrile neutropenia?
Older patient >65 years
Previous chemo or radiation therapy
Pre-existing neutropenia or bone marrow involvement in tumor
Preexisting conditions (neutropenia, infection/open wounds, recent surgery)
Poor performance status
Poor renal function
Liver dysfunction
Patient at high risk (>20%) for febrile neutropenia before first chemotherapy cycle[regardless of chemotherapy intent]
CSF (category 1 for G-CSF)
Patient at intermediate risk (10-20%) for febrile neutropenia before first chemo cycle
Consider CSF
Patient at intermediate risk (<10%) for febrile neutropenia before first chemo cycle
Do not use CSF
Patient presents with febrile neutropenia and has received filgrastim or sargramostim for prophylaxis. How should you manage their febrile neutropenia?
Continue CSF (filgrastim or sargramostim)
If low risk --> PO antibiotics
If high risk --> IV antibiotics
Patient presents with febrile neutropenia and has received prophylaxis with pegfilgrastim. How should they be treated?
No addional CSF
If low risk --> PO antibiotics
If high risk --> IV antibiotics
Patient presents with febrile neutropenia, did not receive CSF prophylaxis and has NO risk factors for infection associated complication. How should they be treated?
No CSF
Since low risk--> PO antibiotics [Cipro + Augmentin]
Patient presents with febrile neutropenia, did not receive CSF prophylaxis and has risk factors for infection associated complication. How should they be treated?
Give CSF
Since high risk--> IV antibiotics
What are the patient risk factors for poor clinical outcomes or for developing infection-associated complications?
Sepsis syndrom
Age >65 yo
Sever neutropenia (ANC <100/mcl)
Neutropenia expected to last more than 10 days
Pneumonia
Invasive fungal infection
Other clincically documeted infections
Hospitalization at time of fever
Prior episode of febrile neutropenia
What are the causes of cancer-related anemia?
Blood loss
Abnormal angiogenesis
Malnutrition or decreased body stores of vitamin B12, iron, or folic acid
What are the causes of chemotherapy-induced anemia?
BMS (caused by chemo)
Nephrotoxicity (decreased erythropoetin production or activity)
What are the adverse effects of Erythropoesis Stimulating Agents (ESA)?
Thrombosis
Seizure
Hypertension
Increased mortality (in cancer-induced anemia)
Pure red cell aplasia (PRCA)
What is pure red cell aplasia (PRCA)?
A condition in which RBC precursors in bone marrow are nearly absent, while WBC and platelet precursors are usually present at normal levels.
In which patients are Erythopoesis Stimulating Agents recommended?
Myelosuppressive-chemotherapy induced anemia when cancer treatment goals are not curative and who have high symptomatic anemia risk.
Erythropoetin
Brand names
EPO: epoetin-α, Epogen, Procrit
Darbepoetin alfa
brand name
Aranesp
Aranesp
Darbepoeitin alfa
What is the advantage of darbepoetin alfa over erythropoetin?
Greater metabolic stability --> three-fold longer half life
Should ESA (erythropoetin, darbepoetin alfa) be used for cancer related anemia?
No. ESA use is not recommended because it shortens overall survival and time-to-tumor progression
Patient has myelosupressive chemotherapy induced anemia and immediate correction is required. How should they be treated?
Transfuse as indicated
Then perform complete physical assessment to assess if patient is asymptomatic or symptomatic
Patient has myelosuppressive chemotherapy-induced anemia and immediate correction is not required. What do you do next
Determine cancer treatment goals (curative or non-curative intent)
Patient has chemotherapy-induced anemia, immediate correction is not required, and curative intent. What treatment can you not use?
ESA is not indicated
Patient has chemotherapy-induced anemia, immediate correction is not required, and has chemotherapy non-curative intent. What do you do next?
Risk/benefit ratio
ESAs may be appropriate based on thorough risk/benefit discussion and patient preference.
Then perform Complete symptom assessment