Nausea & Vomiting / Siadh / Lung Cancer

Front 1

Causes of nausea and vomiting

Back 1

1.Gastrointestinal--gastric outlet obstruction, radiation, uremia, hepatic metastasis

2.Central nervous system--drug induced (opiates, chemotherapy), increased intracranial pressure, anticipatory nausea and vomiting, severe pain

3. Metabolic--hypercalcemia, hypoadrenalism

Front 2

Chemotherapy induced emesis:

Acute emesis

Back 2

Occurring within the first 24 hours

Front 3

Chemotherapy induced emesis:

Delayed emesis

Back 3

Beginning at least 24 hours after administration of cancer chemotherapy.

Front 4

Chemotherapy induced emesis:

Anticipatory nausea and vomiting

Back 4

Conditioned response linked to experiencing poor emetic cotrol with previously administered chemotherapy

Front 5

4 risk factors for N & V

Back 5

1)Age < 40 years old

2)Women > Men

3)Emetic potential of drug MOST IMPORTANT

4)Alcoholics with less N/V

5) Previous history of vomiting after prior doses of chemotherapy.

6) Anxiety/Depression with INCR. N/V potential

Front 6

How to Order antiemetics prophylactically?

Back 6

a. Begin 30 minutes prior to chemotherapy

b. Continue around the clock while receiving chemotherapy

c. Provide as needed antiemetics for 12-24 hours after chemotherapy and longer (72 hours) for agents with delayed N/V, as with cisplatin, mitomycin-c

Front 7

New therapy for acute and delayed N&V:

Emend (Aprepitant)

Dosing

Back 7

125 mg po Day 1 prior to chemo with Decadron 12 mg po

80 mg po days 2-4 with decadron 8 mg po

With other antiemetic drugs!

Front 8

Emend (Aprepitant)

Drug Interactions

Back 8

CYP 3A4 inhibitor
Increases decadron levels therefore the dose reduction
Decreases INR
Decreases effect of Oral contraceptives

Front 9

Emend (Aprepitant)

Approval for and use with which chemo drugs

Back 9

Approval with Cis-pt.

Usefull with highly emetogenic:
Cyclophosphamide
Doxyrubicin
mitomycin

Front 10

Anti-Emitics for Very High >90%

Back 10

PO: Ondansetron 16-24 mg
PO: Granisetron 2 mg

IV: Palonosetron 0.25 mg
IV: Dolasetron 200 mg
IV: Ondansetron 16-20 mg
IV: Granisetron 10 mcg/kg

With: Decadron 10-20 mg
Optional: Ativan 1mg

Front 11

Anti-Emetics for High 60-90%

Back 11

PO: Ondansetron 16 mg
PO: Granisetron 1 mg

IV: Palonosetron 0.25 mg
IV: Dolasetron 100-200 mg
IV: Ondansetron 16-20 mg
IV: Granisetron 10 mcg/kg

With: Decadron 10-20 mg
Optional: Ativan 1mg

Front 12

Anti-Emetics for Moderate 30-60%

Back 12

PO: Ondansetron 16 mg
PO: Granisetron 1 mg

IV: Ondansetron 8mg

With: Decadron 10-20 mg
Optional: Ativan 1mg

Front 13

Anti-Emetics for Low 10-30%
and
Very Low < 10%

TAXANE's HERE!

Back 13

Compazine 10mg

Optional: Decadron 10-20 mg
Optional: Ativan 1mg

Front 14

Anti-Emetics for Anticipatory

Back 14

Ativan 1mg

Front 15

Delayed N/V prophylaxis treatment NON 5-HT3

Cheaper

Back 15

Metoclopramide 0.5 mg/kg po QID X 4 days
+
Dexamethasone 8 mg po BID X 2 days then 4 mg po BID for 2 days

Front 16

Delayed N/V prophylaxis treatment 5-HT3

Expensive

Back 16

Ondansetron 8 mg BID
+/-
Dexamethasone 8mg IM BID on days 2 and 3 and 4 mg IM BID on day 4

Front 17

SIADH (Syndrome of Inappropriate Anti-diuretic Hormone)

Signs/Symptoms

Back 17

1) Nausea and Malaise
2) Headache Lethrgy and obtundation (NON Responsive)
3) Seizure and coma if plasma Na < 115- 120 mEq/L

Front 18

SIADH: LABS

Too much Free H2O diluting Sodium

Back 18

1)Hyponatremia (serum sodium <135 mEq/L)
2)Hypotonicity (plasma osmolality <280 mOsm/kg)
3)Inappropriately concentrated urine (>100 mOsm/kg water)
4)Elevated urine sodium concentration (>20 mEq/L), except during sodium restriction

Front 19

SIADH: TREATMENT

Back 19

• Volume restriction to 1 liter per day or less
• Strict I & O’s
• Daily Na at a minimum
• Monitor of neurologic deterioration
• IV fluids of at least NS.....do not use D5W alone
• Moderately affected person or non-responder to water restriction (Na < 125) should receive demeclocycline

Front 20

SIADH: Demeclocycline Dosage

Back 20

150 mg cap

1 to 2 QID (600 - 1200mg/day)

Delayed onset 3-6 days

Front 21

SIADH: Na < 115 Treatment?

Back 21

3% IV Saline

RARELY USED!

Front 22

LUNG Cancer: Stage IV & IIIB

Chemo General Guidelines:

Supportive care: median survival 3-4 months

Back 22

• Utilize chemotherapy for a maximum of 8 cycles

• Monitor for response after 2-3 cycles at a time with CT scans. CXR on a regular basis can give a general sense of tumor response

• Discontinue therapy if tumor enlarges in size

• Discontinue therapy if tumor size is stable for 2-3 cycles (maint tx not required)

• Continue if shrinking to incr. lifespan and QOL

Front 23

LUNG Cancer: Stage IV & IIIB

Dosage: Carboplatin (AUC)
and
Paclitaxel

Back 23

Carboplatin (AUC= 6 to 8) Day 1 q3-4 weeks

HIGHLY EMETOGENIC

Paclitaxel 175 mg/m2 IV over 3 hours Day 1 (higher dose with neutropenia)

Front 24

LUNG Cancer: Stage IV & IIIB

Dosage: Carboplatin/Paclitaxel
CrCl dosing formula

Back 24

CrCl=((140-Age)IBW)/(72*SCr) multiply by 0.85 for women

Carboplatin dose = target AUC * (CrCl + 25)

Front 25

LUNG Cancer: Stage IV & IIIB

Toxocities: Carboplatin/Paclitaxel

Back 25

neutropenia

mucositis

neurotoxicity

Front 26

LUNG Cancer: Stage IV & IIIB

Pretreatment: Carboplatin/Paclitaxel

Back 26

anti-emetics: dexamethasone 20 mg po 12 & 6 hours

Pre-paclitaxel: pepcid 20 mg & benadryl 25 mg IV prior to paclitaxel