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149 Cards in this Set
- Front
- Back
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Cancer warning signs
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Changes in bowel or bladder habits
Sores that do not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or Trouble Swallowing Obvious change in wart or mole Nagging cough or hoarseness |
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Neurotoxicity Management
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Venlafaxine, Gabapentin
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Vincristine
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HD
Reduce dose by 50% with TBili > 1.5 mg/dl Don't use if TBili > 3.0 mg/dl Do NOT use intrathecally Constipation, Neuropathy, Alopecia Myelosuppression is not severe DOES NOT CAUSE MYELOSUPPRESSION AND NVD |
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Bleomycin
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HD
Idiosyncratic Reactions, Dose-related pulmonary toxicity Pulmonary toxicity risk increases with age > 70 and cumulative lifetime dose of >400 units. Premedicate with acetaminophen to prevent fever |
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High risk Breast Cancer for 5 year risk
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35-59 with 5 year risk of at least 1.66%
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Tamoxifen
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Decreases osteoporotic risk
Increases thromboembolic risks Increases endometrial cancer Only one indicated for premenopausal Avoid black cohash to treat menopausal symptoms Poor 2D6 metabolizers... Decreases breast cancer incidence More effective than raloxifene for reducing risk of noninvasive breast cancer |
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Raloxifene
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Better AE profile than Tamoxifen
Indicated for osteoporosis 60 mg po qd x 5 years Reduction of risk of invasive breast cancer in post-meno women at high risk INTX: Cholestyramine, Warfarin |
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Exemestane
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Maybe more efficacious than raloxifene and tamoxifen in reducing incidence of cancer
Increases osteoporosis risk No survival benefit Better for DVT risk? Take after a meal, administration with high fat meals increases absorption by 40% 3A4 metabolized so increase dose if given with 3A4 inhibitor |
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TC
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Docetaxel and Cyclophosphamide
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Dose Dense AC
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Doxorubicin and cyclophosphamide followed by paclitaxel
ALWAYS use growth factor support |
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TCH
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Docetaxel, Carboplatin, Trastuzumab
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AC
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Doxorubicin and cyclophosphamide followed by paclitaxel and trastuzumab
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Doxorubicin
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Breast Cancer and HD
Total cumulative lifetime dose not to exceed 550 mg/m2 due to heart failure Vessicant if it gets into tissue Turns urine bright red (not dangerous) Comes as liposomal product, different dosing |
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Cyclophosphamide
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Breast Cancer and HD
Prodrug via 2B6 Cardiotoxic due to endothelial capillary damage (manage this with diuretics/BB) Cystitis at high dose (manage with fluids and/or Mesna) Do not crush |
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Carboplatin
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NSCLC
Thrombocytopenia Avoid nephrotoxins (ibuprofen, aminoglycosides) on day of administration Electrolyte abnomralities due to lots of urine being pushed. Monitor urine for blood and contact doctor immediately if so Blindness, Anaphylaxis, Secondary Malignancies |
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Paclitaxel
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NSCLC
Hypersensitivities much more common (to taxane of creamaphor) Peripheral neuropathy is a class effect of M phase inhibitors Give taxane derivatives before platinum derivatives to limit myelosuppression and enhance efficacy Premedicate with dexamethasone, diphenhydramine, and ranitidine for hypersensitivity Infuse through in line filter and nonabsorbing administration set Avoid with clozapine |
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Docetaxel
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For Metastatic Prostate, MM
Fluid retention, often around lungs Infuse with nonsorbing tubing, do not need in line filter. Premedicate with dexamethasone for 3 days to avoid fluid retention Avoid with clozapine |
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Trastuzumab
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Cardiotoxic (d/c if MUGA drops)
Avoid with doxyrubicin/cyclophosphamide due to cardiotoxicity Premedicate with diphenhydramine and APAP Monitor/Dose reduce for ejection fraction |
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Pertuzumab
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Binds to different part of HER-2 than trastuzumab
Same as Trastuzumab, only use in combo with it |
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Risk Factors for CINV
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<50 years
Female Lower risk if alcoholic Motion sickness Previous history of N/V |
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Dolasetron
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5-HT3 Receptor Antagonist for Antiemesis
100 mg daily Only one that is only oral Very expensive QT interval prolongation! |
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Granisetron
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5-HT3 Receptor Antagonist for Antiemesis
2 mg po or 1 mg IV or patch (1-2 days before chemo) |
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Ondansetron
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5-HT3 Receptor Antagonist for Antiemesis
16-24 mg po, 8 mg iv Headache common, switch to granisotron if so Max IV dose is 16 mg due to QTC prolongation above that Lots of formulations Avoid 3A4 interactions |
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Palonosetron
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5-HT3 Receptor Antagonist for Antiemesis
Only IV only Very long half life 0.25 mg IV Most expensive |
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Aprepitent
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Neurokinin Antagonist for antiemesis
125 mg oral or one time Fatigue, Constipation, Hiccups Fosaprepitant is IV form 3A4 substrate Reduce dexamethasone to 12 mg if used concurrently |
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Dexamethasone
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Corticosteroid for antiemesis
12 mg po Hyperglycemia, GI upset 3A4 intx No need to taper Take with food for GI upset |
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Oral Chemo that is pH dependent
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Vismodegib
Erlotinib Dasatinib Ponatinib |
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Guidelines for chemo that is ph dependent
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Antacids separate by 2 hours
H2 antagonists separate by 12 hours DONT use PPI's |
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5-HT3 receptor antagonists INTX
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Apomorphine due to hypotension
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Metoclopramide
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Serotoninc receptor antagonist only at high dose
Words by increasing gastric emptying as PRN anti-emetic Sedation, diarrhea, EPS, neuroleptic syndrome Not used for prevention |
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Benzo's
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Used for anti-emesis, mainly lorazepam due to having the shortest half life
Used for anticipatory CINV and breakthrough CINV |
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Phenothiazines
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Prochlorperazine, Promethazine
For mild emetogenic chemo Sedation, Hypotension |
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Breakthrough N+V rescue options
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Proclorperazine
Metoclopramide Lorazepam Ondansetron Granisetron |
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Treating breakthrough N+V secondary prevention options
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Dolasetron
Haloperidol Dronabinol Dexamethasone Promethazine Olanzapine |
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G-CSF dosing
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Do not administer on day of chemo, give 24-72 hours after
Stop ANC > 2000 x 2 days SubQ Do not dose escalate |
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G-CSF interactions
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Bleomycin (increased pulmonary toxicity)
Topotecan increased topo AE |
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Clinical presentation of febrile neutropenia
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Fever > 101.5 with ANC < 500
Respiratory, skin lesions, neurologic, septic shock |
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How to treat early satiety?
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Metoclopramide
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Cachexia appetite stimulants
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Megesterol
Prednisone |
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Cachexia depression treatment
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Mirtazapine
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Megesterol
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Synthetic Progestin
Appetite stimulant Break throguh bleeding, diarrhea, edema Thromboembolic events |
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Hypercalcemia cutoffs for chemo
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Mild = 12-13.5 mg/dl
Severe > 13.5 mg/dl |
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Hypercalcemia symptoms
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Confusion, N/V, HA, Irritability, Muscle Weakness
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Pamidronate
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Max single dose 90 mg
D/C if creatinine deteriorates Takes several days for effect, do not re-dose more than once a week Single dose over 2-24 hours Avoid concurrent nephrotoxins |
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Zoledronic Acid
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Max single dose is 4 mg
Zometa for oncology Reclast for osteoporosis Single dose Avoid concurrent nephrotoxins |
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Spinal Cord Compression Treatment
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Radiation
Chemo Dexamethasone |
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Terminal Sedation
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Dying within hours to days in opinion of 2 physicians
Thiopental Midazolam |
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Agents for Neuropathic Pain
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Amitriptyline
Duloxetine Venlafaxine Buproprion Gabapentin Pregabalin |
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Antidepressant titration schedule
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Every 3-5 days
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Opioids for Mild to Moderate Pain
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Codeine
Tramadol Hydrocodone |
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Codeine
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1/100th potency of morphine
Prodrug converted via 2D6 Produces the most constipation and nausea! Bad with impaired renal function Busulfan, isoniazide, warfarin etc INTX |
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Tramadol
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Weak Mu agonist, SNRI action
Not controlled Max dose: 400 mg/day IR only 50 mg Lots of N/V Titrate over several weeks Seizures Serotonin Syndrome |
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Hydrocodone
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More potent and longer lasting than codeine
Prodrug metabolized by 2D6 Only available in combo products with non-opioids |
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Meperidine
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Not recommended due to fast on/off due to high lipophilicity
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Morphine
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2 biologically active metabolites
Induces histamine release -Hypotension, Pruritis Hydrophilic (slower onset, longer duration) High FPM. 3:1 Starting dose = 30mg SR q 12 h |
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Hydromorphone
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5-7x more potent than morphine
Same AE profile to morphine Less histamine than morphine No active metabolites (good for renal impairment) Short acting formulations only Quite high FPM 5:1 |
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Oxycodone
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3:2 more potent than morphine
Less histamine Prodrug metabolized by 2D6 (parent compound also active) Requires less dose reductions with renal impairment than morphine Starting dose in opioid naive is 10 mg More abuse potential |
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Oxymorphone
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Twice as potent as oxycodone
More lipophilic than morphine Fast onset, LONGER half life |
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Fentanyl
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100's more potent than morphine
Selective for mu receptor Near immediate onset of action when given IV, VERY lipophilic May be stored in fat leading to prolonged effects No active metabolites. Safest in renal failure Initial patch dose is 25 mcg/hr Titrate q 3 days with initial patch, then no more often than q6days Absorption of patch increased when febrile by up to 30% Effects last 12 hours after patch removed NOT FOR OPIOID NAIVE PATIENT |
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Methadone
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Inexpensive
Good for people who need high doses of others but have significant AE Longest half life (lots of variance) Duration of analgesia shorter than half-life |
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What opioid patients should call about?
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New pain
N/V that prevents eating for a day No BM for 3 days Confusion |
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Actinic Keratosis
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Pre-cancerous sun-induced skin lesions.
Treated with ingenol mebutate gel |
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Ingenol Mebutate Gel
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For actinic keratosis
Eye edema, Eye Pain, Conjunctivitis, Skin flaking, scaling erythema Allow treated area to dry for 15 minutes after application, don't touch area or get it wet for 6 hours after application. |
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Basal Cell Carcinoma
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Most common cancer
More common whites More common in men Chronic Immunosuppression is risk Only use drugs if stage 1 or 4. Those treated are more likely to have another non-melanoma skin cancer within 5 years. |
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Mohs Surgery
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Treatment for Basal Cell Carcinoma
Highest cure rate, preserves lots of normal tissue. Can be done outpatient. Costly, longer procedure, scarring risk. |
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Topical Basal Cell Carcinoma Treatments
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5FU - Inflammatory rxn, stinging, edema, secondary infections
Imiquimod - Inflammatory Reaction, Fatigue, Flu-Like Symptoms |
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Vismodegib
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Basal Cell Carcinoma Stage IV treatment (or in patients with recurrence post surgery)
Hedgehog signaling pathway inhibitor Alopecia, Taste Loss, Weight Loss, N/D (rare, report immediately) PPI's/H2RA/Antacids reduce absorption Must conduct pregnancy test within 1 week of initiating therapy |
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Concerning Features of Melanoma
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Asymmetry
Border Irregularity Color change Diameter change Evolution of the lesion |
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Interferon Alpha-2b
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Adjunct for melanoma Stage III
Contraindicated in liver disease May worsen psychiatric symptoms, increased risk of suicide. May worsen ID, autoimmune disease Hepatotoxicity Myelosuppression Visual Loss Chest Pain N/V/D Avoid with interleukin-2, zidovudine, ribavirin, telbuvudine due to increased AE Dose in evening for tolerability |
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Melanoma Metastatic Regimens
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No drugs if Stage I or II
If no BRAF mutation: Ipilumumab +/- dacarbazine (THESE ARE MORE EFFECTIVE IN COMBO) If Mutation: Dabrafenib or vemurafenib (chosen by toxicity) |
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Decarbazine
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Metastatic Melanoma Mutation Negative
Hepatotoxicity, Bone marrow Suppression, Secondary malignancies 1A2 and 2E1 substrate Hair loss, N/V, Flu-like symptoms Immediately report easy brusing or bleeding, yellowing of eyes or skin, change in color of urine or blackened stool. No overall survival benefit |
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Ipilimumab
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Metastatic melanoma Mutation Negative
Hold for hepatic toxicity Potentially fatal immune-mediated AE due to T-Cells (TEN, Hepatitis, etc) Rash, N/V, Fatigue, lots of others Can require several months for effect In REMS (assess for serious symptoms before each dose, d/c permanently if seen and start high dose corticosteroid) |
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Vemurafenib
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Metastatic Melanoma BRAF mutation positive
BRAF kinase inhibitor QTC prolongation Hand-Foot syndrome Fast response, but maybe short duration Skin exams and sun protection |
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Dabrafenib
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Metastatic Melanoma BRAF mutation positive
BRAF kinase inhibitor Adjust for hepatic dysfunction QTC prolongation Hyperglycemia Premedicate with APAP for febrile reactions Fast response, but maybe short duration Skin Exams and Sun Protection |
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Mammography
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Every 2 years once 50-74
Improves overall survival False positives very common (more so in younger) |
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High risk screening for Breast Cancer
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Known BRCA mutation
First degree relative with BRCA Lifetime risk of 20-25%+ Radiation therapy to chest between ages of 10-30 Li-Fraumeni, Cowden Syndrome, Hereditary diffuse gastric cancer For all of these, annual MRI and mammography |
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Stage I + II Breast Cancer Treatment
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Her-2 Positive: Trastuzumab
ER/PR positive: Tamoxifen or Aromatase Node Positive: Chemo Node Negative: Oncotype DX >31 chemo |
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Metastatic Breast Cancer Treatment
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Palliative
Premenopausal: Antiestrogen or LHRH Post: Antiestrogen or Aromatase Inhibitor (Continue until disease progression) If no response, then chemo |
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Slow Opioid Titration
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Pain score 4-6
Naive: Morphine SR 15-30 mg po bid Not naive: Increase dose 25-5-% daily morphine |
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Prostate Cancer Screening
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No significant effect of PSA based screening on mortality after 10 years
Risk of ED/incontinence, CV events |
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PSA limits by age
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40-49 = 1.0 ng/ml
50-59 = 3.5 60-69 = 4.5 70-79 = 6.5 |
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Finasteride
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30% risk reduction in developing prostate cancer over 7 years.
If PSA < 3 (less than), and are regularly screened, may be beneficial to use this or dutasteride Decreases observed PSA by 50%, double for cancer monitoring May take 6 months for effect Bad news in women even touching it |
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Prostate Cancer Localized Treatment
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Active Surveillance (curative) observation (palliative)
Radiation +/- androgen deprivation therapy Prostatectomy (curative/better survival but leads to incontience, impotence, diarrhea) |
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Prostate Cancer Metastatic Treatment
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Hormone Therapy (eliminate androgens)
-LH-RH +/- antiandrogen -Orchiectomy (removal of testes) Chemo |
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LH-RH
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For metastatic prostate cancer
Leuprolide, Goserelin, Triptorelin Gynecomastia, Osteoporosis, Weight gain, Edema, CV events, Diabetes Monitor serum testosterone @ 4 weeks for efficacy Monitor PSA for efficacy Cause tumor flare early on |
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Gonadotropin Receptor Antagonists
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For metastatic prostate cancer
Degralix No tumor flare Gynecomastia, Osteoporosis, Weight gain, Edema, CV events, Diabetes Monitor serum testosterone @ 4 weeks for efficacy Monitor PSA for efficacy |
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Antiandrogens
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For metastatic prostate cancer
Reduce tumor flare from LH-RH agonists Flutamide, Biclutamide, Nilutamide, Enzalutamide Inferior to LH-RH in monotherapy Edema, GI, Fatigue |
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Flutamide
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Antiandrogen for metastatic prostate cancer
Diarrhea, Methemoglobinemia |
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Bicalutamide
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Antiandrogen for metastatic prostate cancer
D/C if ALT double ULN |
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Nilutamide
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Antiandrogen for metastatic prostate cancer
Visual disturbances Alcohol intolerance Interstitial pneuomonitis |
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Enzalutamide
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Antiandrogen for metastatic prostate cancer
Musculoskeletal disorders Asthenia Peripheral Edema HA/Dizziness Seizures |
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Denosumab vs Zoledronic Acid for Prostate
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Denosumab has lower skeletal event rate
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Asymptomatic metastatic prostate cancer treatment
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Sipleucel-T
Abiraterone Both show survival benefit |
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Abiraterone
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For Asymptomatic metastatic prostate cancer
Always given with prednisone 10 mg C/I in women. 2 forms of birth control Give on empty stomach |
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Metastatic (castration resistant) symptomatic prostate cancer Treatment
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Docetaxel (survival benefit)
Mitoxantrone Abiraterone Enzalutamide |
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Lung Cancer Prevention
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Reduces mortality but not widely implemented due to cost
Stop smoking No effective chemoprevention agents |
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NSCLC Doublet Selection
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Cisplatin + Paclitaxel - Better activity, more toxicity (preferred in academic centers)
Carboplatin + Paclitaxel - Preferred in community/elderly Cisplatin + Docetaxel - Second line Cisplatin + Gemcitabine - Less effective than cisplatin + permetrexed |
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NSCLC Addition of Bevacizumab
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Increased overall survival
Increased hemorrhage Increased hypertension Increased proteinuria |
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Bevacizumab
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Prevents angiogenesis in NSCLC
GI perforation Impaired wound healing Hemorrhage Lots of DI Avoid surgery within 28 days Do not use if CNS metastisis |
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Cisplatin
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NSCLC
Hypersensitivity, ototoxicity, renal issues. Prevent renal toxicity with normal saline and electrolyte repletion Avoid concurrent nephrotoxins on same day |
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Permetrexed
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NSCLC
Begin folic acid daily 7 days prior to treatment. Continue for 21 days post last dose. Being B12 7 days prior to treatment and then every 3 cycles Begin Dexamethasone bid for 3 days starting day before treatment to reduce hypersensitivity |
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Erlotinib
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First line for EGFR+ NSCLC
Expensive! Dose until disease progression Edema (diuretics), Rash, Diarrhea (dose reduce), LFT's (dose reduce) Bleeding, interstitial lung disease Food affects absorption, take on empty stomach |
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Afatanib
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First line for EGFR+ NSCLC (effective in patients with erlotinib resistance)
Expensive! Longer progression free survival and better objective response than cisplatin/permetrexed Edema (diuretics), Rash, Diarrhea (dose reduce) LFT's (dose reduce) Bleeding, Interstitial Lung disease PGP substrate Take on empty stomach |
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Crizotinib
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ALK+ NSCLC
Edema (diuretics), NVD, LFT (dose reduce), Vision issues QTC prolongation, Pneumonitis No food effect |
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Hodgkins Lymphoma Treatment
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Curable, cure while minimizing long term AE
If, after chemo patient does not have complete response, additional cycles or stem cell transplant. |
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ABVD
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Chemo treatment for HD
Doxorubicin Bleomycin Vinblastine Dacarbazine |
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Stanford V
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Chemo Treatment for HD
Doxorubicin Vinblastine Mechorethamine Vincristine Bleomycin Etoposide prednisone |
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BEACOPP
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Chemo for HD
Bleomycin Etoposide Adriamycin Cyclophosphamide Vincristine Procarbazine prednisone |
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HD Treatment Complications
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Joint replacement (steroids)
Cardiac (doxorubicin) Cognitive Dysfunction Pulmonary (Bleomycin) Gonadal dysfunction Secondary Malignancies |
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Autologous vs Allogenic
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Autologous is patient's own stem cells. Must be under 70
Allogenic is donors (also allows immune response against cancer cells) must be under 60 -Matched for HLA type Exclusions: CHF, Uncontrolled DM, Active infections, Renal Insufficiency |
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Stem Cell Transplant Complications
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Mucositis
Sinusoidal Obstructive Syndrome Transplant related infetions (mouth, gut, skin) Pancytopenia Graft Rejection Secondary Tumors Need repeat vaccinations |
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Types of Non-Hodgkins Lymphomas
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Low grade = Chronic Lymphocytic Leukemia
Intermediate = Follicular, Diffuse large Cell High Grade = Burkitts, mantle cell |
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Low Grade lymphomas Treatment
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Incurable, watchful waiting is acceptable
Treat if recurrent infections, organ function decay, massive bulk, patient preference |
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Chlorambucil
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For Low Grade NHL
Hypersensitivity, Interstitial Pneumonia, Secondary Malignancies Must store in refrigerator, protect from light Take on empty stomach |
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Fludarabine
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For Low Grade NHL
Blindness, coma, hemolytic anemia, Immunosuppression, Neurotoxicity Must receive acyclovir and TMP/Sulfa for antiinfective prophylaxis |
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CLL suportive care
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Infections (evaluate IgG, if less than 500 mg/dl start IVIG)
Avoid all live vaccines, get pneumococcal every 5 years |
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Intermediate NHL treatment
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rCHOP
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Rituximab
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Part of rCHOP for intermediate NHL treatment
Infusion reactions, mucocutaneous reactions, progressive multifocal leukoencephalopathy, tumor lysis syndrome (high tumor burden increases risk of tumor lysis) Edema, Rash, Fever, etc |
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Philadelphia chromosome
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Generates abnormal Bcr-Abl fusion gene
Leads to CML |
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CML labs
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Leukocytes over 25,000
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CML Phases
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Chronic Phase - Indolent, WBC increase
Accelerated Phase - Progressive myeloid maturation, WBC continue to increase Blast Crisis - Acute Leukemia, death can occur quickly |
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CML goals
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CHR - Complete hematologic response (no blasts in peripheral blood)
CCyR - Complete cytogenetic response (No phili chromosome cells in bone marrow or peripheral blood) CMR - Complete Molecular Response (No BCR-ABL protein) If no CHR and CCyR at 3 months, go to alternative therapy |
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CML Treatment
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Only allogeneic stem cell transplant is curative
Almost all patients first started on Tyrosine Kinase Inhibitor, transplant it failed. Imatinib (typically first choice due to cost and lots of data), Nilotinib, or Dasatinib first -Bosutinib, Ponatinib if failed |
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Tyrosine Kinase Inhibitors
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Imatinib, Dasatinib, Nilotinib, Bosutinib, Ponatinib
3A4 intx |
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Imatinib
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For CML first line
Increased progression free survival vs Interferon alfa + cytarabine. Very high response rates 3A4 Take with food GI, Edema, Fatigue, Rash |
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TKI resistances
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Bcr-Abl kinase domain mutations may lead to only dasatanib working
T315I causes resistance of imatinib, nilotinib, dasatinib (use ponatinib here) |
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Dasatinib
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For CML when Bcr-Abl kinase domain mutation gives resistance to imatinib
Faster rates of complete response than imatinib, no change in OS or PFS 3A4 Edema, Bleeding, Pulmonary hypertension, QTC prolongation |
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Nilotinib
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For CML resistant to imatinib
Better molecular response compared to imatinib Empty stomach QTc, Elevated serum lipase, Peripheral artery occlusive disease, pancreatitis |
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Bosutinib
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For CML imatinib resistant mutations (except T315I and V299L)
3A4 With food Diarrhea, Myelosuppression, Fluid retention |
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Ponatinib
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For CML imatinib resistant (T315I mutation)
Improved major cytogenic response and hematologic response Arterial thrombosis (temporarily suspended), Liver Toxicity |
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Omacetaxine
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For CML resistant to 2 or more TKIs
Synthetic SubQ Myelosuppression, Hyperglycemia, Bleeding |
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MM Symptoms
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Calcium (hypercalcemia)
Renal Dysfunction (due to accumulation of antibodies in kidney) Anemia (Hbg <10) Bone Disease (Bisphosphonate almost always) Hyperviscosity Thrombosis |
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Renal Dysfunction effect on MM treatment
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Prefer dexamethasone over melphalan
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When to give anticoag in MM
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When receiving thalidomide, lenalidomide or pomalidomide
Aspirin if lower risk, LMWH or Warfarin if higher |
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Stem Cell Transplant Ineligibility in MM
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Over 77
High bilirubin Really high SCr ECOG 3 or 4 unless due to bone pain Functional Status III or IV |
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MM Treatment
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Transplant Eligible:
-Lenalidomide/Dexamethasone -Bortezomib/Thalidomide/Dexamethasone Transplant Ineligible: -Melphalan/Prednisone/Thalidomide -Melphalan/Predisone/Bortezomib |
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MM Maintenance Therapy
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Thalidomide or Lenalidomide preferred
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Immune Modulators
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For MM
Thalidomide, Lenalidomide Take at bedtime at least 1 hour after evening meal DI: Dexamethasone, Docetaxel (both increase thromboembolism) AVOID IN PREGNANCY (2 forms of birth control) Peripheral neuropathy, secondary malignancy Very expensive! REMS Prophylactic anticoag needed! Resistance to one does not mean resistance to other PO |
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Bortezomib
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Proteasome Inhibitor for MM
IV 3A4 Peripheral neuropathy, NVD, Fatigue, Fever, Hepatic failure, Acute respiratory distress syndrome Very expensive! Give subQ (non-inferior and fewer AE) Must have prophylactic acyclovir |
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Capecitabine
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For Colon Cancer
Oral agent, good for avoiding central line with 5FU Very expensive! |
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FOLFOX versus FLOX
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5FU bolus (MOSAIC) vs 5FU infusion (NSABP C07)
More neuropathy with FOLFOX More GI with FLOX FLOX easier |
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Metastatic Colon Cancer Treatment
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Kras-: Cetuximab or panitumomab
Bevacizumab eligible: Bev |
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5-FU
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For Colon Cancer
Myelosuppression dose limiting for bolus Mucositis dose limiting for continuous infusion DPD deficiency with severe toxicity (dihydropyridine dehydrogenase) TS expression may predict efficacy |
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Leucovorin
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For Colon Cancer
S enantiomer active Stabilizes 5FU complex Higher GI toxicity |
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Capecitabine
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For colon cancer
Prodrug of 5FU BBW: DI with warfarin Take with water within 30 minutes after a meal Hand-Foot |
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Ironotecan
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For metastatic colon cancer
Dose alter for UGT1A1*28 homozygotes Severe effects on bone marrow and severe diarrhea Treat diarrhea with loperamide multiple times a day |
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Oxaliplatin
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Stage III colon cancer after resection of primary tumor
Anaphylactic reactions (manage with epinephrine, steroids, antihistamines) Neuropathy exacerbated by cold, avoid ice chips for mucositis. May be reversible with discontinuation |
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Cetuximab
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EGFR inhibitor only for KRAS- colon cancer
Second line for metastatic colon cancer with ironotecan Premedicate with diphenhydramine Electrolyte abnormalities Cardiopulmonary arrest |
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Panitumumab
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EGFR inhibitor only for KRAS- colon cancer
Third line for metastatic colon cancer Improved PFS compared to survival Severe rash Infusion reactions Pulmonary fibrosis |
