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Side Effects of Tx Chemo Essentials Course

Side Effects of Treatment: ONS Chemo Essentials Course
by

Sara Stuever

on 3 December 2018

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Transcript of Side Effects of Tx Chemo Essentials Course

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Side Effects
Myelosuppression

CINV

Cutaneous Toxicities

Myelosuppression
Chemotherapy-Induced Nausea and Vomiting (CINV)
Cutaneous Toxicities
References
Fundamentals
Myelosuppression




Condition where there is a significant decrease in the number of neutrophils, megakaryocytes, and erythrocytes in the bone marrow.
Is a dose-limiting toxicity of many systemic chemotherapy agents.
Understanding hematopoiesis is imperative to fully understand myelosuppression and how it occurs in the bone marrow

Normal Hematopoiesis
Chemotherapy and Myelosuppression
Most chemotherapy causes some degree of myelosuppression.
How much and how long it will last is dependent upon the chemotherapy agent’s mechanism of action.
Cell-cycle specific agents produce more rapid cytopenias.
Dose intense regimens and combination regimens can produce severe and prolonged cytopenias.
Myelosuppression includes…
Neutropenia

Anemia

Thrombocytopenia

...more about each of those ahead.
Neutropenia
Neutropenia
Significant reduction in the absolute number of circulating neutrophils in the blood.

Neutrophils are the type of white blood cell most important in fighting off infection.
Grading of Neutropenia
The absolute neutrophil count (ANC) is the basis for neutropenia classification:
Grade 1 <Lower Limit of Normal (LLN)-1,500 neutrophils/mm3
Grade 2 <1,500-1000 neutrophils/mm3
Grade 3 <1,000-500 neutrophils/mm3
Grade 4 < 500 neutrophils/mm3

Key Points to Consider with Neutropenia
Most common dose-limiting toxicity with chemo.
If not handled appropriately, can lead to life-threatening infections, lengthy and costly hospital stays, dose reductions and dose delays.
Calculate your patients absolute neutrophil count (ANC) prior to every cycle.


Risk assessment should be performed on all patients prior to each cycle of chemo.


Febrile Neutropenia
One time oral temperature > 101°F (38.3°C)
Management of Neutropenic Fever
Obtain cultures
: blood cultures X 2, urine, stool is diarrhea present, skin if lesions present, throat/nasopharynx if respiratory symptoms present.
Perform a site-specific history and physical
trying to identify source of infection.
Obtain CXR
.
After cultures obtained, immediately
initiate empiric broad-spectrum antibiotics
until organism is identified.
Monitor blood cultures daily
and anticipate change in therapy based on results.
Use of colony stimulating factors
(CSFs)
(e.g. filgrastim, pegfilgrastim) are
not recommended
for treatment of neutropenic fever.
Prevention of Infection
Proper hand hygiene is a must!!! (staff, patient, and visitors)
Evidence no longer supports the neutropenic diet but food should be cooked and washed well.
Evidence no longer supports need for strict isolation of these patients.
Avoid caring for fresh plants and flowers.
Colony-stimulating factors are used sometimes to prevent febrile neutropenic episodes.
Protect skin and mucous membranes from trauma.
Educate patients often about ways they can protect themselves:





(From: Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0 Published: May 28, 2009 (v4.03: June 14, 2010))
See “Drug Administration” lesson in this course for instruction on calculating the ANC.
Example of a risk assessment calculator:
Oral temperature > 100.4°F (38°C) lasting at least one hour
ANC is < 500/mcl or < 100/mcl and expected to decline over the next 48 hours
or
Fever is often the only sign of infection in the neutropenic patient.
Frequent oral care and assessment

Meticulous hand washing

Avoid those with cold/flu symptoms

Consider routine vaccinations
ONS PEP Resource: Prevention of Infection
ONS PEP resources are designed to provide evidence-based interventions for patient care and teaching.
PEP topic teams of nurse scientists, advanced practice nurses, and staff nurses summarize and synthesize the available evidence in PEP topic areas.
Click here for the ONS PEP resource:
Prevention of Infection: General


https://www.ons.org/practice-resources/pep/prevention-infection/prevention-infection-general
Anemia
Anemia

A hemoglobin < 11 g/dl or > 2 g/dl below baseline.
Grading of Anemia
Grade 1 Hemoglobin (Hgb) < LLN - 10.0 g/dL
Grade 2 <10g/dL - 8.0 g/dL
Grade 3 Hgb < 8.0 g/dL
Grade 4 Life-threatening consequences;
urgent intervention indicated
Grade 5 Death
Key Points to Consider with Anemia
Many patients (40%-70%) will experience some extent of anemia while receiving chemo.
Certain chemo agents are more likely to cause anemia than others:



Several classifications of common cancer-related anemias:





Clinical Manifestations of Anemia
Management of Anemia
Monitor
lab results.
Provide interventions as necessary for
hypoxia
.
Utilize measures to
manage fatigue
(e.g. frequent rest, exercise, adequate nutritional intake).
REMS
(risk evaluation and mitigation strategy) program for safe use of erythropoietin stimulating agents (ESAs) (e.g. darbopoietin).
Blood transfusions only for
Hgb < 7-8 g/dl and based on other patient characteristics and symptoms.
ONS PEP Resource:
Fatigue
Fatigue is one of the most common problems in patients with cancer.
It may be related to the disease itself or cancer treatment and may even continue beyond the completion of treatment and effect long-term cancer survivors. 
Click here for the ONS PEP resource: Fatigue
https://www.ons.org/practice-resources/pep/fatigue
(From: Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0 Published: May 28, 2009 (v4.03: June 14, 2010))
Platinum drugs
Biotherapies
High-dose chemo for HSCT
Microcytic
Macrocytic
Normocytic
Low reticulocyte count
High reticulocyte count
Cardiopulmonary
Dyspnea, hypoxia
Tachycardia, heart murmurs
Orthostatic hypotension
Neuromuscular
Headache, dizziness
Drowsiness, restlessness, problems with concentration
Paresthesias
Fatigue, weakness
Decreased urine output
Integumentary
Pallor of mucous membranes, hands, feet, lips, nail beds
Hair loss and thinning
Cyanosis
Hypothermia
Thrombocytopenia
Thrombocytopenia
A platelet count of less than 150,000 platelets per microliter.
Grading of Thrombocytopenia
Grade 1: platelets < 75,000/mm3
Grade 2: platelets 50,000 – 75,000/mm3
Grade 3: platelets 25,000 – 50,000/mm3
Grade 4: platelets < 25,000/mm3
Key Points to Consider with Thrombocytopenia
Thrombocytopenia is evident approximately 8 – 14 days after chemo treatment.
Severity varies based on drug, dose, and dosing schedule.
Dose-limiting toxicity for some agents (e.g. gemcitabine, carboplatin, dacarbazine, 5-FU, lomustine, mitomycin C, thiotepa, trimetrexate)
Liver disease can worsen this side effect.
Clinical Manifestations of Thrombocytopenia
Management of Thrombocytopenia
Monitor
blood work
closely
Maintain
safe environment
Avoid activities that may cause injury
Ensure safe home environment (use of non-skid rugs, nightlights, etc.)
Maintain
skin integrity
Educate on use of soft toothbrush, electric razors, lubrication for sexual activity, etc.)
Administer
platelet transfusions
when appropriate
Review your practice/institution policies related to criteria for transfusion
ONS PEP Resource:
Prevention of Bleeding
Thrombocytopenia can be caused by chemotherapy or radiation therapy as well as infection, disseminated intravascular coagulation, liver disease, and platelet dysfunction.
Click here for the ONS PEP resource: Prevention of Bleeding


(From: Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0 Published: May 28, 2009 (v4.03: June 14, 2010))
Petechiae, bruising
Epistaxis
Bleeding from surgical sites/wounds
Change in mental status, confusion, restlessness, lethargy
Rectal bleeding, tarry stools
Hematemesis
Menorrhagia
Hematuria
https://www.ons.org/practice-resources/pep/prevention-bleeding
Types of CINV
Acute
Starts within minutes to hours after chemo is administered and may last up to 24 hours
Emetogenicity of Chemotherapy
First determine the emetogenicity of all chemo agents in the regimen.



NCCN recommends selecting antiemetic therapy based on the drug with the highest emetic risk within the prescribed regimen.
Develop a comprehensive antiemetic care plan based on the above.
Management of CINV with Intravenous Chemotherapy
High
emetic risk
Use three drug combination: 5-HT3 antagonist, an NK1 antagonist, and a corticosteroid prior to chemo
Moderate
emetic risk
Use two drug combination: 5-HT3 antagonist and a corticosteroid
With/without NK1 antagonist
Low
emetic risk
Use a corticosteroid daily, metoclopramide, prochlorperazine, or a 5-HT3 antagonist
Minimal
emetic risk
No routine prophylaxis necessary
Management of CINV with Oral Chemotherapy
Antiemetics for Types of CINV
Anticipatory CINV
Prevention is key!
Use optimal antiemetic therapy for every cycle
Use behavioral therapies (e.g. relaxation, hypnosis, music therapy)
Acupuncture/acupressure
Consider use of anxiolytic therapy (e.g. alprazolam or lorazepam)
Breakthrough CINV
Add one agent from a different drug class to the current CINV regimen
See NCCN Antiemesis guidelines for suggested agents
Patient Education for CINV
Dietary
education
Encourage small, frequent meals
Consider taking antiemetics prior to meals
Avoid spicy, high fat foods
Eat cooler, room temperature foods
Notify staff if n/v persists
for > 24 hours or unable to maintain fluid intake
Consider f
ollow-up phone calls
to patients within 1-2 days after chemo to ensure adherence to and effectiveness of antiemetic regimen
Refer to table 21 Emetogenic Potential of Intravenous Antineoplastic Drugs (pages 194-196) in the course eBook
***See the NCCN Antiemesis (version 2.2015) guidelines for alternative and additive therapy. www.nccn.org (you must create a free profile to access all NCCN guidelines)

ONS PEP Resource: Chemotherapy-Induced Nausea and Vomiting
ONS PEP resources are designed to provide evidence-based interventions for patient care and teaching.
PEP topic teams of nurse scientists, advanced practice nurses, and staff nurses summarize and synthesize the available evidence in PEP topic areas.
Click here for the ONS PEP Resource: Chemotherapy-Induced Nausea and Vomiting


https://www.ons.org/practice-resources/pep/chemotherapy-induced-nausea-and-vomiting/chemotherapy-induced-nausea-and
Key Points about CINV
CINV continues to be one of the most feared side effects of chemotherapy for patients
PREVENTION IS KEY!
Nurses serve such an important role in the prevention of CINV
Risk Factors
for CINV
Female gender
Younger than 50 years
History of low alcohol intake (i.e., less than 1.5 oz per day)
History of motion sickness
History of nausea and vomiting during pregnancy
Delayed
Occurs at least 24 hours after chemo is administered
Anticipatory
Conditioned response that occurs most commonly before treatment and is often associated with triggers (e.g. smells, tastes, sights)
Refractory or breakthrough
CINV that is resistant to treatment; occurs despite prophylactic antiemetic therapy
History of prior CINV
Extreme anxiety
Short infusion time
Higher number of chemotherapy cycles
Emetic potential of each drug in the regimen
High to moderate
emetic risk
5-HT3 antagonist daily

Low to minimal
emetic risk
PRN antiemetics recommended
Metoclopramide, prochlorperazine, haloperidol, 5-HT3 antagonist
Key Points about Cutaneous Toxicities
Chemo causing injury to skin, hair, and nails is increasingly more common in recent years
Increased incidence from emergence of targeted therapy agents
Cancer therapies have shifted towards targeting specific pathways (e.g. EGFR inhibitors (EGFRIs), small molecule inhibitors, etc.)
These types of agents cause less of usual side effects (i.e. myelosuppression, n/v, etc.) but more dermatological adverse effects
EGFRI Skin Toxicity
Pustular/popular rash
Occurs in 45%-100% of patients
Appears in cosmetically sensitive areas
Occurs 8-10 days after initiation of therapy and peaks at 2 weeks
Ocular reactions
Occur in 4%-12% of patients
e.g. trichomegaly, conjunctivitis, lacrimation
Skin toxicities can significantly impact patient’s physical, emotional, and social function and there general quality of life.
Biggest issue with these toxicities is they can lead to dose reductions and discontinuation of therapy if not managed appropriately.
Management of EGFRI-induced
Skin Reactions
Skin care recommendations:
Use gentle soaps and shampoo
Avoid alcohol containing skin care products
Remove makeup with hypoallergenic cleanser
Shave with caution, avoid extra beard growth
Wear smooth cotton clothing
Cut nails straight across and do not trim cuticles
Avoid sun exposure, wear sunscreen daily
Moisturize skin daily with emollients free of perfume, alcohol and petroleum jelly to prevent dryness
Do not use topical acne medications
ONS PEP Resource: Skin Reactions
Grading of Papulopustular Rash
ONS PEP resources are designed to provide evidence-based interventions for patient care and teaching.
PEP topic teams of nurse scientists, advanced practice nurses, and staff nurses summarize and synthesize the available evidence in PEP topic areas.
Click here to review the ONS PEP resource: Skin Reactions


Both NCCN and MASCC have recommendations for management of EGFRI-induced rash
(see figure 28, page 247 in course eBook)
http://www.nccn.org
http://www.mascc.org
https://www.ons.org/practice-resources/pep/skin-reactions
Click arrows to proceed forward or back.
http://www.neutropeniarisk.com/risk-assessment/checklist/
There are many different side effects that can occur with cancer therapy. Each chemotherapy agent has its own side effect profile with those side effects that are most commonly reported with that agent. The side effects in the following presentation are just a few of the more common ones that you will see in your patients following chemotherapy administration.

For a more inclusive discussion on side effects of cancer therapy, refer to your course eBook, chapter 9, beginning on page 171.
Full transcript