1) Helpful Hints During Chemotherapy
2) Common Chemotherapeutic Agents and Their Toxicities
3) Management of Chemotherapy-induced Emesis (Vomiting)
4) Principles of Cancer Pain Management
Helpful Hints During Chemotherapy
(1) Always have another person with you for support, and help listen and ask questions;
(2) Bring medication log to each visit to help keep track of all medications;
(3) Call your doctor if
(a) Fever above 100.4 F day or night after checking twice;
(b) Rash of any kind or any evidence of bleeding;
(c) Severe constipation or diarrhea;
(d) Any pain of unusual intensity or distribution;
(e) Shortness of breath;
(f) Severe and persistent of vomiting;
(g) Marked pain or soreness at chemotherapy site;
(h) Mouth soreness or ulceration and/or pain when swallowing.
Don't:
(1) Do not eat raw food, especially not home-made;
(2) Do not go to a crowded place to avoid infection;
(3) Do not take herbs or excess vitamins without discussing with doctor.
Do:
(1) Take 8-10 glasses of liquids/day;
(2) Maintain your weight:
(3) Exercise as tolerated
1) Alkylating agents impair cell function by bonding with an element of DNA, RNA and proteinmolecules. These include mechlorethamine, cyclophosphamide, ifosphamide, chlorambucil,nitrosoureas, and platinum agents (cisplatin, carboplatin, oxaliplatin).
2) Antimetabolites are structural analogs of the naturally occurring metabolites involved in DNA and RNA synthesis (cell cylcle-specific), such as antifolates and purine and pyrimidine analogs (5-fluorouracil, methotrexate, cytarabine, gemcitabine and floxuridine).
3) Antitumor antibiotics intercalate between DNA base pairs resulting in spontaneous oxidation and formation of free oxygen radicals that cause strand breakage and inhibition of DNA topoisomerase I and II. These include bleomycin, dactinomycin, daunorubicin, doxorubicin, mitomycin, and mitoxantrone.
4) Epipodophyllotoxins inhibits topoisomerase II activity by stabilizing the DNA topoisomerase II complex and ultimately results in the inability to synthesize DNA (ie., etoposide).
5) Vinca Alkaloids bind to tubulin in S-phase, thus polymerization of microtubules is blocked and results in impaired mitotic spindle formation in the M-phase (vinblastin, vincristine, and vinorelbine).
6) Taxanes promotes microtubule assembly and stability, therefore blocking the cell cycle in mitosis. These include docetaxel and paclitaxel.
7) Camptothecins inhibits Topoisomerase I and interrupts the elongation phase of DNA replication (topotecan and irinotecan).
1) Cardiac toxicity
a. Cardiomyopathy is most commonly associated with anthracyclines (especially doxorubicin with cumulative dose > 450 mg/m2), epirubicin, daunorubicin, idarubicin, mitoxantrone, and high dose cyclophosphamide (dose .>100 mg/kg/day).
b. Arrhythmias can be seen when doxorubicin (acute), high dose cyclophosphamide and taxanes are used.
c. Ischemia can be caused by infusion of fluorouracil, cisplatin, vinca alkaloids, bleomycin and mitomycin.
d. Endocardial fibrosis can be associated with use of busulfan.
2) Nephrotoxicity
a. Selected examples Acute toxicities (azotemia, oliguria, and electrolyte abnormalities) and chronic toxicity (decreased GFR) are seen with cisplatin, and carboplatin. Carmustine is associated with interstital fibrosis and glomerular sclerosis (especially after cumulative dose>1200 mg/m2. Cisplatin can cause renal tubular necrosis (dose limiting toxicity). Cyclophosphamide/ ifosphamide is associated with hemorrhagic cystitis. Interferon can cause renal tubular injury and proteinuria. Interleukin 2 is related to pre-renal azotemia and oliguria. Methotrexate can be precipitated in the tubules in acidic environment, especially in high dose. Mitomycin is associated with hemolytic uremic syndrome (cumulative dose >100 mg/m2).
b. Prevention of nephrotoxicities is best done with pre- and post-chemotherapy hydration if indicated. In addition, mesna is used to prevent hemorrhagic cystitis caused by cyclophosphamide and ifosphamide, amifostine for cisplatin nephrotoxicity and alkalinization of the urine for high dose methotrexate.
3) Neurotoxicity
a. Cerebellar dysfunction is associated with use of cytarabine and fluorouracil.
b. Myelopathy can be seen when cytarabine methotrexate, thiotepa, or vinca alkaloids is used.
c. Peripheral neuropathy/myopathy are related to cisplatin, procarbazine, cytarabine, docetaxel, etoposide, paclitaxel, and vinca alkaloids.
d. Encephalopathy can occur when carmustine, cisplatin, thiotepa, cytarabine, fluorouracil, methotrexate, etoposide, or vincristine is administered.
4) Pulmonary toxicity
a. Capillary leak syndrome can be seen with use of cytarabine, methotrexate, docetaxel, cyclophosphamide, mitomycin, bleomycin and interleukin 2.
b. Pulmonary fibrosis is related to use of bleomycin and melphalan.
Chemotherapy-induced emesis is caused by stimulation of receptors in the central nervous system and GI tract. These receptors relay emetogenic signals to the vomiting center in the medulla to coordinate the act of vomiting. The chemoreceptor trigger zone (CTZ), also located in the medulla, serves as a chemosensor and is exposed to blood and CSF. These structures are rich in a variety of neurotransmitters, such as dopamine, serotonin and substance P.
1) Chemotherapy-induced emesis
a. Acute emesis is defined as nausea or vomiting that occurs within 24 hours of chemotherapy administration. The time of greatest risk is from 1 to 4 hours after chemotherapy.
b. Delayed emesis begins >24 hours after chemotherapy. It mostly likely occurs in patients who received cisplatin, carboplatin, or cyclophosphamide.
c. Anticipatory emesis is a conditioned vomiting response due to anxiety about receiving chemotherapy.
Chemotherapy-induced emesis can be effectively prevented and treated. Ask your doctor for recommendations.
Pain management in the cancer patient
1) These numbers are worth to remember: 70% cancer patients experience pain, 75% being inadequately controlled and >90% pain is manageable. No patient should die with severe pain!
2) Pharmacologic treatment options should be generously applied after or while correcting possible underlying etiologies.
3) Selected analgesic agents.
a. Mild to moderate pain
i. Non-steroidal anti-inflammatory drugs: useful in mild pain, have a ceiling effect on analgesia, useful for bone pain, produce reversible inhibition of platelet aggregation.
ii. Codeine is widely used for mild pain: short half life (q3h dosing), ceiling effect (300 mg /day), increase dose = increase side effects, codeine 180 mg po = morphine 30 mg po.
iii. Propoxyphene: weak agonist, methadone derivative, long half life of 12 hours, in combination with tylenol or aspirin, accumulation of norpropoxyphene (toxic metabolite), propoxyphene 130 mg po = morphine 30 mg po.
iv. Hydrocodone: only available po, available in fixed combination with aspirin or tylenol (max dose of tylenol of aspirin is 4gm/day), q6h dosing, slightly weaker than morphine.
b. Moderate to severe pain
i. Oxycodone: potency equal to morphine, duration of analgesia = 4 hours, oxyc acting oxycodone, only available orally, be aware of tylenol and aspirin toxicity when using combination products.
ii. Morphine: most widely used for moderate to severe pain, easy to titrate dose, short duration of action (analgesic half life of 3-4 hours), ms c acting product, multiple dosage forms available: morphine 10 mg parenteral = 30 mg oral, active metabolite of morphine is eliminated renally, therefore must adjust dosage in patients with renal failure.
iii. Hydromorphone: hydromorphone 7.5 mg oral = hydromorphone 1.5 mg parenteral =morphine 30 mg po, duration of acti hours, no active metabolite = better for renal impaired patients.
iv. Methadone: synthetic opioid agonist, long t ½ (18 to 24 hours), duration of analgesia = 6-8 hours, equipotent with morphine, hard to titrate dosage.
v. Fentanyl: fentanyl 0.1 mg iv = morphine 10mg iv, duration of acti hours, lipophilic, transmucosal lollipop; no first pass effect, transdermal patch, 12-18 hour delay before reaching peak plasma level, drug detectable in plasma up to 18 hours after removal, difficult to titrate dose for acute pain, good for patients who can’t tolerate po, sq or no iv access, less GI side effects (nausea, constipation ?), dosing limitation ; max 4-6 patches, absorption; varies, always have to give with breakthrough pain medications, expensive.
4) Management of most common side effects of opioids
a. Constipation: develop no tolerance, cause by inhibition of peristalsis, use stimulative laxative + stool softner prophylactically, senna, colace, lactulose, dulcolax, mom, fleet, prokinetic agents.
b. Sedation: transient, increase frequency and decrease dose (lower peak conc), CNS stimulants (amphetamine, ritalin, caffeine).
d. Respiratory depression: associated with abrupt dose increase in morphine- naïve patients, or elderly patients with underlying disease, relief of pain, naloxone; 0.4 mg qs to 10 ml with normal saline- give slow iv push ( approx 1ml/min) – reverse until rr 15/min, naloxone rapid iv push; cause withdrawal syndrome, naloxone; short t ½ , must observe patients when given long acting narcotics.
Risk factors and Management of Kidney stones
Eating, Diet, & Nutrition for Kidney Stones
Can I help prevent kidney stones by changing what I eat or drink?
Drinking enough liquid, mainly water, is the most important thing you can do to prevent kidney stones. Unless you have kidney failure, many health care professionals recommend that you drink six to eight, 8-ounce glasses a day. Talk with a health care professional about how much liquid you should drink.
Studies have shown that the Dietary Approaches to Stop Hypertension (DASH) diet can reduce the risk of kidney stones. Learn more about the DASH diet .2
Studies have shown that being overweight increases your risk of kidney stones. A dietitian can help you plan meals to help you lose weight.
Does the type of kidney stone I had affect food choices I should make?
Yes. If you have already had kidney stones, ask your health care professional which type of kidney stone you had. Based on the type of kidney stone you had, you may be able to prevent kidney stones by making changes in how much sodium, animal protein, calcium, or oxalate is in the food you eat.
You may need to change what you eat and drink for these types of kidney stones:
Calcium Oxalate Stones
Calcium Phosphate Stones
Uric Acid Stones
Cystine Stones
A dietitian who specializes in kidney stone prevention can help you plan meals to prevent kidney stones. Find a dietitian who can help you.
Calcium Oxalate Stones
Reduce oxalate
If you’ve had calcium oxalate stones, you may want to avoid these foods to help reduce the amount of oxalate in your urine:
nuts and nut products
peanuts—which are legumes, not nuts, and are high in oxalate
rhubarb
spinach
wheat bran
Talk with a health care professional about other food sources of oxalate and how much oxalate should be in what you eat.
Reduce sodium
Your chance of developing kidney stones increases when you eat more sodium. Sodium is a part of salt. Sodium is in many canned, packaged, and fast foods. It is also in many condiments, seasonings, and meats.
Talk with a health care professional about how much sodium should be in what you eat. See tips to reduce your sodium intake.
Limit animal protein
Eating animal protein may increase your chances of developing kidney stones.
A health care professional may tell you to limit eating animal protein, including
beef, chicken, and pork, especially organ meats
eggs
fish and shellfish
milk, cheese, and other dairy products
Although you may need to limit how much animal protein you eat each day, you still need to make sure you get enough protein. Consider replacing some of the meat and animal protein you would typically eat with beans, dried peas, and lentils, which are plant-based foods that are high in protein and low in oxalate.
Talk with a health care professional about how much total protein you should eat and how much should come from animal or plant-based foods.
Get enough calcium from foods
Even though calcium sounds like it would be the cause of calcium stones, it’s not. In the right amounts, calcium can block other substances in the digestive tract that may cause stones. Talk with a health care professional about how much calcium you should eat to help prevent getting more calcium oxalate stones and to support strong bones. It may be best to get calcium from low-oxalate, plant-based foods such as calcium-fortified juices, cereals, breads, some kinds of vegetables, and some types of beans. Ask a dietitian or other health care professional which foods are the best sources of calcium for you.
Calcium Phosphate Stones
Reduce sodium
Your chance of developing kidney stones increases when you eat more sodium. Sodium is a part of salt. Sodium is in many canned, packaged, and fast foods. It is also in many condiments, seasonings, and meats.
Talk with a health care professional about how much sodium should be in what you eat. See tips to reduce your sodium intake.
Limit animal protein
Eating animal protein may increase your chances of developing kidney stones.
A health care professional may tell you to limit eating animal protein, including
beef, chicken, and pork, especially organ meats
eggs
fish and shellfish
milk, cheese, and other dairy products
Although you may need to limit how much animal protein you have each day, you still need to make sure you get enough protein. Consider replacing some of the meat and animal protein you would typically eat with some of these plant-based foods that are high in protein:
legumes such as beans, dried peas, lentils, and peanuts
soy foods, such as soy milk, soy nut butter, and tofu
nuts and nut products, such as almonds and almond butter, cashews and cashew butter, walnuts, and pistachios
sunflower seeds
Talk with a health care professional about how much total protein you should eat and how much should come from animal or plant-based foods.
Get enough calcium from foods
Even though calcium sounds like it would be the cause of calcium stones, it’s not. In the right amounts, calcium can block other substances in the digestive tract that may lead to stones. Talk with a health care professional about how much calcium you should eat to help prevent getting more calcium phosphate stones and to support strong bones. It may be best to get calcium from plant-based foods such as calcium-fortified juices, cereals, breads, some kinds of vegetables, and some types of beans. Ask a dietitian or other health care professional which foods are the best sources of calcium for you.
Uric Acid Stones
Limit animal protein
Eating animal protein may increase your chances of developing kidney stones.
A health care professional may tell you to limit eating animal protein, including
beef, chicken, and pork, especially organ meats
eggs
fish and shellfish
milk, cheese, and other dairy products
Although you may need to limit how much animal protein you have each day, you still need to make sure you get enough protein. Consider replacing some of the meat and animal protein you would typically eat with some of these plant-based foods that are high in protein:
legumes such as beans, dried peas, lentils, and peanuts
soy foods, such as soy milk, soy nut butter, and tofu
nuts and nut products, such as almonds and almond butter, cashews and cashew butter, walnuts, and pistachios
sunflower seeds
Talk with a health care professional about how much total protein you should eat and how much should come from animal or plant-based foods.
Losing weight if you are overweight is especially important for people who have had uric acid stones.
Cystine Stones
Drinking enough liquid, mainly water, is the most important lifestyle change you can make to prevent cystine stones. Talk with a health care professional about how much liquid you should drink.
Tips to Reduce Your Sodium Intake
Most Americans consume too much sodium. Adults should aim to consume less than 2,300 mg a day .3 One teaspoon of table salt has 2,325 milligrams (mg) of sodium. If you have had calcium oxalate or calcium phosphate stones, you should follow this guideline, even if you take medicine to prevent kidney stones.
Here are some tips to help you reduce your sodium intake:
Check the Percent Daily Value (%DV) for sodium on the Nutrition Facts label found on many foods. Low in sodium is 5% or less, and high in sodium is 20% or more.
List of Iron-rich Food to avoid for iron overload but preferred for iron deficiency
Iron-rich Food: Red meats, Shellfish, Leaf greens & Spinach, liver and other organ meats, legumes (beans, peas and lentils), Nuts and Seeds, Quinoa, Turkey, Broccoli, Tofu, Dark chocolate, Prune Juice
Potasium-rich food: Avocado, Acorn squash, Spinach, Sweet potato, Wild-caught salmon, Dried apricots, Pomegranate, Coconut water, White beans, Banana
