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ON15,16,17 Supportive care

Gelöschter Nutzer 47 Fragen Aktualisiert am 9 Okt 2019

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1Mucositis = Painful inflammation and [blank_start]ulceration[blank_end] of the mucous membranes lining the digestive tract (especially [blank_start]mouth and throat[blank_end]). [blank_start]40-75[blank_end]% of all CT patients will experience mucositis. It can lead to infections, [blank_start]nutritional[blank_end] disorders, severe pain, compromised airway, tissue necrosis, and significant [blank_start]bleeding[blank_end].
Usually begins to manifest 5-7 days after CT (typically [blank_start]2-3 weeks[blank_end]).
Risk factors include:
- High-dose CT with alkylating agents (eg [blank_start]cyclophosphamide[blank_end]) or topoisomerase II inhibitors (eg [blank_start]doxorubicin[blank_end])
- Pre-existing oral lesions/infections, poor dental [blank_start]hygiene[blank_end]/dentures
- [blank_start]White[blank_end] ethnicity
- [blank_start]Smoking, alcohol consumption,[blank_end] malnutrition
1. Aulceration
2. Bmouth and throat
3. C40-75
4. Dnutritional
5. Ebleeding
6. F2-3 weeks
7. Gcyclophosphamide
8. Hdoxorubicin
9. Ihygiene
10. JWhite
11. KSmoking, alcohol consumption,
2Mucositis prevention:
Remove risk factors (e.g. [blank_start]dental[blank_end] therapy)
Drink adequate [blank_start]water[blank_end]
Cryotherapy ([blank_start]ice chips swishing for 30 min[blank_end] before bolus CT; not oxaliplatin)
[blank_start]Saline and bicarbonate[blank_end] mouth rinse

Treatment
Routine mouth care
Analgesia (topical [blank_start]lidocaine[blank_end], topical morphine, oral morphine if [blank_start]severe[blank_end])
[blank_start]Magic mouth wash [blank_end]
Saliva substitutes
1. Adental
2. Bwater
3. Cice chips swishing for 30 min
4. DSaline and bicarbonate
5. Elidocaine
6. Fsevere
7. GMagic mouth wash
3Diarrhoea:
Caused by direct toxicity to the [blank_start]epithelial[blank_end] cells leading to inflammation with [blank_start]prostaglandin[blank_end] release .
Most common with [blank_start]5-FU, capecitabine, irinotecan,[blank_end] EGFR inhibitors.
Tx:
[blank_start]Loperamide 4mg[blank_end] orally, then [blank_start]2mg every 2 hours[blank_end] until diarrhoea free
[blank_start]Octreotide[blank_end] – for patients not responding to loperamide
NOTE Anti-diarrhoeals should [blank_start]not[blank_end] be used in patients with suspected [blank_start]C. Diff[blank_end] and do not forget importance of [blank_start]diet and hydration[blank_end]

Constipation:
Affects 50-70% of patients on chemotherapy
Can lead to anorexia, nausea, vomiting, abdominal pain, bowel [blank_start]obstruction and perforation [blank_end]
Risk medications: [blank_start]Vinca alkaloids, opioids, antiemetics[blank_end] (ondansetron)
Treatment: Stool softener, stimulants, fleet enema, manual or surgical evacuation, hydration
1. Aepithelial
2. Bprostaglandin
3. C5-FU, capecitabine, irinotecan,
4. DLoperamide 4mg
5. E2mg every 2 hours
6. FOctreotide
7. Gnot
8. HC. Diff
9. Idiet and hydration
10. Jobstruction and perforation
11. KVinca alkaloids, opioids, antiemetics
4Hypersensitivity reactions can cause acute [blank_start]dyspnoea[blank_end], pruritic [blank_start]rash[blank_end], fever, nausea/vomiting, rigors, flushing, [blank_start]brady[blank_end]cardia, [blank_start]hypo[blank_end]tension, angioedema. These are severe in <[blank_start]5%[blank_end] of patients.
Causes:
Taxanes - [blank_start]2nd/3rd[blank_end] exposure, [blank_start]fast[blank_end] onset, premedicate with [blank_start]H1 and H2 antagonists and steroids[blank_end]
[blank_start]L-asparaginase[blank_end] (first dose requires test dose, IM less frequent)
Monocolonal antibodies (pre-medicate with [blank_start]paracetamol, antihistamines and steroids[blank_end]) - If severe, stop or interrupt infusion and give fluids and [blank_start]adrenaline[blank_end].
1. Adyspnoea
2. Brash
3. Cbrady
4. Dhypo
5. E5%
6. F2nd/3rd
7. Gfast
8. HH1 and H2 antagonists and steroids
9. IL-asparaginase
10. Jparacetamol, antihistamines and steroids
11. Kadrenaline
5Photosensitivity is a dermotological toxicity causes by some medicines. Wear sunscreen, cover up, avoid sunbeds. Which medicines can cause this?
1. A5-FU, MTX, Vinblastine
2. B5-FU, MTX, Vincristine
3. CCapecitabine, MTX, Prednisolone
4. DCapecitabine, MTX, Paclitaxel
6Alopecia
- occurs 1-2 [blank_start]weeks[blank_end] post-chemotherapy
- reversible (1-2 [blank_start]months[blank_end] after cessation of therapy)
- [blank_start]taxanes[blank_end] cause total body alopecia (axillary and pubic hair, eyebrows and eye lashes)
1. Aweeks
2. Bmonths
3. Ctaxanes
7Hand-Foot Syndrome (palmer-plantar/acral erythema):
- Tender erythematous skin on palms of hands and sometimes soles of feet
- Causes: [blank_start]5-FU, capecitabine,[blank_end] liposomal [blank_start]doxorubicin[blank_end], high dose cytarabine
Treatment: drug cessation and symptomatic treatment ([blank_start]10% urea[blank_end] emollient, analgesia, [blank_start]cold[blank_end] compress, topical [blank_start]corticosteroids[blank_end]
1. A5-FU, capecitabine,
2. Bdoxorubicin
3. C10% urea
4. Dcold
5. Ecorticosteroids
8Extravasation
With an irritant drug: [blank_start]Short[blank_end]-term injury. No necrosis. May induce [blank_start]local[blank_end] inflammatory reaction. Blood [blank_start]return[blank_end] remains intact.
With a vesicant drug: Hardening, burning, can lead to tissue [blank_start]necrosis[blank_end]. DNA binding or DNA non-binding. DNA [blank_start]binding[blank_end] may affect underlying ligaments, nerves, and bone.

[blank_start]Anthracyclines[blank_end] (vesicant) cause the most severe extravasation.

Treatment:
Stop [blank_start]infusion[blank_end], Leave [blank_start]venous[blank_end] access, Aspirate, Plan
Anthracyclines: [blank_start]cold[blank_end] compresses
Vinca alkaloids: [blank_start]warm[blank_end] compresses
Antidotes: Dexrazoxane or [blank_start]dimethyl sulfoxide[blank_end] topical solution for anthracycline extravasation; [blank_start]hyalurinodase[blank_end] for vinka alkaloids
1. AShort
2. Blocal
3. Creturn
4. Dnecrosis
5. Ebinding
6. FAnthracyclines
7. Ginfusion
8. Hvenous
9. Icold
10. Jwarm
11. Kdimethyl sulfoxide
12. Lhyaluronidase
9Tumour Lysis syndrome: lysis of large numbers of cancer cells.

Metabolic abnormalities: hyperuricaemia, hyperkalaemia, hyperphosphataemia, secondary hypocalcaemia and uraemia (increased [blank_start]uric acid, potassium, phosphate[blank_end], decreased [blank_start]calcium[blank_end])

Symptoms: nausea and [blank_start]vomiting[blank_end], diarrhoea, anorexia, lethargy, oedema, fluid overload, [blank_start]congestive[blank_end] heart failure, haematuria, cardiac [blank_start]dysrrhythmia[blank_end], seizures, muscle cramps, tetany, syncope.

More common on the [blank_start]first[blank_end] cycle of treatment.

Risk factors: high tumour cell proliferation [blank_start]rate[blank_end], bulky disease (greater than [blank_start]10[blank_end] cm), chemosensitive malignancies*, high intensity or highly [blank_start]potent[blank_end] therapy, novel or targeted therapy.

*Malignancies associated with a higher risk: [blank_start]Non-Hodgkin's[blank_end] lymphoma, Burkitt's lymphoma, [blank_start]acute[blank_end] lymphoblastic leukaemia and acute myeloid [blank_start]leukaemia[blank_end], and occasionally those with solid tumours.

Additional risk factors: [blank_start]renal[blank_end] insufficiency or renal failure, dehydration, decreased [blank_start]urinary[blank_end] flow, pre-existing uraemia or hyperuricaemia, pre-existing hyperphosphataemia.

Prophylaxis in intermediate or high risk: Vigorous [blank_start]IV[blank_end] hydration, [blank_start]allopurinol[blank_end], [blank_start]rasburicase[blank_end] (n those who do not adequately respond to hydration and allopurinol)
1. Auric acid, potassium, phosphate
2. Bcalcium
3. Cvomiting
4. Dcongestive
5. Edysrrhythmia
6. Ffirst
7. Grate
8. H10
9. Ipotent
10. JNon-Hodgkin's
11. Kacute
12. Lleukaemia
13. Mrenal
14. Nurinary
15. OIV
16. Prasburicase
17. Qallopurinol
10Ocular toxicity
- with [blank_start]Cytarabine[blank_end]-HiDAC
- excessive tearing, pain, photophobia, presence of foreign body,
- prevention: [blank_start]artificial[blank_end] tears, [blank_start]topical[blank_end] corticosteroids
Treatment: [blank_start]D/C[blank_end] cytarabine and administer topical corticosteroids

Otological toxicity
- w/ [blank_start]Cisplatin[blank_end]
- Damage to [blank_start]inner ear[blank_end]
- [blank_start]Cumulative and irreversible[blank_end] side effect
- When detected, replace with [blank_start]carboplatin[blank_end] if appropriate
- [blank_start]Monitor[blank_end] auditory function
1. ACytarabine
2. Bartificial
3. Ctopical
4. DStop
5. ECisplatin
6. Finner ear
7. GCumulative and irreversible
8. Hcarboplatin
9. IMonitor

11Nephrotoxicity
- w/ [blank_start]Cisplatin[blank_end]
- Dose [blank_start]limiting[blank_end]
- Risk with [blank_start]higher[blank_end] doses, [blank_start]previous[blank_end] exposure, pre-existing [blank_start]kidney[blank_end] damage, use of other nephrotoxic agents
- [blank_start]25-40[blank_end]% incidence
- Manifests as increases in [blank_start]serum creatinine[blank_end], decreased [blank_start]urine[blank_end] output, [blank_start]hypo[blank_end]kalemia, hypomagnesemia, hyponatremia
- Prevention: [blank_start]lower[blank_end] doses, sub with [blank_start]carboplatin[blank_end], aggressive [blank_start]hydration[blank_end], magnesium, ?mannitol
- Monitor: [blank_start]fluid[blank_end] balance, weight, assess for signs/symptoms of fluid overload
- Treatment: [blank_start]Stop[blank_end] cisplatin, replenish electrolytes – revising ARF in 310
1. ACisplatin
2. Blimiting
3. Chigher
4. Dprevious
5. Ekidney
6. F25-40
7. Gserum creatinine
8. Hurine
9. Ihypo
10. Jlower
11. Kcarboplatin
12. Lhydration
13. Mfluid
14. NStop
12Which of these is NOT a risk factor for chemo induced nausea and vomiting?
1. AFemale
2. B<50
3. CHaving morning sickness in pregnancy
4. DEver having motion sickness
5. ENon-drinker or light drinker
6. FPrevious chemo
7. G>50
13Types of Nausea/Vomiting
Acute (up to 24h after CT; peak [blank_start]5-6[blank_end] hours)
Delayed (starts [blank_start]>24h[blank_end] after CT to [blank_start]7[blank_end] days)
Anticipatory (begins as next [blank_start]dose/cycle[blank_end] becomes closer)
Breakthrough (happens despite [blank_start]treatment/prevention[blank_end])
Refractory (prevention/treatment does [blank_start]not[blank_end] work)

If not managed appropriately:
Serious [blank_start]metabolic[blank_end] imbalance, de[blank_start]hydration[blank_end], anorexia
Deterioration in physical and mental status, [blank_start]treatment[blank_end] withdrawal
1. A5-6
2. B>24h
3. C7
4. Ddose/cycle
5. Etreatment/prevention
6. Fnot
7. Gmetabolic
8. Htreatment
9. Ihydration
14Classiciation of treatment emetogenic risk:
Minimal (<10%)
Low (10-30%) [[blank_start]5-FU, capecitabine[blank_end]]
Moderate (30-90%) [[blank_start]taxanes, doxorubicin[blank_end]]
High (>90%) [[blank_start]cisplatin[blank_end]]

Optimal emetic control in the [blank_start]acute[blank_end] phase (the first 24 hours) is essential to [blank_start]prevent[blank_end] nausea and vomiting in the [blank_start]delayed[blank_end] phase (24 to 72 hours post chemotherapy).
1. A5-FU, capecitabine
2. Btaxanes, doxorubicin
3. Ccisplatin
4. Dacute
5. Eprevent
6. Fdelayed
15Drug: Aprepitant
Class: [blank_start]Neurokinin[blank_end] receptor [blank_start]antagonist[blank_end]
Indicated for prevention of N/V in [blank_start]high and moderate[blank_end] emetogenic chemotherapy. [blank_start]CYP3A4[blank_end] inhibitor. Always used in [blank_start]combination[blank_end].
1. ANeurokinin
2. Bantagonist
3. Chigh and moderate
4. DCYP3A4
5. Ecombination
16Prophylaxis and Treatment:
- High emetogenic potential: use [blank_start]Ondansetron (q8h)[blank_end] + [blank_start]Dexamethasone[blank_end] (q12h) + [blank_start]Aprepitant[blank_end]
- Moderate emetogenic potential: [blank_start]Ondansetron (q12h)[blank_end] + Dexamethasone [blank_start](q12h) [blank_end]
- Low emetogenic potential: [blank_start]Ondansetron stat[blank_end] dose or [blank_start]metoclopramide before[blank_end]
- Minimal emetogenic potential: None but can use as needed (dexamethasone or metoclopramide or prochlorperazine)
1. AOndansetron (q8h)
2. BAprepitant
3. COndansetron (q12h)
4. DDexamethasone
5. E(q12h)
6. FOndansetron stat
7. Gmetoclopramide before
17Anaemia is a lack of red blood cells/haemoglobin.
1. ARichtig
2. BFalsch
18Which of these is NOT a cause of anaemia?
1. ABlood loss
2. BMissing vitamins or minerals, eg iron
3. CMajor organ problems
4. DChronic kidney disease
5. ERed blood cells destroyed faster than they can be made (haemolytic)
6. FCancer and cancer treatment
7. GChronic liver disease
19Anaemia in cancer can be caused by a number of different mechanisms:

The cancer:
- Cancer [blank_start]competes[blank_end] with the marrow’s function and interferes with normal red blood cell production (e.g. leukaemia)
- Cancers of the gastrointestinal system (colon and stomach cancers) or fast growing tumours may cause frequent [blank_start]bleeding[blank_end]
- Triggered immune response with the release of various [blank_start]cytokines[blank_end] that interfere with bone marrow function and [blank_start]shorten[blank_end] red cell survival
- Cancer cells release cytokines that can lead to iron [blank_start]sequestration[blank_end], reducing the production of red blood cells (RBCs)

The treatment
- Chemotherapy agents target rapidly dividing cells
1. Acompetes
2. Bbleeding
3. Ccytokines
4. Dshorten
5. Esequestration
20Which of these is NOT a cancer-specific risk factor for anaemia?
1. APlatinum-based chemotherapy
2. BPre-existing low haemoglobin level before cancer diagnosis
3. CCancers that involve the marrow space (leukaemia or lymphoma)
4. DRisk of tumour bleeding
5. ECertain types of tumors (e.g. ovary)
6. FAlkylating agent chemotherapy
21Select ALL the signs of anaemia.
1. AChest pain
2. BPale skin, nail beds, mouth, gums
3. CSwelling in hands/feet
4. DFatigue
5. ETachycardia
6. FShortness of breath
7. GDizziness
8. HGroin pain
9. IBradycardia
10. JSwelling of nodes
22Terminologies:
Ferritin – amount of iron [blank_start]stored[blank_end] in body (iron storage [blank_start]protein[blank_end] that keeps iron in a soluble and non-toxic form)

Transferrin or total iron [blank_start]binding[blank_end] capacity - a measure of the [blank_start]maximum[blank_end] amount of iron the blood can carry

Haemoglobin – oxygen carrying structures

Haematocrit – volume % of [blank_start]red blood[blank_end] cells in blood

Mean Corpuscular Volume/Mean Cell Volume (MCV) – ‘[blank_start]size[blank_end]’ of red blood cells

Reticulocyte count - measure the level of reticulocytes in your blood
1. Astored
2. Bprotein
3. Cbinding
4. Dmaximum
5. Ered blood
6. Fsize
23The MCV is used to categorise anaemia.
Microcytic anaemia – MCV < [blank_start]80 fL[blank_end]
Normocytic anaemia – MCV [blank_start]80 – 95 fL[blank_end]
Macrocytic anaemia – MCV > [blank_start]95 – 100 fL[blank_end]

(Some references define macrocytic anaemia as > 100 fL.)
1. A80 fL
2. B80 – 95 fL
3. C95 – 100 fL
24High MCV – Macrocytic Anaemia / Megaloblastic anaemia.
- Vitamin [blank_start]B12[blank_end] (dietary or pernicious anaemia) or [blank_start]Folate[blank_end] deficiency
- Both are required for [blank_start]DNA[blank_end] synthesis and so deficiency results in symptoms occurring in rapidly dividing tissues ([blank_start]bone marrow, GI[blank_end])
- Usually deficiency from [blank_start]dietary[blank_end] sources (vegetarians, poor nutrition)
- Treatment: supplementation (oral or injections if poor absorption):
[blank_start]IM[blank_end] injection of vitamin B12 (hydroxocobalamin) – 1mg [blank_start]three[blank_end] times weekly x 2 weeks, then 1mg every 3 [blank_start]months[blank_end]
Oral folic acid – [blank_start]5mg daily[blank_end] for 4 months (may then use as prophylaxis)
1. AB12
2. BFolate
3. CDNA
4. Dbone marrow, GI
5. Edietary
6. FIM
7. Gthree
8. Hmonths
9. I5mg daily
25Normal MCV – Normocytic anaemia:
High reticulocyte count suggests [blank_start]ongoing[blank_end] blood loss – acute blood loss, haemolysis. Low reticulocyte count suggests body is unable to [blank_start]produce[blank_end] RBCs at a healthy rate.
Low WBCs and platelets – [blank_start]leukemia, aplastic anaemia[blank_end]
Normal or high WBCs/platelets – [blank_start]chronic[blank_end] conditions (progress to microcytic as disease progresses), [blank_start]malignancy[blank_end]
- Treatment: Transfusion, [blank_start]erythropoiesis[blank_end]-stimulating agents
1. Aongoing
2. Bproduce
3. Cleukemia, aplastic anaemia
4. Dchronic
5. Emalignancy
6. Ferythropoiesis
26Blood transfusions:
- Raises [blank_start]haemoglobin[blank_end] quickly to improve symptoms and ensure adequate oxygen delivery
- Most commonly administered if haemoglobin is <[blank_start]80 g/L[blank_end]
- Need to match blood type
- Risks:
Transfusion related [blank_start]lung[blank_end] injury
Very low risk of viral contamination (Hep B, C, HIV)
1. Ahaemoglobin
2. B80 g/L
3. Clung
27Erythropoiesis-stimulating agents:
1. Epoetin alfa (recombinant [blank_start]human[blank_end] erythropoietin)
- Stimulate erythropoiesis by binding to [blank_start]erythroid precursor cell receptors[blank_end], stimulating differentiation and proliferation
- Stimulate release of [blank_start]reticulocytes[blank_end] from bone marrow
- Increase synthesis of cellular [blank_start]haemoglobin[blank_end] – need adequate iron stores
- Contraindicated: uncontrolled [blank_start]hypertension[blank_end], unable to receive thromboprophylaxis
- Adverse effects: hypertension, GI [blank_start]intolerance[blank_end], headache, influenza symptoms, very rarely cause [blank_start]red cell aplasia, skin reactions [blank_end]
1. Ahuman
2. Berythroid precursor cell receptors
3. Creticulocytes
4. Dhaemoglobin
5. Ehypertension
6. Fintolerance
7. Gred cell aplasia, skin reactions
28Low MCV - Microcytic Anaemia:
Cell size is decreased due to reduced [blank_start]haemoglobin[blank_end]; either less haem (i.e. iron) or an imbalance in [blank_start]globin chain[blank_end] synthesis (in genetic disorders which alter globin production)

The main causes:
- Low ferritin = [blank_start]Iron[blank_end] deficiency (blood loss, dietary deficiency, occasionally malabsorption)
- Normal or high ferritin =
TIBC low: Anaemia of [blank_start]chronic[blank_end] disease (also associated with normocytic anaemia)
OR TIBC normal or high: [blank_start]Haemoglobinopathies[blank_end] (e.g. thalassaemia), lead intoxication, sideroblastic anaemias (rare [blank_start]genetic[blank_end] or acquired disorders)

- In a primary care setting in New Zealand, [blank_start]iron deficiency and chronic disease[blank_end] will be the most likely causes of microcytic anaemia.
1. Ahaemoglobin
2. Bglobin chain
3. CIron
4. Dchronic
5. EHaemoglobinopathies
6. Fgenetic
7. Giron deficiency and chronic disease
29In cancer patients, iron deficiency is usually due to nutritional deficiencies - poor oral intake, chemotherapy-induced nausea/vomiting.
1. ARichtig
2. BFalsch
30Which of these is NOT an iron rich food?
1. AMeat and fish
2. BSweet potatoes
3. CDark green, leafy vegetables
4. DYogurt
31What dose of elemental iron should deficient patients receive daily?
1. A100-200mg
2. B50-100mg
3. C200-400mg
32Patient education points for iron salts:
More effective if taken on [blank_start]empty[blank_end] stomach
Can take with food if causes stomach upset
May discolor stools ([blank_start]dark/black[blank_end])
Do not take with [blank_start]antacids or calcium[blank_end]
May need to space from certain medications
Vitamin C (orange juice) may increase iron absorption (myth?)
[blank_start]Constipation[blank_end] common
1. Aempty
2. Bdark/black
3. Cantacids or calcium
4. DConstipation
33Aplastic anaemia:
- Non-[blank_start]malignant[blank_end] condition where the bone marrow fails to produce enough blood cells
- Exposes patients to [blank_start]anaemia[blank_end] (RBC), [blank_start]infections[blank_end] (WBC), [blank_start]bleeding[blank_end] (platelets)
- Can occur at any time but usually associated with [blank_start]bone marrow[blank_end] damage
- From:
Chemotherapy, antibiotics, [blank_start]propylthiouracil, phenytoin, quinine[blank_end]
Exposure to certain chemicals such as benzene
Radiation exposure
Viruses
1. Amalignant
2. Banaemia
3. Cinfections
4. Dbleeding
5. Ebone marrow
6. Fpropylthiouracil, phenytoin, quinine
34Which of these is not an appropriate treatment for aplastic anaemia?
1. ABlood transfusions
2. BStem cell transplant
3. CImmunosuppressants (cyclosporine, anti-thymocyte globulin)
4. DBone marrow stimulants eg Epoetin alfa
5. EIron salts
35Cancer pain epidemiology:
- Up to [blank_start]70-80[blank_end]% of patients with advanced cancer in NZ have pain
- Patients managed by oncologists (during active treatment), [blank_start]palliative[blank_end] services, [blank_start]hospices[blank_end], and GPs (advanced cancer)
- Commonly the [blank_start]most[blank_end] troublesome symptom of cancer that negatively influences quality of life
- Major [blank_start]economic[blank_end] impact by loss of productivity and caregiver burdens
- One of the most [blank_start]difficult[blank_end] conditions to treat
1. A70-80
2. Bpalliative
3. Chospices
4. Dmost
5. Eeconomic
6. Fdifficult
36Types of cancer pain:
- Acute vs. chronic pain

- Nerve pain – [blank_start]pressure[blank_end] on nerves or spinal cord (i.e. neuropathic)
- Bone pain – [blank_start]damage[blank_end] to bone tissue (e.g. metastases)
- Soft tissue or visceral pain – [blank_start]body organ or muscle[blank_end] (e.g. back pain due to kidney)
Phantom pain – pain in a body part/area that has been removed
Referred pain – pain from an organ in the body in a [blank_start]different place [blank_end]
1. Apressure
2. Bdamage
3. Cbody organ or muscle
4. Ddifferent place
37Which of thesensigns/symptoms could you observe in a sedated patient unable to communicate, that would NOT indicate pain?
1. ADiaphoresis (sweating)
2. BGrimacing on movement
3. CTachycardia
4. DPupil dilation
38WHO Cancer Pain Ladder:
Step 1 = [blank_start]Non-opioid[blank_end] +/- adjuvant
Step 2 = Opioid for [blank_start]mild-mod pain[blank_end] +/- non-opioid +/- adjuvant
Step 3 = Opioid for [blank_start]severe pain[blank_end] +/- non-opioid +/- adjuvant

[blank_start]Codeine, Dihydrocodeine[blank_end] - mild, mod
[blank_start]Morphine, Fentanyl[blank_end] - mod, strong

Adjuvants:
[blank_start]Anxiety[blank_end] medications
[blank_start]Antidepressants[blank_end]
Topical medications
1. ANon-opioid
2. Bmild-mod pain
3. Csevere pain
4. DCodeine, Dihydrocodeine
5. EMorphine, Fentanyl
6. FAnxiety
7. GAntidepressants
39Treating neuropathic pain:
- Antidepressants, anticonvulsants
- Start at [blank_start]low[blank_end] doses and increase as necessary to usual or maximum recommended doses
- Requires at least [blank_start]2 week[blank_end] trial at an adequate target [blank_start]dose[blank_end]
- Requires continual reassessment and monitoring
- Patient should be educated about [blank_start]INDICATION[blank_end], as may be concerned about stigma with antidepressants or anticonvulsants
- If pain not controlled, [blank_start]opioids[blank_end] may be trialed
1. Alow
2. B2 week
3. Cdose
4. Dindication
5. Eopioids
40People with cancer in the bone have abnormally high levels of [blank_start]osteoclasts[blank_end], causing fractures, bone pain, osteoporosis, and hypercalcaemia.

[blank_start]Bisphosphonates[blank_end] (zoledronate or pamidronate) reduce [blank_start]activity[blank_end] of osteoclasts – strengthen bone, reduce pain, treat hypercalcaemia.

Side effects include [blank_start]headaches, nausea, and flu-like[blank_end] symptoms, which usually subside within [blank_start]48[blank_end] hours of the infusion (treat with paracetamol).

Nephrotoxicity risk: adequate [blank_start]hydration[blank_end] can enhance renal protection., may be contraindicated in [blank_start]renal[blank_end] failure.
1. Aosteoclasts
2. BBisphosphonates
3. Cactivity
4. D48
5. Eheadaches, nausea, and flu-like
6. Fhydration
7. Grenal
41Severe pain may require rapid escalation of parenteral opioid therapy until pain is partially relieved.
Moderate pain: total daily dose (TTD) increased [blank_start]25-50[blank_end]% OR add the amount taken [blank_start]as needed[blank_end] the previous day
Reducing by 25-50% in patients who have pain control but experiencing [blank_start]adverse effects[blank_end] is also an option.

Patients with cancer pain will likely need medication long-term or indefinitely. Long-acting products are more convenient; switch after at least [blank_start]48 hours[blank_end] of short-acting opioid so pain is well controlled. First dose of the modified-release preparation is given [blank_start]with, or within 4 hours of[blank_end] the last dose of the immediate-release preparation, to allow time to be effective.
1. A25-50
2. Bas needed
3. Cadverse effects
4. D48 hours
5. Ewith, or within 4 hours of
42To switch from regular acting to long acting:
1. Add up [blank_start]total daily dose[blank_end] of morphine equivalents
2. Decrease by [blank_start]25% [blank_end]
3. Split into required [blank_start]number[blank_end] of long-acting doses

Example: TTD = 130mg morphine x [blank_start]0.75[blank_end] = 97.5mg
/ 2 doses = 50mg every 12 hours long-acting product
1. Atotal daily dose
2. B25%
3. Cnumber
4. D0.75
43Fentanyl patches:
- Less [blank_start]constipation[blank_end] compared to morphine. It is favourable in the presence of [blank_start]renal[blank_end] impairment
- Starting doses of [blank_start]12.5-25 mcg/h[blank_end] first option for moderate to severe pain
- Usually dosed every [blank_start]72[blank_end] hours but can be increased to every 48 hours
- Start low and go slow (increase dose every 48-72 hours)
- Patient should be on regular morphine prior to patch initiation
When initiating, put on at [blank_start]same[blank_end] time you give last dose of regular morphine
Example: Patient receiving 60mg morphing SR – give last dose of 60mg at same time you put first patch on
1. Aconstipation
2. Brenal
3. C12.5-25 mcg/h
4. D72
5. Esame
44Oxycodone:
- Bi-phasic modified-release tablets for [blank_start]12-hourly[blank_end] administration
- Release [blank_start]40[blank_end]% of drug within 1 hour for most patients and the remaining [blank_start]60[blank_end]% of drug by controlled-release
- The immediate-release and modified-release formulations have [blank_start]similar sounding names[blank_end]! care.
- Usually reserved for patients in whom [blank_start]morphine[blank_end] is not effective at optimal doses, not tolerated, or if morphine is contra-indicated
1. A12-hourly
2. B40
3. C60
4. Dsimilar sounding names
5. Emorphine
45Methadone
- Well tolerated in [blank_start]severe[blank_end] renal impairment. May be effective when there is [blank_start]neuropathic[blank_end] pain because of its [blank_start]NMDA[blank_end] receptor activity.
- Long and widely variable [blank_start]half-life[blank_end]
- Less associated [blank_start]drowsiness, nausea, and constipation.[blank_end]
- Oral dosing is usually [blank_start]2.5-5 mg twice daily[blank_end] initially with [blank_start]weekly[blank_end] dose increases (due to its long half-life and risk of accumulation)

Drowsiness and [blank_start]respiratory[blank_end] depression may develop after several days/weeks on a steady dose.

Has place in palliative care but must be prescribed by experienced practitioner.
1. Asevere
2. Bneuropathic
3. CNMDA
4. Dhalf-life
5. Edrowsiness, nausea, and constipation.
6. F2.5-5 mg twice daily
7. Gweekly
8. Hrespiratory
46Breakthrough dosing:
- [blank_start]10-15%[blank_end] of total daily dose (TTD)
- can be given [blank_start]30 minutes before[blank_end] an activity that causes [blank_start]predictable[blank_end] break-through pain such as a wound dressing
- subcut or IV if swallowing is an issue
1. A10-15%
2. B30 minutes before
3. Cpredictable
47Oral oxycodone is approximately 1.5–2 times more potent than oral morphine.
1. ARichtig
2. BFalsch

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Beschreibung: Der Nutzer hat seine Fachbereichs-Information gelöscht. Quiz am ON15,16,17 Supportive care, erstellt von Gelöschter Nutzer am 09/10/2019.
Autor: Gelöschter Nutzer
Sprache: English
Aufrufe: 71
Verlauf: Erstellt am 9 Okt 2019 · aktualisiert am 9 Okt 2019
Schlagwörter: der nutzer hat seine fachbereichs-information gelöscht.

ON15,16,17 Supportive care

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