ABSTRACT
Very high -> > 90% likelihood of nausea and/or vomiting High ->■60-90% likelihood of nausea and/or vomiting Moderate -> 30-60% likelihood of nausea and/or vomiting Low -> 10-30% likelihood of nausea and/or vomiting Very low < 10% likelihood of nausea and/or vomiting
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Antiemetics 5-HT3 Antagonists
- these agents are typically used only for acute nausea prophy laxis, and not for delayed emesls prophylaxis; they are usually administered only during the period of chemotherapy administration
Agent Dosage Dolasetron (Anzemet) 100 mg PO 30 min before chemotherapy
Granisetron (Kytril)
OR 100 mg IV 30 min before chemotherapy 1 mg PO 30 min before and 12 hr after chemotherapy OR 2 mg PO 30 min before chemotherapy OR 0.01 mg/kg IV 30 min before chemotherapy (typical dose is 1 mg) 8 mg PO 30-60 min before and 8 hr after chemotherapy OR 8-24 mg IV 30 min before chemotherapy
Ondansetron (Zofran)
Phenothiazines Prochlorperazine (Compazine)
Thiethylperazine (Torecan)
10 mg P0Q4-6H 15 mg spansule PO Q8-12H 25 mg rectal suppository Q4-6H 10 mg IV Q4-6H 10 mg P0Q4-6H 2 mg IM Q4-6H 250 mg PO Q4-6H 200 mg rectal suppository Q4-6H 200 mg IM Q4-6H
Trimethobenzamide (Tigan)
Butyrophenones Haloperidoi (Haldol) Droperidol
1-3 mg PO/IV Q4-6H 0.5-2 mg IV Q4H
Benzamide Metoclopramide (Reglan) 0.5 mg/kg PO Q6H
1-2 mg/kg IV over 20 min Q3-4H
Benzodiazepines Lorazepam (Ativan) 1-2 mg PO/IV/IM Q4-6H
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Agent Dosage Cannabinoids Dronabinol (Marinol) 2.5-10 mg P0Q6H
Corticosteroids Acute emesis Dexamethasone 10-20 mg IV prior to chemotherapy for up
to 5 days 4-8 mg PO Q4H (for up to 4 doses)
Delayed emesis Dexamethasone 8 mg PO BID for 2 days, then 4 mg PO BID for
2 days
Other antiemetics Promethazine (Phenergan) 25 mg PO/IV/rectal suppository Q4H Hydroxyzine (Vistaril) 25 mg PO Q6H
Acute emesis guidelines Moderate, high, and very high likelihood of nausea/vomiting-5-HT3 antagonist (as above) and dexamethasone (as above) ± benzodiazepine Low likelihood of nausea/vomiting-Compazine Very low likelihood of nausea/vomiting-Compazine only if needed
Delayed emesis guidelines Regimen A 1. Dexamethasone 8 mg PO BID for 2 days, then 4 mg PO BID for 2 days 2. Metoclopramide 0.5 mg/kg QID for 4 days
Regimen B 1. Dexamethasone 8 mg PO BID for 2 days, then 4 mg PO BID for 2 days 2. Prochlorperazine spansules 15 mg PO TID or prochlorperazine 10 mg PO
Q4-6H for 4 days
May add diphenhydramine (Benadryl) 50 mg PO Q6H if needed May add lorazepam 0.5-2 mg PO Q6H if needed
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Management of Neutropenic Fever High Risk Patients Risk Factors
1. Neutropenia expected to last > 7 days 2. Hematologic malignancies 3. Significant comorbid conditions 4. Clinically evident source of infection 5. Unstable patient (hypoxia, hypotension, etc.) 6. Lack of control of underlying malignancy 7. Transplant patients 8. Elderly 9. Failure of outpatient antibiotics
Treatment protocols A. No Site of Infection Evident
-use monotherapy or combination therapy as indicated by clinical scenario
1. Monotherapy (one of the following) a. Ceftazidime 1-2gmlVQ8H b. Cefepime 1-2gmlVQ12H c. Imipenem/cilastatin 500 mg IV Q6H d. Levofloxacin 500 mg IV Q24H e. Piperacillin/tazobactam 3.375 gm IV Q6H f. Ticarcillin/clavulanate 3.1 gm IV Q6H
2. Combination therapy (one of the following combinations) a. Antipseudomonal beta-lactam (a, b, c, e, or f above) + aminoglycoside -gentamicin 5-6 mg/kg/d IV Q24H -tobramycin 5-6 mg/kg/d IV Q24H -amikacin 15 mg/kg/d IV Q24H b. Antipseudomonal beta-lactam (a, b, c, e, or f above) + fluoroquinolone
B. Site of Infection Evident -therapy should be broad-based, but individualized to the most likely organisms causing infection at that site
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C. Indications for the Use of Vancomycin 1. Catheter infection 2. Severe mucositis 3. Blood culture positive for gram positive organism 4. Known colonization with MRSA or other resistant
organism D. Empiric Antifungal and Antiviral Therapies as Indicated
1. Antifungal a. Fluconazole 400 mg IV/PO Q24H b. Itraconazole 200-600 mg PO Q24H or in divided
doses c. Amphotericin B 0.5-1.5 mg/kg IV Q24H -total dose 1 -1.5 gm for Yeast, and 2-2.5 gm for Mold d. ABLC* (Ablecet) 5 mg/kg IV Q24H over 2 hr e. ABCD* (Amphocil) 2-4 mg/kg IV Q24H f. L-AMB* (AmBisome)
3-5 mg/kg IV Q24H over 1-2 hr
*ABLC = Amphotericin B Lipid Complex *ABCD = Amphotericin B Colloidal Dispersion * L-AMB = Liposomal Amphotericin B
2. Antiviral a. Acyclovir 5-10 mg/kg IV Q8H over 1 hr
800 mg PO 5X daily for 7-10 days (herpes zoster) 400 mg PO BID (prophylaxis for herpes) 400 mg PO TID for 5 days (recurrent genital herpes)
b. Famciclovir 500 mg PO TID for 7 days (herpes zoster) 250 mg PO BID (prophylaxis for herpes) 125 mg PO BID for 5 days (recurrent genital herpes)
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Dexamethasone 0.75 mg OR
PO QID
Megestrol acetate 800 mg - many start at 160 mg QD
PO QD
REF: Loprinzi et al. J Clin Oncol 1999; 17:3299-3306
CONSTIPATION Bisacodyl (Dulcolax) 10-15 mg PO prn
10 mg supp PR prn Castor oil 10-15 cc PO prn Docusate calcium (Surfak) 240 mg PO QD Docusate/casanthranol (Pericolace) 1-2 capsules PO QHS prn
15-30 cc PO QHS prn Docusate sodium (Colace) 100-200 mg PO BID Glycerin 1 supp PR prn Lactulose 15-30 cc PO QHS Magnesium citrate 150-300 cc PO BID prn Magnesium hydroxide (MOM) 30-60 cc PO BID prn Methylcellulose (Citrucel) 1 heaping tablespoon in
8 oz. H20 TID pm Mineral oil 15-45 cc PO prn
120 cc enema PR prn Polycarbophil (FiberCon) 1 gram PO QID prn Polyethylene glycol (MiraLax) 17gms (1 heaping tbs) in
8 oz. H20 QD Psyllium (Metamucil) 1 teaspoon in liquid,
1 packet in liquid, or 1-2 wafers PO TID prn
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Senna (Senokot) 2 tabs or 1 teaspoon of granules or 10-15 cc syrup PO QHS prn 1 supp PR QHS prn
Sodium bisphosphate (Fleet) 1 enema PR prn Sorbitol 30-150 cc PO prn
DIARRHEA Kaolin and pectin (Kaopectate) 15-30 cc PO Q4H prn Loperamide (Imodium) 4 mg PO after first loose
BM, then 2 mg PO after each loose BM
-should not to exceed 6 doses per 24 hours Diphenoxylate/atropine (Lomotil) 1-2 tabs PO Q4H prn Octreotide 0.05-0.1 mg SQTID
-may be helpful for 5-FU induced diarrhea
EXTRAVASATION ANTHRACYCLINES
-dactinomycin, daunorubicin, doxorubicin, epirubicin, idarubicin, ± mitoxantrone
Treatment 1. Application of cold - apply without pressure on and off for 24 hours
2. Topical DMSO -1.5 cc topically Q6H for 14 days; allow to air dry
NITROGEN MUSTARD AND MITOMYCIN C Treatment 1. Mix 4 cc 10% sodium thiosulfate with 6 cc of sterile H20
-inject 2 cc into site for each mg of drug extavasated 2. Topical DMSO -1.5 cc topically Q6H for 7-14 days; allow to air
dry
* cisplatin-large extravasations can also be treated in the above manner
VINCA ALKALOIDS -vinblastine, vincristine, vinorelbine
Treatment 1.150 units hyaluronidase reconstituted in 1-3 cc sterile saline -inject into site using original needle if possible
2. Warm pack-apply to site without pressure after above injection
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Epipodophyllotoxins -etoposide (VP-16), teniposide (VM-26)
Treatment 1. treat for large volume extravasations 2.150 units hyaluronidase reconstituted in 1-3 cc sterile saline -inject into site using original needle if possible 3. Warm pack-apply to site without pressure after above
injection
HICCUPS Amitriptyline 25 mg PO BID Baclofen 10 mg PO Q6-8H Carbamazepine 200 mg PO QID prn Chlorpromazine (Thorazine) 25-50 mg IM Lorazepam (Ativan) 0.5-1 mg PO/IV Q6H prn Metoclopramide 10-20 mg PO QID prn Prochlorperazine (Compazine) 10mg PO Q6-8H Simethicone 40-160 mg PO QID prn
HOT FLASHES Bellergal-S 1 PO QD-BID (start QHS) Clonidine 0.1 mg patch weekly Megestrol (Megace) 20-40 mg PO BID-QID Methyldopa 250 mg PO BID Venlafaxine 75 mg PO QD Vitamin B6 200 mg PO QD Vitamin E 800 IU PO QD
HYPERURICEMIA Allopurinol 300-600 mg PO QD
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Narcotics for mild-moderate pain Name Starting Dose Route Frequency Dosage Forms Codeine 15-30 mg PO Q4-6H prn 15,30,60 mg Injectable 15-30 mg IV/SQ/IM Q4-6H prn 30,60 mg/ml with APAP 1-2 tabs P0 Q4-6H prn 15 mg/300 mg
(Tylenol #2) with APAP 1-2 tabs PO Q4-6H prn 30 mg/300 mg
(Tylenol #3) with APAP 1-2 tabs PO Q4-6H prn 60 mg/300 mg
(Tylenol #4) Hydrocodone with APAP 1-2 tabs PO Q4-6H prn 2.5 mg/500 mg
(Lortab) with APAP 1-2 tabs PO Q4-6H prn 5 mg/500 mg
(Vicodin) 5 mg/500 mg
(Lortab) with APAP 1 tab PO Q4-6H prn 7.5 mg/500 mg
(Lortab) 7.5 mg/750 mg
(Vicodin ES) Propoxyphene
with APAP
1 tab
1 tab
PO
PO
Q4-6H prn
Q4-6H prn
65,100 mg (Darvon)
100 mg/650 mg (Darvocet N-100)
NSAIDS Ibuprofen 400 mg PO Q6-8H prn 200,300,400,
600,800 mg Suspension 400 mg PO Q6-8H prn 100 mg/5 ml
Naproxen 220-500 mg PO Q12H prn 220,250,275, 375,500,550 mg
Suspension 250 mg PO Q12H prn 125 mg/5 ml Salsalate 750-1000 mg PO Q12H.prn 500,750 mg Oxaprozin 600 mg PO Q24H prn 600 mg (Daypro) Sulindac 150 mg PO Q12H prn 150,200 mg
(Clinoril)
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Nabumetone 1000 mg PO Q24H prn 500,750 mg (Relafen)
Piroxicam 10 mg PO Q24H prn 10,20 mg (Feldene)
Celecoxib 100 mg PO Q12H 100,200 mg (Celebrex)
Rofecoxib 12.5 mg PO Q24H 12.5,25 mg (Vioxx^
OTHER ANALGESICS A. Antidepressants Amitriptyline 10-25 mg PO QHS 10,25,50,75,
100 mg (Elavil) Desipramine 10-25 mg PO QHS 10,25,
50 mg (Norpramin) Paroxetine 20 mg PO QD 20,40 mg (Paxil) Sertraline 25 mg PO QD 50,100 mg (Zoloft) Citalopram 20 mg PO QD 20,40 mg (Celexa)
B. Anticonvulsants Gabapentin 100 mg PO Q8H 100,300,400 mg
(Neurontin) Carbamazepine
C. Miscellaneous
100 mg PO BID 100,200,400 mg (Tegretol)
100 mg/5cc suspension
Corticosteroids
Dexamethasone 4 mg PO Q6H 0.75,1,2,4 mg (Decadron)
-taper dose to lowest dose which is effective
Stimulants
Methylphenidate 5 mg PO BID 5,10,20 mg (Ritalin)
Dextroamphetamine 5 mg PO BID 5,10,15 mg (Dexedrine)
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