9/25/16

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AngelaKnox,RN,BSN,OCNUniversityofWashingtonMedical

Center

SymptomManagement:GastrointesInalAlteraIons

•  Describethe– incidence– riskfactors– assessment– intervenIons•  forthemanagementofgastrointesInalsideeffectsfromcancer&cancertreatment

ObjecIve

Picturefrom:hRp://juicing-for-health.com/gastrointesInal-tract.html

•  Nausea&VomiIng•  MucosiIs•  Diarrhea•  ConsIpaIon•  Anorexia/Cachexia

Whatwe’retalkingabout

•  Nausea&vomiIngaresomeofthemostfearedsideeffectsofcancertreatment

•  ProvidersoveresImatehowwellwecontrolnauseaandvomiIngcomparedtoreportedpaIentexperiences

•  HeathcarecostsarehigherforpaIentswithuncontrollednausea&vomiIng

Nausea&vomiIng

– Nausea–unpleasant“wavelike”feeling,mayleadtovomiIng,subjecIve

– Retching(Akadryheaves)-rhythmiccontracIon– VomiIng-forcefulexpulsionofcontentsofthestomach

Nausea&vomiIng:defined

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•  Nausea&vomiIngcanleadto:–  Electrolyteimbalances–  Poorqualityoflife–  Treatmentdelays–  HospitalizaIon–  LossofappeIte– MalnutriIon–  DehydraIon–  Tornesophagus–  Brokenbones–  Reopeningofsurgicalwounds

Sowhat? Pathophysiology

•  Serotonin(5-HT3)-releaseacIvatesvagusnerve•  SubstanceP-foundinvagalafferentneurons-believedtobetriggerfordelayedn/v

•  Dopamine-2•  CorIcosteroid•  Neurokinin-1•  Muscarinic•  Opioid•  Acetylcholine•  Cannabinoid•  Histamine

Neuroreceptors

•  AnIcipatory–before/during•  Acute–within24hours•  Delayed–happensmorethan24hoursager•  Breakthrough–despitetreatment•  Chronic-ongoing

PaRernsofNausea

Incidence•  18–57%ofpaIents

RiskFactors–  Historyofpoorlycontrolled

n/v–  Age<50–  Female–  Higheranxiety–  Feelingwarm,hot,dizzy,

weakagerchemotherapy–  HistoryofmoIonsickness,

pregnancy-inducedn/v

AnIcipatory

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Incidence•  Determinedbytypeof

chemotherapy/treatment•  CombinaIon=higher

incidence•  EmetogenicpotenIal

(NCCN&ASCO)–  Highrisk>90%–  Moderaterisk30-90%–  Low10-30%–  Minimal<10%

Riskfactors•  Female•  Age<50•  Alcoholuse(more=lessn/v)•  Advancedstagedisease•  FaIgue•  Pain•  Tumorburden•  Tastedisturbances•  Anxiety•  SuscepIbilitytoGIdistress•  Poorperformancestatus•  MedicalcondiIons•  N/vwithpregnancy

Acute

Incidence•  Dependsonchemotherapy•  Mostcommonagents:

–  Cispla4n(upto6days)–  CarboplaIn–  Cyclophosphamide–  Doxorubicin

RiskFactors•  CisplaIn•  Previouslypoorlycontrolled

nauseaandvomiIng

Delayed

•  OccursdespitetreatmentfornauseaandvomiIng

•  Ensureappropriateregimenisbeingused•  IdenIfyfurtherriskfactors,issues•  AddaddiIonalmedicaIons•  Usearound-the-clockscheduling•  Considernon-pharmacologicintervenIons

Breakthrough

•  Ongoing,usuallyduetodiseaseortreatment•  Coloncancer,braintumors•  Stomachulcers•  CertainmedicaIons,likeanIdepressantsoropiods

Chronic

•  Francescaisa38yearoldwomanwithAMLandisgoingtoreceiveCyclophosphamideandBusulfanpriortoherallogenictransplant.SheisnervousabouthercondiIoningchemotherapybecausesheexperiencedseverenauseaandvomiIngwithpriorchemotherapyaswellasduringbothherpregnancies.

•  Whatriskfactorsdoesshehave?•  Whattypesofn/vissheatriskfor?

Francesca

•  DetermineemetogenicpotenIal

•  Determinecauses•  ConsidertheduraIonandpaRernofemesis

•  EnsureanI-emeIcprotocolisappropriate

•  EvaluatepaIentresponse

Assessment

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• Prevent!• Medicate!• Dosomethingelse!(Non-pharmacologic)

Treatment PharmacologicManagement

•  Benzodiazepine•  Olanzapine•  Cannabinoid•  CorIcosteroid•  Dopamineantagonist

•  NK1antagonist•  Serotoninantagonist

Polovich,p.199-203

Serotoninantagonist•  Examples:Ondansetron,Dolasetron,Palonosetron,NEPA(Netupitant&Palosetron)•  Mechanism:Serotoninreceptorantagonist(5HT3)•  Route:PO,IV,oraldisintegraIngtablet,transdermalpatch•  IndicaIons:PrevenIonofCINV•  Sideeffects:Headache,diarrhea,consIpaIon,faIgue•  NursingconsideraIons:EnsurecompaIbilitywithconcurrent

drugadministraIon

Polovich,p.201Eisai,packageinsert,2014

CorIcosteroid

•  Example:Dexamethasone•  Mechanism:AnIprostaglandinsynthesis•  Route:POorIV•  IndicaIon:PrevenIonofn/vincludingdelayedn/v•  Sideeffects:insomnia,anxiety,acne•  NursingconsideraIons:AdministerIVdosesslowlytopreventperianalorvaginalburning

Polovich,p.199

AnxiolyIc

•  Example:Lorazepam•  Mechanism:CNSdepressant•  Route:POorIV•  IndicaIons:AnIcipatoryN/Vandasneededforacuteanddelayed

•  Sideeffects:sedaIon,confusion,agitaIon,hallucinaIons

•  NursingconsideraIons:UsewithcauIoninelderlypaIents;givefirstdoseatnight

Polovich,p.199

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Dopamineantagonist

•  Examples:Haloperidol,Metoclopramide,Prochlorperazine

•  Mechanism:Blocksdopaminereceptors•  Route:POorIV•  IndicaIons:Delayedorbreakthrough•  Sideeffects:sedaIon,extrapyramidalsymptoms,dizziness,orthostasis

•  NursingconsideraIons:monitorsedaIon

Polovich,p.199

AnIpsychoIc

•  Example:Olanzapine•  Mechanism:mulIpleCINVreceptors•  Route:PO•  IndicaIons:BreakthroughN/V•  Sideeffects:Drymouth,weightgain,dizziness,sedaIon

•  NursingconsideraIons:ContraindicatedinolderadultpaIentswithdemenIa

Polovich,p.199

Cannabinoid•  Example:Dronabinol•  Mechanism:Interactswithcannabinoidreceptors•  Route:PO•  IndicaIons:TreatmentagerstandardanIemeIcfailure•  Sideeffects:verIgo,euphoria,dysphoria,drymouth,

tachycardia,orthostasis•  NursingconsideraIons:IncidenceofparanoidreacIons;use

withcauIoninpaIentswithhistoryofpsychiatricillness

Polovich,p.199

Neurokinin-1antagonist

•  Example:Aprepitant•  Mechanism:Neurokinin-1receptorantagonist•  Route:predominantlyPO.IVformalsoavailable•  IndicaIon:AcuteanddelayedCINV•  Sideeffects:ConsIpaIon,hiccups,diarrhea,faIgue•  NursingConsideraIons:Drugisdosedfor3days.AssessfordruginteracIons

Polovich,p.200-1

Non-pharmacologicIntervenIons•  Acupuncture•  Behavioral•  Dietary–  Small,frequentmeals–  AvoidovereaIng–  AvoidfaRy,spicy,saltyfood–  Encouragecoldorroom-temperaturefoods–  Dietaryconsult–  Avoidyourfavoritefoods

Polovich,pp.204-5

PaIentandFamilyEducaIon

•  NoIfyteamifitlasts>24hoursorunabletomaintainfluidintake

•  EnsureanI-emeIcsaretakenasprescribed•  Follow-upwithpaIents24-48hoursagertreatmenttoevaluateeffecIveness(orsooner)

•  Provideresources

Polovich,pp.205-6

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Now,she’stwodayspostchemo,callsyouintoherroombeforetheendofyourshigandtellsyoushethrewup.•  Howwouldyouassesshernausea?

•  WhatkindofmedicaIonswouldyouexpecthertobeon?

Francesca

•  PutngevidenceintopracIce(ONS)

•  QuesIons?

PEPResources

•  YoucomeinathreedaysagerFrancescareceivedhertransplant.Inthemorningshetellsyouherlipsarereallydry,shehasanawfultasteinhermouth,andherthroathurts.What’shappening?

Francesca

– InflammaIonofanymucosalmembranes,oraltoanus– OralmucosiIs-inflammaIonofanyoralIssue– StomaIIsincludesoralinfecIons-inflammatorydiseasesoftheoralcavity– AlimentarytractmucosiIs-mucosaldamagethroughoutthedigesIvetract

MucosiIs

PathophysiologyandTimeline

(Sonis,S.2004)

•  Pain•  Limitedoralintake,poornutriIon•  InfecIons•  Decreasedqualityoflife•  TreatmentdelaysordosereducIon•  AspiraIon•  LossofairwayprotecIon

Sowhat?

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•  Overall30-100%•  Transplantrecipientsup

to100%•  HeadandneckradiaIon

65-90%

–  AnImetabolites(bolus5-FU)–  AnItumoranIbioIcs–  AlkylaIngagents(highdosemelphalan)

–  IL-2,Interferon–  Neutropenia–  Oxygentherapy,anIcholinergics,phenytoin,steroids

–  TBI,headandneckradiaIon–  MethotrexateforGVHDprophylaxispostHSCT

)

Incidence&RiskFactors PersonalRiskFactors

•  Dentaldisease,poororalhygiene•  Ill-fitngdentures•  Advancedageandyouth•  Historyofalcoholandtobaccouse•  PoornutriIon•  ConsumpIonofirritaIngfoods•  DehydraIon•  HepaIcorrenaldysfuncIon

Assessment:GradingScales

hRps://www.uspharmacist.com/arIcle/mucosiIs-in-cancer-paIents-a-review

hRp://chicagocancer.com/wp-content/uploads/2014/02/February-2014-EdiIon-The-Use-of-GabapenIn-for-RadiaIon-Induced-MucosiIs-in-Head-and-Neck-Cancer-PaIents.pdf

•  Scalloping•  SecreIons•  Redness•  Ulcers•  Bloodblisters•  Thrush•  Dryness•  Crackedlips

Whattolookfor PrevenIon•  Nostandardofcare•  Treatpre-exisIngdentalissues•  Goodoralcarebeforetreatment•  Oralcareprotocols–  PaIenteducaIon–  Blandrinses

•  Cryotherapy•  Bolus5-FU,bolusedatrexate,highdosemelphalan

•  Palifermin•  AutologousHSCT

•  LowLevelLaserTherapy(LLLT)

)

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Management

•  Nostandardofcare•  SymptomManagement•  NutriIon•  PainManagement– PCA

•  SucIoning•  Oralcare– Frequentrinses,hydraIon(>1500ml)– Sodiumbicarb

PaIentandFamilyEducaIon

• Managetheirexpecta0ons!•  Keeporalcavityclean,moist,intact•  DailyoralselfexaminaIon•  Oralhygiene•  Moisturizelips•  MaintainhydraIon•  AvoidirritaIngfood•  Proteinrichdiet

•  Francesa’smucosiIsisworsening.Yesterdayshesaidshehadafewbitesofapplesaucebuthasn’teatensincethen.YoucheckherI&OsandnoIcethatshe’snegaIve1Lwithnochartedintake.Shealsoratesherpainata9/10whensheswallows,a6/10whenresIng.Shehas6hugepillstoswallowwithhermorningmeds.

Whatorderswouldyouexpectonceyoutalktoherdoctor?WhateducaIondoyouprovide?

Francesca

•  LooseorwaterystoolsabovethepaIent’sbaseline

•  Incidencedependsondisease,treatment– Chemo– RadiaIon

Diarrhea

Pathophysiology

–  OsmoIc•  Gutinjury•  Largevolumesofstool•  ImprovedwithfasIngoreliminaIvecausaIvefactor(lactose)

–  Secretory•  IntesInessecretemorefluidsandelectrolytesthancanbeabsorbed•  Chemo,radiaIon,GVHD•  ImprovedwithparenteralnutriIonfollowedbyslowdietprogression

–  ExudaIve•  AlteraIonsinmucosalintegrity,epithelialloss,defecIveabsorpIon•  InflammaIon•  Morethan6stools/day•  Rehydrate,BRATdiet

Polovich,p.206

Sowhat?

•  DehydraIon•  Orthostasis•  Electrolyteimbalances•  malnutriIon•  Cardiovascularorrenalcompromise

•  ImpairedimmunefuncIon

•  Perianalskinbreakdown

•  ReducedabsorpIonoforalmedicaIons

•  Pain•  Anxiety•  ExhausIon•  DecreasedQOL

Polovich,p.207

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RiskFactors

Treatmentrelated•  RadiaIontopelvis,

abdomen,orspine•  5-FUincombinaIonwith

high-doseleucovorin•  Irinotecan•  EGFR-targetedtherapies•  MulI-targetedtyrosine

kinaseinhibitors•  Immunosuppression

Physical&ClinicalFactors•  IntesInalresecIonor

gastrectomy•  ManipulaIonofbowel

duringsurgery•  IntesInalinfecIon•  GVHD•  Dietarycauses•  InflammaIon,IBS•  ObstrucIon•  Anxietyandstress

Polovich,p.208

Assessment

•  StoolpaRern•  PhysicalAssessment•  Diethistory•  MedicaIonhistory•  ContribuIngfactors•  ObjecIvemeasurement

•  7daysin,Francescahasbeentothebathroom4Imesinthefirst4hoursofyourshig.

•  HowwouldyouobjecIvelymeasureFrancesca’sdiarrhea?

Francesca CollaboraIveManagement

•  Monitorstooloutput•  Replacefluidsandelectrolytes•  Ruleout/treatinfecIouscause•  AdministeranIdiarrheal•  ProbioIcs-underinvesIgaIon•  Assess&treatothercauses(GVHD)

PharmaceuIcalManagement

•  AnImoIlityagents–  LomoIl,Imodium

•  SomostaInanalog–  OctreoIde

•  AnIcholinergic–  Atropine

•  Irinotecancommonprotocol–  atropinesubcutaneous0.5-1mgpre-infusion

–  loperamidefordelayeddiarrhea

PaIent&FamilyEducaIon

•  TakemedicaIonsasprescribed•  Avoidfoodshighininsolublefiber•  Includefoodshighinsolublefiber•  Limitoravoidmilkanddairyproducts•  AvoidhyperosmoIcsupplements•  Cleanrectalareawithmildsoapandwater•  Applymoisturebarrierointment•  Takewarmsitzbaths•  Reportseveresymptoms

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•  Infrequentbowelmovements&stoolthatisdifficulttopass

•  Incidencedependsontreatment,riskfactors– 50-95%ofpaIents– Morecommoninthosetakingopioids

ConsIpaIon SoWhat?

•  Abdominalorrectaldiscomfort•  Nausea/vomiIng•  Anorexia•  ImpacIon•  Ileus•  Analfissures•  Hemorrhoids•  Rupturedbowelandlife-threateningsepsis

RiskFactors•  Opioids•  Vincaalkaloids(decrease

moIlity)•  Thalidomide,lenalidomide,

bortezomib•  5HT3antagonists

ConsIpaIon

•  Advancedage•  Autonomicnervoussystem

dysfuncIon•  Spinalcordcompression•  Metaboliceffects•  DehydraIon•  Immobility

Assessment

ü PaRernsofeliminaIonü Dietaryintakeü Mobility,acIvitylevelü Abdominalpain,distension,bowelsoundsü CharacterisIcsoflastBMü CurrentmedicaIonsü Laboratoryvalues-metabolicevaluaIonü Abdominal/rectalexamifappropriateü Radiographicstudies

Non-PharmacologicTreatment

ü IncreasephysicalacIvityorpassiveexerciseü MaintainusualbowelhabitsduringhospitalizaIonü Increasefluidandfiberintakeü ObtainnutriIonalconsult

CollaboraIveManagementType Example Considera4ons

Bulkforming Psyllium Takewithwater

Lubricant Mineraloil CanleadtomalabsorpIonofvitamins

Saline Magnesiumsalts AcuteevacuaIon

OsmoIc Polyethyleneglycol(PEG) RecommendedforpersistentconsIpaIon

Detergent Docusatesodium Shorttermuse

SImulant Bisacodyl,senna ProphylacIcplan

ProkineIcagents Metoclopramide PromotemoIlity;anIemeIcproperIes

Methylnaltrexone Relistor® Opioid-induced

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CaseStudy

BobJonesisa69yearoldpaIentwithmetastaIcprostatecanceradmiRed3daysagowithseverebony,deeppelvicandbackpain.HehasbeenimmobilizedwithpainandtakingnarcoIcopioidsforanalgesia.Hehasbeenonstoolsogeners.TodayyouhavegavehimMagnesiumcitrate.Duetopainandweakness,youassistedhimseveralImestothebedsidecommodewithunsuccessfulbowelresultstoday.

Whatriskfactorsdoeshehave?Whatelsemightbedoneforhim?

PaIent&FamilyEducaIon

•  Increasefluid•  Increasefiberindiet•  Fruits,vegetables,wholegrains•  Consume25-30g/dayiftolerated

•  Exerciseregularly•  UsediaphragmaIcbreathingtoincreasemuscletone•  CallMDifnoBMfor3days•  PrevenIveplanforallpaIentsonopioids

Anorexia&Cachexia

•  Anorexia-Lossofadesiretoeat•  Cachexia– MulIfactorialsyndrome– Lossofmusclemass– CannotbereversedwithnutriIonalsupport– NegaIveproteinandenergybalance

•  Decreasedadherencetochemotherapy•  Increaseintreatmenttoxicity•  MorefrequenthospitalizaIons•  Decreaseintreatmentresponse•  Decreasedqualityoflife•  Decreaseinsurvival

Sowhat?

Pathophysiology•  Tumoreffect

–  ObstrucIonleadstomalabsorpIon,N/V,pain–  Pro-inflammatorycytokinescausesaIetyandmetabolicabnormaliIes

•  Treatmenteffects–  SurgerymaycausemalabsorpIon,obstrucIon,fluid&electrolyteabnormaliIes

–  Chemotherapy/radiaIonsideeffects:N/V,mucosiIs,consIpaIon,etc.

•  Psychosocialeffects–  Depression,anxiety,grief–  Bodyimagechanges

RiskFactors

•  Advancedcancer•  Head&Neck,GI,lungcancer•  Chronicillness-pulmonarydisease,CHF•  Veryyoungorolderadults•  MulImodalitytherapy

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ClinicalManifestaIons

•  Involuntaryweightlossof>5%

•  ChangesinappeIte–  Changesintasteandsmell

–  EarlysaIety•  ChangesinGItractfuncIon

•  Lossofmusclemass

•  LossofadiposeIssue•  FaIgue/weakness•  Immunesystemimpairment

•  MetabolicdysfuncIon•  Hypoalbuminemia

Assessment

•  Monitorweight•  Obtaindiethistory-usefooddiary•  MeasurebodycomposiIon•  Labtests-endocrineabnormaliIes•  AssessfuncIonalstatus

CollaboraIveManagement

•  AssesspaIent’sgoals•  Treatunderlyingcancer•  ProgesInsandcorIcosteroids– Megace–  ImprovesappeIteandweightgain;doesnotimproveQOL–  Sideeffects:DVT,edema,impotenceinmen,GIdisturbances

PaIentEducaIon&Strategies•  Focusonqualityoflife•  RefertodieIIan-highproteinrecommendaIons•  Providehigh-calorie/highproteinsupplementsastolerated•  EnteralorparenteralnutriIon•  Smallfrequentmeals•  ARracIvesetngformeals•  EncouragephysicalacIvity•  Controlothersymptoms(mucosiIs,n/v,drymouth,etc.)•  IncludepaIentinfamilyacIviIes•  Refertocommunityresources•  ReferforpsychosocialintervenIonsandemoIonalsupport

•  Cancer.gov•  SideeffecttrackersfromtheAmericanCancerSociety

•  InsItuIonalHandouts•  PEPGuidelines•  ONSPublicaIons:hRps://www.ons.org/pracIce-resources/books

Resources

•  hRp://www.slideshare.net/RIPS-14/vomiIng•  hRp://alltaskstraducoes.com.br/vdisk/29/vomiIng-center-hypothalamus

•  NaIonalCancerInsItute(2015).Sideeffects:Nausea.RetrievedfromhRps://www.cancer.gov/about-cancer/treatment/side-effects/nausea/nausea-pdq

•  Polovich,M.,Olsen,M.,LeFebvre(2014).ChemotherapyandBiotherapyGuidelinesandRecommendaIonsforPracIce(4thEdiIon).OncologyNursingSociety

references