3/18/17

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SymptomManagement:Gastrointes7nalAltera7ons

AngelaKnox,RN,BSN,OCNUniversityofWashingtonMedical

Center

Objec7ve

•  Describethe– incidence– riskfactors– assessment– interven7ons•  forthemanagementofgastrointes7nalsideeffectsfromcancer&cancertreatment

GITRACT!

Whatwe’retalkingabout

•  YouTube•  Nausea&Vomi7ng•  Mucosi7s•  Diarrhea•  Cons7pa7on•  Anorexia/Cachexia

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NAUSEA&VOMITING

Nausea&vomi7ng

•  Nausea&vomi7ngaresomeofthemostfearedsideeffectsofcancertreatment

•  Providersoveres7matehowwellwecontrolnauseaandvomi7ngcomparedtoreportedpa7entexperiences

•  Heathcarecostsarehigherforpa7entswithuncontrollednausea&vomi7ng

Nausea&vomi7ng:DEFINED

– Nausea–unpleasant“wavelike”feeling,mayleadtovomi7ng,subjec7ve

– Retching(Akadryheaves)-rhythmiccontrac7on– Vomi7ng-forcefulexpulsionofcontentsofthestomach,reflex

Reference:Clayton&Willinhnganz(2013).BasicPharmacologyforNurses(16thed)

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Neuroreceptors(don’tmemorize)•  Serotonin(5-HT3)-releaseac7vatesvagusnerve•  SubstanceP-foundinvagalafferentneurons-believedtobetriggerfordelayedn/v

•  Dopamine-2•  Cor7costeroid•  Neurokinin-1•  Muscarinic•  Opioid•  Acetylcholine•  Cannabinoid•  Histamine

Sowhat?

•  Nausea&vomi7ngcanleadto:–  Dehydra7on–  Electrolyteimbalances–  Lowappe7te– Malnutri7on–  Poorqualityoflife–  Treatmentdelays–  Hospitaliza7on–  Tornesophagus–  Brokenbones–  Reopeningofsurgicalwounds

Riskfactors

DiseaseRelated

•  TumorsofCNS•  Delayedgastricemptying•  Obstruc7on•  Foodtoxins,infec7on,mo7on

sickness•  Metabolicchanges

TreatmentRelated

•  S7mula7onofreceptorsonlabyrinthininnerear

•  Obstruc7on,irrita7on,inflamma7on,delayedemptying

•  Chemotherapy•  Medica7onsideeffects

RiskFactors

Situa;onal•  <50yearsold•  Female•  Stress,anxiety•  Odors,s7muli•  An7cipa7on•  PriorGIissues

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PamernsofNausea

•  An7cipatory–beforeorduringtreatment

•  Acute–within24hoursoftreatment

•  Delayed–morethan24hoursanertreatment

•  Breakthrough–despitean7eme7cs

•  Chronic-ongoing

Chemotherapy

•  N/V-Determinedbytypeofchemotherapy/treatment

•  Combina7on=higherincidence

•  Emetogenicpoten7al(NCCN&ASCO)–  Highrisk>90%–  Moderaterisk30-90%–  Low10-30%–  Minimal<10%

   

 

 

 

 

 

Emetogenicity  Agents (alphabetically)  Emetogenicity  Agents (alphabetically)  

5 1 1 2 4 1 3 1 3 3 1 2 1 1 4 2 4 4 5 1 1 5 4 1 3 1 3 3 4 5 2 4 5 4 1 3 1 1 2 2 3 4 3 4 1 2 2 1/2 

AC combo: doxorubicin or epirubicin + cyclophosphamide Alemtuzumab Alpha Interferon < 5000 IU/m2 Amifostine < 300 mg Amifostine > 300 ‐ 500 mg/m2 Androgens Arsenic trioxide Asparaginase Azacitadine Bendamustine Bevacizumab Bexarotene (oral) Bleomycin Bortezomib Busulfan > 4 mg/d Capecitabine (oral) Carboplatin Carmustine ≤ 250 mg/m2 Carmustine > 250 mg/m2 Cetuximab Chlorambucil (oral) Cisplatin ≥50 mg/m2 Cisplatin < 50 mg/m2 Cladribine Clofarabine Corticosteroids Cyclophosphamide (oral) Cyclophosphamide ≤ 750 mg/m2 Cyclophosphamide > 750 mg/m2 to ≤ 1,500 mg/m2 Cyclophosphamide > 1,500 mg/m2 Cytarabine (low dose) 100‐200 mg/m2 Cytarabine > 1 g/m2 Dacarbazine Dactinomycin Dasatinib (oral) Daunorubicin Denileukin diftitox Dexrazoxane Docetaxel Doxorubicin (liposomal) Doxorubicin < 60 mg/m2 Doxorubicin >60mg/m2 Epirubicin ≤ 90 mg/m2 Epirubicin > 90 mg/m2 Erlotinib (oral) Etoposide Fluorouracil Fludarabine 

 

2 1 1 3 1 1 3 1 3 3 1 1 2 3 5 1 4 1 2 3 4 2 2 1 3 2 1 2 1 5 1 2 5 2 3 1 2 1 2 1 1 1 1 1 1 3 2  

 

Gemcitabine Gemtuzumab ozogamicin Gefitinib (oral) Hexamethylmelamine (oral) Hydroxyurea (oral) Ibritumomab tiuxetan Ifosfamide Imatinib mesylate (oral) Interleukin‐2 > 12‐15 million units/m2 Irinotecan Ixabepilone Lapatinib (oral) Lenalidomide Lomustine (oral) Mechlorethamine Melphalan (oral low‐dose) Melphalan > 50 mg/m2 Methotrexate ≤ 50 mg/m2 Methotrexate > 50 mg/m2 < 250 mg/m2 Methotrexate 250‐1,000 mg/m2 Methotrexate > 1,000 mg/m2 Mitomycin Mitoxantrone < 15 mg/m2 Nelarabine Oxaliplatin > 75 mg/m2 Paclitaxel/Paclitaxel albumin‐bound Panitumumab Pemetrexed Pentostatin Procarbazine (oral) Rituximab Sorafenib (oral) Streptozocin Sunitinib (oral) Temozolomide (oral) Temsirolimus Teniposide Thioguanine (oral) Topotecan Tositumomab Trastuzumab Tretinoin (oral) Vinblastine Vincristine Vinorelbine Vinorelbine (oral) Vorinostat (oral) 

NCCN Levels of Emetogenicity: Level 5 – High Emetic Risk: 90% frequency of emesis Level 3/4 – Moderate Emetic Risk: 30‐90% frequency of emesis Level 2 – Low Emetic Risk: 10‐30% frequency of emesis Level 1 – Minimal Emetic Risk: <10% frequency of emesis

Emetogenic Risk of Chemotherapy and Biotherapy Agents  

 

Francesca

•  Francescaisa38yearoldwomanwithAMLandisgoingtoreceiveCyclophosphamideandBusulfanpriortoherallogenictransplant.Sheisnervousabouthercondi7oningchemotherapybecausesheexperiencedseverenauseaandvomi7ngwithpriorchemotherapyaswellasduringbothherpregnancies.

•  Whatriskfactorsdoesshehave?•  Whattypesofn/vissheatriskfor?

Assessment

•  Signsofdehydra7on•  Swea7ng,tachycardia,dizziness,weakness

•  Labvalues:electrolytes,kidney&liverfunc7ontests,I&Os

•  Weights

•  Emetogenicpoten7alofchemo

•  Poten7alcauses/riskfactors

•  Dura7onandpamernofemesis

•  Isan7-eme7cprotocolisappropriate?

•  Pa7entresponsetotreatment

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Treatment

•  Prevent!•  Medicate!•  Trysomethingelse!

PharmacologicManagement

•  Serotoninantagonist•  Benzodiazepine•  Cannabinoid•  Cor7costeroid•  Dopamineantagonist

•  NK1antagonist•  An7psychoitc

Polovich,p.199-203

Serotoninantagonist•  Examples:Ondansetron(Zofran),Dolasetron(Anzamet),

Granisetron(Kytril),Palonosetron(Aloxi),NEPA(Netupitant&Palosetron)

•  Mechanism:Serotoninreceptorantagonist(5HT3)•  Route:PO,IV,oraldisintegra7ngtablet,transdermalpatch•  Indica;ons:Preven7on•  Sideeffects:Headache,diarrhea,cons7pa7on,fa7gue•  Nursingconsidera;ons:Ensurecompa7bilitywithconcurrent

drugadministra7on,QTprolonging

Polovich,p.201Eisai,packageinsert,2014

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Cor7costeroid

•  Example:Dexamethasone(Decadron)•  Mechanism:An7prostaglandinsynthesis•  Route:POorIV•  Indica;on:Preven7on,includingdelayed•  Sideeffects:insomnia,anxiety,acne•  Nursingconsidera;ons:AdministerIVdosesslowlytopreventperianalorvaginalburning

Polovich,p.199

Anxioly7c

•  Example:Lorazepam(A7van)•  Mechanism:CNSdepressant•  Route:POorIV•  Indica;ons:An7cipatory&asneededforacuteanddelayed

•  Sideeffects:seda7on,confusion,agita7on,hallucina7ons

•  Nursingconsidera;ons:Usewithcau7oninelderlypa7ents;givefirstdoseatnight

Polovich,p.199

Dopamineantagonist

•  Examples:Haloperidol(Haldol),Metoclopramide(Reglan),Prochlorperazine(Compazine)

•  Mechanism:Blocksdopaminereceptors•  Route:POorIV•  Indica;ons:Delayedorbreakthrough•  Sideeffects:seda7on,extrapyramidalsymptoms,dizziness,orthostasis

•  Nursingconsidera;ons:monitorseda7on

Polovich,p.199

An7psycho7c

•  Example:Olanzapine(Zyprexa)•  Mechanism:mul7pleCINVreceptors•  Route:PO•  Indica;ons:Breakthrough•  Sideeffects:Drymouth,weightgain,dizziness,seda7on

•  Nursingconsidera;ons:Contraindicatedinolderadultpa7entswithdemen7a

Polovich,p.199

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Cannabinoid•  Example:Dronabinol(Marinol)•  Mechanism:Interactswithcannabinoidreceptors•  Route:PO•  Indica;ons:Treatmentanerstandardan7eme7cfailure•  Sideeffects:ver7go,euphoria,dysphoria,drymouth,

tachycardia,orthostasis•  Nursingconsidera;ons:Incidenceofparanoidreac7ons;use

withcau7oninpa7entswithhistoryofpsychiatricillness

Polovich,p.199

Neurokinin-1antagonist

•  Example:Aprepitant(Emend)•  Mechanism:Neurokinin-1receptorantagonist•  Route:predominantlyPO.IVformalsoavailable•  Indica;on:Acute&delayed•  Sideeffects:Cons7pa7on,hiccups,diarrhea,fa7gue•  NursingConsidera;ons:Drugisdosedfor3days.Assessfordruginterac7ons

Polovich,p.200-1

Non-pharmacologicInterven7ons

•  Acupuncture•  Behavioral•  Dietary– Mealpamerns,bland,chilled– Fluidintake

Polovich,pp.204-5

Pa7entandFamilyEduca7on

•  No7fyteamifitlasts>24hoursorunabletomaintainfluidintake

•  Ensurean7-eme7csaretakenasprescribed•  Follow-upwithpa7ents24-48hourstoevaluateeffec7veness(orsooner)

•  Provideresources

Polovich,pp.205-6

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Francesca

Now,she’stwodayspostchemo,callsyouintoherroombeforetheendofyourshinandtellsyoushethrewup.•  Howwouldyouassesshernausea?

•  Whatkindofmedica7onswouldyouexpecthertobeon?

PEPResources

•  Puwngevidenceintoprac7ce(ONS)

•  Ques7ons?

Francesca•  YoucomeinathreedaysanerFrancescareceivedher

transplant.Inthemorningshetellsyouherlipsarereallydry,shehasanawfultasteinhermouth,andherthroathurts.What’shappening?

MUCOSITIS

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Mucosi7s-Defini7on

– Mucosi7s-Inflamma7onofanymucosalmembranes,oraltoanus– Oralmucosi7s-inflamma7onofanyoral7ssue– Stoma77s-includesoralinfec7ons-inflammatorydiseasesoftheoralcavity– Alimentarytractmucosi7s-mucosaldamagethroughoutthediges7vetract

PathophysiologyandTimeline

(Sonis,S.2004)

Sowhat?

•  Pain•  Limitedoralintake,poornutri7on•  Infec7ons•  Decreasedqualityoflife•  Treatmentdelaysordosereduc7on•  Aspira7on•  Lossofairwayprotec7on

RiskFactors

Personal

•  Dentaldisease,poororalhygiene

•  Ill-fiwngdentures•  Advancedageandyouth•  Historyofalcoholand

tobaccouse•  Poornutri7on•  Consump7onofirrita7ng

foods•  Dehydra7on•  Hepa7correnaldysfunc7on

Treatment–  Drugs:An7metabolites(bolus

5-FU);An7tumoran7bio7cs;Alkyla7ngagents(highdosemelphalan)

–  IL-2,Interferon–  Neutropenia–  Oxygentherapy,

an7cholinergics,phenytoin,steroids

–  Radia7on:Head,NeckBody–  MethotrexateforGVHD

prophylaxis

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Assessment:GradingScales

hmps://www.uspharmacist.com/ar7cle/mucosi7s-in-cancer-pa7ents-a-review

GradingScale

hmp://chicagocancer.com/wp-content/uploads/2014/02/February-2014-Edi7on-The-Use-of-Gabapen7n-for-Radia7on-Induced-Mucosi7s-in-Head-and-Neck-Cancer-Pa7ents.pdf

Assessment

•  Scalloping•  Secre7ons•  Redness•  Ulcers•  Bloodblisters•  Thrush•  Dryness•  Crackedlips

•  Treatmenthistoryandriskfactors,weighthistory

•  Symptoms,ea7nganddrinkingpamers

•  EffectonQOL

Preven7on

Nostandardofcare

•  Treatpre-exis7ngdentalissues•  Goodoralcarebeforetreatment•  Oralcareprotocols•  Cryotherapy•  Goodnutri7on–proteinintake•  Palifermin•  LowLevelLaserTherapy

)

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Management

Nostandardofcare

•  Symptom&PainManagement•  Nutri7on•  Suc7oning•  Oralcare– Frequentrinses,hydra7on(>1500ml)

Pa7entandFamilyEduca7on

Manageexpecta-ons•  Keeporalcavityclean,moist,intact•  Dailyoralselfexamina7on•  Oralhygiene•  Moisturizelips•  Maintainhydra7on•  Avoidirrita7ngfood•  Proteinrichdiet

FrancescaFrancesa’smucosi7sisworsening.Yesterdayshehadafewbitesofapplesaucebuthasn’teatensincethen.YoucheckherI&Osandno7cethatshe’snega7ve1Lwithnochartedintake.Shealsoratesherpainata9/10whensheswallows,a6/10whenres7ng.Shehas6hugepillstoswallowwithhermorningmeds.

•  Whatorderswouldyouexpectonceyoutalktoherdoctor?

•  Whateduca7ondoyouprovide? DIARRHEA

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Diarrhea

•  Looseorwaterystoolsabovethepa7ent’sbaseline

•  Incidencedependsondisease,treatment– Chemo– Radia7on

Pathophysiology

–  Osmo7c•  Unabsorbablesubstancesingut,increasedfluidinGItract•  I.e.lactoseintolerance,tubefeedings,GIhemhorrage

–  Secretory•  Intes7nessecretemorefluidsandelectrolytesthancanbeabsorbed•  I.e.Cdiff,laxa7ves,neuroendocrinetumors

–  Hypermo7lity•  Limitedabsorbp7onduetoincreasemo7lity•  Inflammatoryboweldisease,chemo,radia7on,GVHD

Polovich,p.206

Sowhat?

•  Dehydra7on•  Electrolyteimbalances•  Orthostasis•  Malnutri7on•  Cardiovascularorrenalcompromise

•  Impairedimmunefunc7on

•  Perianalskinbreakdown

•  Reducedabsorp7onoforalmedica7ons

•  Pain•  Anxiety•  Exhaus7on•  DecreasedQOL

Polovich,p.207

RiskFactors

Treatmentrelated•  Surgery•  Radia7ontoabdomen•  Chemo:Irinotecan,EGFR-

targetedtherapies,Mul7-targetedtyrosinekinaseinhibitors

•  Meds:an7bio7cs,laxa7ves,antacids

•  Tubefeedings•  GVHD

Physical&Clinical•  Dietarycauses•  Inflamma7on,IBS•  Obstruc7onorimpac7on•  Anxietyandstress

Polovich,p.208

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Assessment

History•  Stoolpamerns•  Diethistory•  Medica7on,treatments•  Stress•  Allergiesorintolerances

PhysicalAssessment•  Weightloss•  I&Os•  Bowelsounds•  Flatus,cramping,pain,

urgency,bloa7ng•  Signsofdehydra7on•  Perianalskin

Collabora7veManagement

•  Monitorstooloutput•  Replacefluidsandelectrolytes•  Ruleout/treatinfec7ouscause•  Administeran7diarrheal•  Probio7cs-underinves7ga7on•  Assess&treatothercauses

Pharmaceu7calManagement

•  An7mo7lityagents– Lomo7l,Imodium

•  Somosta7nanalog– Octreo7de

•  An7cholinergic– Atropine

•  Irinotecancommonprotocol– atropinesubcutaneous0.5-1mgpre-infusion

–  loperamidefordelayeddiarrhea

Pa7ent&FamilyEduca7on

•  Takemedica7onsasprescribed•  Dietmodifica7on

–  Avoidhighresiduefoods–  Includeinsolublefiber–  Limitoravoiddairy

•  Avoidhyperosmo7csupplements•  Cleanrectalarea•  Applymoisturebarrierointment•  Reportseveresymptoms

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CONSTIPATION

Cons7pa7on

•  Infrequentbowelmovements&stoolthatisdifficulttopass

•  Incidencedependsontreatment,riskfactors– 50-95%ofpa7ents– Morecommoninthosetakingopioids

SoWhat?

–  Abdominalorrectaldiscomfort–  Nausea/vomi7ng–  Anorexia–  Impac7on–  Ileus–  Analfissures–  Hemorrhoids–  Rupturedbowelandlife-threateningsepsis

Cons7pa7on

RiskFactors•  Advancedage•  Autonomicnervoussystem

dysfunc7on•  Spinalcordcompression•  Metaboliceffects•  Dehydra7on•  Immobility•  Anorexia•  Surgery•  Situa7onal

•  Opioids•  Certainchemotherapy:

VincaalkaloidsThalidomide,lenalidomide,bortezomib

•  5HT3antagonists

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Assessment

Physical

•  Abdominalpain,distension,bowelsounds

•  Bowelsounds,palpa7on•  Laboratoryvalues•  Abdominal/rectalexamif

appropriate•  Radiographicstudies

History•  LastBM•  Pamernsandcharacteris7cs•  Medica7onchanges•  Dietchanges/fluids•  Mobility,ac7vitylevel

Collabora7veManagement

•  Surgicalcorrec7onofobstruc7on•  Correctfluidandelectrolytes•  Enemasorirriga7ons•  Increasedfiber,fluids– Nutri7onalconsult?

•  Exercise/ac7vity•  Medica7ons….

Medica7ons•  S7mulantlaxa7ves–bowelcontrac7ons

–  Senna,bisacodyl•  Osmo7claxa7ves–increasebulkbyretainingwater

– MiraLax,Magnesiumsalts,Sodiumphosphate•  Bulk-forminglaxa7ves–increasebulkofstool

–  Psyllium•  Emollientandlubricantlaxa7ves–sonenhardenedfeces

– Mineraloil,docusate•  Other

–  Glycerinsuppository,lactulose•  Realistor–foropioidinducedcons7pa7on

CaseStudy

BobJonesisa69yearoldpa7entwithmetasta7cprostatecanceradmimed3daysagowithseverebony,deeppelvicandbackpain.Hehasbeenimmobilizedwithpainandtakingopioids.Hehasbeenondocusateathome.Today,youhavegavehimMagnesiumcitrate.Youhelphimtothebedsidecommodetwicewithunsuccessfulbowelresultstoday.•  Whatriskfactorsdoeshehave?•  Whatelsemightbedoneforhim?

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Pa7ent&FamilyEduca7on

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

•  Exerciseregularly•  Usediaphragma7cbreathingtoincreasemuscletone•  CallMDifnoBMfor3days•  Preven7veplanforallpa7entsonopioids

TASTECHANGES,ANOREXIA&CACHEXIA

Tastechanges,Anorexia,Cachexia

•  TasteChanges–actualorperceivedchangesintastesensa7onorlossoftaste

•  Anorexia-Lossofadesiretoeat•  Cachexia– Mul7factorialsyndrome– Lossofmusclemass– Cannotbereversedwithnutri7onalsupport– Nega7veproteinandenergybalance

Sowhat?

•  Decreasedadherencetochemotherapy•  Increaseintreatmenttoxicity•  Morefrequenthospitaliza7ons•  Decreaseintreatmentresponse•  Decreasedqualityoflife•  Decreaseinsurvival

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Pathophysiology•  Tumoreffect

–  Obstruc7onleadstomalabsorp7on,N/V,pain–  Pro-inflammatorycytokinescausesa7etyandmetabolicabnormali7es

•  Treatmenteffects–  Surgerymaycausemalabsorp7on,obstruc7on,fluid&electrolyteabnormali7es

–  Chemotherapy/radia7onsideeffects:N/V,mucosi7s,cons7pa7on,etc.

•  Psychosocialeffects–  Depression,anxiety,grief–  Bodyimagechanges

RiskFactors

•  Advancedcancer•  Head&Neck,GI,lungcancer•  Chronicillness-pulmonarydisease,CHF•  Veryyoungorolderadults•  Mul7modalitytherapy

ClinicalManifesta7ons

•  Involuntaryweightlossof>5%

•  Changesinappe7te–  Changesintasteandsmell

–  Earlysa7ety•  ChangesinGItractfunc7on

•  Lossofmusclemass

•  Lossofadipose7ssue•  Fa7gue/weakness•  Immunesystemimpairment

•  Metabolicdysfunc7on•  Hypoalbuminemia

Assessment

•  Monitorweight•  Obtaindiethistory-usefooddiary•  Measurebodycomposi7on•  Labtests-endocrineabnormali7es•  Assessfunc7onalstatus

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Collabora7veManagement

•  Assesspa7ent’sgoals•  Treatunderlyingcancer•  Proges7nsandcor7costeroids

– Megace–  Improvesappe7teandweightgain;doesnotimproveQOL–  Sideeffects:DVT,edema,impotenceinmen,GIdisturbances

Pa7entEduca7on&Strategies•  Focusonqualityoflife•  Refertodie77an•  Providehigh-calorie/highproteinsupplements•  Enteralorparenteralnutri7on•  Smallfrequentmeals•  Amrac7vesewngformeals•  Encouragephysicalac7vity•  Controlothersymptoms(mucosi7s,n/v,drymouth,etc.)•  Includepa7entinfamilyac7vi7es•  Refertocommunityresources•  Referforpsychosocialinterven7onsandemo7onalsupport

GeneralResources

•  Cancer.gov•  SideeffecttrackersfromtheAmericanCancerSociety

•  Ins7tu7onalHandouts•  PEPGuidelines•  ONSPublica7ons:hmps://www.ons.org/prac7ce-resources/books

references

•  hmp://www.slideshare.net/RIPS-14/vomi7ng•  hmp://alltaskstraducoes.com.br/vdisk/29/vomi7ng-center-hypothalamus

•  Na7onalCancerIns7tute(2015).Sideeffects:Nausea.Retrievedfromhmps://www.cancer.gov/about-cancer/treatment/side-effects/nausea/nausea-pdq

•  Polovich,M.,Olsen,M.,LeFebvre(2014).ChemotherapyandBiotherapyGuidelinesandRecommenda7onsforPrac7ce(4thEdi7on).OncologyNursingSociety