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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