DRUG EXTRAVASATION. Vesicants. Irritants

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Jeffery Hunt
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5 DRUG EXTRAVASATION Vesicants Irritants

7 Vesicants Antineoplastic drugs Amsacrine Dactinomycin Daunorubicin Docetaxel (rare) Doxorubicin Epirubicin Idarubicin Mechlorethamine Mitomycin Oxaliplatin (rare) Streptozocin Vinblastine Vincristine Vindesine Vinorelbine

8 Irritants Bleomycin Carboplatin Carmustine Cisplatin* Cyclophosphamide Dacarbazine* Docetaxel Etoposide Fluorouracil/Floxuridine Ifosfamide Mitoxantrone Oxaliplatin Paclitaxel Teniposide Thiotepa

9 MANAGEMENT OF EXTRAVASATION Initial management Application of heat or cold Specific antidotes to prevent necrosis and ulceration Dimethylsulfoxide---- antracycline Hyaluronidase-----vincristine Sodium thiosulfate---- cisplatin and dacarbazine

10 MONITORING AND TOXICITY

11 DRUG TOXICITY Renal and Urinary tract Cardiotoxicity Ototoxicity Hepatotoxicity Skin toxicity Central nervous system Hematotoxicity Gastrointestinal toxicity

12 SKIN TOXICITY Mucositis: cytarabine, doxorubicin, etoposide, methotrexate, 5-FU Rash, urticaria: methotrexate, cytarabine Allergy: L-asparaginase

13 MUCOSITIS Usually completely healed within days after chemotherapy Infectious complications: The majority of oral infections are due to Candida albicans, second; Herpes simplex virus

15 TREATMENT OF ESTABLISHED MUCOSITIS Supportive and symptom control o o o Oral care Mucosal protectants Topical or systemic analgesia

16 GASTROINTESTINAL TOXICITY Stomatitis Abdominal pain Constipation Diarrhea Nausea Vomiting

17 CHEMOTHERAPY-INDUCED VOMITING Acute symptoms: during 1 st 24 hrs after chemotherapy Delayed symptoms: from hrs post chemotherapy Severe after cisplatin Moderate after cyclophosphamide Anticipatory symptoms: N/V before chemotherapy Related to anxiety Difficult to treat

18 MANAGEMENT OF VOMITING Antiemetic agents: Highest therapeutic index: 5-HT3 receptor antagonists Ondansetron dosing in children: Most studies: 0.15 mg/kg IV Q 8 hr 5 mg/m2 IV Q 8 hrs

19 HEMATOTOXICITY Anemia Thrombocytopenia Neutropenia

20 INDICATIONS FOR RED CELL TRANSFUSION Hemoglobin < 6-7 g/dl with symptoms of anaemia. Comorbidities must be considered Not be given routinely if recovery from chemotherapy-induced aplasia is imminent If invasive procedures are planned, Hb > 9-10 g/dl may minimize perioperative bleeding

21 INDICATIONS FOR PLATELETS TRANSFUSION Always indicated for a bleeding patients with thrombocytopenia Prophylactic use is more controversial Avoidance of bleeding precipitants may decrease the need Nonspecific treatment for bleeding: topical agents

22 RENAL AND URINARY TRACT Electrolyte abnormalities: - Hypocalcemia - Hypokalemia - Hypomagnesemia - Hypophosphatemia Creatinine rising Hematuria Proteinuria

23 SUPPORTIVE CARE Primary prevention o o o o Adequate hydration Maintenance of normal intravascular fluid status Avoidance of intravascular volume depletion Avoid: nephrotoxic medication

24 SUPPORTIVE CARE Prevention of bladder toxicity Encourage to void at least every 2 hrs Strongly encourage oral or IV intake pre/post

25 SUPPORTIVE CARE Specific measures o o o Hydration Alkalinization: metrotrexate Uroprotectant: Mesna A total mesna dose equivalent to the total ifosfamide dose and 80% of the total cyclophosphamide dose

26 CARDIOTOXICITY Arrhythmias Myocardial necrosis causing a dilated cardiomyopathy Vasospasm or vasoocclusion resulting in angina or myocardial infarction

27 CRITERIA FOR DETERIORATING CARDIAC FUNCTION A decrease in the FS by an absolute value of 10 percentile points from the previous test An FS < 29% Development of arrhythmia EF < 55%

28 OTOTOXICITY Contributing factors o Diminished renal function o Age 3 yrs at time ototoxic agent administered o Rapid IV administration of agent: platinumbased chemotherapy

29 HEPATOTOXICITY Liver enzyme elevation Hyperbilirubinemia

30 CENTRAL NERVOUS SYSTEM Sensory loss Weakness Cerebellar symptoms: incoordination, tremor, ataxia Seizure, psychosis

West of Scotland Cancer Network Guideline for Managing Chemotherapy Induced Nausea and Vomiting

West of Scotland Cancer Network Guideline for Managing Chemotherapy Induced Nausea and Vomiting Definitions Acute nausea and vomiting Delayed nausea and vomiting Anticipatory nausea and vomiting Initial