Nausea and Vomiting. Symptom Management of Gastrointestinal Alterations. Gastrointestinal Alterations. Nausea/Vomiting Patterns

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Symptom Management of Gastrointestinal Alterations Elise Frans, MN, RN, CWON Oncology Clinical Nurse Specialist University of Washington Medical Center delterzo@uw.

1 Symptom Management of Gastrointestinal Alterations Elise Frans, MN, RN, CWON Oncology Clinical Nurse Specialist University of Washington Medical Center Nausea and Vomiting Mucositis Taste Alterations Anorexia and Cachexia Gastrointestinal Alterations Constipation Diarrhea Nausea/Vomiting Patterns Anticipatory nausea: a conditioned response that occurs most commonly before treatment and can be triggered by a particular smell, taste, or sight (NCCN, 2008). Occurs in about 18-54% of patients Nausea and Vomiting Risk Factors: Poorly controlled previous CINV Being young or middle aged Female gender High levels of anxiety Susceptibility to motion sickness Hx of pregnancy induced nausea and vomiting

2 Nausea/Vomiting Patterns Acute nausea: Starts within minutes to hours after chemotherapy administration and may last up to 24 hours depending on the agent (NCCN, 2008). Risk factors: Type of chemotherapy dose Combination chemotherapy Emetogenicity of chemotherapy Female gender Alcohol & smoking history use Tumor burden Susceptibility to GI distress Duration of infusion Nausea/Vomiting Patterns Delayed nausea: Occurs at least 24 hours after chemotherapy administration and may last up to 6 days (O Bryant et al., 2004). Peak is usually hours after chemotherapy has started. Risk Factors: 60-90% of patients receiving Cisplatin (Jordan, Sipple, & Schmoll, 2007) High dose chemotherapy, Cyclophosphamide, Ifosfamide, Doxorubicin Poor control of acute nausea/vomiting Consequences of Nausea/Vomiting Emetogenic Potential of Chemotherapy Agents Loss of appetite Malnutrition Dehydration Chemical changes in the body Mental changes A torn esophagus Broken bones Reopening of surgical wounds Level 5: Level 4: Level 3: Level 2: Level 1: Emesis occurs in >90% of patients Emesis occurs in 60-90% of patients Emesis occurs in 30-60% of patients Emesis occurs in 10-30% of patients Emesis occurs in <10% of patients

Emetogenic Potential of Chemotherapy Agents Level 5: Carmustine >250 mg/m2, Cisplatin >50 mg/m2, Cyclophosphamide >1,500 mg/m2, Dacarbazine Level 4: Carboplatin, Cyclophosphamide 750-1,500 mg/m2,

3 Emetogenic Potential of Chemotherapy Agents Level 5: Carmustine >250 mg/m2, Cisplatin >50 mg/m2, Cyclophosphamide >1,500 mg/m2, Dacarbazine Level 4: Carboplatin, Cyclophosphamide 750-1,500 mg/m2, Cytarabine >1g/m2, Doxorubicin >60mg/m2, Methotrexate >1g/m2 Case Study for Nausea/Vomiting Francesca is a 38 year old woman with AML and is going to receive high dose Cyclophosphamide and Busulfan prior to her allogenic transplant. She is nervous about her conditioning chemotherapy because she experienced severe nausea and vomiting with prior chemotherapy as well as during both her pregnancies. Level 3: Epirubicin, Ifosfamide, Irinotecan, Idarubicin, PO cyclophosphamide Level 2: Capecitabine, Bleomycin, Etoposide, Gemcitabine, Paclitaxel, 5-FU <1g/m2 Level 1: Vincristine, Busulfan, Docetaxel, Thiotepa, Bortezomib Nausea/Vomiting Management Nausea and Vomiting Pathophysiology First step is prevention! Stay on a scheduled regimen throughout entire anticipated period of nausea and vomiting Reduce stimuli (e.g. strong odors perfume or foods) Administer appropriate antiemetic based on treatment regimen D.E. Becker, 2010.

4 Pharmacological Management Anticipatory nausea: Lorazepam (Ativan) -begin night prior to treatment and morning of treatment -side effects include: sedation, confusion, dizziness Acute nausea: Ondansetron (Zofran), Granisetron (Kytril), Palonosetron (Aloxi) 5HT3 antagonists -give 30 mins prior to moderate-high emetogenic chemo -side effects include: constipation, headache, fever Pharmacological Management Delayed nausea: Aprepitant (Emend) PO or Fosaprepitant (IV) NK1 antagonists side effects: constipation, hiccups, diarrhea Treatment of breakthrough nausea: Prochlorperazine (Compazine) or Metocloperamide (Reglan) *Dexamethasone added to 5HT3 regimens increases efficacy by 15-25%! Question Which of the following interventions helps to relieve nausea? a) Medicating with an antiemetic on an around-the-clock basis until nausea subsides b) Encouraging bland, chilled foods c) Replacing fluids with popsicles and sports drinks d) All of the above Mucositis

Mucositis Pathophysiology of Mucositis Definition: general term referring to inflammation & ulceration to any of the mucosal membranes from oral cavity to anus Stomatitis refers specifically to the

5 Mucositis Pathophysiology of Mucositis Definition: general term referring to inflammation & ulceration to any of the mucosal membranes from oral cavity to anus Stomatitis refers specifically to the mouth Occurs in 30-40% of patients receiving standard-dose chemotherapy (NCI, 2008c) and 80% of HSCT patients (Goldberg et. al, 2004). Occurs around the nadir (10-14 days after chemotherapy) Grade 1: Soreness, erythema Grading of Mucositis WHO-NCI Toxicity Scale Grade 2: Erythema, ulcerations present, patient still able to eat solid diet, secretions thicken Grade 3: Extensive erythema, ulcerations preventing patient from eating solid diet, ropey secretions Grade 4: Mucositis to the extent that any kind of oral nutrition is impossible, airway compromise, inability to control secretions *Note there are many grading scales! Consequences of Mucositis Pain Difficulty swallowing Difficulty speaking Infection Bleeding Nutritional issues Aspiration Possible loss of airway protection

Risk factors for Mucositis Age (very young and very old) Gender (females > males) Poor oral hygiene, ill-fitting dentures Smoking history or alcohol use Total Body Irradiation Head/neck radiation

6 Risk factors for Mucositis Age (very young and very old) Gender (females > males) Poor oral hygiene, ill-fitting dentures Smoking history or alcohol use Total Body Irradiation Head/neck radiation Patient on oxygen therapy or anticholinergic drugs (dries out membranes) Dehydration Chemotherapeutic agents that affect DNA synthesis Chemotherapeutic Agents associated with Mucositis Bleomycin Cytarabine Cisplatin Carboplatin Cyclophosphamide Docetaxel Daunorubicin Etoposide 5-Fluorouracil Melphalan Methotrexate Mitoxantrone Paclitaxel Thiotepa Topotecan Vinblastine Vincristine Mucositis & Nursing Assessment Assess everyday with a light source (flash light)! Objective findings: Erythema Ulceration Bleeding Cracked lips Scalloping, Paleness Edema Thick secretions Difficulty speaking/hoarseness Drooling Subjective findings: Pain (burning, raw) Taste alterations Inability to swallow or chew Case Study for Mucositis Francesca completed her conditioning chemotherapy. It has been 12 days since her transplant. During your assessment she complains of moderate throat pain that is worse when swallowing and oral dryness. She is unable to eat foods, but can drink liquids. When you look in her mouth you notice this: Treister et al., 2015

7 Management of Mucositis No standard of care for the prevention and treatment of oral mucositis Prevention: Treat oral problems before treatment, high protein diet, encourage hydration, cryotherapy for bolus 5-FU and melphalan, Palifermin in auto HSCT patients receiving high dose TBI Treatment: Pain medications (often PCA), suction, good oral hygiene Keep the oral cavity clean and moist Oral hygiene Floss daily if patient has been a regular flosser Brush with a soft bristle toothbrush if tolerated Saline swish and spit frequently (may add sodium bicarbonate per preference) Keep suction at the bedside, elevate patient s HOB Oral hygiene Do not use magic mouthwash Benadryl can be very drying Aluminum hydroxide coats oral cavity, traps bacteria Topical lidocaine to individual sores Taste Alterations

8 Causes of Taste Alterations Disease related causes: mucositis, oral thrush, antibiotic use, zinc deficiency, xerostomia Treatment related causes: radiation, chemotherapy Chemotherapy lowers threshold for bitter taste while increasing threshold for sweet, sour, and salty Patients often report a metallic taste in their mouth Patients often have an aversion to meat Consequences of Taste Alterations Anorexia Dehydration Decreased nutritional status Strasser et al., 2008 Management of Taste Alterations Experiment with flavors: add seasonings, sugar, spices Use aromatic foods to stimulate saliva Oral hygiene before and after meals Avoid alcohol, smoking Gum or hard-candy during chemotherapy to rid mouth of metallic taste Marinate meats to change taste Use other sources of protein Choose bland foods Avoid metallic silverware Avoid favorite foods Drink plenty of water Anorexia/Cachexia

9 Definitions Anorexia: involuntary, abnormal loss of appetite for food. which can lead to. Cachexia: wasting syndrome characterized by malnutrition and the substantial loss of adipose and muscle tissue, along with involuntary weight loss of more than 5% of usual weight Causes of Anorexia Physiological: nausea, vomiting, pain, dysphagia, mucositis, ascites, fatigue, metabolic abnormalities, tumor effect proinflammatory cytokines Medications: opioids, chemotherapy, antibiotics Structural: poor dentition, obstructions, surgery Illman et al., 2005 Psycho-social: Anxiety, depression, food preparation, environment Consequences of Anorexia/Cachexia Decreased adherence to chemotherapy Increase in treatment toxicity Case Study for Anorexia/Cachexia Francesca is now 37 days post her transplant. During your daily nursing assessment you ve noticed she s lost 20 pounds since being admitted to start her conditioning chemotherapy More frequent hospitalizations Decrease in treatment response Decreased quality of life Decrease in survival Del Fabbro et al., 2007

10 Anorexia/Cachexia Management Assessment: monitor weight, obtain diet history, measure body composition. Refer to dietician if warranted Evaluate laboratory results: pre-albumin, albumin, and transferrin Less than normal indicates protein depletion Manage symptoms: nausea, vomiting, mucositis, taste changes, fatigue, diarrhea Anorexia/Cachexia Management Provide high calorie/high protein supplements (Odwalla, Ensure, etc) Encourage small, frequent meals Encourage physical activity: improved lean muscle mass Anorexia/Cachexia Management Pharmacologic appetite stimulants: Progestins and corticosteroids are the only two classes of drugs that have limited effectiveness (Jatoi, 2006). Megestrol acetate is most commonly used progestin side effects include: DVTs, edema, GI disturbances Diarrhea and Constipation Dexamethasone and prednisone are commonly used corticosteroids side effects include: euphoria, immunosuppression, hyperglycemia

$Question A 63-year-old patient has metastatic colon cancer. His disease is refractory to 5-FU. He received his first dose of Irinotecan (Camptosar) 2 days ago.$

11 Question A 63-year-old patient has metastatic colon cancer. His disease is refractory to 5-FU. He received his first dose of Irinotecan (Camptosar) 2 days ago. He began having diarrhea 36 hours after his therapy. Which of the following is an appropriate intervention for management of diarrhea in this patient? a) Administer Atropine to manage his diarrhea b) Administer loperamide (Imodium-AD) and monitor closely for dehydration and fluid-electrolyte imbalance c) Premedicate with dexamethasone before the next dose of Irinotecan to prevent diarrhea d) Modify his diet by decreasing fiber and roughage as diarrhea is an expected side effect We eat at celebrations/gatherings We eat for healing We eat together Food is cultural! All you need is love. But a little chocolate now and then doesn't hurt. ~Charles Schulz Cancer.gov Institutional Handouts PEP Guidelines Resources and References National Cancer Institute (2018). Treatment-Related Nausea and Vomiting (PDQ ) Health Professional Version. Retrieved from Polovich, M., Olsen, M., LeFebvre (2014). Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (4 th Edition). Oncology Nursing Society Questions?

Symptom Management of Gastrointestinal Alterations

Symptom Management of Gastrointestinal Alterations Parisa Tsutsumi RN, BSN, OCN, BMTCN University of Washington Medical Center Nausea and Vomiting Mucositis Taste Alterations Gastrointestinal Alterations