GASTROINTESTINAL TOXICITIES ORAL MUCOSITIS AND DIARRHEA

Transcription

1 GASTROINTESTINAL TOXICITIES ORAL MUCOSITIS AND DIARRHEA Christina Pierce, ANP-C, AOCNP Nurse Practitioner Department of Hematology and Hematopoietic Cell Transplantation How the Experts Treat Hematologic Malignancies Las Vegas, NV March 11, 2016 Click to edit Master Presentation Date

2 Disclosures Christina Pierce serves on the Speaker s Bureau for Celgene Corporation and Onyx Pharmaceuticals, Inc.

3 Objectives Discuss risk factors and assessment of oral mucositis Discuss strategies to prevent and manage oral mucositis Review the implications of chemotherapy/radiation induced diarrhea Review assessment of patient and treatment strategies for patients experiencing diarrhea

4 Oral Mucositis One of the most common complications in patients undergoing chemotherapy and/or radiation Tissues affected Buccal mucosa, soft palate, tonsillar pillars, lateral tongue, esophagus Progressive and painful inflammation of the mucous membranes Can lead to secondary complications such as dehydration, dysgeusia, and malnutrition Harris DJ et al. CJON. 2007;12(1): ; Rubenstein et al. Cancer. 2004;100(9 Suppl): ; Keefe DM et al. MASCC Guidelines. Cancer Mar 1;109(5): ; National Cancer Institute (NCI). Oral complications of chemotherapy and head/neck radiation (PDQ). Last modified: 11/2013. Accessed: January Available from:

5 Oral Mucositis: Risk Factors Poor nutrition Children and elderly Genetic factors Specific chemotherapy Neutropenia Patient ORAL MUCOSITIS Treatment Poor oral hygiene Impaired salivary function Use of alcohol and tobacco Radiation therapy + chemotherapy Chemotherapy dose Concomitant medications Regimen Barasch Oral Oncol 2003;39:91-100; Erowele GI,US Pharm 2009;34( Oncol suppl):10-4.

6 Oral Mucositis: Risk Factors Increasing Severity and Duration Patient-related Young age, due to increased cell turnover rate Female gender Ethnicity (Caucasian) Poor nutritional status Type of malignancy Previous cancer treatment Oral care during treatment Low body mass index Decreased saliva production (xerostomia) Production of high levels of cytokines involved in immune mediation

7 Oral Mucositis: Risk Factors Increasing Severity and Duration Therapy Related Multi-cycle chemotherapy Chemotherapy agent (cisplatin, 5-FU, MTX, cyclophosphamide) Radiation for head and neck cancer (increases with concomitant chemotherapy) Conditioning regimens for hematopoietic SCT Induction therapy in patients with leukemia or lymphoma

8 Phases of Mucositis PHASE Phase I Inflammatory Phase II Epithelial Phase III Ulcerative Phase IV Healing ETIOLOGY Release of cytokines Local tissue damage Dividing cells affected Decreased epithelial renewal Atrophy and ulcerations occur Breakdown of mucosal barriers Erosions appear Microbial colonization of lesions occur Tissue repair begin Proliferation of cells begin 8

9 Oral Mucositis Erythema (redness) Edema (swelling) White patches of dead mucosa Mucosal thinning Ulcerations Infections Clinical Appearance Virtual Cancer Centre. Last modified: 20July2010. Accessed: 29Dec2013. Available at:

10 Tips for Oral Assessment Explain importance of assessment in daily oral care Do not stretch a dry mouth Allow patients to moisten or lubricate lips Use best possible light source - flashlight Moisten tongue depressor or disposable mouth mirror before retracting lips or cheeks Farrington M, et al. ORL Head Neck Nurs 2010; 28(3): 8-15; Harris DL, et al. Clin J Oncol Nurs 2008; 12(1):

11 Grading Mucositis: WHO Oral Toxicity Scale A wide variety of scales have been used to record the extent and severity of oral mucositis in clinical practice and research None Erythema and soreness No ulcers May include buccal mucosal scalloping with/without erythema Ulcers Able to eat a solid diet Ulcers with/without erythema Ulcers Requires a liquid diet Subject not able to eat solids Ulcers with/without erythema Ulcers Not able to tolerate solid / liquid diet Requires IV or feeding tube Mucositis to the extent that alimentation is not possible Quinn B et al. Eur J Oncol Nurs. 2007;11(Suppl 1):S10-8.

12 Oral Mucositis: Prevention Strategies Palifermin (Kepivance TM ) KGH- Human keratinocyte growth factor Indication - decrease incidence of severe oral mucositis in patients with hematologic malignancies receiving myelotoxic therapy requiring hematopoietic stem cell support Used with TBI conditioning Cryotherapy Promotes vasoconstriction resulting in reduction of delivery of cytotoxic drugs to at risk tissue Indicated for patients receiving High-dose Melphalan as a conditioning agent in HSCT Kepivance PI Peterson DE, et al. Support Care Cancer 2013;21:

13 Oral Mucositis: Treatment Strategies Cleansing agents Mix a batch of baking soda & water to keep in the refrigerator: 1 tsp salt + 1 tsp baking soda + 1 quart water Diluted, alcohol-free, dry mouth mouthwashes Prescription calcium phosphate rinses Avoid chlorhexidine-increases dryness Utensils should be soft and non traumatic Infection prevention and treatment Pain and symptom management COH TEAM: Critical Oral Hygiene for Treatment of Edematous Aggressive Mucositis The more severe the mucositis, the higher the risk for airway obstruction Early identification of patients at risk Harris DL, et al. Clin J Oncol Nurs 2008; 12(1):

14 Diarrhea Common side effect of many cancer treatments Can lead to serious consequences including malnutrition, electrolyte imbalance and immune attenuation May involve impaired absorption and/or excessive secretions of fluid and electrolytes through the GI tract Causes multifactorial including: Chemotherapy/Conditioning regimens GVHD in Allo HCT patients Infections Medications Viele, CS Sem in Onc Nursing 2003; 19(4): 2-5.

15 Diarrhea: Impact on Patients & Treatment Outcomes Impaired quality of life: Depression, anxiety, low self esteem, irregular sleep, malnutrition, travel restrictions Physical effects: Pain, weakness, lethargy, dehydration, weight loss, electrolyte imbalance, and/or renal insufficiency Impact on treatment plans: May necessitate reduction of chemotherapy or treatment interruption/delays Consumption of Healthcare resources Increasing hospitalizations and medical attention Tarricone, R, et al. Crit Rev Oncol/Hematol 2015, Viele, CS Sem in Onc Nursing 2003; 19(4): 2-5.

16 Diarrhea: Patient Assessment Detailed History: frequency, duration, volume, and appearance associated sxs and/or changes in weight fluid intake/output Examination: Abdomen- tenderness, bloating, bowl sounds, Perianal area- skin break down, hemorrhoids, or fissures Hydration status- skin turgor, oral mucosal moisture, orthostatics, laboratory data R/O infections- C.difficile, E. Coli, Salmonella sp., Shigella sp. Viele, CS Sem in Onc Nursing 2003; 19(4): 2-5.

17 Diarrhea: Treatment Dietary Adjustments BRAT diet Avoiding dairy, juices high in sorbitol, caffeine, alcohol, insoluble fibers Fluid/Electrolyte Loss Encourage fluid intake Electrolyte monitoring and administration Oral intake of electrolyte drinks Gatorade, pedialyte, Medications First line: (Intestinal transit inhibitors)- Lomotil, Imodium, Tincture of Opium Second line: (Anti-secretory agent)- Octreotide Supplements Probiotics, guar gum, glutamine Stern, J & Ippoliti, C. Seminars in Onc Nur 2003; 19(4):