Chemotherapy
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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
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Overview Purpose of chemotherapy Types of chemotherapy Toxicity associated with chemotherapy Side effect management
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Chemotherapy Treatment of: cancer autoimmune disorders
Goal: cure, control or palliation of disease Cancer cell growth & division Action is most pronounced in rapidly growing and dividing cells www.indiandentalacademy.com
Types of chemotherapy Cell cycle dependent Cell cycle phase specific
Cell cycle independent Cell cycle phase non-specific
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Classes of antineoplastic drugs Alkylating agents Interact directly with cellular DNA
Antimetabolites Resemble cellular metabolites (folic acid, purine, pyrimidine) Interfere with DNA precursors & cellular metabolism
Antitumor antibiotics Derived from soil fungus, some antiinfective activity Interfere with DNA activity
Mitotic Inhibitors Derived from plant extracts Interfere with formation of mitotic spindle, arresting mitosis www.indiandentalacademy.com
Classes of antineoplastic drugs Miscellaneous Hormones and hormone antagonists Angiogenesis inhibitors Destroy capillary network to tumor causing tumor shrinkage
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Normal cells most susceptible to chemotherapy Bone marrow GI tract Hair follicles Many adverse effects seen in these systems
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Factors influencing response of cancer to chemotherapy Size of tumor Resistance Intrinsic no prior exposure
Acquired after start of therapy
Temporary Permanent www.indiandentalacademy.com
Chemotherapy cycles Cycle a drug protocol, given over a period of time (usually 3-6 weeks) chemotherapy prescribed as a certain number of cycles evaluation of effectiveness reevaluation and planning of further treatment
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Chemotherapy dosing Based on body size in m2 using nomogram Goal: maximal dose, minimal interval
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Chemotherapy regimens
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Biologic Response Modifiers Interferons Interleukins Colony Stimulating Factors
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Routes of administration Oral IV Site-specific intrathecal: cerebrospinal fluid intraventricular: ventricle of brain, Ommaya reservoir
intraperitoneal
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Intravenous access devices Peripheral IV Nontunneled central venous catheter PICC: peripherally inserted central catheter Tunneled central venous catheter Hickman, Groshong
Implantable port Port-a-cath www.indiandentalacademy.com
Hickman catheter
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Portacath
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Accessed Portacath
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Extravasation of infusions
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Handling of chemotherapy Potential carcinogenic & teratogenic effects Chemotherapy precautions Disposal of waste Body fluids
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Adverse effects of chemotherapy Alopecia: hair loss Myelosuppression: bone marrow suppression anemia: decreased red blood cells fatigue, dyspnea
thrombocytopenia: decreased platelets risk for bleeding
neutropenia: decreased white blood cells risk for infection
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Adverse effects of chemotherapy GI effects: Stomatitis: ulcerated or painful oral mucous membranes Anorexia, nausea & vomiting
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Toxicities of chemotherapy Ototoxicity: hearing loss monitor hearing
Nephrotoxicity: kidney dysfunction monitor I&O, weight, fluid status, creatinine, BUN, electrolytes
Hepatotoxicity: liver dysfunction monitor for jaundice, liver function tests
Neurotoxicity: nerve damage monitor for CNS problems, neuropathies
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Toxicities of chemotherapy Pulmonary toxicity: lung damage monitor for dyspnea, pulmonary function tests
Cardiotoxicity: heart damage monitor for signs of heart failure, arrhythmias, chest discomfort
Gastrointestinal toxicity: monitor for stomatitis, diarrhea, fluid status
Gonadal toxicity: offer reproductive options
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Management of chemotherapy side effects Anticipate adverse effects Prophylactic treatment
Monitor for toxic effects Laboratory tests Diagnostic screening tests
Importance of patient & family education Multidisciplinary team management www.indiandentalacademy.com
Bone marrow suppression Anemia: decreased red blood cells Erythropoietin (EPO): stimulates production of red blood cells in the bone marrow administered SC or IV Side effects: headache, hypertension, arthralgia (bone or joint pain), diarrhea, nausea, fatigue
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Bone marrow suppression Neutropenia: decreased white blood cells G-CSF (granulocyte-colony-stimulating factor): stimulates production of white blood cells in the bone marrow Administered SC or IV Common side effect: bone pain Do not give < 24 hrs before or after chemotherapy, or within 12 hours of radiation www.indiandentalacademy.com
Bone marrow suppression Thrombocytopenia: decreased platelets GM-CSF (granulocyte-magrophage-colonystimulating factor) Stimulates neutrophils and platelets
Platelet transfusion to keep platelet count >20,000
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Gastrointestinal effects: Stomatitis & Esophagitis May be due to chemotherapy or radiation Pain medications: narcotic analgesics Viscous Lidocaine: topical anesthetic Oral ulcer solutions: I.e. lidocaine + antacid + benadryl elixir
Nystatin swish & swallow: used to treat thrush Artificial saliva: salivary gland deactivation
Remember: pain with oral medication administration, may need elixirs or IV www.indiandentalacademy.com
Gastrointestinal effects: Nausea & Vomiting Acute: first 24 hours Delayed: after 24 hours Anticipatory: stimulated by the experience of chemotherapy Nausea control during first 24 hours prevents delayed response
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Gastrointestinal effects: Nausea & Vomiting Combinations of chemotherapy drugs can stimulate different nausea pathways Combinations of antiemetics work on different pathways, increasing effectiveness Routine administration: before or during chemotherapy and for 24-48 hours after www.indiandentalacademy.com
Types of Antiemetics: Serotonin Antagonists Ondansetron (Zofran): first drug serotonin antagonist, 1992 Granisetron (Kytril): longer acting, more potent Blocks serotonin receptors of chemoreceptor trigger zone and vagal nerve endings Most effective antiemetics, first-line for chemotherapy Side effects: headache, weakness, drowsiness, constipation
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Types of antiemetics Corticosteriods Inhibit prostaglandin synthesis Decadron (dexamethasone) Solumedrol (methylprednisolone) Side effects: anxiety, euphoria, insomnia, edema
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Types of antiemetics Anxiolytics Decrease sensitivity of vomiting center Benzodiazepines : lorazepam (Ativan), diazepam (Valium) Useful in anticipatory nausea & vomiting Side effects: sedation, confusion, amnesia
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Types of antiemetics Phenothiazines: Prochlorperazine (Compazine) Promethazine (Phenergan) Useful in mild to moderate nausea treatment (second-line with chemotherapy) Often used after surgery Side effects: sedation, orthostatic hypotension, extrapyramidal symptoms
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Antiemetic combinations Decadron (dexamethasone) + Ondansetron + Lorazepam (Ativan)
Decadron (dexamethasone) + Kytril (granisetron) www.indiandentalacademy.com
www.indiandentalacademy.com Leader in continuing dental education
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