Patients being treated for malignant tumors often develop side effects. The treatment of these side effects improves quality of life. Nausea and vomiting Nausea and vomiting are the most common side effects in which tumor patients suffer. You can either be a result of the tumor itself (eg. As paraneoplastic syndromes) or treatment (eg. As chemotherapy or radiation to the brain or abdomen). Nevertheless, intractable nausea and vomiting should be further clarified. These include some basic laboratory tests (electrolytes, liver function tests, lipase) and imaging methods for detecting obstructions in the gastrointestinal tract or intracranial metastases. Serotonin receptor antagonists are the most effective but also the most expensive drugs. Granisetron and ondansetron have virtually with the exception of headache and orthostatic hypotension no side effects. Ondansetron (0.15 mg / kg), and Granisetron (10 ug / kg) 30 minutes prior to i.v. start of chemotherapy administered. The administration of ondansetron can be repeated 4-8 hours after the first dose. Efficacy against hochemetogene substances such. B. platinum complexes can (8 mg i.v. 30 minutes before chemotherapy, and repeat doses of 4 mg i.v. every 8 h) can be improved by the simultaneous administration of dexamethasone. A Substance-P / neurokinin-1 antagonist, aprepitant can alleviate nausea and vomiting after a highly emetogenous chemotherapy. The dosage is 125 mg p.o. 1 hour prior to chemotherapy treatment on Day 1, then 80 mg p.o. 1 hour prior to chemotherapy treatment on days 2 and 3. To the other, already longer in use antiemetic phenothiazines (eg. B. prochlorperazine, promethazine 12.5-25 mg po or iv every 8 are 10 mg iv every 8 h, h ) and metoclopramide (10 mg po or iv 30 minutes before chemotherapy, repeated every 6-8 h). These can be used as an alternative for patients where nausea and vomiting are mild to moderate. Dronabinol (?-9-tetrahydrocannabinol, THC) is another treatment option for chemotherapy-induced nausea and vomiting. THC is the psychoactive amount of marijuana. His antiemetic mechanism is unclear, but it is known that cannabinoids bind to opioid receptors in the forebrain and can inhibit the vomiting center indirectly. Dronabinol is in a dosage of 5 mg / m2 p.o. 1-3 h before chemotherapy administered with repeated doses 2-4 h after the start of chemotherapy (max. 4-6 doses / day). However, it has a highly variable oral bioavailability and is not effective in the treatment of nausea and vomiting associated with platinum-based chemotherapy regimens. In addition, it is associated with significant side effects (eg. Sleepiness, orthostatic hypotension, dry mouth, mood changes, limitations of visual and temporal perception). Smoking marijuana can be more effective. In some countries marijuana can be used legally for this purpose. Due to the limited availability and because some patients can not tolerate smoking in itself, but it is less commonly used. Benzodiazepines such. As lorazepam (1-2 mg po or iv 10-20 minutes before chemotherapy, repeat doses every 4-6 h), sometimes are helpful in refractory or anticipatory nausea and vomiting. Cytopenia during chemotherapy or radiation therapy of anemia, leukopenia and thrombocytopenia may develop. Anemia Clinical symptoms or reduced effectiveness of radiation therapy usually occur at hematocrit <30% or hemoglobin levels <10 g / dl. In patients with coronary heart disease or peripheral vascular disease rather symptoms can already occur. Treatment with recombinant erythropoietin can be started when - falls of hemoglobin level to <10 g / dl - depending on the symptoms. Generally, 150-300 I.U./kg are s.c. 3 times a week is sufficient (a suitable dosage in adults is 10,000 IU) to reduce the need for transfusions. Longer-acting formulations of erythropoietin require less frequent administration (Darbepoetin alpha 2.25-4.5 ug / kg s.c. every 1-2 weeks). An unnecessary administration of erythropoietin should be avoided because it increases the risk of cardiovascular thrombosis. Transfusions of packed red blood cells may be required to relieve acute cardiorespiratory symptoms but not asymptomatic patients should be administered in general, provided that no significant underlying cardiopulmonary disease haben.Thrombozytopenie platelet counts <10,000 / ul, v. a. the occurrence of bleeding requiring transfusion of platelet concentrates. Small molecules that act as thrombopoietin are in place but are not often used in oncological therapy. (Editor's note: are Registered in Germany romiplostim and eltrombopag.) A leukocyte depletion of transfused blood products can prevent alloimmunization against platelets and should be used in all patients who expected a platelet transfusion during multiple cycles of chemotherapy is necessary or where a stem cell transplant is planned , (Editor's note: In Germany, all platelet concentrates are leucocyte-depleted.) In addition, the leukocyte depletion reduces the likelihood of cytomegalovirus, which can be transmitted by leukocytes. The use of gamma rays of blood products to inactivate lymphocytes and for the prevention of transfusion-associated graft-versus-host disease in patients who erhalten.Neutropenie a highly immunosuppressive chemotherapy Neutropenia increases the risk of life-threatening infections (neutropenia). It is usually defined as the presence of absolute neutrophil counts <500 / ul. Clinical Calculator: Absolute neutrophil count Afebrile neutropenic patients require close ambulatory monitoring to detect fever early. Furthermore, they should be advised to avoid contact with sick people and not places to visit, where people are plentiful (eg. As shopping malls, airports, etc.). Although most patients do not need antibiotics, patients with severe immunosuppression (d. E. Simultaneous T-cell depletion and loss of function) and leukopenia occasionally trimethoprim-sulfamethoxazole as prophylaxis against Pneumocystis jirovecii. In transplant patients, or patients receiving high-dose chemotherapy, a viral prophylaxis should be considered (acyclovir 800 mg po 2 times daily or 400 mg iv every 12 h) when the serological test is positive on the herpes simplex virus. Fever> 38 ° C is in a patient with neutropenia an emergency. The diagnosis should include an immediate chest x-ray as well as bacterial cultures of blood, sputum, urine, stool and suspicious skin areas. The physical examination includes places of potential abscesses (eg., Skin, ears), skin and mucous membranes for the presence of herpes lesions and the retina to vascular lesions that may indicate metastatic infection and catheter injection sites. A rectal exam and the use of Rektalthermometern should be avoided in neutropenic patients as possible in order to reduce the risk of bacteremia. Febrile neutropenic patients should immediately receive a broad-spectrum antibiotic, whose selection is based on the most likely organism. Typical regimes are cefepime or ceftazidime 2 g i.v. every 8 h immediately after collection of cultures. In the presence of diffuse pulmonary infiltrates the sputum P. jirovecii should be tested. If the findings are positive, immediately should be initiated appropriate therapy. Disappears fever within 72 hours after starting antibiotic therapy, it should be continued until neutrophil counts of> 500 / ul. If the fever over 120 h persists, additional antifungal medications should be used to treat fungal infections possible. (Editor’s note: In Germany, the recommendation states 72 h.) Furthermore, it should at this time a new search for occult infections occur (often including thoracic and abdominal CT.). For certain patients with chemotherapy-induced neutropenia, especially with high-dose chemotherapy can granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor used (GM-CSF), to shorten the duration of leukopenia , The use of G-CSF (5 g / kg s.c. 1 time daily for up to 14 days) or long-acting forms (eg. As pegfilgrastim s.c. as a single dose per chemotherapy cycle) can lead to the strengthening of Leukozytenerholung. These drugs should not be administered within the first 24 hours after chemotherapy, and pegfilgrastim should at least 14 days elapse until the next dose of chemotherapy. With the administration of these drugs is started when fever or sepsis occur or if the neutrophil counts drop to <500 / ul in afebrile high-risk patients. Many clinics treat selected low-risk patients with fever and neutropenia-patient with G-CSF. However, you must have no hypotension, changes in level of consciousness, respiratory restrictions, uncontrolled pain or severe comorbidities such as diabetes mellitus, heart failure, or hypercalcemia. Outpatient treatment requires in such cases, a daily monitoring and frequent involvement of an outpatient care service and domestic antibiotic infusions. Some treatment regimen using oral antibiotics such. As ciprofloxacin 750 mg p.o. plus amoxicillin-clavulanic acid 875 mg po 2 times a day 2 times daily or 500 mg po 3 times a day. Is the monitoring of neutropenic patients in the outpatient setting is not possible, hospitalization is required. Gastrointestinal side effects Gastrointestinal side effects are common in cancer patients. Oral lesions, oral lesions such as ulcers, infections and inflammations are frequently observed. An oral candidiasis may Nystatinsuspension with 5-10 ml p.o. 4 times a day, clotrimazole 10 mg p.o. 4 times daily or fluconazole 100 mg po be treated 1 times daily. Mucositis due to radiation therapy can cause pain and prevent adequate oral food intake, which can malnutrition and weight loss occur. Mouthwashes with analgesics or topically effective anesthetic (2% viscous lidocaine, 5-10 ml every 2 h or other commercially available solutions) before eating, a mild diet without citrus or fruit juices and the avoidance of extreme feed temperatures may patient's food intake and so the maintaining their weight allow. If this fails, a feeding tube may be useful if the bowel function is preserved. In cases of severe mucositis and diarrhea or bowel dysfunction parenteral nutrition may be necessary sein.Diarrhoe A diarrhea as a result of radiation or chemotherapy can be improved by the use of antidiarrheal agents (eg. As kaolin / Pektinsuspension 60-120 mL normal strength or 30-60 ml concentrate po at the first signs of diarrhea and after each soft stool; loperamide 2-4 mg po after each soft stool; or diphenoxylate / atropine 1-2 tablets po every 6 h). Patients in whom an abdominal operation or broad spectrum antibiotic treatment has been performed within the past 3 months should a stool test for Clostridium difficile subjected werden.Konstipation Blockage may be the result of treatment with opioids. A co-administered laxative therapy (eg. B. Senna 2-6 tablets p.o. before bedtime or bisacodyl 10 mg p.o. before going to bed) should be used when repeated opioid doses are likely. A present constipation can be treated with various drugs (eg. B. bisacodyl 5-10 mg PO every 12-24 h, 15-30 ml magnesium hydroxide po before bedtime, lactulose 15-30 ml every 12-24 h, magnesium citrate 250- 500 ml po 1 times daily). In patients with neutropenia or thrombocytopenia enemas or suppositories should be avoided werden.Anorexie The appetite may be reduced due to the tumor therapy or a paraneoplastic syndrome. Corticosteroids (e.g., dexamethasone 4 mg p.o. 1 times a day, prednisone 5-10 mg p.o. 1 time daily) and megestrol acetate, 400-800 mg of 1-times daily here are the most effective. However, these drugs do not result in improved survival or quality of life, but only to an increased appetite and weight gain. The pain onset of pain should be anticipated and treated aggressively (pain treatment). Here, the use of different drug classes to better pain control can lead to fewer or less severe side effects than the use of only one substance. NSAIDs should be avoided in patients with thrombocytopenia. The treatment relies mainly on opioids administered around the clock in sufficient doses, as well as occasional pain peaks in additional doses. Is an oral tablet containing not possible, fentanyl can be administered transdermally. In the opioid therapy often antiemetics and prophylactically defecation inducing medications are needed. Neuropathic pain can be high-dose gabapentin (up to 1200 mg po three times / day) are treated. The administration must be started at a low dose (eg., 300 mg 3 times / day) and increased over a few weeks are. Alternatively, a tricyclic antidepressant can (z. B. nortriptyline 25-75 mg p.o. before going to bed) can be tried. Helpful non-pharmacological pain therapies include the local radiation therapy, nerve blocks or surgery. Depression Depression is often overlooked. It can occur as a result of disease (their symptoms and the dreaded consequences) and / or the side effects of treatments. Patients receiving interferon therapy may develop as a side effect of depression. Also occurring as a side effect of radiation therapy or chemotherapy hair loss can contribute to the development of depression. Often a frank discussion with the patient about his fears helps to reduce the anxiety symptoms. Depression can be treated effectively in many cases (Depressive disorders). Tumorlysesyndrome tumor lysis syndrome may occur after chemotherapy secondary to the release of intracellular constituents in the blood as a result of tumor cell destruction. Most often they are in acute leukemia and non-Hodgkin's lymphoma, but they can occur hematological tumors and less frequently after the treatment of solid tumors in others. The suspected tumor lysis syndrome, patients with a large tumor mass that develop acute renal failure after initial treatment. T-cell vaccination, which are used to treat B-cell leukemias (s modalities of oncological therapy. Vaccines), a life-threatening tumor lysis and release of cytokines can induce days to weeks after the administration of the vaccine. The diagnosis is confirmed by a combination of the following findings: renal failure hypocalcemia (<8 mg / dl) hyperuricemia (> 15 mg / dl) hyperphosphatemia (> 8 mg / dl) Treatment is (with allopurinol 200-400 mg / m2 1 Twice a day, a maximum of 600 mg / day) and iv administered saline to achieve a diuresis> 2 l / day. Here, a close-knit biochemical and cardiac monitoring is needed. In patients with a malignant tumor and high cell growth allopurinol should be used before and during chemotherapy at least two days. In patients with a high tumor burden, this therapy may be continued for 10 to 14 days after the end of chemotherapy. All these patients should receive a generous intravenous hydration to achieve a diuresis of at least 100 ml / h before the start of therapy. Although some doctors i.v. NaHCO3 used for alkalization of urine and increasing the solubility of uric acid, the alkalization in patients with hyperphosphataemia can promote the deposition of calcium phosphate. A pH of about 7 should be avoided. Alternatively, the enzyme rasburicase, the uric acid to allantoin oxidized (higher solubility) can be used for the prevention of tumor lysis syndrome. The dose is 0.15-0.2 mg / kg i.v. as a 30-minute infusion 1 times daily for 5-7 days. The initiation of treatment is usually 4-24 hours before the first chemotherapy. Among the side effects of rasburicase include anaphylaxis, hemolysis, hemoglobinuria and methemoglobinemia.


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