Nutritional Support Antineoplastic Therapy

1. Nutritional Support Antineoplastic Therapy Principles of IV Therapy BSN336

2. Nutritional Support • The care of individuals with potential or known nutritional alterations.

3. Nutritional Support • Goals of Parenteral nutrition include: • Provide all essential nutrients in adequate amounts to sustain nutritional balance during periods when oral or eteral routes of feedings are not possible or are insufficient to meet the patient’s caloric needs. • Preserve or restore the body’s protein metabolism and prevent the development of protein or caloric malnutrition

4. Nutritional Support • Diminish the rate of weight loss and to maintain or increase body weight. • Promote wound healing • Replace nutritional deficits

5. Concepts of Nutrition Nutritional balance depends on 3 things: • Intake of nutrients (Quantity and Quality) • Relative need for nutrients • Ability of the body to use nutrients

6. Concepts of Nutrition • Nutritional Deficiency • Body’s components are used to provide energy for essential metabolic processes • Malnutrition • Nutritional deficit associated with an increased risk of morbidity and mortality

7. Concepts of Nutrition Three types of Malnutrition: • Marasmus – decrease in the intake of calories with adequate protein calorie ratio. Gradual wasting • Kwashiorkor – adequate intake of calories along with a poor protein intake. • Mixed Malnutrition – characterized by aspects of both Marasmus, and kwashiorkor

8. Nutritional Assessment • Mild malnutrition: 85 to 95 % IBW • Moderate malnutrition: 75 to 84% IBW • Severe Malnutrition: less than 75% IBW • Biochemical Assessment: • Serum Albumin and Transferrin Levels • Prealbumin and Retinol-Binding protein • Total Lymphocyte Count • Serum Electrolytes

9. Nutritional Requirements • Carbohydrates: provide energy • Glucose provides calories in parenteral sol. • Spare body protein • Fats: primary source of heat and energy • Essential for the structural integrity of all cell membranes • Fewer problems with glucose homeostasis, carbon dioxide production is lower, hepatic tolerence may improve • EFAD – Essential Fatty Acid Deficiency

10. Nutritional Requirements • Protein: body-building nutrient, functions to promote tissue growth and repair and replacement of body cells. • Amino Acids are the basic units of protein • 8 essential Amino Acids needed by adults • Electrolytes: infused as a component already contained in the amino acid solution or as an additive

11. Nutritional Requirements • Vitamins: necessary for growth and maintenance, multiple metabolic processes • Both fat and water soluble are needed • Vitamin K can be given IM • Trace Elements: Basic requirements are very small but essential

12. Parenteral Nutrition Medication Additives • Insulin • Heparin • Histamine 2 (H2) Inhibitors • Cimetidine, Pepsid, Reglan, Zantac

13. Admixture Complications • Amounts of Calcium and Phosphorus added • Phosphate Ions • Line should be flushed: incompatible components • Lipid emulsion: obscure presence of precipitates

14. Admixture Complications • Filter used for administration: 1.2 micron • Administered with in 24hr after mixing or removal from the refrigerator • If symptoms of acute respiratory distress, pulmonary embolus, or interstitial pneumonitis develop stop immediately, check for precipitates

15. Antineoplastic Therapy • Goal of therapy: • Curative: given as primary therapy • Palliative: symptom management

16. Antineoplastic Therapy Basic considerations in chemotherapy treatment: • Smaller the tumor burden the easier the patient is to treat • Surgical dubulking decreases the tumor burden and recruits resting malignant cells to start dividing, thereby increasing the sensitivity to chemotherapy. • The higher the dose, the better the chance for response

17. Antineoplastic Therapy 4. Doses are altered based on the degree of toxicity the patient experiences • Therapeutic margin is the difference between the dose producing the desired benefit and the dose resulting in unacceptable toxicity. • The therapeutic margin is narrow compared with that of other types of drugs

18. Cell Cycle • Chemotherapy exerts a cytotoxic action by interfering with the reproductive cell cycle • Cancer cells are the intended target, but cytotoxic action also affects normal cells

19. Cell Cycle • Five phases complete the cell growth cycle: G0, G1, S, G2, and M • G refers to gap phases or the time when the cell is preparing for a more active phase of reproduction • Cells can be come resting and nondividing

20. Cell Cycle • G1: the first growth phase characterized by the production of RNA, enzymes and proteins, essential to later cycles • S phase: enzymes necessary for DNA synthesis increase in activity. Predominant event is the production of DNA, the genetic code of all information needed for cell life.

22. Cell Cycle • G2: another resting phase, Tna and protein necessary for mitosis are synthesized. • M phase: last phase, mitosis takes place, lasts about ½ hour to 1 hour. • The phases of the cell cycle are correlated to the efficacy of the antineoplastic agents for specific types of cancer • Most agents kill only cells that are actively reproducing,

23. Tumor Kinetics • Cycling cells: cells that are dividing continuously • Nondividing cells: cells that divide for a time and then complete their life cycle with out dividing again • G0 or resting cells: further divided into • Stem cells: replenish the stem cell pool • Nonstem cells: differentiate and enter the maturing groups of cells

24. Growth Fraction • Cell cycle time: amount of time required to move from one mitosis to another • Growth fraction: percentage of cycling cells in the entire cell population • Total number of cells • Rate of cell loss or the number of cells that die or leave the cell population

25. Doubling Time • As the tissue mass increases in size, the doubling time slows • Decrease in nutrition available for each cell as the total mass increases and blood supply is outgrown • Tumor cells may die spontaneously

26. Cell Kill Hypothesis • Certain drugs doses destroy a constant fraction of tumor cells in the body, rather than a constant number of cells • Cell kill caused by antineoplastic drugs is related to the relative growth fraction of the tumor at the time of treatment

27. Drug Resistance • Cell resistance to drug therapy can be natural or aquired.

28. Antineoplastic Agents • Classifications: classified according to the cell life cycle • Cell cycle phase-specific (CCS) agents • Cell cycle phase-nonspecific (CCNS) agents • Combination Chemotherapy: Drugs given in specific combinations to work at different phases of the cell cycle

29. Antineoplastic Agents • Reductive Therapy: debulking, decreases the body burden of cancer cells • Adjuvant Chemotherapy: administration of chemotherapy to destroy micrometastasis and to prevent secondary tumors

30. Antineoplastic Agents • Intermittent Therapy: Intermittent high-dose (pulse) therapy with CCS and CCNs agents gives better therapeutic results with fewer toxic side effect than more frequent divided doses. Yields better cell kill.

31. Antineoplastic Agents • Chemotherapy Dosing: • Dose calculations using Body Surface Area (BSA) • Formula: BSA x mg/m2 = total dose • Dose Calculation using the Calvert Formula • Attempts to individualize the does so that optimal therapeutic response is achieved without toxic effects

32. Classes of Drugs • Alkylating Agents: mustard Gas • Effect the DNA thereby blocking replication • CCNS act at any stage • Antimetabolites: Low molecular weight compounds that exert their effect because of similarity to naturally occurring metabolites involved in nucleic acid synthesis • Folic acid antagonists, pyrimidine antagonists, purine antagonists, and immunosuppresant azathioprine (Imuran)

33. Classes of Drugs • Mitotic Inhibitors: Natural products, modes of action are different • Vinblastine, vincristine, etoposide, taxol, • Cytotoxic Antibiotics: produced by the mold streptomyces • Bleomycin, Dactinomycin, Mitomycin • Topoisomerase-1 Inhibitors: activity against a broad range of tumors • Inhibit the enzyme topoisomerase-1 causing reversible single strand DNA breaks

34. Classes of Drugs • Miscellaneous: • Altretamine • L-Asparaginase • Cladribine • Hydroxyurea • Mitotane • Hormonal agents

35. Classes of Drugs • Hormones and Hormone Antagonists: • Steroidal estrogens, progestins, androgens, corticosteroids and synthetic derivatives • Biotherapy: six categories • Cytokines • Monoclonal antibodies, • Differentiation agents • Cellular therapies • Immunostimulants • Gene thereapy

36. Short term Complications • Venous Fragility • Alopecia • Diarrhea • Constipation • Altered Nutritional Status • Anorexia and Alteration in Taste • Fatigue

37. Acute Reactions • Hypersensitivity and Anaphylaxis • Extravasation • Stomatitis and Mucositis • Nausea and Vomiting • Myelosupression • Neutropenia • Thrombocytopenia • Anemia

38. Toxicities • Neurotoxicity • Cardiac Toxicity • Pulmonary Toxicity • Renal Toxicity

39. Routes of Administration • Intravenous • Intrathecal • Regional • Intra-arterial • Intraperitoneal • Cerebrospinal Fluid Reservoirs • Infusion Pumps