1. Minimizing the Side Effects Of Chemotherapy Joseph T. Ruggiero, M.D. Medical Oncologist The Jay Monahan Center for Gastrointestinal Health Associate Professor of Clinical Medicine Weill Medical College of Cornell University

2. Nausea and Vomiting Certain classes of drugs are worse than others --Cis-Platinum --Doxorubicin (Adriamycin) Which anti-emetic agents should be used is determined by the emetic potential of the drug

3. Neurotransmitter Sites For Nausea Muscarinic Dopaminergic Histamine Serotonin (5HT-3) Neurokinin 1 (NK 1)

4. Serotonin Receptor Inhibitors Granisetron (Kytril) Ondansetron (Zofran) Palonosetron (Aloxi) : Benefit of longer duration of action Best used as a “cocktail” with steroid (dexamethasone) and lorazepam

5. Serotonin Receptor Inhibitors: Common Side Effects Headache Constipation –Prevent with use of laxatives and stool softeners

6. NK 1 Receptor Inhibitor Aprepitant (Emend) –Used for acute and delayed nausea in combination with a serotonin receptor-blocking drug

7. Dopamine Antagonists Phenothiazines –Prochlorperazine (Compazine) Metoclopramide (Reglan) Trimethobenzamide (Tigan) –Limited role except for mildly emetogenic drugs and may be helpful in delayed nausea

8. Delayed Nausea Dexamethasone Lorazepam (Ativan) Dopamine antagonists –Prochlorperazine (Compazine) –Trimethobenzamide (Tigan)

9. Mucositis (Mouth Sores) More common with certain drugs: –5-fluorouracil (5-FU) –Methotrexate –Doxorubicin (Adriamycin) –Cyclophosphamide (Cytoxan)

10. Mucositis (Mouth Sores) Prevention –Icing of the mouth during treatment Treatment Options –Gel Clear –Magic Mouthwash –Viscous lidocaine

11. Diarrhea Major toxicity of several drugs used to treat gastrointestinal cancers, for example, 5-FU and irinotecan (Camptosar) Acute diarrheal reaction to irinotecan –Atropine at time of treatment

12. Delayed Diarrhea: Treatment Anti-Motility Drugs –Loperamide (Imodium) –Diphenoxylate (Lomotil) Octreotide (Sandostatin) –Somatostatin analogue –Works to prolong GI transit time –Subcutaneous administration

13. Diarrhea: Changes in Diet Increased fluid intake Increased starch content

14. Hand-Foot Syndrome Pain, redness, swelling, and peeling of the skin of the palms and soles Associated with certain agents –Capecitabine (Xeloda) –Liposomal doxorubicin (Doxil) –Infusional 5-FU –Weekly taxane therapy

15. Hand-Foot Syndrome: Treatment Options Dose reduction Avoid tight-fitting shoes; repetitive rubbing or prolonged heat to hands and feet Emollients –Eucerin –Bag Balm –Can be used effectively with cotton socks and/or gloves at bedtime

16. Fatigue: Multifactorial Anemia –Erythropoietin (Procrit)/darbepoetin (Aranesp) Depression –Selective serotonin reuptake inhibitor (SSRI) Sleep Disturbance --Sleep aid: zolpidem tartrate (Ambien), eszopiclone (Lunesta) Psychostimulants -- Methylphenidate (Ritalin)

17. Neuropathy Painful burning sensation Progressive numbness Motor weakness

18. Neuropathy Acute, cold induced –Oxaliplatin (Eloxatin) Chronic, dose related –Oxaliplatin –Taxanes

19. Neuropathy: Prevention Avoidance of cold exposure for 48-72 hours after oxaliplatin therapy Amino acid therapy (glutamine) Vitamin B6 (pyridoxine)

20. Neuropathy: Treatment Options Dose reduction Gabapentin (Neurontin) Amitriptyline (Elavil)

21. Report Your Side Effects Early It is important to report any side effects to your oncologist Side effects can be minimized effectively with early intervention