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Infusion Reactions COLORECTAL CANCER
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Albert, 83M Retired fashion designer and entrepreneur Presented to Cabrini Brighton for C6 chemotherapy Metastatic CRC with liver met FOLFOX6 regimen with good effect INTRODUCTION
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Nov 2014 U/S and CT-CAP revealed extensive metastatic disease involving entire liver Suspected to be secondary to a previously resected sigmoid polyps Initial presentation Persistent nausea, anorexia and generalised weakness Bowel symptoms of constipation Weight loss 5kg Denied symptoms of liver disease Deranged LFT HOPC
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Hx of colonic polyps Routine colonoscopy for many years Dec 2012 Polypectomy with histopathology revealing adenocarcinoma Follow-up CT showed no evidence of nodal or distant metastasis Follow-up colonoscopy all clear HOPC
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Referral to A/Prof. Gary Richardson Work-up PET scan – bowel and liver involvement Tumour markers – CEA and CA19-9 Liver core biopsy – moderately differentiated adenocarcinoma Colonoscopy + biopsy – recurrent adenocarcinoma CRC grade IVA HOPC
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FOLFOX6 regimen Oxaliplatin, Leucovorin, 5FU, Bevacizumab Serum CEA LFTs Side effects Fatigue – exercise tolerance and sleep Bowel symptoms GORD Infusion reaction Weight stable Hypertension well controlled Nil other significant chemo toxicity CHEMOTHERAPY
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Ongoing issues Hyperlipidaemia – on Lipitor IHD and hypertension – on Coversyl and Tenormin Inactive issues Gout – on prophylactic allopurinol AF – asymptomatic since 1999 Meningioma – excised in 1997 NKDA PAST MEDICAL HISTORY
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Lives at home with wife Breast cancer Previously IADL Golfed twice weekly, walked 18 holes Cleaner fortnightly Currently more fatigable Golf once a week, requires buggy Still gardens One daughter Lives nearby and helps SOCIAL HISTORY
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Albert 83M Currently C6 of FOLFOX6 regimen for metastatic CRC with liver met Has been progressing well on treatment with decline in serum CEA and improvement in LFTs Has had relatively minor side effects from chemo But most recently had an infusion reaction that settled with anti- histamines, and since have had oxaliplatin removed from regimen SUMMARY
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1.Metastatic CRC with liver met Chemotherapy and post-chemo management 2.Medical management of IHD 3.Decline in function and exercise tolerance EP and OT assessment 4.Social issues Age Assistance with ADL ISSUES
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INFUSION REACTION
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Definition An unexpected reaction that cannot be explained by the known toxicity profile of the drug Virtually all chemotherapeutic agents have the potential to initiate an infusion reaction INFUSION REACTION
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Standard Infusion Reactions (SIRS) Cutaneous Flushing, itching, urticaria ± angioedema Respiratory Cough, nasal congestion, SOB, chest tightness, wheeze, hypoxia Cardiovascular Dizziness or syncope, tachycardia, hypotension, hypertension Gastrointestinal N/V, abdo pain and diarrhoea Neuromuscular Sense of impending doom, tunnel vision, dizziness, seizures, severe back/chest/pelvic pain Anaphylaxis if more severe SIGNS AND SYPMTOMS
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Usually occurs during or within a few hours of drug infusion Occasionally one to two days after administration Infusion reactions found to be more common in these settings IV administration After multiple cycles of certain agents Prior infusion reactions to drug of same chemical class History of multiple drug allergies TIMING AND RISK FACTORS
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Taxanes Platinum Doxorubicin L-asparaginase Procarbazine Etoposide Bleomycin Cytarabine Ixabepilone COMMONLY IMPLICATED AGENTS
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GRADE
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Immediate Symptomatic management ± resuscitation Rechallenge Reduced infusion rate Premedication Desensitisation techniques MANAGEMENT OF SIR
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Classic type 1 IgE-mediated allergic reaction Characterised by Pruritus, urticaria, bronchospasm, facial swelling and hypotension Abdominal pain, nausea, vomiting and diarrhoea are also relatively common in platinum drug-induced anaphylaxis One study of 272 patients receiving oxaliplatin found 48 (18%)patients who developed infusion reaction despite prevention regimen of famotidine and dexamethasone 3 Another study suggested benefit from higher doses of dexamethasone in conjunction with H1 and H2 receptor blockers (7% vs. 20% reaction rate) OXALIPLATIN AND PLATINUM DRUGS
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