Side Effect Management

Question 1

Short term fasting has been shown in animal models to improve treatment with which chemotherapy agents?

Answer 1

Etoposide, mitoxantrone, oxaliplatin, cisplatin, cyclophosphamide, and doxorubicin

Question 2

What is xerostomia?

Answer 2

Dry mouth

Question 3

What are some common nutrition interventions to help manage treatment-related fatigue?

Answer 3

1. Develop an individualized eating plan and encourage caregivers to get involved
2. Use foods that are easy to prepare and eat
3. Use medical nutrition therapy beverages as needed
4. Monitor weight and nutrition status
5. Promote physical activity as tolerated

Question 4

What are some common nutrition interventions to help manage impaired bone health among breast, prostate, uterine corpus, ovarian cancer, and leukemia patients?

Answer 4

1. Ensure adequate Ca and vitamin D intake
2. Promote weight bearing exercises, if appropriate

Question 5

What are some common nutrition interventions to help manage weight gain and/or metabolic syndrome among breast cancer, leukemia, or non-Hodgkin lymphoma patients?

Answer 5

1. Adjust energy, carbohydrate, fat, and fiber intakes to promote a healthy weight and achieve recommended BG, circulating insulin, and lipid levels
2. Promote physical activity to meet current guidelines

Question 6

What are some common nutrition interventions to help manage cardiovascular complications among breast cancer patients?

Answer 6

1. Recommend a plant-based diet
2. Promote weight control

Question 7

What are some common nutrition interventions to help manage enteritis and/or chronic diarrhea among prostate or colon/rectal cancer patients?

Answer 7

1. Increase fluid intake and balance electrolytes
2. Decrease fat intake, alter fiber intake, and limit dairy intake as needed

Question 8

What are some common nutrition interventions to help manage esophageal pain and/or dysphagia among lung and bronchus cancer patients?

Answer 8

1. Alter food and beverage consistency
2. Use medical nutrition beverages as needed
3. Alter food temperature and avoid alcohol, spicy foods, acidic foods
4. Monitor nutrition status and weight

Question 9

What are some common nutrition interventions to help manage respiratory failure among lung and bronchus cancer patients?

Answer 9

1. Monitor and correct fluid balance
2. Decrease carbohydrate intake, if indicated

Question 10

What are some common nutrition interventions to help manage malabsorption among colon and rectal cancer patients?

Answer 10

1. Increase intake or modify sources of nutrients that are malabsorbed
2. Monitor nutrition status and weight

Question 11

What are some common nutrition interventions to help manage altered liver function and/or cirrhosis among colon and rectal cancer patients?

Answer 11

1. Increase intake of nutrients that are malabsorbed
2. Monitor liver enzymes
3. If cirrhotic, follow evidenced-based MNT for liver cirrhosis

Question 12

What are some common nutrition interventions to help manage weight change among colon and rectal cancer patients?

Answer 12

1. Ensure balanced nutrient intake for maintaining or achieving a healthy weight
2. Balance energy intake with physical activity

Question 13

What are some common nutrition interventions to help manage irregular bowel movements among colon, rectal, bladder, ovarian, or pancreatic cancer patients?

Answer 13

1. Alter fiber intake as needed
2. Consume adequate fluids, monitor fluid intake
3. Use probiotics or prebiotics, if appropriate

Question 14

What are some common nutrition interventions to help manage bowel strictures or obstructions among colon, rectal, or ovarian cancer patients?

Answer 14

1. Depending on location of stricture or obstruction and presence of bowel sounds, provide enteral or parenteral nutrition support as appropriate

Question 15

What are some common nutrition interventions to help manage hypothyroidism among thyroid cancer, non-Hodgkin lymphoma, or leukemia patients?

Answer 15

1. Adjust energy intake to maintain a healthy weight
2. Promote physical activity to meet current guidelines

Question 16

What are some common nutrition interventions to help manage decreased creatinine clearance and/or renal failure among kidney cancer patients?

Answer 16

1. Monitor renal labs and adjust nutrient intake as needed following evidence-based MNT for renal disease

Question 17

What are some common nutrition interventions to help manage hypertension among kidney cancer patients?

Answer 17

1. Monitor sodium intake and reduce intake as needed
2. Promote weight control and physical activity as appropriate
3. Promote adequate intake of K+ and Ca

Question 18

What are some common nutrition interventions to help manage xerostomia among oral cavity and pharynx cancer patients?

Answer 18

1. Ensure nutrient requirements are met via oral intake if possible
2. Promote consumption of “wet” foods
3. Promote good oral care
4. Alter food and beverage consistency as needed
5. Use medical nutrition beverages and supplemental energy, protein, and nutrient products as indicated
6. Consider nutrition support if needed

Question 19

What are some common nutrition interventions to help manage dysphagia among oral cavity and pharynx cancer patients?

Answer 19

1. Alter food and beverage consistency as needed
2. Use medical nutrition beverages and supplemental energy, protein, and nutrient products as indicated
3. Monitor nutrition and weight status
4. Consult with SLP

Question 20

What are some common nutrition interventions to help manage tooth decay and/or periodontal disease among oral cavity and pharynx cancer patients?

Answer 20

1. Alter food and beverage consistency as needed
2. Use medical nutrition beverages and supplemental energy, protein, and nutrient products as indicated
3. Alter food temperature if tooth sensitivity is an issue
4. Alter types of food consumed if dysgeusia is an issues
5. Consult a dentist

Question 21

What are some common nutrition interventions to help manage kidney stones among leukemia patients?

Answer 21

1. Increase fluid intake to recommended levels

Question 22

What are some common nutrition interventions to help manage malabsorption among pancreatic cancer patients?

Answer 22

1. Modify intake of nutrients that are unabsorbed, if indicated
2. Consider use of pancreatic enzyme replacement therapy
3. Monitor weight, nutrition, and fluid status

Question 23

Describe the common terminology criteria for adverse events (CTCAE) grades for anorexia and early satiety.

Answer 23

1: loss of appetite without alteration in eating habits
2: oral intake altered without significant weight loss or malnutrition; ONS indicated
3: associated with significant weight loss or malnutrition; EN or PN indicated
4: life-threatening consequences; urgent intervention indicated
5: death

Question 24

What nutrition interventions can be recommended to help with anorexia and early satiety?

Answer 24

• Small, frequent meals that include nutrient-dense foods and fluids
• Schedule SF meals & snacks (6-8x/day), “eat by the clock”
• Maximize intake when appetite is best
• If eating is difficult, use ONS
• Consume liquids between meals rather than with meals
• Enhance nutrient density of food, as tolerated
• Use foods that are easy to prepare and serve to preserve energy
• Keep convenience foods on hand
• Approach eating as part of overall treatment
• Engage in light physical activity to help move food through GI tract

Question 25

What pharmacotherapies can be used to help with anorexia and early satiety?

Answer 25

Antihistamines: cyproheptadine (Periactin) - in children Corticosteroids: dexamethasone (Decadron) Progestational agents: medroxyprogesterone acetate (Provera), megestrol acetate (Megace) Prokinetic agents: metoclopramide (Reglan) Cannabinoids: dronabinol (Marinol), liquefied dronabinol (Syndros), nabilone (Cesamet) Antidepressants: mirtazapine (Remeron)

Question 26

Describe the common terminology criteria for adverse events (CTCAE) grades for taste and smell changes.

Answer 26

1: altered taste, but no change in diet 2: altered taste with change in diet (ONS), noxious or unpleasant taste, loss of taste

Question 27

What nutrition interventions can be recommended to help if foods have little flavor or an "off" taste?

Answer 27

- Opt for foods with fruity and salty flavors - Use marinades for meats to change the flavor - Add herbs, spices, lemon, vinegar, pickles, or strongly flavored sauces and condiments to season foods - Understand that hot ("spicy") seasoning many not make a difference since heat is a sensation, not a flavor

Question 28

What nutrition interventions can be recommended to help if foods have a bitter, acidic, or metallic taste?

Answer 28

- Eat sweet fruits alongside meals (watermelon, cantaloupe...) - Drink sweet or sour beverages (lemonade, apple or cranberry juice...) - Use strongly flavored spices or seasonings, such as onion, garlic, or chili powder - Use sugar-free lemon drops, gum, or mints to improve mouth taste - Choose alternative protein sources, such as chicken, eggs, tofu, dairy foods, nuts, or beans - Use bamboo or plastic silverware to reduce sense of metal in the mouth

Question 29

What nutrition interventions can be recommended to help if foods have a salty taste?

Answer 29

- Choose foods that are naturally sweet - Eat boiled foods to reduce flavor - Use low-sodium products or recipes

Question 30

What nutrition interventions can be recommended to help if foods have an enhanced sweet taste?

Answer 30

- Choose bland or sour flavors - Dilute juices or serve over ice - Choose vegetables rather than fruits

Question 31

What nutrition interventions can be recommended to help if food smells are bothersome?

Answer 31

- Eat food that is served at cold or room temperature - Avoid food with strong odors (fish, onions, cabbage...) - Avoid cooking areas during meal preparation - Avoid lengthy cooking processes (ex: crockpot) - Avoid cooking areas during meal preparation - Ventilate cooking areas

Question 32

What pharmacotherapies can be used to help with taste and smell changes?

Answer 32

- cleansing rinse ( 3/4 tsp salt, 1 tsp baking soda in 4 C water); rinse 3-4x/day - "miracle fruit" may help reduce bitter, acidic, or metallic taste sensors - herbal tea (gymnema sylvestra) before meals may inhibit sweet taste * zinc supplementation has not been proven to prevent loss of taste or taste changes in head & neck treatment patients

Question 33

Describe the common terminology criteria for adverse events (CTCAE) grades for constipation.

Answer 33

1: occasional or intermittent symptoms, occasional use of stool softeners, laxatives, dietary modification, or enema 2: persistent symptoms with regular use of laxatives or enemas, limiting instrumental ADL 3: obstipation with manual evacuation indicated, limiting self-care ADL 4: life-threatening consequences, urgent intervention indicated 5: death

Question 34

What nutrition interventions can be recommended to help with constipation?

Answer 34

- Aim for min 64-80 oz (8-10 C) fluid daily - Drink additional 32 oz fluid if using medicinal fibers - Consume adequate fiber (25 g/d for women, 38 g/d for men) - Adopt daily routine that includes the use of hot beverages, hot cereal, or high-fiber foods to stimulate BMs - Use food-related probiotics or other supps - Engage in light physical activity or stretching - Modify bowel regimen if taking opioids

Question 35

What pharmacotherapies can be used to help with constipation?

Answer 35

- Insoluble food fiber: bran, flaxseed, wheat germ, inulin - Medicinal fibers: psyllium (Metamucil), wheat dextrin (Benefiber), carboxymethycellulose (Trulance), methylcellulose (Citrucel), polycarbophil (FiberCon) - Stool softeners: docusate (Colace, Surfak) - Lubricants: mineral oil - Osmotic laxatives: polyethylene glycol (Miralax), lactulose (Duphalac, Cadilose), magnesium hydroxide (Milk of Magnesia), magnesium citrate (Loso, Tridate) - Stimulant laxative agents: bisacodyl (Dulcolax, Correctol, Carter's Pills), sennosides (Senokot, Ex-lax) - Opioid antagonists: methylnaltrexone bromide (Relistor), lubiprostone (Amitiza), naloxegol (Morantik), naldemedine (Symproic) Herbals: probiotics, slippery elm, aloe juice, cascara sagrada

Question 36

Describe the common terminology criteria for adverse events (CTCAE) grades for diarrhea.

Answer 36

1: increase of less than 4 stools per day over baseline, mild increase in ostomy output compared to baseline 2: increase of 4-6 stools per day over baseline, moderate increase in ostomy output compared to baseline, limiting instrumental ADL 3: increase of 7 or more stools per day over baseline, hospitalization indicated, severe increase in ostomy output compared to baseline, limiting self-care ADL 4: life-threatening consequences, urgent intervention needed 5: death

Question 37

What nutrition interventions can be recommended to help with diarrhea?

Answer 37

- Eat small, frequent meals - Drink 64-80 oz (8-10 C) of fluid daily, adding 8 oz (1 C) for each loose BM - Eat a low-fat, low-insoluble fiber, or low-lactose diet, if indicated - Increase soluble fiber intake (pectin, applesauce, bananas, oatmeal, potatoes, rice) - Limit gas-forming foods and carbonation, avoid use of straws and chewing gum if gaseous or bloated - Eliminate caffeine, alcohol, and highly spiced foods - Avoid sorbitol and other sugar alcohols - Use oral rehydration salts (ORS) if appropriate

Question 38

What pharmacotherapies can be used to help with diarrhea?

Answer 38

- Opioid receptor agonists: loperamide (Imodium), dipheoxylate atropine (Lomotil) - Hormonal: octreotide (Sandostatin) - Opioids: (anhydrous morphine (Paregoric), camphorated tincture of opium - Anti-inflammatory, anti-diarrheal: bismuth subsalicylate (Pepto-Bismol), attapulgite (Kaopectate) - Bile acid sequestrant: cholestyramine (Questrant) - Anticholinergics: diphenhydramine (Benadryl) - Medicinal fibers: psyllium (Metamucil), psyllium or calcium polycarbophil caplets (Konsyl), methylcellulose (Citrucel) - Preventative for gut radiotherapy: amifostine (Ethyol) - Amino acids: L-glutamine (may reduce duration, but not severity), Enterade (proprietary blend of AAs) - Probiotics: Saccharomyces boulardii, Lactobacillus rhamnosus GG

Question 39

Describe the common terminology criteria for adverse events (CTCAE) grades for dysphagia.

Answer 39

1: symptomatic, able to eat regular diet 2: symptomatic and altered eating or swallowing 3: severely altered eating or swallowing, EN or TPN or hospitalization indicated 4: life-threatening consequences, urgent intervention indicated 5: death

Question 40

What nutrition interventions can be recommended to help with dysphagia?

Answer 40

- Alter food textures as directed by SLP - Use thickeners in liquids as directed by SLP - Choose moist foods of similar texture to for cohesive bolus in the mouth - Avoid dry foods and foods that separate into pieces - Moisten dry foods (add gravies, sauces, etc) - Alternate bite of solid food with sip of liquid - Eat & drink in upright position - Avoid distractions and limit talking while eating - Avoid straws unless recommended by SLP - For odynophagia, use systemic pain med or topical anesthetics, sprays, and lozenges - Practice chin tuck swallowing and double swallowing to help food clear the pharynx - Practice verbalization after swallowing liquids to ensure clearing of pharynx

Question 41

What pharmacotherapies can be used to help with dysphagia?

Answer 41

- Topical anesthetics: lidocaine spray (Xylocaine) - Analgesia: opioids, various pain meds - Thickeners: Simply Thick, Thicken Right, Thicken Up, Thich & Easy, Thick It

Question 42

Describe the common terminology criteria for adverse events (CTCAE) grades for fatigue.

Answer 42

1: fatigue relieved by rest 2: fatigue note relieved by rest, limiting instrumental ADL 3: fatigue not relieved by rest, limiting self-care ADL

Question 43

What nutrition interventions can be recommended to help with fatigue?

Answer 43

- Eat small, frequent meals and snacks - Consider ONS - Keep nonperishable snacks at the bedside (granola bars, trail mix...) - Plan a larger meal for when appetite is best - Consume soft, easy-to-chew foods if eating is difficult - Consider using frozen meals, meal boxes, or grocery pick-up services - Use easy-to-prepare meals, snacks, prepared foods, and energy-dense foods - Save energy by limiting chores as much as possible - Continue to perform ADL and light activities - Monitor weight weekly, report weight loss, monitor hydration status - Consider PT consult for muscle strengthening - Avoid excessive daytime sleep to help improve nighttime sleep quality

Question 44

What pharmacotherapies can be used to help with fatigue?

Answer 44

- Blood transfusions - Erythropoietin given as epoetin alfa (Epogen, Procrit)

Question 45

Describe the common terminology criteria for adverse events (CTCAE) grades for malabsorption.

Answer 45

2: altered diet, oral intervention indicated 3: inability to aliment adequately, PN indicated 4: life-threatening consequences, urgent intervention indicated 5: death

Question 46

What nutrition interventions can be recommended to help with bloating and gas r/t malabsorption?

Answer 46

- Avoid swallowing air by limiting straw use - Avoid carbonated beverages and chewing gum - Eat slowly and chew thoroughly

Question 47

What nutrition interventions can be recommended to help with bloating, cramping, and gas from milk products r/t malabsorption?

Answer 47

- Follow a low-lactose diet - Use lactase-treated dairy products or lactase pills or drops

Question 48

What nutrition interventions can be recommended to help with gas from vegetables r/t malabsorption?

Answer 48

- Avoid cruciferous vegetables, beans, and legumes or take enzyme supplements with alpha-galactosidase and invertase (ex: Beano)

Question 49

What nutrition interventions can be recommended to help with bulky, foul-smelling, or fatty stools r/t malabsorption?

Answer 49

- Take pancreatic enzymes with fat-containing foods and beverages before the first bite and halfway through the meal - Use MCT oil, if needed - Educate patient about symptoms of fat malabsorption - Educate patient about use of fat-gram counters or nutrition apps to help track intake and enzyme adequacy - Educate patient about which foods and beverages do not require enzyme use - Educate patient about appropriate dosing of pancreatic enzymes

Question 50

What pharmacotherapies can be used to help with malabsorption?

Answer 50

- Simethicone (Gas-X) - Lactase enzyme (Lactaid) - alpha-galactosidase (Beano) - Probiotics (for gas, diarrhea): Saccharomyces boulardii, Lactobacillus rhamnosus GG - Pancreatic enzymes

Question 51

What are dosing recommendations for pancreatic enzymes?

Answer 51

Per fat-gram content: - Prescribe 500-1000 lipase units/g of fat - Do not exceed 4000 lipase units/g of fat - Do not exceed 2500 lipase units per kg body weight per meal or 10000 lipase units per kg body weight per day Per meal or snack: - 20k-75k lipase units per meal and 5k-50k lipase units per snack Per kg BW: - 500 lipase units per kg BW for meals - 25 lipase uniter per kg BW for snacks

Question 52

Describe the common terminology criteria for adverse events (CTCAE) grades for nausea.

Answer 52

1: loss of appetite without alteration in eating habits 2: oral intake decreased without significant weight loss, dehydration, or malnutrition 3: inadequate oral energy or fluid intake, EN or PN or hospitalization indicated

Question 53

Describe the common terminology criteria for adverse events (CTCAE) grades for vomiting.

Answer 53

1: intervention not indicated 2: outpatient IV hydration, medical intervention indicated 3: En, PN, or hospitalization indicated 4: life-threatening consequences 5: death

Question 54

What nutrition interventions can be recommended to help with nausea and vomiting?

Answer 54

- Make small, frequent attempts at oral nutrition - Choose bland, starchy foods and clear liquid, all served at room temp - Avoid greasy, high-fat foods and highly seasoned foods - Consume liquids between meals rather than with meals - Limit exposure to cooking odors by avoiding food prep areas, using exhaust fans, or opening windows - Avoid or limit strong-smelling lotions, soaps, perfumes, and air fresheners - Rest with head elevated for 30 min after eating - Time meals for when nausea meds are working best - Take pain meds with crackers or light food

Question 55

What pharmacotherapies can be used to help with nausea and vomiting?

Answer 55

- For acute N/V: serotonin antagonists: ondansetron (Zofran), dolasetron (Anzemet) granistreon (Kytril), palonosetron (Aloxi), tropisetron (Navoban)9 - For delayed N/V: dopamine antagonists: prochlorperazine (Compazine), promethazine (Phenergan) neurokinin-1 (NK-1) receptor antagonists: aprepitant or fosaprepitant (Emend), netupitant and palonsetron (Akynzeo), rolapitant (Varubi) - Benzamides: metoclopramide (Reglan) - Cannabinoids: dronabinol (Marinol), liquefied dronabinol (Syndros), nabilone (Cesamet) - Benzodiazapines: lorazepam (Ativan), diazepam (Valium) - Corticosteroids: dexamethasone (Decadron), prednisone - Combination meds for chemo-induced N/V: steroid + 5-HT3 receptor antagonist + NK-1 receptor antagonist, with or without benzamide - Investigational complementary therapies: ginger tea, ginger ale, 0.5-1 g ginger extract, acupressure bracelets, acupuncture, massage, transcutaneous electrical nerve stimulation, relaxation techniques, self-hypnosis

Question 56

Describe the common terminology criteria for adverse events (CTCAE) grades for mucositis.

Answer 56

1: asymptomatic or mild symptoms, intervention not indicated 2: moderate pain or ulcer that does not interfere with oral intake, modified diet indicated 3: severe pain, interfering with oral intake 4: life-threatening consequences, urgent intervention indicated 5: death

Question 57

Describe the common terminology criteria for adverse events (CTCAE) grades for esophagitis.

Answer 57

1: asymptomatic or mild symptoms, intervention not indicated 2: symptomatic, altered eating or swallowing, ONS indicated 3: severely altered eating or swallowing, EN or PN or hospitalization indicated 4: life-threatening consequences, urgent intervention indicated 5: death

Question 58

What nutrition interventions can be recommended to help with mucositis and esophagitis?

Answer 58

- Encourage good oral care - Prescribe cryotherapy during 5-FU bolus and high-dose melphalan chemo; have patient consume ice chips, ice water, or popsicle for 30 min to reduce development of mucositis - Choose foods lower in acidity and void tomato products, citrus juice, and pickled foods - Avoid strong seasonings and spices (chilis, curry, cloves, black pepper, hot sauce) - Moisten dry foods with gravies, sauces, dressings, etc - Choose soft foods - Sevre food cold or at room temp - Prepare smoothies with low-acid fruits (melons, bananas, peaches) and add yogurt, milk, or silken tofu - Limit carbonated beverages - Avoid alcohol-containing mouthwashes

Question 59

What pharmacotherapies can be used to help with mucositis and esophagitis?

Answer 59

- Amino acids: L-glutamine - Topical anesthetics: gels or rinses containing lidocaine, codeine, or morphine - Analgesia: opioids, anti-inflammatory agents - Topical anti-inflammatory gel: gel containing dexamethasone - Mucosal barrier and protectants: zinc gluconate and taurine (Gel-X), adherent gel (Gelclair) - Soothing rinse: 3/4 tsp salt + 1 tsp baking soda in 4 C water; rinse with 1C mixture 3-4x daily - Anti-infective prophylaxis: swish & spit with a topical analgesic (viscous lidocaine), anti-inflammatory (diphenhydramine), and a coating agent (aluminum hydroxide and magnesium hydroxide suspension) 3-4x/day

Question 60

Describe the common terminology criteria for adverse events (CTCAE) grades for oral candidiasis.

Answer 60

1: asymptomatic, local symptom management 2: oral intervention indicated (antifungal) 3: IV antifungal indicated

Question 61

What nutrition interventions can be recommended to help with oral candidiasis?

Answer 61

- Practice good oral hygiene, using saltwater rinses, and avoid mouthwashes containing alcohol - Replace or sanitize toothbrushes, oral appliances, and dentures - Choose soft-textured, low acid foods and beverages - Avoid carbonation - Consume active-culture yogurt several times daily

Question 62

What pharmacotherapies can be used to help with oral candidiasis?

Answer 62

- Polyene antifungal: nystatin (Mycostatin) - Azole antifungal: fluconazole (Difulcan) - Germicidal mouthwash: chlorhexidine gluconate (Peridex) - Probiotics; use caution in immunocompromised patients - Cleansing rinse: 3/4 tsp salt + 1 tsp baking soda in 4 C water; rinse with 1C mixture 3-4x daily

Question 63

Describe the common terminology criteria for adverse events (CTCAE) grades for xerostomia.

Answer 63

1: symptomatic (dry or thick saliva) without significant dietary alterations, unstimulated saliva flow >0.2 mL/min 2: moderate symptoms, oral intake alterations, unstimulated saliva flow 0.1-0.2 mL/min 3: inability to adequately aliment orally, EN or PN indicated, unstimulated saliva flow <0.1 mL/min

Question 64

What nutrition interventions can be recommended to help with xerostomia?

Answer 64

- Eat small, frequent meals - Alternate bites and sips at meals - Add broth, gravies, and sauces to meals - Sip liquids throughout the day, aim for 8-10 C fluid daily - Swish and spit with club soda or carbonated water - Use humidifier to moisten the air - Practice good oral hygiene Suck on hard candy, frozen grapes, or melon balls - Avoid mouthwash containing alcohol - Avoid alcoholic beverages and tobacco products