Page 33 Complete Your CE Test Online - Click Here Management of discomfort and dryness [181]: ● ● Topical anesthetics like lidocaine in gels, ointments or sprays can help, as can diphenhydramine solution. ● ● Mucosal coating agents like Amphojel, kaolin-pectin suspension, hydroxypropyl methylcellulose film-forming agents (e.g., Zilactin), and Gelclair (approved by the U.S. FDA as a device). ● ● Water-soluble lubricating agents, such as artificial saliva, can be used for xerostomia. ● ● A single application of topical doxepin, a tricyclic antidepressant, in cancer patients produces analgesia for four hours or longer. Its application to damaged mucosa does not cause burning. ● ● Topical morphine has been shown to be effective for relieving pain, but there is concern about dispensing large volumes of the medication. ● ● Topical fentanyl prepared as lozenges in a randomized placebo- controlled study showed relief for pain of oral mucositis. ● ● Systemic analgesia (such as opioids) should be used for pain unrelieved by these measures. NSAIDs are contraindicated when thrombocytopenia is present. Head and neck radiation typically causes not only acute oral toxicities such as mucositis in almost all recipients. In contrast to chemotherapy stomatitis, which tends to resolve after treatment ends, head and neck radiation can induce permanent tissue damage (to mucosa, bone, taste buds and more) that result in lifelong risk for the patient. Amifostine can be used to help prevent damage to the salivary glands [181]. Patients who do not respond well to topical treatments and symptomatic nursing management should be referred for dietary consultation to avoid dehydration and weight loss. Peripheral neuropathy Chemotherapy-induced peripheral neuropathy (CIPN) is a result of damage to the peripheral nerves. Symptoms depend on which peripheral nerves (sensory, motor, or autonomic) are affected. CIPN usually starts in the feet and hands that may spread proximally to arms or legs [179]. It is one of the most common reasons that cancer patients stop treatment early. It can sometimes be lessened by lowering the chemotherapy dose or delaying doses, which might diminish the pain. Other patients report symptoms last long beyond chemotherapy treatment for months or years [153]. Drugs associated with CIPN: ● ● Platinum compounds (cisplatin, carboplatin, oxaliplatin). ● ● Plant alkaloids (vincristine, vinblastine, vinorelbine, etoposide) [17]. ● ● Taxanes (docetaxel, paclitaxel, cabazitaxel). ● ● Epothilones (ixabepilone). ● ● Bortezomib. ● ● Thalidomide. ● ● Lenalidomide [153]. ● ● Eribulin [17]. Damage to sensory nerves can cause [179]: ● ● Tingling, numbness, or “pins-and-needles” in feet and hands. ● ● Inability to feel heat or cold in extremities. ● ● Inability to feel pain in the extremities. ● ● Hyperesthesia (increased sensitivity to heat, cold, or pressure) [17]. Damage to motor nerves can cause: ● ● Weak or achy muscles, loss of balance, difficulty with fine motor function (buttoning shirts or opening jars). ● ● Twitching, cramping, or muscle wasting. ● ● Dysphagia or dyspnea if chest or throat muscles are affected. Damage to autonomic nerves can cause: ● ● Gut motility problems such as constipation or diarrhea. ● ● Hypotension with dizziness and light-headedness. ● ● Sexual problems: Men may have erectile dysfunction and women may not reach orgasm. ● ● Sweating too much or too little. ● ● Urinary issues, such as leakage or incomplete bladder emptying. Injury prevention is important after CIPN develops. Advise affected patients to take actions to [179]: 1. Prevent falls: ○ ○ Get help moving rugs out of pathways to reduce the risk of tripping. ○ ○ Wear sturdy shoes with soft soles, not slippers that feet can accidentally slide out of. ○ ○ Home care services may be needed to put rails along the walls and in the bathroom. ○ ○ Use “gripper” bathmats in the shower or tub. ○ ○ Get up slowly after sitting or lying down, especially if the patient reports dizziness. 2. Take extra care in the kitchen and shower: ○ ○ Use potholders in the kitchen to protect hands from burns. ○ ○ Be careful when handling knives or sharp objects. ○ ○ Use oven gloves to handle hot pans, oven racks, and dishes. ○ ○ Ask someone to check the water temperature, or use a thermometer to make sure bath or shower water is not too hot. Set hot water heaters between 105° and 120°F to reduce risk of scalding when washing hands or dishes. 3. Protect hands and feet: ○ ○ Wear shoes, both inside and outside. ○ ○ Wear protective gloves when gardening, cleaning, or doing repairs. ○ ○ Check arms, legs, and feet for cuts or scratches every day. ○ ○ When the weather is cold, wear warm clothes, gloves, and socks to protect hands and feet. 4. Slow down and ask for help: ○ ○ Let others help with difficult tasks. ○ ○ Slow down and allow more time to do things. For patients with long-term CIPN, nurses may also want to ask the doctor to offer a referral to occupational therapy to help the patient with safety and mobility in the home and community [17]. Pain management for CIPN In 2014, the American Society of Clinical Oncology put out a review of evidence and a recommendation noting that no agents have been proven to prevent CIPN, and recommended duloxetine as a proven pain reliever for CIPN. They further added that tricyclic antidepressants (such as nortriptyline), gabapentin, and a topical gel containing baclofen, amitriptyline HCL, and ketamine, might all be offered because there is data that supports their efficacy in other types of neuropathic pain [101]. However, more research is needed on these agents for CIPN. The ASCO also had a long list of medications and supplements that they specifically recommended against, including amifostine, amitriptyline, calcium and magnesium infusion, vitamin E, glutathione, all-trans- retinoic acid, nimodipine, acetyl-L-carnitine, and others. Some patients with incomplete pain relief may be helped somewhat by distraction and practices such as massage, physical therapy, yoga, guided meditation, acupuncture, and other modalities [179]. Neutropenia Chemotherapy, radiation therapy, and stem cell transplants (which usually involve both chemo and RT) can lower the white blood cell count [208]. Especially important are the granulocytes or neutrophils that have an important role in fighting infection. Many chemotherapy drugs can depress the entire bone marrow production, not just white cells but also red blood cells (erythrocytes) and platelets. This leads to defects in fighting infection as well as oxygenation and blood clotting. Practice note: Look on the lab report for the white blood count differential (most often done with a complete blood count, CBC): sometimes neutrophils show up listed as “segs,” which refer to segmented neutrophils, or mature neutrophils; “bands,” which are less mature neutrophils; or to “polys,” which are polymorphonuclear leukocytes, yet another term for neutrophils.