Some patients with cancer may look to their local pharmacy for help with managing the side-effects of chemotherapy, says Sam Malton, advanced pharmacy practitioner in cancer care, Nottingham University Hospitals.

 

 

Nearly all patients receiving anticancer chemotherapy will experience some kind of side-effects, the management of which is key to ensuring the optimum efficacy of treatment. The management of sideeffects is often dependent on a number of factors including:

• The type and dose of chemotherapy
• Co-morbidities and concomitant drug treatment
• Chemotherapy intent (i.e. curative or palliative)
• Prophylaxis received as part of treatment such as anti-emetics or granulocyte-colony stimulating factor (GCSF)
• How much chemotherapy or other treatment, such as radiotherapy, is planned
• Whether or not the patient is on a clinical trial – some trials may require specific ways of managing toxicity.

Supportive care is usually the mainstay of managing chemotherapy side-effects.

Most cancer treatment centres operate telephone triage systems and will have a facility where chemotherapy patients with toxicities can be assessed as an outpatient.

Some patients may live a considerable distance from their treatment centre so their GP or community pharmacy may be the most readily available source of help. Let us now look at six of the commonest side-effects and focus on how pharmacists can help in managing toxicity.

Nausea and vomiting

Chemotherapy induced nausea and vomiting (CINV) is often the side-effect feared most by patients. The key to management is often prophylaxis. The majority of chemotherapy treatments will be given with prophylactic anti-emetics but many patients will still experience CINV. Before treating it is important to establish the severity of the CINV as there is a risk of dehydration.

If this is a concern the patient should be referred to his/her treatment centre or to the nearest hospital if the situation is clinically urgent. Anti-emetic treatments used are variable and often include corticosteroids, dopamine antagonists, 5HT3 antagonists and anti-psychotic agents.

The route of any anti-emetic used must be considered, as some patients may not be able to tolerate enteral administration. Various self-care actions can often help with CINV including:

• Avoiding fatty/fried food
• Eating small amounts when feeling able
• Eating cold foods or foods that only require heating up if the smell of cooking induces nausea
• Eating dry food (e.g. toast or crackers)
• Crystallised ginger, ginger tea or ginger biscuits can help with nausea
• Sipping fizzy drinks such as mineral water, ginger beer/ale, lemonade or soda water slowly through a straw.

After episodes of CINV it may be necessary to amend the prophylactic regimen given to a patient with subsequent cycles of chemotherapy or the chemotherapy itself. Newer agents such as NK1 antagonists are often successful.

Diarrhoea

Diarrhoea is a common sideeffect of CINV. It is worse with certain drugs, including irinotecan, capecitabine and erlotinib. As with CINV it is essential to assess severity.

Dehydration can occur quickly and requires proactive rehydration, often with intravenous fluids. Any patient with more than four to six episodes of diarrhoea a day should be referred to a doctor. Patients with diarrhoea should be advised to maintain a good fluid intake of at least two litres a day.

An infective cause for the diarrhoea should be considered, especially in the presence of fever. Loperamide and codeine are often used to manage diarrhoea, which can prove to be a dose limiting toxicity.

Fatigue

Fatigue can be a result of anaemia, which is treatable, but many patients will experience debilitating fatigue with a normal haemoglobin. There is conflicting evidence surrounding drug treatments for fatigue and in practice these are rarely used.

Gentle exercise is thought to have some role in the management of fatigue, but plenty of rest and arrangements for help with things like childcare and housework are often necessary. Reassurance that fatigue can improve after treatment is vital.

Skin reactions

Various skin reactions are seen with different chemotherapies, ranging from mild to dose limiting. Often treatment is with simple emollients or other topical agents, but specialist management is frequently required for consideration of steroids, antibiotics and other therapies. As a general rule patients should be advised to avoid wet shaving, to use a moisturiser if the skin is dry (patients on radiotherapy should seek advice before using any topical agents), and to use sun cream (SPF30 or above) when exposed to the sun. Nails can be protected with moisturiser and the use of gloves, as they may become brittle during treatment. False nails should be avoided.

Mucositis/stomatitis

Mucositis/stomatitis can be a troublesome complication leading to reduced oral intake and severe pain for the patient. Various products are available including antiseptic and antiinflammatory mouthwashes, ionic solutions and oral gels, which are specifically designed to help chemotherapy patients. The goal of treatment is usually to minimise pain and to maintain oral intake.

Stomatitis and mucositis will usually heal shortly after chemotherapy. Oral infections are common and oral thrush, which is frequently seen, can be treated topically or systemically depending on severity. Some patients may require systemic analgesics for oral pain. Good oral hygiene should be maintained including gentle brushing with a soft toothbrush.

Flossing should be encouraged unless patients are thrombocytopenic and vaseline used to keep lips moist. Spicy, salty or acidic foods should be avoided. Sucking ice cubes can help to relieve pain.

Myelosuppression

Myelosuppression can be a dangerous side-effect of chemotherapy leading to anaemia, increased risk of infection and bleeding. Any patient on chemotherapy with a temperature above 38^oC should be advised to seek medical attention immediately as urgent antibiotic therapy is indicated.

Many patients will receive prophylactic antibiotics or (GCSF) with chemotherapy. General advice around reducing the risk of infection includes:

• Maintaining good hand hygiene, especially after using the toilet and when preparing food
• Staying away from crowded places and people who may have an infection
• Ensuring food is cooked correctly and avoiding highrisk foods such as raw meat.

Patients should be advised to report any symptoms of anaemia or bleeding to their treatment centre as soon as possible.