Neutropenia

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Rebecca Donohue, who will be talking with us about any and all questions you have regarding Neutropenia. Welcome Rebecca!

 Rebecca Donohue 

Hello!

 Rebecca Donohue 

Where are you from?

 oncnurse 

Massachusetts

 Lori Salvador 

Nevada

 khowlett 

California

 shoshaz 

New York

 Rebecca Donohue 

Inpatient or Outpatient?

 khowlett 

Inpatient

 Lori Salvador 

outpatient

 shoshaz 

outpatient

 oncnurse 

Neither - in education

 Rebecca Donohue 

Are there any burning questions?

 Lori Salvador 

Should Neupogen be used prophylactically vs letting a patient recover on their own following chemotherapy?

 Rebecca Donohue 

The recommendation is for prophylactic use if >20% of FN

 Rebecca Donohue 

FN = febrile neutropenia

 Rebecca Donohue 

Also, should be initiated with first course?

 oncnurse 

What is the recommendation re: plants in the room? I know that the stagnant water in cut flowers is not good.

 Rebecca Donohue 

Although no research specifically evaluated this the CDC recommends no flowers & plants in rooms if neutropenic.

 Rebecca Donohue 

What are the biggest issues with neutropenia?

 Rebecca Donohue 

I've heard that outpatient areas are concerned with keeping infected & neutropenic pt separate.

 Rebecca Donohue 

How is this done where you are?

 Lori Salvador 

Could you explain the >20% fn?

 Rebecca Donohue 

Sure, RE: FN: Lyman's study with Taxotere (a 17% risk of FN) indicated that use of CSF's (colony stimulating factors) with this population decreased risk of FN complications.

 Rebecca Donohue 

This study and others was the stimulus for NCCN to recommend >20% risk should be prophylaxed.

 lc 

What constitutes >20% risk?

 Rebecca Donohue 

There is a list on NCCN website of regimens with >20% risk.

 lc 

Ok thanks

 Lori Salvador 

Thanks

 Rebecca Donohue 

You can also find this in some of the package inserts.

 Lori Salvador 

What are the advantages of Neupogen vs Neulasta?

 susandegennaro 

Many patients can't tolerate Neulasta and we need to switch to neupogen. What interventions have been found helpful to prevent or treat the boney pain?

 Rebecca Donohue 

Neupogen requires daily injections for 7-10d (check package insert).

 Rebecca Donohue 

Neulasta is one injection per cycle.

 Rebecca Donohue 

For boney pain: In our practice we recommend all pts begin Claritin (NOT Claritin D) daily.

 Lori Salvador 

?

 Rebecca Donohue 

This has been shown, because of antihistamine effect, to decrease bone pain.

 lc 

That's interesting

 Rebecca Donohue 

Specifically not Claritin D, because the decongestant may have some adverse effect on patients with hypertension.

 Rebecca Donohue 

I will also recommend ibuprofen.

 Rebecca Donohue 

If this does not work we try narcotics.

 Rebecca Donohue 

Another trick is to delay the injection for 2-3 days.

 Rebecca Donohue 

Remember you have 72 hours to give the injection with maximum effect.

 susandegennaro 

We've tried Claritin and Motrin or Tylenol but not found to be effective. Any other suggestions? Percocet also not very helpful and more side effects.

 Rebecca Donohue 

Try the delay…

 susandegennaro 

Difficult with dose dense regimens.

 Rebecca Donohue 

Also, we find that younger pts have worse bone pain. Probably because of healthier bone marrow

 Rebecca Donohue 

The delay is not possible with dose dense.

 Rebecca Donohue 

We have in extreme cases tried decadron.

 susandegennaro 

Most already on decadron as part of antiemetic protocol.

 Rebecca Donohue 

May want to try non-pharm things such as warm baths, massage, etc

 susandegennaro 

If patient received Neulasta post chemo and subsequently admitted 12 days later with neutropenic sepsis, any role for additional G-CSF?

 Rebecca Donohue 

No role for G-CSF if already with Neulasta on board…

 Rebecca Donohue 

I have heard this before, but Neulasta stays in the system until neutrophil recovery. Extra will not help.

 Rebecca Donohue 

Remember pt will still nadir, but the idea with Neulasta is that they will not go as low & not stay down as long -- thus decreasing risk of sepsis.

 susandegennaro 

MDs seem to order based on neutropenia alone.

 Rebecca Donohue 

G-CSF's are not indicated to treat neutropenia, but I do realize this is done.

 Rebecca Donohue 

G-CSF's are indicated to prevent infection by decreasing the intensity and duration of the nadir.

 Rebecca Donohue 

If sepsis occurs with Neulasta on board, this may be a pt that needs prophylactic antibiotics to maintain the chemo dose.

 Rebecca Donohue 

Are prophylactic antibiotics used at your facilities?

 Lori Salvador 

no

 susandegennaro 

We institute "Neutropenic Precautions" when ANC< 500. Private room, HEPA ventilation, masks, no fresh flowers, raw food, and of course HAND HYGIENE. What ANC is commonly used as threshold to institute precautions?

 Rebecca Donohue 

Actually, prophylactic antibx on all patients is not recommended.

 susandegennaro 

We prophylax with certain chemo protocols which include Campath, Fludara etc, HYPerCVAD, etc.

 Rebecca Donohue 

However, studies have shown that prophylactic fluoroquinolones decreased infection in chemo pts.

 Rebecca Donohue 

We use ANC <500 also as threshold to institute precautions.

 Rebecca Donohue 

I am in an outpt setting so we teach the pt/family neutropenic precautions.

 Rebecca Donohue 

We institute prophylactic antibx with ANC<500 .

 susandegennaro 

What temp are patients told to report?

 Rebecca Donohue 

Temp is tricky depending on what literature you read. We use >100.4F.

 Rebecca Donohue 

I think it is important for the institution to decide on a temp parameter.

 Rebecca Donohue 

There is controversy on prophylactic antibx

 Rebecca Donohue 

Infectious disease docs are afraid of creating resistant strains.

 Rebecca Donohue 

Let's talk about isolation.

 Rebecca Donohue 

Protective isolation sounds like a great idea; however, there is no evidence that this is effective.

 Rebecca Donohue 

HCP should recommend avoiding exposure to infectious people.

 Rebecca Donohue 

I also always recommend that all visitors wash there hand when entering the pt’s home

 Rebecca Donohue 

HCP = health care personnel

 karen 

In our outpt facility, I emphasize good hand hygiene ESP for the patient and not touching their face as well as keeping some distance (3ft) from others.

 Rebecca Donohue 

Good practices Karen

 karen 

The practices I mention come from flu prevention literature.

 Rebecca Donohue 

I tell my pts about washing their hands with soap for the time it takes to sing “Happy Birthday” to themselves slowly; and to dry thoroughly.

 Rebecca Donohue 

Makes sense if it prevents flu it would also prevent other infections.

 karen 

I would love to seem more prevention practices with immunizations, flu, shingles, pneumonia.

 Rebecca Donohue 

Vaccinations are recommended for all cancer patients.

 karen 

Shingles pain on top of cancer, chemo...heart breaking…

 karen 

Recommendations and practice are 2 different things...

 Rebecca Donohue 

Many feel the vaccines will not work, but if timed correctly (when counts are good) it is recommended.

 lc 

What about exposure to recently vaccinated children?

 Rebecca Donohue 

The only concern is for vaccines with live viruses -- MMR, and previously, injected polio.

 karen 

Or flu nasal spray

 lc 

ok

 Rebecca Donohue 

Good point Karen

 karen 

How fast does Neulasta take effect?

 Rebecca Donohue 

The shingles vaccine is indicated for those >60(?). I'm not sure if it will be reimbursed for cancer pts that are younger.

 Rebecca Donohue 

RE: Neulasta: You will see a rise in the WBC's in the 1st couple of days.

 karen 

RE: Vaccines: Not usually reimbursed, even for Medicare. Cash only about $250 or so.

 Rebecca Donohue 

Pt with Neulasta will nadir 1-2days earlier.

 Lori Salvador 

Why would they nadir 1-2 days earlier?

 Rebecca Donohue 

Besides hand-washing & plants, what else to you teach pts?

 Rebecca Donohue 

I'm not sure of the reason for the earlier nadir, but it happens.

 susandegennaro 

I believe there are some recommendations to hold vaccination during chemotherapy treatment times... effectiveness is decreased.

 Rebecca Donohue 

Whose recommendations are these?

 oncnurse 

Teach re: bathing daily, good oral care, gloves when gardening, DRY hands after you wash them!

 karen 

Optimally, vaccinations should be addressed prior to initiating chemo.

 oncnurse 

Also teach use electric razors only, do not share utensils, common sense...

 susandegennaro 

RE: Vaccine recommendations: Can't remember, we did a search on the subject last year in view of the inpatient vaccination recommendation and measures.

 Rebecca Donohue 

There is a small study that says increased efficacy when the vaccine is administered between cycles rather than on day of chemo.

 karen 

I would love to see ONS get onboard with preventative immunizations prior to chemo. Could send pts back to PCP for this care.

 Rebecca Donohue 

What we do is have the vaccine during the week before treatment, when counts have recovered.

 Rebecca Donohue 

ONS guidelines do say to consider flu/pneumonia vaccine

 Rebecca Donohue 

ONS guidelines say that pts at high risk (cancer) & their family & healthcare providers should be vaccinated for flu.

 Rebecca Donohue 

Pts should avoid persons vaccinated with live vaccine for 30 days (CDC recommendation)

 karen 

Do you have any recommendations to help get reluctant infusion nurses to get annual flu vaccines? They can get away with signing the Letter of Declination in CA.

 Laurl at ONS 

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 Lori Salvador 

Thank you all very much

 Rebecca Donohue 

Unfortunately they cannot be forced. However, maybe emphasizing the studies supporting and the risk to their pt.

 karen 

Is there a study looking at chemo patients and the incidence of flu?

 Rebecca Donohue 

I'm not aware of any study on flu. I will check on this and if found will add as a post to the transcript.

 karen 

Ok, thanks