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Gastrointestinal Adverse Events in Patients With Multiple Myeloma
Part 2: Management Tips

Reiko Torgeson, MN, RN, OCN®, Celgene Clinical Nurse Consultant, discusses interventions and management of gastrointestinal side effects in patients with multiple myeloma.

Tip Sheet about this topic

Hello, I’m Reiko Torgeson. Welcome to Part 2 of the Multiple Myeloma Center for Nurses videos on Gastrointestinal Adverse Events in Patients With Multiple Myeloma.

In part 1, we looked at the risk factors for and impact of gastrointestinal, or GI, adverse events in patients with multiple myeloma. In part 2, we’ll explore recommended interventions and management tips you can use in your practice to help ease symptoms and help prevent more serious problems.

Remember, that although common adverse events like constipation, diarrhea, nausea, and vomiting can be potentially serious, they are largely predictable and manageable.1 As nurses, we have an important role in recognizing these events and addressing them with patients.

The severity of GI adverse events is often defined according to the National Cancer Institute’s Common Terminology Criteria for Adverse Events, or NCI CTCAE.We will refer to NCI CTCAE version 4.03 in this video. The NCI CTCAE grading system uses a five-point scale to grade adverse events. This system allows for consistent adverse events reporting and recommends interventions based on severity.You are probably familiar with the NCI CTCAE in your practice, but let’s review how these criteria can be applied to the four key GI adverse events we discussed in part 1: constipation, diarrhea, nausea, and vomiting.

Constipation with abdominal discomfort is clinically defined as a decrease in defecation frequency, with patients typically experiencing fewer than 3 bowel movements per week.This table shows how constipation severity is characterized, ranging from grade 1 (abdominal discomfort), through grade 2 and 3 (persistent symptoms that limit the patient’s activities of daily living), to grade 4 (where symptoms can lead to the possibility of hospitalization).2

You can consult the NCI CTCAE for guidance on grading these events in your patients.Recommended interventions include increased fluid and fiber intake, environmental adjustments to assure the patient’s privacy and convenience, and increased physical activity.1,2

Bowel medications, such as laxatives and stimulants, can also be considered along with nutritional consultations for patients with persistent symptoms.1

Grade 3 constipation may call for manual evacuation and intravenous fluid, and assessment for bowel obstruction.1,2 

Grade 4 constipation may call for urgent intervention and possibly hospitalization and examination for obstruction or perforation.1,2 

Diarrhea is graded based on progressive increase in defecation (watery bowels) frequency.2 Grade 1 diarrhea is defined as an increase of less than 4 stools per day; grade 2 as an increase of 4 to 6 stools per day; and grade 3 as an increase of 7 or more stools per day.2 Grade 4 diarrhea is considered life-threatening and calls for urgent intervention including hospitalization, aggressive fluid replacement, and possible switch to total parenteral nutrition.1

For mild diarrhea, recommendations include urging patients to increase fluid intake and avoid GI irritants such as caffeine, alcohol, high-fiber foods, and heavily spiced foods. Perineal care with soap and warm water may be indicated.If a patient’s diarrhea becomes more severe, electrolyte imbalance should be assessed and corrected and outpatient pharmacologic management should be considered.

Grade 3 diarrhea may require hospitalization for fluid replacement and evaluation for bacteria such as Clostridium difficile.1,3 Patients should be monitored continuously, and you should consider pharmacologic interventions such as an empiric antibiotic or a tincture opium.Based on clinical judgment, patients who develop severe GI side effects due to certain oral antimyeloma therapies that the patient is taking may benefit by continuing at a lower dose or either temporarily or permanently discontinuing the specific antimyeloma medication.1,4 Please consult the appropriate product prescribing information for guidelines on dose modification, interruption, and/or discontinuation of the specific antimyeloma therapy.1

Nausea is a common side effect for many patients on chemotherapy and antimyeloma agents. It is clinically defined as an uncomfortable, unpleasant feeling in the throat or stomach that may or may not result in vomiting.Patients may experience three different types of nausea: acute, delayed, and anticipatory.1,5

Acute nausea appears within minutes to hours of administration of anticancer therapy and usually disappears within about 24 hours.Delayed nausea peaks 48 to 72 hours after anticancer therapy and can last 6 or 7 days.1 Anticipatory nausea is a conditioned response in anticipation of the anticancer treatment.1

To prevent anticipatory nausea, patients should eat small amounts of food throughout the day. Some suggestions may be to eat before they get too hungry and eat dry foods such as toast, cereal, or crackers.1 Other selected ways to prevent or reduce anticipatory nausea include distraction, relaxation exercises, acupuncture, systematic desensitization, and biofeedback.1

All of the recommendations for anticipatory nausea apply for grade 1 nausea, defined as a loss of appetite without alteration in eating habits.1 For some patients, consider starting mild pharmacologic therapy, such as antiemetics or 5-HT3 antagonists, the night before scheduled anticancer treatments.6

Grade 2 nausea is characterized by decreased oral intake without significant weight loss, dehydration, or malnutrition.2 Patients may require higher doses of the pharmacologic therapies we mentioned for grade 1. They may also need intravenous fluids, which should be given in bolus doses to help with hydration and to maintain electrolyte balance.1,2

Grade 3 nausea involves inadequate oral caloric intake or fluid intake. Patients may require hospitalization, total parenteral nutrition, or tube feeding.2 To help with grade 3 nausea, pharmacologic interventions may be necessary. You should also watch for abdominal distention or obstruction.1,7,8 For grade 4 nausea, consider total parenteral nutrition. Note that grade 4 nausea will most likely occur with vomiting.1,2

Finally, let’s discuss vomiting. Many people confuse vomiting and nausea when clinically they are considered separate side effects.Vomiting specifically refers to the expulsion of gastric contents through the mouth. Like nausea, vomiting can be anticipatory, acute, or delayed.1,2

Grade 1 vomiting is defined as 1 to 2 episodes within 24 hours, each separated by 5 minutes. It can be managed with and without medications.1,2 Suggest that patients have small, frequent meals, eating bland food. Acupuncture may work for some patients, and you might also consider administering short-acting phenothiazines.1,9

Grade 2 vomiting is characterized by 3 to 5 episodes separated by 5 minutes within 24 hours. Additional pharmacologic interventions to consider include benzodiazepines or serotonin 5-HT3 receptor antagonists.1,2,6,10 Additionally, intravenous fluid replacement may be required.1

Cases of grade 3 vomiting—defined as 6 or more episode separated by 5 minutes in 24 hours—may call for hospitalization, total parenteral nutrition, or tube feeding.1,2 Antiemetics should be given around the clock, and patients should be assessed for intestinal obstruction.1

Grade 4 vomiting requires urgent intervention and can be life-threatening.2 Hospitalization, referral to a gastroenterologist, and total parenteral nutrition are indicated.1

This concludes part 2 of the Multiple Myeloma Center for Nurses video, Gastrointestinal Adverse Events in Patients With Multiple Myeloma: Management Tips. To watch part 1 or to find out more on this and other topics related to multiple myeloma, please see additional videos and resources on this site. Here you will find a number of educational tools including tip sheets to help you discuss these topics with your patients, answers to common questions, and other downloadable materials.

Thank you.

References:

  1. Smith LC, Bertolotti P, Curran K, Jenkins B; IMF Nurse Leadership Board. Gastrointestinal side effects associated with novel therapies in patients with multiple myeloma: consensus statement of the IMF Nurse Leadership Board. Clin J Oncol Nurs. 2008;12(3 suppl):37-51.
  2. National Cancer Institute (2009) Common Terminology Criteria for Adverse Events v4.03 (CTCAE) Published: June 14, 2010. http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5×11.pdf. Accessed February 12, 2016.
  3. Jung KS, Park JJ, Chon YE, et al. Risk factors for treatment failure and recurrence after metronidazole treatment for Clostridium difficile-associated diarrhea. Gut Liver. 2010;4(3):332-337.
  4. Multiple Myeloma Research Foundation. Treatment FAQs. http://www.themmrf.org/multiple-myeloma/multiple-myeloma-treatment-options/treatment-frequently-asked-questions/. Accessed March 25, 2016.
  5. Janelsins MC, Tejani MA, Kamen C, Peoples AR, Mustian KM, Morrow GR. Current pharmacotherapy for chemotherapy-induced nausea and vomiting in cancer patients. Expert Opin Pharmacother. 2013;14(6):757-766.
  6. Schwartzberg L, Barbour SY, Morrow GR, Ballinari G, Thorn MD, Cox D. Pooled analysis of phase III clinical studies of palonosetron versus ondansetron, dolasetron, and granisetron in the prevention of chemotherapy-induced nausea and vomiting (CINV). Support Care Cancer. 2014;22(2):469-477.
  7. Jones JM, Qin R, Bardia A, Linquist B, Wolf S, Loprinzi CL. Antiemetics for chemotherapy-induced nausea and vomiting occurring despite prophylactic antiemetic therapy. J Palliat Med. 2011;14(7):810-4.
  8. Dix S, Cord M, Howard S, Coon J, Belt R, Geller R. Safety and efficacy of a continuous infusion, patient controlled anti-emetic pump to facilitate outpatient administration of high-dose chemotherapy. Bone Marrow Transplant. 1999;24(5):561-566.
  9. Chien TJ, Liu CY, Hsu CH. Integrating acupuncture into cancer care. J Tradit Complement Med. 2013;3(4):234-239.
  10. Kamen C, Tejani MA, Chandwani K, et al. Anticipatory nausea and vomiting due to chemotherapy. Eur J Pharmacol. 2014;722:172-179.