Principles of supportive care in hematooncology

Part of supportive treatment in hematooncology the symptomatic treatment of the underlying disease (pain treatment), control the side effects of treatment (anti-emetics), nutritional care (nutritional support), and prevention of complications (antibiotic and antifungal prophylaxis, substitution and support growth factors).

Prophylaxis and treatment of infections (the most common agranulocytosis)

 * Initiation of empirical treatment with broad-spectrum ATBs, preferably in combination
 * antibiotic replacement in case of ineffectiveness or according to the sensitivity of the cultured agent
 * consider empirical antifungals in patients with febrile neutropenia> 4 days

TIP: Check Febrile Neutropenia for more info!

Antifungal prophylaxis
In the prophylaxis of systemic mycoses, posaconazole is used despite its high cost, mainly due to its low side effects and the possibility of intake after. Posaconazole as a prophylaxis is indicated in the induction treatment of AML, in the induction treatment of MDS and as treatment or prevention of graft versus host disease (GVHR).

Growth factors
Used erythropoietin, analogs thrombopoietin and granulocyte colony stimulating factor (G-CSF).

Primary prevention

 * in regimens that have at least a 40% incidence of febrile neutropenia
 * in patients at high risk of early death (age> 60 years, performance status> 1, lymphocytes <700)
 * in patients at risk of non-compliance with dose intensity due to prolonged neutropenia
 * Secondary prevention
 * In patients who have already experienced febrile neutropenia.

Erythropoietin
Erythropoietin is indicated in anemia of chronic diseases.

Thrombopoietin analogues
There are two analogs of thrombopoietin: romiplostin and eltrombopag. They are used concomitantly with rituximab in immune thrombocytopenic purpura if it does not respond to first-line corticosteroid and IV immunoglobulin therapy or to second-line splenectomy.

G-CSF
Recombinant G-CSF can be administered in free form as so-called filgrastim (half-life 3-4 hours) or in pegylated form as so-called pegfilgrastim (PEG-G-CSF, half-life 15-80 hours). GM-CSF administration has no advantages over G-CSF and is not widely used.

Factors are used to shorten the duration of neutropenia after chemotherapy. (The second indication outside supportive care is for peripheral stem cell flushing in bone marrow transplantation.) Chronic myeloid leukemias and chronic lymphocytic leukemias are administered two days after chemotherapy.

Replacement therapy

 * Erythrocyte concentrates
 * It is used in patients with Hb <80 or Hb <100 in patients with associated heart or lung disease.


 * Thromboconcentrate
 * In patients with platelets <10 thousand in the absence of bleeding, <20 thousand in sepsis or with mild bleeding, <50 thousand before moderate surgery, <100 thousand before major surgery.
 * TIP: Check Hemotherapy for more details!

Pain therapy (WHO principles)
If possible orally and regularly (around-the-clock), individualize, verify effectiveness and use a ladder:


 * 1) degree: mild pain: non-opiate analgesic
 * 2) grade: moderate pain: weak opiate ( codeine ) + non-opiate analgesic
 * 3) degree: severe pain: strong opiate ( morphine ) + non-opiate analgesic + adjuvant
 * 4) grade: if oral or parenteral opiate does not help at maximum doses, try epidural analgesia

Anti-emetic therapy
It is more effective to prevent vomiting than to treat it after it has occurred.


 * Serotonin antagonists ( granisetron, ondansetron )
 * corticoids ( dexamethasone 20 mg or equivalent) - mostly in combination with setrons
 * dopamine antagonists: metoclopramide (1 mg / kg daily)
 * NK 1 receptor (neurokinin- 1 receptor) antagonists - represented by aprepitant
 * TIP: CHeck Antiemetics for more details!

Damage to the mucous membranes → Treatment of diarrhea and mucositis

 * Mild diarrhea: loperamide 4 mg initially + 2 mg every 4 hours, oral hydration - 8-10 glasses of clear fluid daily
 * moderate diarrhea, prophylaxis with irinothecan: loperamide 4 mg initially and 2 mg every 2 hours
 * severe diarrhea: octreotide 150 ug sc 3 times daily with escalation at 50 ug / dose
 * TIP: CHeck Antidiaroics for more details!

Special areas of supportive car
Chemoprotectants that include: Mesna - prevents hemorrhagic cystitis during treatment with ifosfamide and high-dose cyclophosphamide) and Dexrazoxane - prevents cardiomyopathy during treatment with anthracyclines. It is also important nutritional support, nutritional supplements , erythropoietin and bisphosphonates. Bisphosphonates reduce the frequency of pathological fractures in patients with myeloma and metastases of solid tumors to the bone (ca mammy), prolong the time to the first pathological fracture, and may prevent corticoid-induced osteoporosis. Do not use in patients with creatinine> 265 μmol / l. The most effective are pamidronate and zoledronic acid iv, less effective clodronate po (in the Czech Republic, however, most used for economic reasons).