Principles of supportive care in hematooncology

A part of the supportive care in hematooncology is symptomatic treatment of the underlying disease (e.g., pain treatment), control of the side effects of treatment (e.g., antiemetics), nutritional care (nutritional support), and prevention of complications (e.g., antibiotic and antifungal prophylaxis, and substitution and support of growth factors).

Prophylaxis and treatment of infections (most commonly agranulocytosis)

 * Initiation of empirical treatment with broad-spectrum ATBs, preferably as a 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.

Antifungal prophylaxis
In the prophylaxis of systemic mycoses, Posaconazole is used despite its high cost, mainly due to its relatively few side effects. Posaconazole as a prophylaxis is indicated in the induction treatment of AML and MDS and as treatment or prevention of graft-versus-host reaction (GVHR).

Growth factors
Used substances include erythropoietin, analogs of 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 analoges
There are two analogs of thrombopoietin: romiplostim and eltrombopag. They are used with rituximab in the treatment of immune thrombocytopenic purpura if it does not respond to first-line treatment of corticosteroid and IV immunoglobulin therapy or to second-line therapy (splenectomy).

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

Growth factors are used to shorten the duration of neutropenia after chemotherapy (another indication outside supportive care is for peripheral stem cell flushing in bone marrow transplantation). In chronic myeloid leukemias and chronic lymphocytic leukemias, growth factors are administered two days after chemotherapy.

Replacement therapy

 * Erythrocyte concentrates
 * It is used in patients with Hb <80 or Hb <100 in patients with 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, and <100 thousand before major surgery.

Pain therapy (WHO principles)
If possible, drugs are administered orally and regularly (around-the-clock). The drug choice is individualized and effectiveness is verified. The following algorithm is used:


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

Antiemetic therapy
It is more effective in treating vomiting before it has occurred (as opposed to afterward).


 * 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 - such as aprepitant

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 irinotecan: loperamide 4 mg initially and then 2 mg every 2 hours
 * severe diarrhea: octreotide 150 ug s.c. 3 times daily with escalation of 50 ug / dose

Special supportive care
The use of chemoprotectants, which include: Mesna - prevents hemorrhagic cystitis during treatment with ifosfamide and high-dose cyclophosphamide) and Dexrazoxane - prevents cardiomyopathy during treatment with anthracyclines. Nutritional support, nutritional supplements, erythropoietin, and bisphosphonates are also important. Bisphosphonates reduce the frequency of pathological fractures in patients with myeloma and metastases of solid tumors to the bone, prolong the time until the first pathological fracture, and may prevent corticoid-induced osteoporosis. They should not be used in patients with creatinine> 265 μmol / l. The most effective examples are pamidronate and zoledronic acid iv, while less effective examples include clodronate po (in the Czech Republic, mostly used for economic reasons).