Supportivtherapie der medikamentösen Tumortherapie bei Kopf-Hals-Tumoren

Zusammenfassung

Fieber bei Neutropenie muss immer als lebensbedrohliche Infektion gewertet werden, die sofort standardisiert antibiotisch therapiert werden muss, bei Nichtansprechen ist eine Therapiemodifikation erforderlich. Die erforderliche Diagnostik darf die Therapie nicht verzögern. Wenn das Risiko der febrilen Neutropenie nach Chemotherapie ≥20% beträgt, dann ist immer eine prophylaktische Stimulation der Granulopoese mit G-CSF erforderlich. Ebenso soll G-CSF verwendet werden bei einem Risiko der febrilen Neutropenie von 10–20% und patientenbezogenen Risikofaktoren wie z.B. Alter >65 Jahre, reduzierter Allgemeinzustand, offene Wunden, schwerere Komorbidität. Die Anämie bei Krebs muss ätiologisch, auch präoperativ, abgeklärt werden. Transfusionen sind bei Hämoglobinwerten unter 7–8g/dl indiziert. Erythropoese stimulierende Faktoren (ESA) sind nach Chemotherapie bei Anämiebeschwerden und Hb-Werten unter 11g/dl angezeigt. Der Hb-wert darf nicht über 12g/dl angehoben werden. Bei Anämie mit funktionellem Eisenmangel (Transferrinsättigung <20%) ist intravenöses Eisen und nicht orales Eisen erforderlich, das nicht absorbiert wird. Die Schmerztherapie muss nach adäquater Diagnostik entsprechend einem Stufenschema adaptiert werden. Bei chronischen tumorassoziierten Schmerzen sollten Analgetika in pharmakologisch sinnvollen Abständen nach festen Uhrzeiten appliziert werden und den individuellen Bedürfnissen des Patienten angepasst werden. Zytostatika bedingte Übelkeit und Erbrechen können in die 4 Schweregrade minimal, gering, moderat und hoch eingeteilt werden. Die antiemetische Prophylaxe muss entsprechend gesteigert werden. Bei geringer Emetogenität reichen Steroide, bei moderater kommen 5-HT3-Rezeptorantagonisten dazu (Setrone) und bei der höchsten Stufe als dritte Substanz Aprepitant.

Abstract

Supportive Therapy, Neutropenia, Febrile Neutropenia, Lung Infiltrates, Documented Infection

Fever during neutropenia may be a symptom of severe life threatening infection, which must be treated immediately with antibiotics. If signs of infection persist, therapy must be modified. Diagnostic measures should not delay treatment. If the risk of febrile neutropenia after chemotherapy is ≥20%, then prophylactic therapy with G-CSF is standard of care. After protocols with a risk of febrile neutropenia of 10–20%, G-CSF is necessary, in patients older than 65 years or with severe comorbidity, open wounds, reduced general condition. Anemia in cancer patients must be diagnosed carefully, even preoperatively. Transfusions of red blood cells are indicated in Hb levels below 7–8 g/dl. Erythropoiesis stimulating agents (ESA) are recommended after chemotherapy only when hemoglobin levels are below 11g/dl. The Hb-level must not be increased above 12g/dl. Anemia with functional iron deficiency (transferrin saturation < 20%) should be treated with intravenous iron, as oral iron is ineffective being not absorbed. Therapy of pain must follow diagnostic and treatment standards. Nausea or emesis following chemotherapy can be classified as minimal, low, moderate and high. The antiemetic prophylaxis should be escalated accordingly. In chemotherapy with low emetogenic potential steroids are sufficient, in the moderate level 5-HT3 receptor antagonists (setrons) are added, and in the highest level Aprepitant as third drug.

Schlüsselwörter

Neutropenie - febrile Neutropenie - dokumentierte Infektionen - antibotische Therapie - G-CSF - Anämie - Erythropoese-stimulierende Agentien - Schmerztherapie - Übelkeit, Erbrechen nach Chemotherapie - Diarrhoe

Key words

neutropenia - febrile neutropenia - documented infection - antibiotic therapy - G-CSF - anemia - erythropoiesis stimulating agents - pain therapy - nausea and emesis after chemotherapy - diarrhea

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