Malignant disease

Question 1

What should be done if azathioprine or mercaptopurine is used concurrently with allopurinol?

Answer 1

Reduce the dose of azathioprine/ mercaptopurine to 1/4 of the usual dose.
Because allopurinol inhibits the metabolism and will lead to toxic levels if dose not reduced.

Question 2

What is the relation with azathioprine and mercaptopurine?
What is the MOA?
What is the relation to TPMT?

Answer 2

MOA- inhibit purine metabolism hence inhibits DNA synthesis.
Azathioprine is metabolised to mercaptopurine.
TPMT metabolises thiopurine drugs in the body,
The risk of myelosuppression whilst on these drugs is increased in patients who have low TPMT.

Hence CONTRAINDICATED in patients with LOW TPMT.

Question 3

What is antithromocyte (rabbit) immunoglobulin for?

What improves its tolerability?

Answer 3

Rejection prophylaxis in renal and heart transplants.

Pretreatment with IV cortiosteroids, an antihistamine and and antipyretic (paracetamol) improves tolerability.

Question 4

Which are the calcineurin inhibitors?

What is the MHRA alert associated with them?

Answer 4

Ciclosporin and Tacrolimus

MHRA alert: Prescribe by brand- for steady blood concentrations

Question 5

What should be avoided in excess in patients on Tacrolimus and ciclosporin?

Answer 5

Avoid excessive sunlight (and other UV lights)

Question 6

What is the MHRA alert regarding mycophenolate?

Answer 6

Genotoxic
Males to use contraception during and 90 days after treatment.

Females to exclude pregnancy and be on PPP during and 6 weeks after treatment.

NOTE: increased risk of skin cancer avoid sunlight

Question 7

Which medicines can be used for muscle spasms related to MS?

Answer 7

Baclofen
Tizanidine/ dantrolene
Gabapentin
Benzos
Cannabis extract (not NICE approved)

Question 8

How is emesis related to the use of cytotoxic drugs managed?

Answer 8

Low risk: pre-treat with dex or lorazepam

High risk: ondansetron + dex + aprepitant

Question 9

What is mesna for?

Answer 9

Cytotoxic (mostly cyclophosphamide) related urothelial toxicity.
Causes haemorragic cystitis.

Question 10

What are some of the serious side effects of methotrexate?

Answer 10

blood disorders
liver toxicity (dark urine, abdominal pain, jaundice)
respiratory effects
GI toxicity

Question 11

How long should a patient who has been on methotrexate continue contraception?

Answer 11

6 months

Question 12

Which common medicines should not be used with methotrexate?

Answer 12

NSAIDs.

Question 13

What should be done before treatment with taxanes (e.g docetaxel, paclitaxel) ?

Answer 13

Pretreatment with dex and H2 antagonist (ranitidine) to prevent severe hypersensitivity.

Question 14

Via which route should vinca alkaloids be given?

Answer 14

IV ONLY.

NOT to be given intrathecally under any circumstances- neurotoxic and fatal.

Question 15

What is the difference between folic and folinic acid?

Answer 15

Both forms of folate (vitamin B9)
Folinic acid is the metabolically active form of folic acid, that doesn’t need enzymatic conversion.
Folinic acid is IV/IM only, folic acid is oral

Question 16

Which are the anthracyclines?

What are the side effects?

Answer 16

RUBICINs- Doxorubicin, epirubicin, daunorubimcin.
Cause cardiotoxicity- dexrazoxane can prevent this.
Red urine
Hand and foot syndrome (keep hands and feet cool to prevent this)

Question 17

Which drugs can be used for breast cancer?

How does treatment differ depending on if the woman is pre or post menopausal?

Answer 17

Pre- menopausal: tamoxifen should be used.

Post-menopausal: first line: aromatase inhibitors (anastrozole or letrozole)
2nd line is tamoxifen.

Adjuvant bisphosphonates can be of benefit if metastatic.
Aromatase inhibitors NOT for pre-menopausal women.
If advanced breast cancer, go with tamoxifen first line.

Question 18

What should be done if a woman on HRT develops breast cancer?

Answer 18

STOP the HRT.

Question 19

How is prostate cancer managed?

Answer 19

Anti androgen therapy: cyproterone, goserelin, buserelin

Bicalutamide can be used in prostate cancer to maintain sexual function but it can case gynaecomastia (this can be treated with weekly tamoxifen)
Medroxyprogesterone can be used for hot flushes
Osteoporosis can become a problem- bisphosphonates

Question 20

What is a major contraindication of immunosuppressants when it comes to vaccines?

Answer 20

AVOID live vaccines- high risk of infections

Question 21

For which drug should patients avoid potassium and grapefruit juice?

Answer 21

Tacrolimus and ciclosporin- increases levels

Question 22

Which are the cytotoxic induced side effects?

Answer 22

Thromboembolism
Hyperuricaemia
Alopecia
Nausea + vomitting
bone marrow suppression
urothelial toxicity
oral mucositis
extravasation of IVs
effects on reproductive function.

Question 23

Which cytotoxic drugs may cause permanent male sterility?

Answer 23

Alkylating drugs (most cytotoxics) and procarbazine.
Advise patients on sperm storage.

Question 24

What are some risks with use of tamoxifen?

Answer 24

Thromboembolism

Endometrial cancer

Question 25

Which cytotoxics do not cause bone marrow suppression?

Answer 25

Vincristine

bleomycin

Question 26

How is hyperuricemia associated with cytotoxic drugs managed?

Answer 26

allopurinol
febuxostat
rasburicase (if associated with blood cancers)

Question 27

Which cytotoxic drugs case the most N+V?

Answer 27

cisplatin

high dose cyclophosphamide.

Question 28

Which cytotoxics are most likely to cause extravasation?

Answer 28

Vinca alkaloids

anthracyclines