chapter 8

Question 1

what are immunosuppressants used for?

Answer 1

to suppress transplant injections

to treat chronic or inflammatory or autoimmune diseases

Question 2

what are the 6 types of immunosuppressant drugs and give examples of each?

Answer 2

1. monoclonal antibodies: infiliximab, belimumab
2. corticosteroids: prednisolone
3. antiproliferative immunosuppressants eg mycophenolate mofetil
4. calcineurin inhibitor: ciclosporin
5. non calcineurin inhibitor: sirolimus
6. t cell activtating inhibitors: belatacept

Question 3

what is a disadvantage of corticosteroids?

Answer 3

can increase spread of infection and mask signs of infection

Question 4

what are the 2 key side effects of immunosuppressants?

what is the specialist advice regarding pt on immunosuppressants?

Answer 4

bone marrow suppression and mask signs of infection/increase risk of infection

live vaccines for patients

Question 5

why is folic acid given to those who take methotrexate?

are they given on the same day?

Answer 5

given to reduce toxicity of methotrexate

given on diff day of the week

Question 6

what is azathioprine metabolised to?

when are they used?

Answer 6

mercaptopurine

used when corticosteroids are not enough alone to provide adequate control

Question 7

what is the interaction between allopurinol and azathioprine and what is the action?

Answer 7

allopurinol increases risk of haematological toxicity

must reduce the azathioprine dose to 1/4 of the usual dose when given with allopurinol

Question 8

what are the side effects of azathioprine?

Answer 8

bone marrow suppression
leukopenia
increased risk of infection
hypersensitivity 
nausea 
thrombocytopenia

Question 9

how is nausea managed in a patient taking azathioprine?

Answer 9

divided doses
taken with or after food
take antiemetics
temporarily reduce dose

Question 10

is azathioprine safe in pregnancy?

Answer 10

no teratogenic. but if pt already on it do not discontinue, just monitor

Question 11

what should be measured before treatment with azathioprine?

what do you do if a patient has low levels of this?

Answer 11

TMPT enzyme metabolises thiopurine drugs so must measure

pt with low levels, monitor. pt with absent levels must not receive this drug

Question 12

what are the monitoring requirements of azathioprine?

Answer 12

toxicity
myelosuppression
full blood count weekly

Question 13

what is the pt and carer advice of azathioprine?

Answer 13

report signs of bone marrow suppression

Question 14

what s mycophenolate metabolised to?

Answer 14

mycophenolic acid

Question 15

what are the cautions of mycophenolate?

Answer 15

increased risk of skin cancer [avoid sun]
when used together with other immunosuppressants can increase risk of hypogammaglobinemia
bronchiectasis [wide bronchi increase risk of infection]

Question 16

is mycophenolate it safe in pregnancy?

Answer 16

no causes congenital malformations and spontaneous abortions

Question 17

what is the contraception and conception advice regarding mycophenolate>

Answer 17

must wear effective contraception throughout treatment and for 6 weeks after.
partner should also wear contraception
2 pregnancy tests must be done at least 8-10 days apart before treatment

Question 18

what is the patient and carer advice of mycophenolate?

Answer 18

females should be on pregnancy prevention programme

report signs of bone marrow suppression

Question 19

what class of immunosuppressants is ciclosporin?

what is the risk associated with its use?

Answer 19

calcineurin inhibitor

nephrotoxic

Question 20

what are the prescribing requirement of ciclopsorin?

Answer 20

must prescribe by brand or changes in blood ciclosporin changes

Question 21

what are the contraindications of ciclopsorin? [3]

Answer 21

• uncontrolled infection
• uncontrolled hypertension
• malignancy

Question 22

what are the monitoring requirements of ciclosporin? [5]

Answer 22

• ciclosporin blood concentrations
• blood pressure and renal function checked at least twice before treatment
• liver function
• serum potassium and magnesium
• blood lipids

Question 23

what is the patient and carer advice associated with ciclosporin? [4]

Answer 23

• avoid excessive exposure to UV light
• avoid UVB and PUVA light
• signs of bone marrow suppression must be reported
• when used by eye: affects driving and skilled tasks

Question 24

how many times should a full blood count be conducted in patients on ciclopsorin?

Answer 24

weekly for the first month, then monthly for the next 3 months, then every 3 months for the next year

Question 25

which 2 immunosuppressants do not cause bone marrow suppression?

Answer 25

vincristine and bleomycin

Question 26

what is a common side effect of ciclosporin?

Answer 26

eye inflammation

Question 27

what are 2 juices that interact with ciclosporin?

Answer 27

purple grape fruit juice decreases exposure pomelo juice increases exposure

Question 28

what class of immunosuppressants is tacrolimus in? what is the prescribing requirement for it?

Answer 28

calcineurin inhibitor? brand specific

Question 29

what risks are associated with tacrolimus? [4]

Answer 29

- neurotoxicity - hyperglycaemia - cardiomyopathy - bone marrow suppression

Question 30

can tacrolimus be used in pregnancy?

Answer 30

avoid unless benefits outweigh risks

Question 31

what must you monitor with tacrolimus?

Answer 31

liver and kidney

Question 32

what is the patient and carer advice of tacrolimus?

Answer 32

avoid excess exposure to UV light may affect performance of skilled tasks

Question 33

what drug class is sirolimus in? what is it licensed for? is it safe in pregnancy?

Answer 33

non-calcineurin inhibitor renal transplantation avoid unless essential

Question 34

what is the contraception and conception advice of sirolimus?

Answer 34

wear contraception during and 12 weeks after treatment

Question 35

what kinds of patients require higher doses of sirolimus?

Answer 35

african caribbean patients

Question 36

what is the pt and carer advice of sirolimus?

Answer 36

avoid exposure to uv light

Question 37

what are the 2 phases of chemotherapy treatment?

Answer 37

neoadjuvant: initial treatment to shrink tumour adjuvant: to prevent cancer after neoadjuvant tumour

Question 38

what is the guideline for handling cytotoxic drugs?

Answer 38

1. trained personnel should reconstitute them 2. protective clothing should be worn 3. protect eyes 4. pregnant staff should stay away from them 5. local procedures for dealing with spillages/safe disposal 6. staff exposure to cytotoxic drugs should be monitored

Question 39

what are the 8 side effects of cytotoxic drugs?

Answer 39

``` bone marrow suppression teratogenic in pregnancy nausea and vomiting alopecia hyperuricaemia tumour lysis syndrome oral mucositis extravasation of iv drugs [local tissue death] ```

Question 40

which cytotoxic drugs cause oral mucositis? [3]

Answer 40

flame fluorouracil anthracylines methotrexate

Question 41

which drug can be used to treat hyperuricaemia with cytotoxic drugs?

Answer 41

allopurinol

Question 42

which patients are at higher risk of N&V side effects of cytotoxic drugs?

Answer 42

women pt under 50 pt with motion sickness pt with repeat exposure to cytotoxic drugs

Question 43

what are acute, delayed and anticipatory symptoms of nausea and vomiting side effect of cytotoxic drugs?

Answer 43

acute: occur within 24 hours delayed: more than 24 hours anticipatory: occur prior to subsequent doses

Question 44

what is the treatment of anticipatory nausea and vomiting symptoms?

Answer 44

lorazepam

Question 45

what is the treatment of acute n&v symptoms in pt who are MILD risk of emesis? in patients who are at high risk of emesis?

Answer 45

dexamethasone or lorazepam 5ht3 receptor antagonist with dexamethasone and aprepitant

Question 46

what is the treatment of delayed n&v symptom for patients who are at moderate risk of emesis? those who are at high risk?

Answer 46

dexamethasone and 5ht3 receptor antagonist dexamethasone and aprepitant

Question 47

what is the treatment for haemorrhagic cystitis side effect caused by the cytotoxic drug cyclophosphamide?

Answer 47

mesna

Question 48

what is an important side effect of anthracycline antibiotics eg doxorubicin? [2]

Answer 48

red urine and cardiotoxicity

Question 49

what are the important side effects of doxorubicin? [3]

Answer 49

- extravasation [tissue death] - cardiomyopathy - hand foot syndrome

Question 50

how do alkylating drugs work in cancer chemotherapy? | give an example

Answer 50

damage DNA and prevents cell replication cyclophosphamide

Question 51

what is the drug action of methotrexate?

Answer 51

inhibit dihydrofolate reductase enzyme which is needed for synthesis of purines

Question 52

what is the only strength of methotrexate and how often should methotrexate be taken?

Answer 52

2.5mg once a week on same day every week

Question 53

what things must the patient report when on methotrexate? [3]

Answer 53

- blood disorder symptoms - liver toxicity symptoms - respiratory symptoms

Question 54

what are the cautions of methotrexate? [4]

Answer 54

low blood count gi toxicity liver toxicity pulmonary toxicity

Question 55

what are the monitoring requirements of methotrexate?

Answer 55

full blood count, liver and renal tests every 1-2 weeks then every 2-3 months

Question 56

what is the pt and carer advice of methotrexate?

Answer 56

``` report signs of blood disorders report signs of liver toxicity report abnormal respiratory effects give methotrexate treatment booklet avoid self medication eg nsaids ```

Question 57

what are the important interactions of methotrexate?

Answer 57

``` trimethoprim penicillins most antibiotics NSAIDs aspirins statins ```

Question 58

give examples of drugs in vinca alkaloids drug class which route of admin is contraindicated in vinca alkaloids and why?

Answer 58

vincristine, vinblastine intrathecal bc causes neurotoxicity

Question 59

what are the 2 side effects of vincristine?

Answer 59

neurotoxicity and bronchospasm

Question 60

what drug is used in breast cancer?

Answer 60

tamoxifen