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Chemotherapy Flashcards

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1
Q

What are the main classes of cytotoxic chemotherapy?

A
  • Alkylating agents
  • Antimetabolites
  • Enzyme inhibitors
  • Antimicrotubule agents
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2
Q

What is the mechanism of action of alkylating agents?

A
  • Covalently bind DNA
  • Form cross-links between strands
  • Inhibit replication and transcription
  • Cause DNA strand breaks
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3
Q

Which cell cycle phase do alkylating agents target?

A
  • Cell cycle nonspecific (CCNS)
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4
Q

What are examples of alkylating agents?

A
  • Cyclophosphamide
  • Ifosfamide
  • Melphalan
  • Busulfan
  • Nitrosoureas (carmustine, lomustine)
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5
Q

What are the primary toxicities of alkylating agents?

A
  • Myelosuppression
  • Secondary malignancies (AML/MDS)
  • Nausea and vomiting
  • Infertility
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6
Q

What is the toxic metabolite responsible for hemorrhagic cystitis in cyclophosphamide and ifosfamide?

A
  • Acrolein
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7
Q

How is hemorrhagic cystitis prevented in patients receiving ifosfamide or high-dose cyclophosphamide?

A
  • Hydration
  • Mesna (binds and detoxifies acrolein in urine)
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8
Q

What is the mechanism of action of mesna?

A
  • Sulfhydryl compound
  • Binds acrolein in bladder
  • Prevents hemorrhagic cystitis
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9
Q

What is a unique neurotoxicity associated with ifosfamide?

A
  • Encephalopathy (confusion, somnolence, hallucinations)
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10
Q

What can be used to treat ifosfamide-induced encephalopathy?

A
  • Methylene blue
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11
Q

Which alkylating agent is used as conditioning for hematopoietic stem cell transplant?

A
  • Busulfan
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12
Q

What are the toxicities of busulfan?

A
  • Seizures (high dose)
  • Pulmonary fibrosis
  • Hepatic veno-occlusive disease
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13
Q

What prophylaxis is given to patients on high-dose busulfan?

A
  • Anticonvulsants (e.g., levetiracetam)
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14
Q

Which alkylating agents cross the blood-brain barrier?

A
  • Nitrosoureas: carmustine and lomustine
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15
Q

What is a unique toxicity of carmustine?

A
  • Pulmonary fibrosis
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16
Q

What alkylator is used in the treatment of glioblastoma multiforme?

A
  • Temozolomide
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17
Q

What is the mechanism of action of temozolomide?

A
  • DNA methylation at O6 position of guanine
  • Leads to DNA mismatch and apoptosis
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18
Q

What biomarker predicts response to temozolomide?

A
  • MGMT promoter methylation
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19
Q

What is the major toxicity of dacarbazine?

A
  • Severe nausea and vomiting (highly emetogenic)
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20
Q

What are the nitrosoureas and how are they administered?

A
  • Carmustine (IV, wafer implant)
  • Lomustine (oral)
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21
Q

What is the delayed toxicity common to nitrosoureas?

A
  • Delayed myelosuppression (4–6 weeks after dosing)
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22
Q

Which alkylating agents are associated with secondary leukemia?

A
  • Cyclophosphamide
  • Melphalan
  • Procarbazine
  • Nitrosoureas
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23
Q

What is the latency period for secondary leukemia after alkylator exposure?

A
  • 5–7 years
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24
Q

How does procarbazine differ from other alkylators?

A
  • Also inhibits MAO → avoid tyramine-rich foods and alcohol
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25
What are dietary restrictions for patients on procarbazine?
- Avoid aged cheese, wine, fermented meats, alcohol
26
What monitoring is necessary during alkylator therapy?
- CBC with differential - Renal and liver function tests - Fertility counseling
27
What is the primary route of elimination for cyclophosphamide?
- Hepatic metabolism → active and toxic metabolites
28
Why should cyclophosphamide be taken in the morning?
- To minimize nighttime bladder exposure and cystitis risk
29
What is the dose-limiting toxicity of melphalan?
- Myelosuppression
30
What special handling precautions are required for alkylating agents?
- Use PPE - Avoid skin/mucous membrane exposure - Dispose as hazardous waste
31
Which alkylators have oral formulations?
- Melphalan - Temozolomide - Lomustine - Procarbazine
32
What is the purpose of fractionated dosing in alkylators?
- Reduces toxicity - Allows marrow recovery
33
Which chemotherapy agents are considered vesicants?
- Mechlorethamine - Anthracyclines - Vinca alkaloids
34
What alkylator is available as an implantable wafer for brain tumors?
- Carmustine (Gliadel wafer)
35
What is the mechanism of resistance to alkylating agents?
- Increased DNA repair - Decreased drug uptake - Increased glutathione activity
36
What is the definition of a bifunctional alkylating agent?
- Has two reactive sites → can cross-link DNA strands
37
What role does glutathione play in alkylator resistance?
- Detoxifies reactive intermediates - Overexpression leads to resistance
38
What is the risk of infertility with alkylators?
- High risk → affects both male and female fertility
39
What counseling is needed for patients on alkylating agents?
- Risk of infertility - Secondary cancers - Use of contraception
40
What prophylaxis should be given with high-dose cyclophosphamide?
- Mesna - Aggressive hydration - Antiemetics
41
Why is it important to monitor for cumulative toxicity with alkylators?
- Risk increases with total exposure - Long-term marrow suppression and secondary cancers
42
Which alkylator requires anticonvulsant prophylaxis?
- Busulfan (high dose)
43
What patient education is needed regarding alkylator-induced nausea?
- Take antiemetics as prescribed - Maintain hydration and nutrition
44
What labs should be closely followed during nitrosourea therapy?
- CBC for delayed myelosuppression - Pulmonary function (if carmustine)
45
What late-onset toxicities may occur with alkylating agents?
- Secondary leukemia - Infertility - Pulmonary fibrosis
46
What are signs of hemorrhagic cystitis to report immediately?
- Hematuria - Suprapubic pain - Dysuria
47
What is the major pharmacogenomic factor in alkylator sensitivity?
- Currently limited; some data on glutathione pathway enzymes
48
What supportive care is needed with ifosfamide?
- Mesna - Hydration - Monitoring for neurotoxicity
49
How should melphalan be administered for optimal effect?
- Oral or IV - Fasting may enhance absorption for oral formulation
50
What is a key safety instruction regarding procarbazine and medications?
- Avoid MAO inhibitors and serotonergic drugs (risk of serotonin syndrome)
51
What is the general mechanism of action of antimetabolites?
- Structural analogs of nucleotides - Inhibit DNA and RNA synthesis - Act during S phase of the cell cycle
52
What are the main subclasses of antimetabolites?
- Folate antagonists - Pyrimidine analogs - Purine analogs
53
What is the mechanism of action of methotrexate (MTX)?
- Inhibits dihydrofolate reductase (DHFR) - Depletes reduced folate - Impairs thymidine and purine synthesis
54
What is leucovorin rescue?
- Provides reduced folate - Bypasses DHFR block - Prevents toxicity in normal cells
55
When is leucovorin rescue used?
- After high-dose methotrexate (HD-MTX)
56
What toxicities are associated with methotrexate?
- Myelosuppression - Mucositis - Nephrotoxicity - Hepatotoxicity
57
What drug is used in methotrexate overdose or delayed clearance?
- Glucarpidase
58
What monitoring is necessary with high-dose MTX?
- Serum creatinine - Methotrexate levels - Urine output and pH
59
What drug interactions increase MTX toxicity?
- NSAIDs - PPIs - Penicillins
60
How is urine pH managed during HD-MTX therapy?
- Urinary alkalinization (pH >7) - Use sodium bicarbonate IV fluids
61
What is the mechanism of action of 5-fluorouracil (5-FU)?
- Inhibits thymidylate synthase - Prevents thymidine synthesis - Disrupts DNA replication
62
What enhances the efficacy of 5-FU?
- Leucovorin (stabilizes binding to TS enzyme)
63
What are the routes of administration for 5-FU?
- IV bolus - Continuous IV infusion
64
What are the main toxicities of bolus 5-FU?
- Myelosuppression
65
What toxicities are associated with infusional 5-FU?
- Diarrhea - Hand-foot syndrome
66
What is capecitabine?
- Oral prodrug of 5-FU - Converted enzymatically in tumor tissue
67
What are administration tips for capecitabine?
- Take within 30 minutes after a meal - Swallow whole
68
What toxicity is more prominent with capecitabine than 5-FU?
- Hand-foot syndrome
69
What enzyme deficiency increases 5-FU and capecitabine toxicity?
- DPD (dihydropyrimidine dehydrogenase) deficiency
70
What are signs of fluoropyrimidine overdose?
- Severe mucositis - Diarrhea - Neutropenia
71
What is the mechanism of action of cytarabine (ara-C)?
- Pyrimidine analog - Inhibits DNA polymerase - Incorporates into DNA
72
What is the dose-limiting toxicity of high-dose cytarabine?
- Cerebellar neurotoxicity
73
How is neurotoxicity monitored in cytarabine therapy?
- Neurologic exams (handwriting, gait, speech)
74
What ocular toxicity is associated with cytarabine?
- Conjunctivitis (chemical)
75
How is cytarabine-related conjunctivitis prevented?
- Prophylactic steroid eye drops
76
What are the toxicities of cytarabine?
- Myelosuppression - Nausea/vomiting - Rash - Hepatotoxicity
77
What is gemcitabine and its MOA?
- Pyrimidine analog - Inhibits DNA polymerase - Incorporates into DNA
78
What are common side effects of gemcitabine?
- Myelosuppression - Flu-like symptoms - Rash
79
What are rare toxicities of gemcitabine?
- Pulmonary toxicity - Hemolytic-uremic syndrome (HUS)
80
What is the mechanism of action of fludarabine?
- Purine analog - Inhibits DNA polymerase and ribonucleotide reductase
81
What are toxicities of fludarabine?
- Profound immunosuppression - T-cell depletion - Autoimmune hemolytic anemia
82
What prophylaxis is needed with fludarabine?
- PCP prophylaxis - Antiviral prophylaxis (HSV) - Antifungal coverage
83
What is cladribine used for?
- Hairy cell leukemia
84
What is the primary toxicity of cladribine?
- Myelosuppression - Immunosuppression
85
What is the metabolism pathway of 6-mercaptopurine (6-MP)?
- TPMT (thiopurine methyltransferase) - Xanthine oxidase
86
What increases toxicity risk of 6-MP?
- TPMT deficiency - Allopurinol use (XO inhibition)
87
What should be done if allopurinol is given with 6-MP?
- Reduce 6-MP dose by 50–75%
88
What is the mechanism of action of 6-thioguanine (6-TG)?
- Incorporates into DNA/RNA - Purine analog
89
How does 6-TG differ from 6-MP?
- 6-TG less hepatotoxic - More myelosuppressive
90
What are general toxicities of antimetabolites?
- Myelosuppression - Mucositis - Diarrhea - Hepatic dysfunction
91
Which antimetabolites require renal dose adjustment?
- Methotrexate - Cytarabine - Fludarabine
92
What is the purpose of folinic acid in antimetabolite therapy?
- Leucovorin rescue with MTX - Potentiates 5-FU activity
93
What are key monitoring parameters for antimetabolite therapy?
- CBC - LFTs - Renal function
94
What are high-risk symptoms of antimetabolite toxicity?
- Oral ulcers - Severe diarrhea - Neutropenic fever
95
What antimetabolite is used with Ara-C in AML induction?
- Idarubicin or daunorubicin (7+3 regimen)
96
What is the cell cycle phase specificity of antimetabolites?
- S phase
97
How is methotrexate administered for CNS prophylaxis?
- Intrathecal MTX
98
What is a critical safety issue with intrathecal chemotherapy?
- Vincristine must never be given intrathecally (fatal)
99
What antimetabolite has better CNS penetration?
- Cytarabine (liposomal or high dose)
100
What is a unique toxicity of high-dose methotrexate?
- Acute renal failure due to MTX precipitation
101
What are the main classes of antitumor antibiotics?
- Anthracyclines - Bleomycin - Mitomycin C - Dactinomycin (Actinomycin D)
102
What is the mechanism of action of anthracyclines?
- Intercalate into DNA - Inhibit topoisomerase II - Generate reactive oxygen species (free radicals) - Disrupt DNA replication and transcription
103
What are common anthracyclines used in chemotherapy?
- Doxorubicin - Daunorubicin - Epirubicin - Idarubicin
104
What is the dose-limiting toxicity of doxorubicin?
- Irreversible cardiotoxicity
105
What monitoring is required before and during anthracycline therapy?
- LVEF by echocardiogram or MUGA scan - Cumulative lifetime dose tracking
106
What is the typical lifetime cumulative dose limit of doxorubicin?
- 450–550 mg/m²
107
What agent can reduce anthracycline-induced cardiotoxicity?
- Dexrazoxane
108
What are common acute side effects of anthracyclines?
- Nausea and vomiting - Alopecia - Red-orange urine discoloration
109
What is dexrazoxane's dual indication?
- Cardioprotection (prior to doxorubicin) - Extravasation antidote
110
What happens with anthracycline extravasation?
- Severe tissue necrosis (vesicant)
111
What are signs of anthracycline cardiotoxicity?
- Dyspnea on exertion - Fatigue - Signs of heart failure
112
How does epirubicin differ from doxorubicin?
- Similar efficacy - Slightly reduced cardiotoxicity
113
What is a distinguishing feature of mitoxantrone?
- Blue-green discoloration of urine, sclera - Lower free radical generation than doxorubicin
114
What is the mechanism of action of bleomycin?
- Binds DNA and generates free radicals - Causes single- and double-strand breaks
115
What is the dose-limiting toxicity of bleomycin?
- Pulmonary fibrosis
116
What increases the risk of bleomycin pulmonary toxicity?
- Age >70 - Prior chest radiation - Cumulative dose >400 units - Supplemental oxygen
117
What is the maximum lifetime dose of bleomycin?
- 400 units
118
How is bleomycin eliminated?
- Primarily renal excretion
119
What monitoring is needed with bleomycin?
- Pulmonary function tests (PFTs) before and during treatment
120
What is mitomycin C and how does it work?
- Bioreductive alkylating agent - Cross-links DNA under hypoxic conditions
121
What are the toxicities of mitomycin C?
- Myelosuppression - Hemolytic-uremic syndrome (HUS) - Interstitial pneumonitis
122
What are common uses of mitomycin C?
- Anal cancer (with 5-FU) - Bladder cancer (intravesical)
123
What class of chemotherapy is dactinomycin (actinomycin D)?
- Antitumor antibiotic
124
What is the mechanism of action of dactinomycin?
- Intercalates into DNA - Inhibits RNA polymerase
125
What are clinical indications for dactinomycin?
- Pediatric tumors (Wilms tumor, rhabdomyosarcoma) - Gestational trophoblastic neoplasia
126
What are toxicities of dactinomycin?
- Severe myelosuppression - Mucositis - Radiation recall
127
What is radiation recall?
- Inflammatory reaction in previously irradiated skin - Triggered by chemotherapy agents like dactinomycin
128
What is the vesicant risk of actinomycin D?
- Potent vesicant → extravasation can cause tissue necrosis
129
What safety measures should be used with vesicant drugs?
- Central line preferred - Monitor site for pain, swelling, redness
130
What supportive care is essential during anthracycline therapy?
- Antiemetics - Baseline and ongoing cardiac monitoring
131
What anthracycline analog is used in AML induction therapy?
- Daunorubicin
132
How is idarubicin different from daunorubicin?
- More lipophilic - Improved intracellular penetration
133
What baseline labs are required before anthracycline initiation?
- CBC - CMP (esp. LFTs) - Cardiac function
134
What are signs of anthracycline extravasation?
- Burning, redness, swelling during infusion - Blistering and necrosis
135
What is the management of anthracycline extravasation?
- Stop infusion - Apply cold compress - Administer dexrazoxane
136
What is a unique counseling point for patients receiving mitoxantrone?
- Urine and sclera may turn blue-green temporarily
137
What is the role of anthracyclines in breast cancer therapy?
- Doxorubicin + cyclophosphamide (AC regimen) - Often followed by paclitaxel
138
What is the mechanism of free radical damage in anthracycline cardiotoxicity?
- Iron-dependent formation of hydroxyl radicals - Lipid peroxidation in cardiomyocytes
139
What is the difference between acute and chronic anthracycline cardiotoxicity?
- Acute: arrhythmias, ECG changes - Chronic: cardiomyopathy, heart failure
140
What patient factors increase anthracycline cardiotoxicity risk?
- Age >65 - Cardiac comorbidities - Cumulative dose - Chest radiation
141
What is the onset of bleomycin pulmonary fibrosis?
- Weeks to months after treatment begins
142
What symptoms may indicate bleomycin lung toxicity?
- Dry cough - Dyspnea - Crackles on auscultation
143
What is the role of oxygen in bleomycin toxicity?
- Supplemental oxygen can exacerbate lung injury
144
What is the proper infusion time for doxorubicin?
- Typically over 15–60 minutes - Slower infusion reduces extravasation risk
145
What is a cumulative toxicity shared by mitomycin and bleomycin?
- Pulmonary toxicity
146
What is the mechanism of resistance to anthracyclines?
- P-glycoprotein overexpression - Increased DNA repair mechanisms
147
What non-oncology use is approved for mitoxantrone?
- Multiple sclerosis (progressive forms)
148
What formulation of doxorubicin reduces cardiotoxicity?
- Liposomal doxorubicin (Doxil)
149
What is the advantage of liposomal anthracyclines?
- Reduced cardiotoxicity - Altered distribution profile
150
What skin reaction is associated with liposomal doxorubicin?
- Palmar-plantar erythrodysesthesia (hand-foot syndrome)
151
What are the main classes of microtubule-targeting agents?
- Vinca alkaloids - Taxanes - Epothilones - Eribulin
152
What is the mechanism of action of vinca alkaloids?
- Bind tubulin - Prevent microtubule polymerization - Arrest cell in M phase
153
What are examples of vinca alkaloids?
- Vincristine - Vinblastine - Vinorelbine
154
What is the dose-limiting toxicity of vincristine?
- Peripheral neuropathy
155
What is the dose-limiting toxicity of vinblastine and vinorelbine?
- Myelosuppression
156
What are signs of vincristine-induced neurotoxicity?
- Constipation - Paresthesias - Weakness - Ataxia
157
What is a critical safety concern with vincristine administration?
- Fatal if given intrathecally
158
What label warning is required for vincristine?
"For IV use only – fatal if given intrathecally"
159
What vesicant risks are associated with vinca alkaloids?
- Extravasation can cause tissue necrosis
160
What antidote is used for vinca extravasation?
- Hyaluronidase
161
How are vinca alkaloids metabolized?
- CYP3A4 in the liver
162
What is a major drug interaction concern with vincristine?
- CYP3A4 inhibitors increase toxicity
163
What is the maximum recommended dose of vincristine per cycle?
- 2 mg
164
What class of drugs are taxanes?
- Microtubule-stabilizing agents
165
What is the mechanism of action of taxanes?
- Promote tubulin polymerization - Prevent microtubule disassembly - Arrest mitosis in M phase
166
What are common taxanes?
- Paclitaxel - Docetaxel - Cabazitaxel
167
What are toxicities of paclitaxel?
- Peripheral neuropathy - Myelosuppression - Hypersensitivity reactions
168
What causes hypersensitivity with paclitaxel?
- Cremophor EL solvent
169
What premedications are required with paclitaxel?
- Diphenhydramine - H2 blocker (e.g., ranitidine) - Dexamethasone
170
How does nab-paclitaxel differ from paclitaxel?
- Albumin-bound formulation - No premedication required - Reduced hypersensitivity risk
171
What are the side effects of docetaxel?
- Fluid retention - Myelosuppression - Alopecia
172
What is the premedication for docetaxel?
- Dexamethasone for 3 days (to prevent fluid retention)
173
How is cabazitaxel used clinically?
- Metastatic castration-resistant prostate cancer (post-docetaxel)
174
What makes cabazitaxel effective in resistant tumors?
- Poor P-glycoprotein substrate
175
What is the dose-limiting toxicity of cabazitaxel?
- Neutropenia
176
What supportive therapy is recommended with cabazitaxel?
- G-CSF (e.g., pegfilgrastim)
177
What is the mechanism of action of ixabepilone?
- Epothilone B analog - Stabilizes microtubules
178
What is ixabepilone used for?
- Metastatic breast cancer (taxane-resistant)
179
What premedication is needed for ixabepilone?
- Antihistamines (contains Cremophor)
180
What are major toxicities of ixabepilone?
- Peripheral neuropathy - Myelosuppression - Hypersensitivity
181
What is eribulin and how does it work?
- Halichondrin B analog - Inhibits microtubule growth (non-stabilizing)
182
What is eribulin approved for?
- Metastatic breast cancer - Liposarcoma
183
What are unique toxicities of eribulin?
- QT prolongation - Neutropenia - Alopecia
184
What should be avoided during eribulin administration?
- Dextrose-containing IV fluids (incompatible)
185
What is a shared toxicity among all microtubule inhibitors?
- Peripheral neuropathy
186
What is a clinical sign of cumulative taxane neuropathy?
- Gait imbalance - Burning/tingling in hands and feet
187
What is stocking-glove distribution in neuropathy?
- Distal symmetrical sensory loss - Affects hands and feet
188
How is taxane-induced neuropathy managed?
- Dose reduction - Delay therapy - Consider duloxetine
189
What is a critical administration precaution with vincristine?
- NEVER give intrathecally → fatal
190
Why is cold exposure avoided with oxaliplatin?
- Triggers acute neuropathy
191
What is the onset of acute oxaliplatin neuropathy?
- Minutes to hours after infusion - Resolves within 14 days
192
What are symptoms of acute oxaliplatin-induced neuropathy?
- Throat tightness - Jaw stiffness - Sensitivity to cold
193
What are the signs of chronic oxaliplatin neuropathy?
- Persistent numbness - Trouble walking - Impaired fine motor skills
194
What cumulative dose of oxaliplatin increases risk of permanent neuropathy?
- >850–1000 mg/m²
195
How is oxaliplatin-induced neuropathy monitored?
- Neurologic exams - Patient-reported symptoms
196
What microtubule agent requires caution in hepatic impairment?
- Vincristine
197
Which microtubule agents are vesicants?
- Vincristine - Vinblastine - Vinorelbine
198
What is a common class toxicity of taxanes and vinca alkaloids?
- Neuropathy
199
Why are taxanes usually given before platinum agents in regimens?
- To reduce hematologic toxicity
200
What are key counseling points for patients on microtubule inhibitors?
- Report neuropathy early - Take care when walking or using hands - Avoid cold exposure if on oxaliplatin
201
What are the two main types of topoisomerase inhibitors used in chemotherapy?
- Topoisomerase I inhibitors (e.g., irinotecan, topotecan) - Topoisomerase II inhibitors (e.g., etoposide, teniposide)
202
What is the role of topoisomerase enzymes in cells?
- Resolve supercoiling during DNA replication and transcription - Introduce transient breaks in DNA strands
203
What is the mechanism of action of topoisomerase I inhibitors?
- Bind topoisomerase I-DNA complex - Prevent DNA re-ligation - Cause single-strand DNA breaks
204
What are the clinical uses of irinotecan?
- Colorectal cancer (FOLFIRI regimen) - Small cell lung cancer
205
What are the two types of diarrhea associated with irinotecan?
- Early (cholinergic) - Late (secretory, dose-limiting)
206
How is early-onset irinotecan diarrhea managed?
- Atropine
207
How is late-onset irinotecan diarrhea managed?
- Loperamide (high-dose protocol) - Hydration and electrolyte monitoring
208
What enzyme polymorphism increases irinotecan toxicity?
- UGT1A1*28 polymorphism
209
What is the primary dose-limiting toxicity of irinotecan?
- Diarrhea
210
What are other toxicities of irinotecan?
- Neutropenia - Nausea/vomiting - Fatigue
211
What is the mechanism of action of topotecan?
- Inhibits topoisomerase I - Induces single-strand DNA breaks
212
What are the primary indications for topotecan?
- Ovarian cancer - Small cell lung cancer
213
What is the dose-limiting toxicity of topotecan?
- Myelosuppression (particularly neutropenia)
214
What are signs of myelosuppression with topotecan?
- Low ANC - Increased risk of infection - Fatigue, bruising
215
What is the elimination route of topotecan?
- Primarily renal
216
What adjustment is necessary for topotecan in renal impairment?
- Dose reduction
217
What is the mechanism of action of etoposide?
- Inhibits topoisomerase II - Prevents re-ligation of DNA double-strand breaks
218
What cancers is etoposide used to treat?
- Small cell lung cancer - Testicular cancer - Lymphomas
219
What is the major dose-limiting toxicity of etoposide?
- Myelosuppression
220
What is a rare but serious toxicity of etoposide?
- Secondary AML (usually with MLL gene translocation)
221
How is etoposide administered?
- Oral or IV infusion
222
What are infusion-related reactions to IV etoposide?
- Hypotension - Bronchospasm
223
How can infusion reactions to etoposide be prevented?
- Slow infusion over 30–60 minutes - Premedication if needed
224
What are stability issues with etoposide IV formulation?
- Precipitates at high concentrations - Use proper diluent and administration time
225
What is the oral bioavailability of etoposide?
- ~50%
226
What is the mechanism of action of teniposide?
- Similar to etoposide: inhibits topoisomerase II
227
What is teniposide used for?
- Pediatric ALL - Lymphomas
228
What are key toxicities of teniposide?
- Myelosuppression - Hypotension (infusion-related)
229
What is a counseling point for patients on etoposide capsules?
- Take on empty stomach for optimal absorption
230
What supportive care is often required with topo inhibitors?
- Growth factor support (G-CSF) - Antiemetics
231
What causes secondary leukemia with etoposide?
- Topoisomerase II inhibition → chromosomal translocations
232
What is the latency period for etoposide-related leukemia?
- Typically 1–3 years
233
What lab monitoring is needed with irinotecan?
- CBC - Electrolytes - LFTs
234
What drugs increase irinotecan toxicity?
- CYP3A4 inhibitors - UGT1A1 inhibitors
235
What drugs reduce irinotecan effectiveness?
- CYP3A4 inducers (e.g., phenytoin, rifampin)
236
What are signs of cholinergic syndrome from irinotecan?
- Diarrhea - Sweating - Abdominal cramping - Bradycardia
237
What is the role of atropine in irinotecan therapy?
- Antidote for early-onset cholinergic symptoms
238
How is late diarrhea from irinotecan managed with loperamide?
- 4 mg at onset, then 2 mg every 2 hours until diarrhea-free for 12 hours
239
What dietary recommendations apply to irinotecan patients?
- Hydration - Low-fiber diet during diarrhea episodes
240
What is a black box warning for topoisomerase inhibitors?
- Severe myelosuppression
241
What baseline labs are essential before starting topoisomerase inhibitors?
- CBC with differential - Renal and liver function
242
What risk factors predispose to irinotecan toxicity?
- UGT1A1*28 allele - Hepatic dysfunction - Dehydration
243
What is a supportive measure to prevent irinotecan diarrhea?
- Prophylactic loperamide in some cases
244
What form of irinotecan has altered PK and toxicity?
- Irinotecan liposomal injection (Onivyde)
245
What is the elimination pathway for etoposide?
- Hepatic metabolism and renal excretion
246
What are storage considerations for topotecan oral capsules?
- Store at room temperature - Protect from moisture
247
What supportive agents are commonly used with topo inhibitors?
- Antiemetics - Antidiarrheals - Growth factors
248
Why is combination therapy often used with topoisomerase inhibitors?
- Synergistic effects - Reduce resistance development
249
What is a unique side effect of topotecan?
- Pneumonitis (rare but serious)
250
How should patients on irinotecan monitor and report diarrhea?
- Keep loperamide on hand - Report >24 hours duration or signs of dehydration
251
What are the main platinum-based chemotherapy agents?
- Cisplatin - Carboplatin - Oxaliplatin
252
What is the general mechanism of action of platinum agents?
- Form DNA crosslinks - Inhibit DNA replication and transcription - Lead to cell cycle arrest and apoptosis
253
What type of DNA crosslinking do platinum agents cause?
- Intrastrand and interstrand DNA crosslinks
254
What is the dose-limiting toxicity of cisplatin?
- Nephrotoxicity
255
What are additional toxicities of cisplatin?
- Nausea/vomiting (highly emetogenic) - Ototoxicity - Neurotoxicity - Hypomagnesemia
256
What electrolyte abnormalities are common with cisplatin?
- Hypomagnesemia - Hypokalemia - Hypocalcemia
257
How is cisplatin nephrotoxicity prevented?
- Aggressive IV hydration - Mannitol diuresis in some protocols
258
What premedications are essential with cisplatin?
- Antiemetics (5HT3 antagonist, dexamethasone, NK1 antagonist) - IV fluids with electrolytes
259
What is the cumulative toxicity of cisplatin?
- Ototoxicity and neurotoxicity may be irreversible
260
What monitoring is required with cisplatin?
- Renal function (SCr, BUN) - Electrolytes (Mg, K, Ca) - Audiometry in some cases
261
What is the main dose-limiting toxicity of carboplatin?
- Myelosuppression (especially thrombocytopenia)
262
How is carboplatin dosed?
- Calvert formula: Dose = AUC × (GFR + 25)
263
What are advantages of carboplatin over cisplatin?
- Less nephrotoxicity - Less emetogenic - No need for aggressive hydration
264
What are disadvantages of carboplatin?
- Greater myelosuppression - Hypersensitivity reactions (delayed)
265
What are common hypersensitivity reactions to carboplatin?
- Rash - Anaphylaxis - Often after >6 cycles
266
How is carboplatin hypersensitivity managed?
- Desensitization protocol - Premedications (antihistamines, steroids)
267
What are common indications for carboplatin?
- Ovarian cancer - Lung cancer - Breast cancer
268
What is the mechanism of action of oxaliplatin?
- Forms platinum-DNA adducts - Similar to cisplatin, but different adducts
269
What is the dose-limiting toxicity of oxaliplatin?
- Peripheral neuropathy
270
What are the two types of oxaliplatin-induced neuropathy?
- Acute (cold-triggered, reversible) - Chronic (cumulative, persistent)
271
What are symptoms of acute oxaliplatin neurotoxicity?
- Throat tightness - Jaw stiffness - Cold sensitivity
272
What strategies reduce risk of oxaliplatin neuropathy?
- Limit cumulative dose - Avoid cold exposure - Consider dose modifications
273
What are other toxicities of oxaliplatin?
- Nausea/vomiting - Diarrhea - Neutropenia
274
How is oxaliplatin administered to minimize neuropathy?
- Warm fluids during and after infusion - Avoid cold liquids or environments
275
What is the FOLFOX regimen?
- 5-FU + leucovorin + oxaliplatin
276
What cancers are treated with FOLFOX?
- Colorectal cancer - Gastroesophageal cancers
277
What are shared toxicities of all platinum agents?
- Nausea/vomiting - Myelosuppression - Nephrotoxicity (esp. cisplatin) - Hypersensitivity
278
What is a key counseling point for patients on cisplatin?
- Maintain hydration - Report ringing in ears or hearing changes
279
Why is audiometry used in cisplatin patients?
- Monitor for ototoxicity, especially in pediatric or high-dose therapy
280
How is cisplatin-induced nausea managed?
- Triple antiemetic therapy - Add olanzapine for refractory cases
281
How does magnesium supplementation help in cisplatin therapy?
- Prevents hypomagnesemia - May reduce nephrotoxicity risk
282
What is a risk of cisplatin re-challenge after ototoxicity?
- Worsening or irreversible hearing loss
283
How is carboplatin dosed if GFR cannot be accurately measured?
- Use estimated creatinine clearance - Consider capping GFR at 125 mL/min
284
What is the emetogenic potential of platinum agents?
- Cisplatin: High - Carboplatin: Moderate - Oxaliplatin: Low to moderate
285
What is a sign of oxaliplatin neuropathy worsening?
- Impaired fine motor skills - Gait disturbance
286
What are signs of platinum hypersensitivity reaction?
- Rash - Wheezing - Hypotension - Angioedema
287
When does platinum hypersensitivity typically occur?
- After multiple cycles (usually >6)
288
What diagnostic test may help identify platinum allergies?
- Skin testing (not routinely done)
289
What are treatment options for platinum-allergic patients?
- Desensitization - Switch to alternative platinum agent
290
What is the role of mannitol in cisplatin regimens?
- Promotes diuresis - Reduces contact time with renal tubules
291
What is the maximum tolerated dose of cisplatin per cycle?
- Typically 100 mg/m²
292
What precautions are needed for cisplatin administration?
- Verify pre- and post-hydration - Monitor urine output
293
What are signs of platinum-induced nephrotoxicity?
- Rising creatinine - Electrolyte disturbances - Decreased urine output
294
What labs should be monitored with platinum agents?
- SCr, BUN - Mg, K, Ca - CBC
295
What patient factors increase risk of cisplatin nephrotoxicity?
- Older age - Volume depletion - Pre-existing renal disease
296
Why is carboplatin preferred in patients with renal dysfunction?
- Less nephrotoxic than cisplatin - Can be dosed based on renal function
297
What is the mechanism of platinum hypersensitivity?
- IgE-mediated (type I hypersensitivity)
298
What premedication is recommended for carboplatin desensitization?
- Antihistamines - Corticosteroids - H2 blockers
299
What supportive medications are critical for cisplatin therapy?
- Antiemetics - IV fluids with electrolytes - Possibly mannitol
300
What is the typical cumulative dose of cisplatin associated with ototoxicity?
- >400 mg/m²
301
What is the mechanism of action of trabectedin?
- Binds DNA minor groove - Causes DNA bending and double-strand breaks - Inhibits transcription-coupled nucleotide excision repair
302
What is trabectedin approved to treat?
- Liposarcoma - Leiomyosarcoma
303
What are common toxicities of trabectedin?
- Hepatotoxicity (elevated LFTs) - Rhabdomyolysis - Fatigue - Neutropenia
304
What premedications are required for trabectedin?
- Dexamethasone (hepatoprotection) - Antiemetics
305
What baseline monitoring is needed before trabectedin?
- LFTs - CK (creatine kinase) - CBC
306
What is the mechanism of action of lurbinectedin?
- Inhibits oncogenic transcription - Binds DNA and stalls RNA polymerase II
307
What is lurbinectedin approved to treat?
- Small cell lung cancer (SCLC)
308
What toxicities are associated with lurbinectedin?
- Myelosuppression - Fatigue - Hepatotoxicity
309
What should be monitored during lurbinectedin therapy?
- CBC - LFTs - Signs of fatigue or infection
310
What supportive medications are needed with lurbinectedin?
- Antiemetics - Growth factors if needed
311
What is the mechanism of action of asparaginase?
- Depletes asparagine - Inhibits protein synthesis in leukemic cells lacking asparagine synthetase
312
What malignancy is asparaginase primarily used to treat?
- Acute lymphoblastic leukemia (ALL)
313
What are common toxicities of asparaginase?
- Hypersensitivity reactions - Pancreatitis - Coagulopathy (thrombosis/bleeding) - Hepatotoxicity
314
What is peg-asparaginase and how does it differ?
- PEGylated form of E. coli asparaginase - Longer half-life - Less frequent dosing
315
What are signs of asparaginase hypersensitivity?
- Rash - Urticaria - Hypotension - Respiratory distress
316
What lab monitoring is essential with asparaginase?
- Amylase/lipase (pancreatitis) - PT/aPTT, fibrinogen - LFTs
317
How is asparaginase-induced pancreatitis managed?
- Discontinue drug - Supportive care (IV fluids, NPO)
318
What is the risk of thrombosis with asparaginase?
- Decreased antithrombin III and fibrinogen - Risk of venous and CNS thrombosis
319
What is Erwinia asparaginase and when is it used?
- Derived from Erwinia chrysanthemi - Used in patients with allergy to E. coli asparaginase
320
What are dosing differences between peg-asparaginase and Erwinia?
- Peg-asparaginase: Q2 weeks - Erwinia: more frequent dosing due to shorter half-life
321
What is the mechanism of action of bortezomib?
- Reversibly inhibits 26S proteasome - Leads to accumulation of misfolded proteins - Induces apoptosis in cancer cells
322
What malignancies is bortezomib used for?
- Multiple myeloma - Mantle cell lymphoma
323
What are toxicities of bortezomib?
- Peripheral neuropathy - Myelosuppression - Herpes zoster reactivation
324
What prophylaxis is recommended with bortezomib?
- Antiviral (e.g., acyclovir) to prevent herpes zoster
325
How does route of administration affect bortezomib toxicity?
- SubQ has lower neuropathy risk than IV
326
What is the mechanism of action of carfilzomib?
- Irreversibly inhibits 20S proteasome
327
What are key toxicities of carfilzomib?
- Cardiotoxicity (HF, ischemia) - Hypertension - Pulmonary toxicity
328
What is ixazomib and its advantage?
- Oral proteasome inhibitor - Used in relapsed multiple myeloma
329
What is the risk of infection with proteasome inhibitors?
- Immunosuppression → herpes zoster, bacterial infections
330
What are signs of bortezomib-induced neuropathy?
- Numbness - Tingling - Burning pain in extremities
331
How can bortezomib-induced neuropathy be managed?
- Dose reduction or discontinuation - Switch to SubQ route - Gabapentin, duloxetine
332
What supportive labs should be monitored on proteasome inhibitors?
- CBC - Renal and hepatic function - Signs of infection
333
What pre-infusion requirements exist for carfilzomib?
- Hydration to prevent renal toxicity - Monitor for cardiac issues
334
What are common infusion-related reactions with proteasome inhibitors?
- Fever - Chills - Hypotension
335
What are advantages of proteasome inhibition in multiple myeloma?
- Targets protein turnover in plasma cells - Induces apoptosis
336
What combination regimens include bortezomib?
- VRd: bortezomib, lenalidomide, dexamethasone - VCd: bortezomib, cyclophosphamide, dexamethasone
337
What are dose-limiting toxicities of carfilzomib?
- Cardiotoxicity - Dyspnea - Fatigue
338
What is a critical warning with ixazomib?
- Risk of thrombocytopenia and gastrointestinal toxicity
339
What are counseling points for ixazomib?
- Take on empty stomach - Monitor for diarrhea, rash
340
What is the main difference between carfilzomib and bortezomib?
- Carfilzomib is irreversible - Bortezomib is reversible
341
How often is ixazomib typically administered?
- Once weekly on days 1, 8, and 15 of 28-day cycle
342
Why is herpes zoster prophylaxis standard with proteasome inhibitors?
- High risk of viral reactivation due to immune suppression
343
What baseline assessments are required for bortezomib?
- Neurologic exam - CBC - Hepatic/renal panel
344
How are proteasome inhibitors excreted?
- Primarily hepatic metabolism
345
What is the impact of liver dysfunction on bortezomib dosing?
- May require dose adjustments
346
What infection prophylaxis is recommended with carfilzomib?
- Antivirals - Antibacterial and antifungal if neutropenic
347
What are signs of infusion reaction with carfilzomib?
- Chills - Rigors - Dyspnea - Hypotension
348
How is carfilzomib infusion reaction prevented?
- Premedication with dexamethasone - Slower infusion rates
349
What are common combination backbones in relapsed multiple myeloma?
- Bortezomib- or lenalidomide-based triplets
350
What labs guide proteasome inhibitor dosing?
- CBC - Creatinine - ALT/AST - Albumin
351
What is the general mechanism of action of alkylating agents?
- Add alkyl groups to DNA - Form covalent bonds - Cause crosslinking, mispairing, strand breaks
352
What are the major classes of alkylating agents?
- Nitrogen mustards - Nitrosoureas - Non-classic alkylators - Triazenes
353
What is the mechanism of action of cyclophosphamide?
- Prodrug activated by liver enzymes - Forms DNA crosslinks via alkylation - Leads to apoptosis
354
What toxic metabolite is produced by cyclophosphamide?
- Acrolein (causes hemorrhagic cystitis)
355
How is hemorrhagic cystitis prevented with cyclophosphamide?
- Adequate hydration - Mesna co-administration
356
What are dose-limiting toxicities of cyclophosphamide?
- Myelosuppression - Hemorrhagic cystitis (high doses)
357
What is the mechanism of action of ifosfamide?
- DNA alkylation via phosphoramide mustard - Crosslinking and apoptosis
358
How does ifosfamide toxicity differ from cyclophosphamide?
- More neurotoxicity (encephalopathy) - More hemorrhagic cystitis
359
What causes ifosfamide-induced neurotoxicity?
- Chloroacetaldehyde metabolite
360
How is ifosfamide neurotoxicity managed?
- Methylene blue - Discontinue drug
361
What are common side effects of ifosfamide?
- Encephalopathy - Hematuria - Nausea/vomiting - Myelosuppression
362
What prophylactic agent must always be given with ifosfamide?
- Mesna
363
How is mesna administered?
- IV or PO - Before and after ifosfamide or high-dose cyclophosphamide
364
What is the mechanism of action of melphalan?
- DNA alkylation - Induces interstrand crosslinks
365
What are indications for melphalan?
- Multiple myeloma - Stem cell transplant conditioning
366
What is the main toxicity of melphalan?
- Myelosuppression
367
What are administration tips for oral melphalan?
- Take on empty stomach - Refrigerate capsules
368
What class do carmustine and lomustine belong to?
- Nitrosoureas
369
What is a unique property of nitrosoureas?
- Lipophilic – can cross the blood-brain barrier
370
What are toxicities of carmustine and lomustine?
- Delayed myelosuppression - Pulmonary fibrosis
371
What monitoring is needed with carmustine?
- Pulmonary function tests (PFTs) - CBC
372
What is the dose-limiting toxicity of lomustine?
- Myelosuppression (delayed)
373
What is streptozocin and what is it used for?
- Nitrosourea class - Used in pancreatic neuroendocrine tumors
374
What are toxicities of streptozocin?
- Nephrotoxicity - Nausea/vomiting
375
What is the mechanism of action of bendamustine?
- Alkylator and purine analog - DNA crosslinking and synthesis inhibition
376
What are indications for bendamustine?
- Chronic lymphocytic leukemia (CLL) - Indolent B-cell lymphomas
377
What are toxicities of bendamustine?
- Myelosuppression - Rash - Infusion reactions
378
What supportive care is recommended with bendamustine?
- Antihistamines - Antivirals (herpes prophylaxis)
379
What is the mechanism of action of dacarbazine?
- DNA methylating agent - Inhibits DNA synthesis
380
What are indications for dacarbazine?
- Hodgkin lymphoma - Melanoma
381
What are toxicities of dacarbazine?
- Nausea/vomiting (highly emetogenic) - Myelosuppression - Hepatotoxicity
382
What is the mechanism of action of temozolomide?
- DNA methylation at O6 and N7 guanine - Leads to DNA strand breaks
383
What is temozolomide primarily used for?
- Glioblastoma multiforme - Anaplastic astrocytoma
384
What is the typical schedule for temozolomide in brain tumors?
- Daily during radiation - Then 5/28-day cycle as adjuvant
385
What is a key toxicity of temozolomide?
- Lymphopenia → risk of PCP pneumonia
386
What prophylaxis is required with temozolomide?
- TMP-SMX for PCP prevention
387
What are counseling points for temozolomide?
- Take on empty stomach - Refrigerate capsules if needed - Use effective contraception
388
What is a common side effect of alkylating agents as a class?
- Secondary malignancies (especially AML/MDS)
389
What is the latency period for alkylator-related AML?
- Typically 5–7 years post-treatment
390
What precautions should be taken when handling alkylating agents?
- Use protective equipment - Avoid direct skin contact
391
What patient population is at higher risk for alkylator toxicity?
- Elderly - Renally impaired - Poor performance status
392
What is the typical administration route for cyclophosphamide and ifosfamide?
- IV infusion - Oral (cyclophosphamide only)
393
What class is thiotepa and what is it used for?
- Alkylating agent - High-dose conditioning prior to transplant
394
What is a unique side effect of thiotepa?
- Skin desquamation due to excretion via sweat
395
How is thiotepa skin toxicity managed?
- Frequent bathing - Skin barrier creams
396
What is the mechanism of action of procarbazine?
- Methylates DNA - Inhibits DNA, RNA, and protein synthesis
397
What is a major drug-food interaction with procarbazine?
- Tyramine-containing foods → hypertensive crisis
398
What are toxicities of procarbazine?
- Nausea - Myelosuppression - Neurotoxicity
399
What are key counseling points for procarbazine?
- Avoid alcohol and aged cheeses - Report neurologic symptoms
400
What are long-term risks of alkylator exposure?
- Infertility - Secondary cancers - Bone marrow suppression
401
Which phase of the cell cycle do antimetabolites primarily target?
S phase
402
Which chemotherapy agents are M-phase specific?
- Vinca alkaloids - Taxanes
403
Which agents are considered cell cycle non-specific?
- Alkylating agents - Anthracyclines - Platinum compounds
404
Why is cell cycle specificity important in chemotherapy?
- Guides scheduling and timing - Impacts combination strategies - Affects toxicity profile
405
What is the rationale for using continuous infusion 5-FU vs. bolus?
- Continuous: more effective TS inhibition, more mucosal toxicity - Bolus: more marrow suppression
406
What is fractionation in chemotherapy scheduling?
- Dividing total dose into smaller repeated doses - Reduces toxicity - Enhances efficacy in dividing cells
407
Why are corticosteroids scheduled in combination chemotherapy?
- Enhance apoptosis - Reduce inflammation and edema - Antiemetic support
408
What is the benefit of dose-dense chemotherapy?
- Reduced tumor regrowth intervals - Improved outcomes in some cancers (e.g., breast)
409
What supportive therapies enable dose-dense regimens?
- G-CSF (filgrastim, pegfilgrastim)
410
What is metronomic chemotherapy?
- Continuous low-dose administration - Antiangiogenic and immunomodulatory effects
411
What are examples of metronomic agents?
- Cyclophosphamide (low-dose oral) - Methotrexate - Capecitabine
412
What is a primary mechanism of resistance to alkylating agents?
- Increased DNA repair capacity
413
What resistance mechanism affects anthracyclines?
- P-glycoprotein (efflux pump overexpression)
414
What is the impact of MGMT expression in tumors?
- Repairs alkylation damage - Confers resistance to temozolomide, dacarbazine
415
What predictive biomarker supports temozolomide use in gliomas?
- MGMT promoter methylation
416
What mechanism causes resistance to methotrexate?
- DHFR gene amplification - Decreased drug uptake
417
What is the mechanism of resistance to 5-FU?
- Increased thymidylate synthase expression - DPD enzyme overactivity
418
What are common lab tests to monitor chemotherapy toxicity?
- CBC with differential - LFTs - Renal function
419
What baseline test is recommended before cisplatin or high-dose methotrexate?
- Audiometry - Renal panel
420
What are signs of chemotherapy-induced myelosuppression?
- Neutropenia - Anemia - Thrombocytopenia
421
What is nadir and when does it occur?
- Lowest point of blood counts - Typically 7–14 days after chemotherapy
422
What is the primary concern with neutropenia?
- Increased infection risk - Febrile neutropenia
423
What is the ANC threshold for severe neutropenia?
- <500 cells/μL
424
How is febrile neutropenia defined?
- Fever ≥38.3°C once or ≥38.0°C for over 1 hour - ANC <500
425
What is first-line treatment for febrile neutropenia?
- Broad-spectrum IV antibiotics (e.g., cefepime)
426
What agents are used for neutropenia prophylaxis?
- G-CSF (filgrastim, pegfilgrastim)
427
What are signs of chemotherapy-induced anemia?
- Fatigue - Dyspnea - Pallor
428
When is erythropoiesis-stimulating agent (ESA) used in cancer?
- Palliative intent - Hemoglobin <10 g/dL
429
What are risks of ESA therapy in cancer?
- Increased thrombosis risk - Potential tumor progression
430
What supportive treatment is used for chemotherapy-induced thrombocytopenia?
- Platelet transfusion
431
What are signs of bleeding due to thrombocytopenia?
- Petechiae - Bruising - Mucosal bleeding
432
At what platelet count is transfusion generally considered?
- <10,000/μL (asymptomatic) - <50,000/μL (procedures or bleeding)
433
What is tumor lysis syndrome (TLS)?
- Rapid tumor cell death - Release of intracellular contents - Electrolyte abnormalities
434
What are key lab abnormalities in TLS?
- Hyperuricemia - Hyperkalemia - Hyperphosphatemia - Hypocalcemia
435
What is used to prevent TLS?
- Hydration - Allopurinol - Rasburicase (high-risk)
436
What chemotherapy agents most commonly cause TLS?
- High-grade lymphomas - Leukemias (e.g., ALL, AML)
437
What are signs of severe TLS?
- Arrhythmias - Seizures - Acute kidney injury
438
How is rasburicase different from allopurinol?
- Breaks down uric acid - Works faster - Used in established TLS or high-risk
439
What is a contraindication to rasburicase?
- G6PD deficiency (risk of hemolysis)
440
What tests are needed before rasburicase administration?
- G6PD screening
441
What is the main difference between targeted and cytotoxic chemotherapy?
- Cytotoxic: kills all dividing cells - Targeted: inhibits specific molecular pathways
442
What are key goals of chemotherapy monitoring?
- Detect toxicity early - Guide dose adjustments - Ensure patient safety
443
What factors affect chemotherapy pharmacokinetics?
- Liver and kidney function - Body surface area (BSA) - Drug interactions
444
What chemotherapy drugs require BSA dosing?
- Most traditional cytotoxics (e.g., 5-FU, cyclophosphamide)
445
What is the most commonly used BSA formula?
- Mosteller formula: √(height(cm) × weight(kg)/3600)
446
Why might BSA dosing be inaccurate in obesity?
- May overestimate exposure - Use adjusted body weight when needed
447
What is the dose capping principle in chemotherapy?
- Limits dose at certain BSA (e.g., 2.0 m² max) to reduce toxicity
448
What is the difference between relative dose intensity and actual dose intensity?
- Relative: % of planned dose delivered - Actual: dose per time unit given
449
Why is maintaining dose intensity important in curative regimens?
- Improves survival - Reduces relapse risk
450
What are common dose-limiting toxicities across chemotherapy?
- Myelosuppression - Neuropathy - GI toxicity
451
What is the purpose of leucovorin rescue with high-dose methotrexate?
- Reduces toxicity to healthy cells - Supplies folinic acid to bypass DHFR inhibition
452
How is leucovorin dosed in methotrexate rescue?
- Based on methotrexate serum levels - Typically started 24 hours after MTX administration
453
What is the antidote for methotrexate in renal failure or delayed clearance?
- Glucarpidase
454
What is the mechanism of action of glucarpidase?
- Cleaves methotrexate into inactive metabolites
455
When is glucarpidase indicated?
- MTX toxicity with renal dysfunction - Delayed MTX elimination
456
How long should leucovorin and glucarpidase be separated if co-administered?
- At least 2 hours
457
What labs are monitored with high-dose methotrexate therapy?
- Serum MTX levels - SCr, BUN - LFTs
458
How is hyperuricemia prevented in tumor lysis syndrome?
- Allopurinol or rasburicase - IV hydration
459
What is the function of MESNA?
- Binds acrolein in urine - Prevents hemorrhagic cystitis
460
What chemotherapy drugs require MESNA?
- Ifosfamide (always) - High-dose cyclophosphamide
461
What is extravasation?
- Leakage of chemotherapy into surrounding tissue - May cause tissue damage or necrosis
462
What are vesicant chemotherapy agents?
- Anthracyclines - Vinca alkaloids - Mitomycin C
463
What are irritant chemotherapy agents?
- Cisplatin - Carboplatin - Taxanes
464
What are antidotes for anthracycline extravasation?
- Dexrazoxane (Totect) - Cold compress
465
What are antidotes for vinca alkaloid extravasation?
- Hyaluronidase - Warm compress
466
How is extravasation managed acutely?
- Stop infusion immediately - Aspirate drug from IV line - Apply compress (warm or cold depending on agent) - Administer antidote if indicated
467
What is dexrazoxane used for?
- Cardioprotection with anthracyclines (Zinecard) - Extravasation management (Totect)
468
What are signs of chemotherapy hypersensitivity reactions?
- Rash - Hypotension - Bronchospasm - Anaphylaxis
469
Which chemotherapy agents have high risk of hypersensitivity?
- Paclitaxel (Cremophor EL) - Carboplatin (delayed) - L-asparaginase
470
How are paclitaxel hypersensitivity reactions prevented?
- Premedication with steroids and antihistamines - Avoid in patients with prior anaphylaxis
471
What is the mechanism of hypersensitivity to paclitaxel?
- Cremophor EL solvent (non-IgE-mediated)
472
What is the strategy for re-challenging after carboplatin allergy?
- Desensitization protocol under close monitoring
473
What supportive medications are used with highly emetogenic chemotherapy?
- 5HT3 antagonist - NK1 receptor antagonist - Dexamethasone - +/- Olanzapine
474
What is breakthrough nausea and how is it treated?
- Nausea despite prophylaxis - Treated with dopamine antagonists or benzodiazepines
475
What is anticipatory nausea and how is it managed?
- Conditioned response before chemo - Treated with behavioral therapy or lorazepam
476
What are long-term toxicities of many chemotherapy agents?
- Secondary malignancy - Infertility - Cardiomyopathy - Neurotoxicity
477
What vaccines are recommended during chemotherapy?
- Inactivated flu shot - Avoid live vaccines during active treatment
478
When should live vaccines be given to chemotherapy patients?
- At least 3 months after treatment ends
479
What is the purpose of growth factor support in chemotherapy?
- Reduce neutropenia risk - Maintain dose intensity
480
What is the difference between filgrastim and pegfilgrastim?
- Filgrastim: daily dosing - Pegfilgrastim: single dose per cycle
481
What is the role of erythropoietin in cancer care?
- Stimulates red blood cell production - Used for anemia in palliative patients
482
What are risks of erythropoiesis-stimulating agents (ESAs)?
- Thromboembolism - Shortened survival in some settings
483
What is palifermin and when is it used?
- Keratinocyte growth factor - Prevents severe mucositis with stem cell transplant
484
What are side effects of palifermin?
- Oral discomfort - Edema - Rash
485
What agents commonly cause mucositis?
- 5-FU - Methotrexate - Melphalan
486
What is the best strategy for mucositis prevention?
- Oral hygiene - Cryotherapy during infusion (ice chips) - Palifermin (high risk)
487
What are common agents causing diarrhea?
- Irinotecan - 5-FU - Capecitabine
488
How is chemotherapy-induced diarrhea managed?
- Loperamide - Octreotide (refractory) - Hydration
489
What drugs commonly cause constipation in cancer patients?
- Vincristine - Opioids
490
What are first-line treatments for opioid-induced constipation?
- Stimulant laxatives (senna, bisacodyl) - +/- stool softeners
491
What are signs of chemotherapy-related neurotoxicity?
- Paresthesias - Gait disturbance - Trouble buttoning clothing
492
What chemo agents commonly cause neurotoxicity?
- Vinca alkaloids - Taxanes - Platinum compounds
493
What is the approach to dose modification for neurotoxicity?
- Hold or reduce dose - Assess for cumulative symptoms
494
What are protective agents against chemo-induced neuropathy?
- Duloxetine (some evidence) - Vitamin B6 (limited data)
495
What is the main risk of long-term anthracycline therapy?
- Cardiomyopathy
496
What is the cumulative dose limit for doxorubicin?
- ~450–550 mg/m²
497
What agent reduces cardiotoxicity of anthracyclines?
- Dexrazoxane
498
What is the mechanism of dexrazoxane as cardioprotectant?
- Iron chelation - Prevents free radical formation
499
What should be monitored during anthracycline therapy?
- Baseline and periodic echocardiogram - LVEF assessment
500
What are signs of anthracycline-induced cardiotoxicity?
- Decreased ejection fraction - Dyspnea - Fatigue
501
What enzyme metabolizes many chemotherapy agents including paclitaxel and cyclophosphamide?
CYP3A4
502
What are examples of CYP3A4 inducers that may reduce chemotherapy effectiveness?
- Rifampin - Phenytoin - St. John's Wort
503
What are examples of CYP3A4 inhibitors that may increase chemotherapy toxicity?
- Azole antifungals (e.g., ketoconazole) - Macrolides (e.g., erythromycin) - Grapefruit juice
504
Which drugs interact with warfarin due to CYP450 metabolism changes?
- Capecitabine - 5-FU - Tamoxifen
505
What is the interaction between methotrexate and NSAIDs?
- Decreased MTX clearance - Increased risk of nephrotoxicity and myelosuppression
506
What is the impact of proton pump inhibitors on capecitabine efficacy?
- May reduce absorption and effectiveness
507
What drug should not be given with leucovorin due to increased toxicity?
- Fluorouracil (increased cytotoxicity if dosed improperly)
508
Which chemo agents require renal dose adjustment?
- Methotrexate - Carboplatin - Cisplatin - Capecitabine
509
What renal function test is most commonly used to assess chemo dosing?
Creatinine clearance (CrCl)
510
What formula is commonly used to estimate CrCl in adults?
Cockcroft-Gault equation
511
What chemotherapy drugs require hepatic dose adjustment?
- Doxorubicin - Vincristine - Etoposide
512
How does hepatic dysfunction increase chemo toxicity?
- Reduced metabolism - Accumulation of active drugs or metabolites
513
What labs guide hepatic dosing decisions?
- AST/ALT - Total bilirubin - Albumin
514
What is the consequence of giving full-dose vincristine in liver failure?
- Severe neurotoxicity
515
What chemo drug should not be given intrathecally due to fatal toxicity?
Vincristine
516
What chemotherapy drugs can be given intrathecally?
- Methotrexate - Cytarabine - Hydrocortisone
517
What precautions are taken with intrathecal chemotherapy?
- Administer only by trained staff - Use preservative-free formulations - Label clearly “FOR INTRATHECAL USE”
518
What is the appropriate syringe for intrathecal chemotherapy?
Only preservative-free solutions in appropriate volume syringes
519
What cancer type commonly requires intrathecal chemotherapy?
Acute lymphoblastic leukemia (ALL)
520
What is the impact of renal failure on high-dose methotrexate?
- Prolonged clearance - Increased risk of toxicity
521
What are signs of methotrexate accumulation in renal failure?
- Mucositis - Myelosuppression - Renal dysfunction
522
What drug interactions increase the risk of irinotecan toxicity?
- UGT1A1 inhibitors (e.g., atazanavir) - CYP3A4 inhibitors
523
What are chemotherapy dosing considerations in obese patients?
- Use actual body weight for dosing - Avoid underdosing based on ideal weight
524
What is ASCO’s recommendation for chemo dosing in obese patients?
Use full weight-based doses for curative intent
525
What is the key consideration for chemo dosing in elderly patients?
- Organ function (renal/hepatic) - Performance status - Comorbidities
526
Why is chemotherapy more toxic in older adults?
- Decreased organ reserve - Altered pharmacokinetics - Polypharmacy
527
What tools are used to assess chemo tolerability in older adults?
- Geriatric assessment tools - CARG, CRASH scores
528
What is the most common chemotherapy adjustment needed in pediatrics?
- BSA-based dosing - Close monitoring of organ function
529
Why is vincristine neurotoxicity more concerning in children?
- Higher incidence of foot drop and neuropathic pain
530
What is the role of pediatric oncology dosing guidelines?
- Standardize regimens - Reduce dose-related complications
531
What adjustments may be needed for hepatic metastases?
Dose reduction for hepatically metabolized agents
532
What is a common hepatic complication of chemotherapy?
Sinusoidal obstruction syndrome
533
What are symptoms of sinusoidal obstruction syndrome?
- Hepatomegaly - Right upper quadrant pain - Weight gain - Ascites
534
What chemo drugs are associated with sinusoidal obstruction?
- Cyclophosphamide - Busulfan - Oxaliplatin
535
How is sinusoidal obstruction syndrome treated?
- Supportive care - Defibrotide (FDA approved)
536
What is the function of defibrotide?
- Protects endothelial cells - Restores thrombo-fibrinolytic balance
537
What chemo agent is most nephrotoxic and requires pre/post hydration?
Cisplatin
538
How is nephrotoxicity from cisplatin monitored?
- Daily SCr and electrolytes - Urine output
539
What electrolyte abnormalities are common with cisplatin?
- Hypomagnesemia - Hypokalemia
540
What is a safe strategy to administer cisplatin in at-risk patients?
- Divide dose over multiple days - Use lower doses - Prehydration with saline and electrolytes
541
What is the recommended infusion duration for paclitaxel?
Typically 3 hours (weekly formulation is shorter)
542
Why are patients premedicated before paclitaxel?
To reduce hypersensitivity to Cremophor EL solvent
543
What are the components of standard paclitaxel premedication?
- Dexamethasone - Diphenhydramine - H2 blocker (e.g., ranitidine)
544
What is the benefit of nab-paclitaxel (Abraxane)?
- No solvent - Less hypersensitivity - No need for premedication
545
What is a key administration precaution for doxorubicin?
- Use central line to avoid extravasation - Monitor for red urine (non-harmful)
546
What are signs of doxorubicin extravasation?
- Burning or pain at IV site - Swelling - Tissue discoloration
547
How is doxorubicin extravasation managed?
- Stop infusion - Apply cold compress - Administer dexrazoxane
548
What cumulative dose of bleomycin increases pulmonary toxicity risk?
>400 units
549
What are signs of bleomycin-induced pulmonary toxicity?
- Dry cough - Dyspnea - Infiltrates on imaging
550
How is bleomycin pulmonary toxicity monitored?
Baseline and periodic pulmonary function tests (PFTs)
551
What is the general recommendation for chemotherapy use in pregnancy?
- Avoid during 1st trimester - Some agents can be used in 2nd and 3rd trimester if benefits outweigh risks
552
Which trimester poses the highest risk for teratogenicity from chemotherapy?
First trimester
553
What chemotherapy agents are generally considered safer in the 2nd/3rd trimesters?
- Anthracyclines (e.g., doxorubicin) - Cyclophosphamide - 5-FU
554
What chemo agents should be avoided throughout pregnancy?
- Methotrexate - Alkylating agents (high dose) - Hormonal agents (e.g., tamoxifen)
555
What are the concerns with chemotherapy during breastfeeding?
- Most agents are excreted in breast milk - Breastfeeding is generally contraindicated
556
How long after chemotherapy should breastfeeding be avoided?
- At least one week for most agents - Longer for agents with long half-life or delayed toxicity
557
What are the risks of chemotherapy exposure via breast milk?
- Cytotoxic effects in infant - Bone marrow suppression - Gastrointestinal toxicity
558
What is the safest approach to chemotherapy and breastfeeding?
- Pump and discard - Resume breastfeeding only after drug clearance
559
What are examples of vesicant chemotherapy agents?
- Doxorubicin - Vincristine - Mechlorethamine
560
What is the difference between a vesicant and an irritant?
- Vesicant: causes severe tissue damage with extravasation - Irritant: causes pain/inflammation but not necrosis
561
How should vesicant agents be administered?
Through a central line whenever possible
562
What are examples of irritant chemotherapy agents?
- Cisplatin - Etoposide - Oxaliplatin
563
What is the general shelf-life of reconstituted chemotherapy drugs?
- Varies by agent - Often 24–48 hours refrigerated or per manufacturer’s guidelines
564
What is the impact of light on some chemotherapy drugs?
- Degrades light-sensitive agents (e.g., dacarbazine, anthracyclines) - Requires light protection
565
Which chemotherapy drugs require light protection during administration?
- Dacarbazine - Anthracyclines - Methotrexate
566
What is the appropriate storage temperature for most chemotherapy vials?
2–8°C (refrigerated) or per labeling
567
Which chemotherapy drug requires freezing for storage?
None routinely; freezing usually avoided
568
What is required PPE for handling chemotherapy?
- Chemotherapy-rated gloves - Gown - Eye/face protection if splash risk
569
What defines a USP <800> compliant facility?
- Engineering controls for hazardous drugs - PPE use - Safe compounding and disposal
570
What type of hood is used for chemo compounding?
Class II Biological Safety Cabinet (BSC)
571
What is the purpose of a closed-system transfer device (CSTD)?
Prevents aerosolization and contamination during chemo preparation
572
When are CSTDs recommended?
For preparation and administration of hazardous drugs
573
What organization publishes guidelines for handling hazardous drugs?
NIOSH (National Institute for Occupational Safety and Health)
574
What is considered a hazardous drug under NIOSH criteria?
- Carcinogenic - Teratogenic - Reproductive or organ toxicity
575
How are hazardous drugs disposed of?
- In black hazardous waste containers - Per institutional and EPA regulations
576
What is the purpose of a chemotherapy spill kit?
- Safely clean hazardous drug spills - Prevent personnel exposure
577
What should be done immediately after a chemotherapy spill?
- Isolate area - Use PPE - Clean using chemo spill kit
578
What information is found on a chemo drug safety data sheet (SDS)?
- Hazards - Handling precautions - First-aid and disposal measures
579
What chemo agents require non-PVC tubing?
- Paclitaxel - Etoposide - Carmustine
580
Why avoid PVC with certain chemo drugs?
- Leaching of plasticizers - Reduced drug potency
581
What color is the chemotherapy biohazard disposal bag?
Typically yellow or red
582
What patient instructions should be given after oral chemotherapy?
- Use gloves when handling - Store separately from other medications - Avoid crushing or splitting tablets
583
How should unused oral chemotherapy be disposed?
- Return to pharmacy - Follow hazardous waste protocols
584
What precautions apply to caregivers of patients on oral chemo?
- Wear gloves - Avoid contact with body fluids - Wash hands after handling
585
What are safe handling tips for oral chemo pills?
- Do not open or crush - Handle with dry gloves - Store in original container
586
What chemo agents are oral formulations of IV drugs?
- Capecitabine (oral 5-FU) - Temozolomide - Cyclophosphamide
587
What is the major advantage of oral chemotherapy?
- Patient convenience - Fewer clinic visits
588
What are disadvantages of oral chemotherapy?
- Adherence variability - Monitoring challenges - Insurance access issues
589
What are signs of non-adherence to oral chemotherapy?
- Missed doses - Disease progression - Lack of side effects
590
How can adherence to oral chemo be improved?
- Pill organizers - Medication calendars - Caregiver support
591
What chemo agents pose high reproductive risk?
- Alkylating agents - Antimetabolites - Platinum compounds
592
What is the general pregnancy recommendation for patients on chemotherapy?
- Avoid conception during and for 6–12 months post-treatment
593
What contraceptive advice should be given during chemotherapy?
- Use effective contraception (barrier + hormonal) - Avoid pregnancy in both partners
594
What are common fertility preservation methods before chemo?
- Sperm banking - Oocyte/embryo cryopreservation
595
What is a concern with hormonal contraception in cancer patients?
- May be contraindicated in hormone-sensitive tumors (e.g., breast cancer)
596
How does chemo affect fertility in men and women?
- Damages sperm and ovarian reserve - May cause permanent infertility
597
What is the role of GnRH agonists in fertility preservation?
- May reduce ovarian damage - Used in premenopausal women
598
What long-term reproductive counseling is advised after chemotherapy?
- Fertility testing - Referral to reproductive endocrinology
599
What are potential pregnancy complications from prior chemo?
- Preterm birth - Low birth weight - Preeclampsia
600
When is it generally safe to conceive after completing chemotherapy?
- Typically 6–12 months after last dose (longer in some cases)
601
How does chemotherapy cause immunosuppression?
- Myelosuppression → neutropenia, lymphopenia - Mucosal barrier injury - Altered humoral and cellular immunity
602
Which chemo agents are most associated with prolonged neutropenia?
- Fludarabine - Clofarabine - Temozolomide
603
What infections are common in neutropenic patients?
- Bacterial (gram-negative rods, gram-positive cocci) - Fungal (Candida, Aspergillus) - Viral (HSV, CMV, respiratory viruses)
604
What is the definition of febrile neutropenia?
- Fever ≥38.3°C once or ≥38.0°C for ≥1 hour - ANC <500 cells/µL
605
What is the initial treatment for febrile neutropenia?
Empiric IV broad-spectrum antibiotics (e.g., cefepime)
606
What factors guide empiric antibiotic choice in febrile neutropenia?
- Local antibiogram - Mucositis presence - Risk for resistant organisms
607
What is high-risk neutropenia?
- ANC <100 for >7 days - Comorbidities, active infections, or hospitalization
608
What prophylactic antibiotics are used in high-risk neutropenia?
Fluoroquinolones (e.g., levofloxacin)
609
What antifungal prophylaxis is used in high-risk patients?
- Fluconazole - Posaconazole - Voriconazole (if mold coverage needed)
610
What antiviral prophylaxis is given with certain chemo regimens?
Acyclovir or valacyclovir for HSV/VZV reactivation
611
What chemo agents require antiviral prophylaxis?
- Bortezomib - Proteasome inhibitors - Alemtuzumab
612
What is PJP prophylaxis and when is it used?
- TMP-SMX or alternatives (e.g., dapsone) - Used with temozolomide, fludarabine, steroids
613
What chemo drug increases risk of HBV reactivation?
Rituximab
614
What screening should be done before rituximab therapy?
HBsAg and anti-HBc
615
What is done if patient is HBV-positive prior to rituximab?
- Start antiviral prophylaxis (e.g., entecavir) - Monitor HBV DNA levels
616
What is the role of IVIG in chemotherapy patients?
- For hypogammaglobulinemia or frequent infections - Common in CLL or after rituximab
617
When are granulocyte transfusions considered?
- Profound neutropenia with life-threatening infection - Failure of antimicrobial therapy
618
What is the impact of mucositis on infection risk?
- Breaches mucosal barriers - Increases bacteremia risk
619
How can mucositis-related infections be prevented?
- Oral hygiene - Cryotherapy - Antimicrobial prophylaxis
620
What immunizations should be avoided during chemotherapy?
- Live vaccines (e.g., MMR, varicella, intranasal flu)
621
What is the safest vaccination timing in chemotherapy patients?
- ≥2 weeks before starting chemo or - ≥3–6 months after completion
622
What inactivated vaccines are recommended during chemotherapy?
- Annual influenza - Pneumococcal (PCV13, PPSV23) - Hepatitis B
623
What vaccination should close contacts of cancer patients receive?
- Inactivated flu vaccine - Varicella and MMR if no contraindications
624
What is herd immunity and its importance in cancer care?
- Protection from spread of infections by vaccinating contacts - Essential in immunocompromised patients
625
What vaccine-preventable diseases pose high risk in cancer patients?
- Influenza - Pneumococcus - Varicella
626
What is the impact of chemotherapy on vaccine efficacy?
- Reduced immune response - Lower seroconversion rates
627
What strategies enhance vaccine response in cancer patients?
- Timing after therapy - Higher doses or booster shots
628
Which chemo agents most impair lymphocyte function?
- Purine analogs (e.g., fludarabine) - Alemtuzumab
629
What is CMV reactivation and who is at risk?
- Reactivation of latent virus - Common in T-cell depletion regimens (e.g., alemtuzumab)
630
How is CMV monitored and prevented during chemo?
- PCR testing - Prophylactic or preemptive antivirals
631
What is neutropenic enterocolitis and its clinical presentation?
- Fever, abdominal pain, diarrhea - Thickened bowel wall on imaging
632
What chemo agents are associated with neutropenic enterocolitis?
- Cytarabine - Taxanes - Irinotecan
633
How is neutropenic enterocolitis managed?
- Bowel rest - IV antibiotics - Supportive care
634
What is the risk of sepsis in neutropenic patients?
- High mortality - Prompt recognition and treatment critical
635
What is the role of G-CSF in infection prevention?
- Reduces duration of neutropenia - May prevent febrile neutropenia
636
What are the limitations of G-CSF?
- Bone pain - Does not prevent all infections - May not be appropriate in palliative setting
637
What is the typical duration of neutropenia after standard chemotherapy?
7–14 days
638
What is the benefit of pegfilgrastim over filgrastim?
- Once per cycle dosing - Improved adherence
639
What is the consequence of early pegfilgrastim administration?
- Reduced efficacy - Should be given ≥24 hrs after chemo
640
What is the function of plerixafor in stem cell mobilization?
- Enhances CD34+ stem cell release into blood - Used with G-CSF
641
What patient group benefits from plerixafor use?
- Poor mobilizers (e.g., heavily pretreated, older patients)
642
What are side effects of plerixafor?
- Injection site reactions - Diarrhea - Headache
643
What is the impact of long-term immunosuppression on malignancy risk?
Increased risk of secondary cancers
644
What malignancies are associated with long-term immunosuppression?
- Lymphomas - Skin cancers - HPV-related cancers
645
What screening is recommended during long-term immunosuppression?
- Skin exams - Pap smears - Colonoscopy
646
What is IRIS (immune reconstitution inflammatory syndrome)?
- Inflammatory response upon immune recovery - Seen after stopping immunosuppressants or during HAART
647
What is the role of steroids in managing IRIS?
Dampen excessive immune response
648
What is the purpose of antimicrobial stewardship in cancer care?
- Prevent resistance - Optimize outcomes - Minimize toxicity
649
What are risks of prolonged antibiotic use in oncology?
- C. difficile infection - Resistance - Renal/hepatic toxicity
650
What are signs that infection is not the cause of fever in cancer patients?
- Negative cultures - Fever refractory to antibiotics - No neutropenia
651
What chemotherapy agents are associated with ototoxicity?
- Cisplatin (most common) - Carboplatin (less frequent)
652
What are signs of ototoxicity from chemotherapy?
- Tinnitus - High-frequency hearing loss - Balance disturbance
653
What baseline test is recommended before starting cisplatin?
Audiometry
654
What patient populations are at higher risk of cisplatin ototoxicity?
- Children - Elderly - Those receiving high cumulative doses
655
What is the cumulative dose threshold for cisplatin-related ototoxicity?
Typically >400 mg/m²
656
What is the mechanism of cisplatin-induced ototoxicity?
- Accumulation in cochlea - Reactive oxygen species generation - Damage to hair cells
657
What monitoring is done for cisplatin-induced neurotoxicity?
- Audiograms - Neurological exams - Renal function
658
What chemotherapy agents are associated with peripheral neuropathy?
- Vinca alkaloids - Taxanes - Platinum agents (cisplatin, oxaliplatin) - Bortezomib
659
What is the presentation of chemotherapy-induced peripheral neuropathy?
- Tingling, numbness - Gait imbalance - Loss of fine motor coordination
660
What exacerbates chemotherapy-induced neuropathy?
- Cold exposure (esp. oxaliplatin) - Repeated cumulative dosing
661
What is the hallmark acute toxicity of oxaliplatin?
- Cold-induced paresthesias - Pharyngolaryngeal spasm
662
How is oxaliplatin neuropathy prevented or mitigated?
- Avoid cold - Calcium/magnesium infusions (controversial) - Dose delay/reduction
663
What chemotherapy agents can cause pulmonary fibrosis?
- Bleomycin - Busulfan - Carmustine
664
What are symptoms of chemo-induced pulmonary toxicity?
- Dyspnea - Cough - Hypoxia
665
What is the cumulative dose limit for bleomycin?
400 units
666
What factors increase risk of bleomycin lung toxicity?
- Age >70 - High cumulative dose - Prior radiation - Oxygen exposure
667
What test is used to monitor bleomycin pulmonary toxicity?
Pulmonary function tests (PFTs)
668
What chemotherapy drugs are associated with cardiotoxicity?
- Anthracyclines (doxorubicin) - Trastuzumab (not cytotoxic but notable)
669
What is the mechanism of anthracycline cardiotoxicity?
- Free radical formation - Iron-dependent damage to myocytes
670
What is the cumulative lifetime dose limit for doxorubicin?
450–550 mg/m²
671
What agent reduces anthracycline cardiotoxicity?
Dexrazoxane
672
What monitoring is needed for patients on anthracyclines?
- Echocardiogram or MUGA scan - LVEF assessment at baseline and periodically
673
What chemotherapy agent causes non-ischemic cardiomyopathy?
Doxorubicin
674
How is doxorubicin-induced cardiomyopathy treated?
- Standard heart failure therapy - Discontinue further anthracycline
675
What agents increase QT prolongation risk?
- Arsenic trioxide - Anthracyclines (rarely) - Certain tyrosine kinase inhibitors
676
What are risk factors for chemotherapy-induced QT prolongation?
- Electrolyte abnormalities - Baseline QTc >450 ms - Concomitant QT-prolonging drugs
677
What agents are associated with cerebellar neurotoxicity?
High-dose cytarabine
678
What are signs of cerebellar toxicity from cytarabine?
- Ataxia - Dysarthria - Nystagmus
679
What monitoring is recommended during high-dose cytarabine therapy?
- Neurologic exams every shift or daily - Renal function assessment
680
What is the renal excretion profile of cytarabine?
- Renally cleared - Toxicity risk increases in renal impairment
681
What agents require dose reduction in renal dysfunction?
- Methotrexate - Cisplatin - Carboplatin - Capecitabine
682
What agents require hepatic dose adjustment?
- Doxorubicin - Vincristine - Irinotecan
683
What parameters are used for hepatic dosing?
- Total bilirubin - AST/ALT - Albumin
684
What is Child-Pugh score used for?
Assess liver function and guide drug dosing
685
What BSA formula is most commonly used in oncology?
Mosteller formula = √((height cm × weight kg)/3600)
686
What is dose capping and when is it used?
- Limiting dose based on max BSA (e.g., 2.0 m²) - Used to reduce toxicity
687
What are examples of chemotherapy drugs with flat dosing?
- Rituximab - Trastuzumab - Vincristine
688
What drugs are commonly dosed using AUC-based methods?
Carboplatin
689
What formula is used to calculate carboplatin dose?
Calvert formula: Dose = AUC × (GFR + 25)
690
Why is capped CrCl used in the Calvert formula?
- To avoid overdosing - Often capped at 125 mL/min
691
What is the impact of low albumin on chemotherapy drugs?
- Increases free (active) drug - Higher toxicity risk
692
Which chemotherapy drugs are highly protein bound?
- Paclitaxel - Etoposide - Methotrexate
693
What is relative dose intensity (RDI)?
Delivered dose intensity ÷ standard dose intensity
694
Why is maintaining RDI important in curative chemo?
- Improves overall survival - Reduces risk of recurrence
695
What are common causes for dose reductions in chemotherapy?
- Neutropenia - Mucositis - Neuropathy - Renal or hepatic impairment
696
What is the impact of dose delays on treatment outcomes?
- May reduce cure rates - Allows tumor regrowth
697
How is dose modification different in palliative vs. curative settings?
- Curative: try to maintain dose intensity - Palliative: prioritize quality of life, reduce toxicity
698
What strategies help maintain dose intensity?
- Growth factor support - Dose-dense regimens - Close monitoring
699
What is metronomic chemotherapy and its dosing strategy?
- Continuous low-dose therapy - Less toxic, antiangiogenic effect
700
What are signs that chemotherapy dose should be held?
- ANC <1000 - Platelets <100,000 - Severe non-hematologic toxicity
701
What are the common routes of chemotherapy administration?
- Intravenous (IV) - Oral - Subcutaneous - Intrathecal - Intraperitoneal
702
What route is used for CNS prophylaxis in leukemia?
Intrathecal
703
What chemo agents are safe for intrathecal use?
- Methotrexate - Cytarabine - Hydrocortisone
704
What chemo agent must never be given intrathecally?
Vincristine (fatal)
705
What safety measures prevent intrathecal vincristine errors?
- Labeling “FOR IV USE ONLY” - Administer separately from intrathecal doses - Separate administration times
706
What is extravasation in chemotherapy?
- Leakage of drug into tissue surrounding vein - Can cause pain, necrosis
707
What are common vesicants that cause tissue necrosis if extravasated?
- Anthracyclines - Vinca alkaloids - Mitomycin C
708
What are signs of chemotherapy extravasation?
- Swelling, burning at site - Redness or blanching - Delayed ulceration
709
How is extravasation managed immediately?
- Stop infusion - Leave catheter in place - Attempt aspiration - Apply appropriate compress
710
What antidote is used for anthracycline extravasation?
Dexrazoxane
711
What antidote is used for vinca alkaloid extravasation?
- Hyaluronidase - Warm compress
712
What compress is used for anthracycline extravasation?
Cold compress
713
What compress is used for vinca alkaloids?
Warm compress
714
What is the advantage of a central line in chemotherapy?
- Reduces risk of extravasation - Better for vesicants and long-term therapy
715
What are types of central lines used in oncology?
- Peripherally inserted central catheter (PICC) - Tunneled catheter (e.g., Hickman) - Implanted port (Port-a-Cath)
716
What are pros of a Port-a-Cath?
- Less infection risk - Hidden under skin - Long-term use
717
What are cons of external catheters like Hickman lines?
- Higher infection risk - Requires external care
718
What are signs of central line infection?
- Fever - Redness at insertion site - Drainage or tenderness
719
What is the typical dwell time for an implanted port?
Several years if well-maintained
720
What are complications of central lines?
- Infection - Thrombosis - Dislodgement
721
What is chemotherapy cycle timing based on?
- Bone marrow recovery - Normal tissue repair - Tumor cell kill schedule
722
What defines dose-dense chemotherapy?
- Shorter intervals between cycles - Same total dose but more frequent
723
What regimens commonly use dose-dense scheduling?
Breast cancer (e.g., AC-T every 2 weeks with growth factors)
724
What is fractionated chemotherapy dosing?
- Dividing total dose into smaller, repeated doses - Reduces toxicity, targets cell cycle phases
725
What is bolus chemotherapy administration?
- Large dose over short period (minutes) - Often more myelosuppressive
726
What is continuous infusion chemotherapy?
- Prolonged delivery (hours to days) - Sustained exposure to drug
727
What drugs are often given by continuous infusion?
- 5-FU - Cytarabine
728
What is a portable infusion pump used for?
Administering chemo (like 5-FU) over 46–96 hours
729
What is the advantage of continuous 5-FU over bolus?
- Less myelosuppression - More mucositis, hand-foot syndrome
730
What is the major toxicity of bolus 5-FU?
Neutropenia
731
What is the advantage of oral chemotherapy?
- Convenience - No IV access needed - Can be taken at home
732
What is a major risk of oral chemotherapy?
- Nonadherence - Incorrect dosing by patient
733
What instructions should patients receive for oral chemo?
- Take exactly as prescribed - Store properly - Use gloves when handling
734
What agents are oral prodrugs of IV chemotherapy?
- Capecitabine → 5-FU - Cyclophosphamide (also IV)
735
What is the role of caregivers in oral chemo adherence?
- Ensure dosing - Recognize toxicity - Track schedules
736
What is chemotherapy drug incompatibility?
- Chemical or physical reaction between drugs - Can cause precipitation or inactivation
737
What factors cause drug incompatibility?
- pH differences - Concentration - Solvent used
738
What chemo drugs are incompatible with D5W?
Cisplatin (requires NS)
739
What drugs are incompatible with saline?
- Etoposide - Amphotericin B
740
What resource is used to check chemo compatibility?
Trissel’s Handbook of Injectable Drugs
741
What is the Y-site in IV administration?
- Point where two IV lines meet - Must check compatibility for simultaneous infusion
742
What is a chemotherapy double-check process?
- Independent dose, drug, and patient ID verification - Required for high-alert drugs
743
What is the role of barcoding in chemo safety?
- Matches drug to patient - Prevents administration errors
744
What is an example of a chemo-related medication error?
- Intrathecal vincristine - Wrong dose or route
745
What system-wide changes reduce chemo errors?
- Standardized order sets - Protocol-based dosing - EMR checks
746
What is the NCCN Chemotherapy Order Template (COT)?
- Standardized orders with supportive care - Reduces variability and errors
747
What is the benefit of computer physician order entry (CPOE)?
- Reduces transcription errors - Integrates alerts and dosing rules
748
What is the ISMP?
- Institute for Safe Medication Practices - Publishes high-alert drug guidelines
749
What does USP <800> regulate?
- Handling of hazardous drugs - PPE, engineering controls, and policies
750
What is the Joint Commission standard for chemo safety?
- Requires policies for prescribing, preparing, and administering antineoplastics
751
What are the three types of chemotherapy-induced nausea and vomiting (CINV)?
- Acute (within 24 hours) - Delayed (after 24 hours) - Anticipatory (before treatment)
752
What drugs are used for acute CINV prevention?
- 5-HT3 receptor antagonists (ondansetron) - Dexamethasone - NK1 antagonists (aprepitant)
753
What agents are most effective for delayed CINV?
- NK1 antagonists (aprepitant, fosaprepitant) - Dexamethasone - Olanzapine
754
What is used for anticipatory nausea?
- Benzodiazepines (e.g., lorazepam) - Behavioral therapy
755
What chemo agents are highly emetogenic?
- Cisplatin - Dacarbazine - Cyclophosphamide (high dose)
756
What is the definition of highly emetogenic chemotherapy (HEC)?
Causes emesis in >90% of patients without prophylaxis
757
What is the optimal antiemetic regimen for HEC?
- 5-HT3 antagonist + NK1 antagonist + dexamethasone ± olanzapine
758
What are side effects of 5-HT3 antagonists?
- Headache - Constipation - QT prolongation
759
What is the role of olanzapine in CINV?
- Used for prevention and treatment - Especially for breakthrough and delayed nausea
760
What non-pharmacologic strategies reduce nausea?
- Small frequent meals - Acupressure - Relaxation techniques
761
What is cancer-related fatigue?
- Persistent exhaustion unrelated to activity - Not relieved by rest
762
What are pharmacologic options for cancer fatigue?
- Psychostimulants (methylphenidate, modafinil) - Corticosteroids (short-term)
763
What non-drug treatments help manage fatigue?
- Exercise - Energy conservation - Psychosocial support
764
What are common causes of fatigue in chemotherapy patients?
- Anemia - Pain - Depression - Hypothyroidism
765
What is the role of erythropoiesis-stimulating agents (ESAs) in cancer?
- Used in palliative setting for anemia - May reduce transfusion needs
766
What are risks of using ESAs in cancer patients?
- Thromboembolic events - Tumor progression (in some cancers)
767
What are first-line treatments for cancer pain?
- Opioids (e.g., morphine, oxycodone) - NSAIDs (for bone pain)
768
What are examples of adjuvant analgesics in cancer pain?
- Anticonvulsants (gabapentin) - Antidepressants (duloxetine, amitriptyline) - Corticosteroids
769
What is the WHO analgesic ladder?
- Stepwise approach to pain control: 1. Non-opioids 2. Weak opioids 3. Strong opioids ± adjuvants
770
What is opioid-induced constipation and how is it managed?
- Common side effect of opioids - Treated with stimulant laxatives ± stool softeners
771
What are opioid rotation and opioid equivalence?
- Switching to another opioid for better tolerance - Use equianalgesic tables
772
What is breakthrough cancer pain?
- Transient pain flare despite baseline analgesia - Requires rapid-onset opioid (e.g., fentanyl)
773
What is myelosuppression?
- Suppression of bone marrow function - Leads to anemia, neutropenia, thrombocytopenia
774
What are signs of anemia in chemotherapy patients?
- Fatigue - Pallor - Dyspnea - Tachycardia
775
What are transfusion thresholds for red blood cells?
- Hemoglobin <7–8 g/dL in stable patients - Higher threshold if symptomatic
776
What platelet count warrants transfusion?
- <10,000/mm³ - <20,000/mm³ with bleeding or fever
777
What is the role of G-CSF in neutropenia?
- Reduces risk and duration of neutropenia - May allow continuation of planned chemo
778
What are examples of G-CSF products?
- Filgrastim (Neupogen) - Pegfilgrastim (Neulasta)
779
What are side effects of G-CSF?
- Bone pain - Fever - Spleen enlargement (rare)
780
What is tumor lysis syndrome (TLS)?
- Rapid lysis of cancer cells → electrolyte imbalance - Life-threatening
781
What labs are abnormal in tumor lysis syndrome?
- ↑ Uric acid - ↑ Potassium - ↑ Phosphate - ↓ Calcium
782
What drugs prevent TLS?
- Allopurinol - Rasburicase - IV hydration
783
How does rasburicase differ from allopurinol?
- Rasburicase breaks down uric acid - Allopurinol prevents formation
784
What is the role of urine alkalinization in TLS?
- Not routinely recommended - May cause calcium phosphate precipitation
785
What is spinal cord compression in cancer patients?
- Tumor compresses spinal cord - Neurologic emergency
786
What are symptoms of spinal cord compression?
- Back pain - Weakness - Bowel/bladder dysfunction
787
What is the treatment for spinal cord compression?
- High-dose corticosteroids - Radiation or surgery
788
What is superior vena cava (SVC) syndrome?
- Obstruction of blood flow through SVC - Caused by mediastinal tumor
789
What are symptoms of SVC syndrome?
- Facial swelling - Dyspnea - Distended neck/chest veins
790
What is the management of SVC syndrome?
- Radiation or chemo - Supportive care
791
What is hypercalcemia of malignancy?
↑ Calcium from tumor secretion of PTHrP or bone metastases
792
What are symptoms of hypercalcemia of malignancy?
- Confusion - Constipation - Polyuria - Muscle weakness
793
How is hypercalcemia treated in cancer?
- IV fluids - Bisphosphonates (zoledronic acid) - Calcitonin
794
What is SIADH and its cancer-related causes?
- Syndrome of Inappropriate Antidiuretic Hormone - Often from small cell lung cancer
795
What are lab findings in SIADH?
- Hyponatremia - Low serum osmolality - High urine sodium/osmolality
796
What are treatments for SIADH?
- Fluid restriction - Hypertonic saline (severe) - Demeclocycline or tolvaptan
797
What is chemotherapy extravasation?
- Accidental drug leak into tissue - Can cause necrosis
798
What agents require warm compress for extravasation?
- Vinca alkaloids - Etoposide
799
What agents require cold compress for extravasation?
- Anthracyclines - Mechlorethamine
800
What are key supportive care goals in oncology?
- Minimize treatment toxicity - Maintain quality of life - Enable treatment completion
801
What are the three main types of hematologic toxicity from chemotherapy?
- Neutropenia - Anemia - Thrombocytopenia
802
What is considered Grade 4 neutropenia?
ANC < 500 cells/µL
803
What is febrile neutropenia defined as?
ANC < 500 and temperature ≥ 38.3°C once or ≥ 38.0°C for ≥ 1 hour
804
What is the typical recovery time from chemotherapy-induced neutropenia?
7–14 days post-chemo
805
What growth factor shortens neutropenia duration?
G-CSF (e.g., filgrastim, pegfilgrastim)
806
What is pegfilgrastim’s recommended timing post-chemo?
At least 24 hours after completion of chemotherapy
807
What lab values define chemotherapy-induced anemia?
- Hemoglobin < 11 g/dL (CTCAE Grade 1) - < 8 g/dL may require transfusion
808
What are ESA initiation criteria in oncology?
- Symptomatic anemia in non-curative setting - Hb <10 g/dL
809
What are risks of ESA use in cancer?
- Thrombosis - Tumor progression - Hypertension
810
What parameters guide platelet transfusion decisions?
- Platelet count <10,000–20,000/µL - Bleeding, fever, or surgery
811
What chemotherapy agents are most myelosuppressive?
- Alkylators (e.g., cyclophosphamide) - Anthracyclines - Antimetabolites
812
What are signs of thrombocytopenia in chemotherapy patients?
- Petechiae - Bruising - Epistaxis - Heavy menses
813
What agents commonly cause thrombocytopenia?
- Carboplatin - Gemcitabine - Temozolomide
814
What drug is used for thrombopoiesis stimulation?
- Romiplostim - Eltrombopag
815
What is leucovorin used for in chemotherapy?
- Rescue after high-dose methotrexate - Enhancer of 5-FU cytotoxicity
816
How does leucovorin rescue work?
- Replenishes reduced folate pools - Bypasses methotrexate inhibition
817
When is leucovorin administered after methotrexate?
Typically starts 24 hours after methotrexate infusion ends
818
What drug prevents methotrexate-induced nephrotoxicity?
- IV hydration and urinary alkalinization - Leucovorin for rescue
819
What is glucarpidase and when is it used?
- Enzyme that rapidly hydrolyzes methotrexate - Used in delayed MTX clearance or renal dysfunction
820
What lab must be used post-glucarpidase for MTX level monitoring?
- HPLC-based assay (not immunoassay, which is falsely elevated)
821
What is the role of uridine triacetate (Vistogard)?
Antidote for 5-FU or capecitabine overdose or early-onset toxicity
822
When must uridine triacetate be started?
Within 96 hours of 5-FU or capecitabine administration
823
What is mesna used for?
Uroprotection from hemorrhagic cystitis caused by ifosfamide and high-dose cyclophosphamide
824
How is mesna administered?
- IV or oral - Typically as 3 doses (0, 4, and 8 hours)
825
What is dexrazoxane used for?
- Prevents doxorubicin cardiotoxicity - Treats anthracycline extravasation
826
What is amifostine’s role in chemotherapy?
Cytoprotectant used with cisplatin to reduce nephrotoxicity
827
What are side effects of amifostine?
- Hypotension - Nausea/vomiting - Flushing
828
What is palifermin used for?
Prevents severe oral mucositis in HSCT patients receiving TBI
829
What are side effects of palifermin?
- Tongue thickening - Rash - Edema
830
What is the mechanism of methotrexate nephrotoxicity?
- Precipitation in renal tubules - Direct tubular injury
831
What is the ideal urine pH for MTX excretion?
pH > 7
832
How is urine alkalinization achieved in high-dose MTX?
Sodium bicarbonate infusion
833
What medications delay MTX clearance?
- NSAIDs - PPIs - Penicillins - Trimethoprim
834
What is the role of hydration in preventing tumor lysis syndrome?
- Increases urine output - Dilutes solutes and supports renal excretion
835
What are signs of early TLS?
- Nausea - Muscle cramps - Arrhythmia - Seizure
836
What cancers are most associated with TLS?
- Burkitt lymphoma - ALL - AML - High tumor burden solid tumors
837
What is the Cairo-Bishop definition used for?
Diagnostic criteria for laboratory and clinical TLS
838
What is the mechanism of action of rasburicase?
Converts uric acid to allantoin (more soluble)
839
What patients should not receive rasburicase?
G6PD deficiency (risk of hemolysis and methemoglobinemia)
840
What blood handling precaution is needed for rasburicase?
- Collect blood in pre-chilled tube - Transport on ice - Test within 4 hours
841
What is the role of IV calcium in TLS?
- Only for symptomatic hypocalcemia - Otherwise avoided due to risk of calcium phosphate precipitation
842
What electrolyte abnormality can worsen seizures in TLS?
Hypocalcemia
843
What is the management of hyperkalemia in TLS?
- Calcium gluconate (cardiac protection) - Insulin + dextrose - Albuterol - Dialysis (if severe)
844
What are indications for dialysis in TLS?
- Volume overload - Severe electrolyte imbalance - Persistent hyperuricemia
845
What is the mechanism of ifosfamide-induced neurotoxicity?
- Chloroacetaldehyde metabolite crosses BBB - Alters neurotransmitters
846
What is the treatment for ifosfamide neurotoxicity?
Methylene blue
847
What are signs of ifosfamide-induced encephalopathy?
- Confusion - Somnolence - Hallucinations - Seizures
848
What is the mechanism of irinotecan-induced diarrhea?
- Early: cholinergic stimulation - Late: SN-38 metabolite-induced mucosal injury
849
How is early irinotecan diarrhea treated?
Atropine
850
How is late irinotecan diarrhea treated?
Loperamide high-dose regimen
851
What is pharmacogenomics in oncology?
- Study of how genetic variations affect drug response - Helps guide chemo choice and dosing
852
What genetic polymorphism affects 5-FU metabolism?
Dihydropyrimidine dehydrogenase (DPD) deficiency
853
What are signs of DPD deficiency in 5-FU therapy?
- Severe mucositis - Myelosuppression - Neurotoxicity - Diarrhea
854
What test can identify risk of DPD deficiency?
- DPYD gene mutation testing - DPD enzyme activity assay
855
What chemo agents are contraindicated in complete DPD deficiency?
- 5-FU - Capecitabine
856
What enzyme is important in irinotecan metabolism?
UGT1A1 (glucuronidation of SN-38 metabolite)
857
What UGT1A1 polymorphism increases irinotecan toxicity?
UGT1A1*28 homozygosity
858
What toxicities are linked to UGT1A1*28 variant?
- Severe neutropenia - Diarrhea
859
What adjustment is made for UGT1A1*28 homozygotes on irinotecan?
Consider dose reduction
860
What drug has increased risk of neurotoxicity in TPMT deficiency?
Mercaptopurine (6-MP)
861
What are consequences of TPMT deficiency with thiopurines?
- Myelosuppression - Increased toxicity
862
What test is used to assess TPMT activity?
- TPMT genotyping - TPMT enzyme activity assay
863
What is NUDT15 testing used for?
Identify thiopurine toxicity risk in Asians
864
What HLA allele increases risk of SJS/TEN with carbamazepine or allopurinol?
- HLA-B*1502 for carbamazepine - HLA-B*5801 for allopurinol
865
What chemo drug requires G6PD screening?
Rasburicase (risk of hemolysis)
866
What is the mechanism of hemolysis in G6PD deficiency?
- Inability to detoxify oxidative stress - RBC lysis
867
Why are pharmacogenomics important in pediatrics?
- Metabolism varies with age - Enzymes may be underdeveloped
868
What chemo agent requires dose capping in pediatrics?
Vincristine (neurotoxicity risk)
869
What is the most important PK parameter for chemo in neonates?
Renal and hepatic immaturity → longer half-lives
870
What chemo agents accumulate in renal dysfunction?
- Methotrexate - Cisplatin - Capecitabine
871
What is BSA and why is it used in oncology?
- Body Surface Area - Dosing standardization across body sizes
872
What is the Mosteller formula for BSA?
BSA (m²) = √[(height in cm × weight in kg)/3600]
873
Why is dose banding used in chemotherapy?
- Round doses to reduce preparation error - Improve efficiency
874
What patient populations may require dose reductions?
- Elderly - Frail - Organ dysfunction - Poor performance status
875
What is ECOG performance status?
- 0 (fully active) to 5 (dead) - Guides treatment decisions
876
What is the Karnofsky performance scale?
- 100 (normal) to 0 (dead) - Used to assess functional status
877
What chemo considerations are unique to obese patients?
- Use actual body weight for dosing - Risk of underdosing with adjusted weight
878
What is the ASCO guideline for chemo dosing in obesity?
Use full weight-based dosing unless contraindicated
879
What organ system has the most impact on chemo clearance?
Liver (cytochrome P450 enzymes)
880
What hepatic parameters are most relevant for dosing?
- Bilirubin - AST/ALT - Albumin
881
What are examples of CYP3A4-metabolized chemo drugs?
- Vincristine - Paclitaxel - Etoposide
882
What can inhibit CYP3A4 and increase drug levels?
- Azole antifungals - Macrolides - Grapefruit juice
883
What drugs induce CYP3A4 and reduce efficacy?
- Rifampin - Phenytoin - Carbamazepine
884
What is first-pass metabolism?
- Drug breakdown in liver after oral administration - Reduces bioavailability
885
What is enterohepatic circulation?
- Drug recirculated via bile - Prolongs half-life
886
What chemo drugs undergo enterohepatic recycling?
- Irinotecan - Etoposide
887
What is the effect of diarrhea on enterohepatic drugs?
- May reduce reabsorption - Lower drug exposure
888
What food affects oral etoposide absorption?
High-fat meals may delay absorption
889
What is the impact of antacids on oral capecitabine?
- May increase absorption - Not clinically significant
890
What is the oral bioavailability of capecitabine?
~100%
891
What is the benefit of pharmacogenetic testing in oncology?
- Prevent toxicity - Optimize dose - Improve outcomes
892
What is the major challenge of pharmacogenomic integration?
- Cost - Interpretation complexity - Test availability
893
What professional groups provide PGx guidelines?
- CPIC (Clinical Pharmacogenetics Implementation Consortium) - DPWG (Dutch Pharmacogenetics Working Group)
894
What are actionable gene-drug pairs in chemo?
- DPYD–5-FU - UGT1A1–irinotecan - TPMT/NUDT15–thiopurines
895
What is phenoconversion in pharmacogenomics?
- When drug interactions alter genetic phenotype expression - e.g., CYP inhibition mimics poor metabolizer
896
What is a poor metabolizer phenotype?
- Reduced or absent enzyme activity - Increased drug exposure
897
What is an ultrarapid metabolizer?
- Increased enzyme activity - Lower drug levels and efficacy
898
How are metabolizer phenotypes determined?
- Genotype testing - Metabolic ratio measurement
899
What is the effect of pharmacogenomics on cost-effectiveness?
- May reduce hospitalization and adverse events - Long-term savings despite upfront cost
900
What is a gene-drug interaction with black box warning?
- DPYD–5-FU (toxic in DPD deficiency) - HLA-B*5701–abacavir (not chemo but PGx example)
901
What factors commonly require chemotherapy dose adjustments?
- Organ dysfunction (renal, hepatic) - Age/frailty - Performance status - Toxicity history
902
What lab values are used to guide renal dose adjustments?
- Serum creatinine - Creatinine clearance (CrCl) - Estimated GFR
903
What formula is most commonly used to estimate CrCl for chemo dosing?
Cockcroft-Gault equation
904
What factors affect hepatic dose adjustments?
- Total bilirubin - AST/ALT - Child-Pugh score
905
What chemotherapy drugs require hepatic adjustment?
- Doxorubicin - Vincristine - Irinotecan - Paclitaxel
906
Which agents are contraindicated in severe hepatic dysfunction?
- Vincristine - Docetaxel - Irinotecan
907
What is considered dose-limiting toxicity (DLT)?
- The toxicity that prevents further dose escalation in trials - Common examples: neutropenia, mucositis
908
What is maximum tolerated dose (MTD)?
Highest dose with acceptable side effects in trials
909
What is relative dose intensity (RDI)?
Delivered dose over time ÷ planned dose over time Reflects adherence to dose and schedule
910
Why is maintaining RDI important in curative chemotherapy?
- Improves efficacy - Reduces risk of recurrence
911
What is dose delay and when is it used?
- Holding a dose due to toxicities (e.g., ANC <1000) - Allows recovery before next cycle
912
What is the risk of frequent dose delays or reductions?
- Reduced treatment efficacy - Potential resistance development
913
What chemo drugs are associated with significant food interactions?
- Oral etoposide (food delays absorption) - Capecitabine (take within 30 min of meal)
914
What agents interact with warfarin to increase INR?
- Fluorouracil - Capecitabine - Methotrexate
915
What is a major CYP3A4 inhibitor that affects chemo levels?
- Ketoconazole - Clarithromycin
916
What common herbal supplements interact with chemotherapy?
- St. John's Wort (induces CYP3A4, reduces efficacy) - Ginseng - Ginkgo
917
What is the importance of drug half-life in scheduling chemo?
- Affects frequency of dosing - Determines clearance and toxicity risk
918
What agents are cell-cycle specific?
- Antimetabolites (S phase) - Vinca alkaloids (M phase)
919
What agents are cell-cycle nonspecific?
- Alkylating agents - Anthracyclines
920
What is the mechanism of action of taxanes?
- Stabilize microtubules - Prevent depolymerization → mitotic arrest
921
What are key administration considerations for taxanes?
- Use non-PVC tubing for paclitaxel - Premedicate for hypersensitivity
922
What is the order of administration for taxanes and platinum agents?
Taxanes before platinum (e.g., paclitaxel before carboplatin)
923
Why is paclitaxel given before cisplatin or carboplatin?
- Reduces myelosuppression - Minimizes drug interaction
924
What are precautions for handling chemotherapy drugs?
- Use PPE (gloves, gown, mask) - Prepare in biological safety cabinet - Follow USP <800> guidelines
925
What are closed-system transfer devices (CSTDs)?
- Prevent drug aerosolization - Enhance safety in compounding
926
What is required when administering vesicants via peripheral IV?
- Use large vein - Monitor closely - Avoid prolonged infusion
927
What is extravasation and why is it dangerous?
- Infiltration of vesicant into tissue - Can cause necrosis
928
What drugs are vesicants?
- Anthracyclines - Vinca alkaloids - Mitomycin C
929
How is anthracycline extravasation managed?
- Stop infusion - Apply cold compress - Administer dexrazoxane
930
How is vinca alkaloid extravasation managed?
- Apply warm compress - Use hyaluronidase
931
What are irritants in chemotherapy?
- Drugs that cause inflammation but not necrosis - Example: carboplatin
932
What is the purpose of a central line in chemo?
- Allows administration of vesicants - Reduces extravasation risk
933
What is a port-a-cath?
- Implanted central venous catheter under the skin - Used for long-term chemo
934
How is a port accessed safely?
- With a non-coring Huber needle - Sterile technique
935
What complications can arise from central lines?
- Infection - Thrombosis - Occlusion
936
What is the most common cause of catheter-related bloodstream infections?
Gram-positive cocci (e.g., Staphylococcus epidermidis)
937
What is used to maintain catheter patency?
- Heparin flush - Saline lock
938
What is chemoembolization?
Direct delivery of chemo to tumor vasculature (e.g., liver)
939
What cancers may be treated with chemoembolization?
- Hepatocellular carcinoma - Liver metastases
940
What is intraperitoneal chemotherapy (IP)?
- Administered directly into abdominal cavity - Used in ovarian cancer
941
What are complications of intraperitoneal chemotherapy?
- Abdominal pain - Infection - Adhesions
942
What is hyperthermic intraperitoneal chemotherapy (HIPEC)?
- Heated chemo administered during surgery - Enhances penetration and cytotoxicity
943
What is the rationale for heated chemotherapy in HIPEC?
- Increases drug penetration - Improves efficacy against peritoneal tumors
944
What cancers may be treated with HIPEC?
- Ovarian - Colorectal - Gastric with peritoneal spread
945
What are patient risks with HIPEC?
- Infection - Adhesions - Postoperative complications
946
What is intrathecal chemotherapy used for?
- CNS prophylaxis or treatment in leukemia, lymphoma
947
What drugs are safe for intrathecal administration?
- Methotrexate - Cytarabine - Hydrocortisone
948
What drug is fatal if given intrathecally?
Vincristine
949
What are safety protocols to prevent vincristine intrathecal errors?
- Label “FOR IV USE ONLY” - Administer at separate time and site
950
What is the role of the oncology pharmacist in safe chemo use?
- Dose verification - Drug interaction screening - Compounding oversight - Patient counseling
951
What are hazardous drugs as defined by NIOSH?
- Carcinogenic - Teratogenic or impair fertility - Cause organ toxicity at low doses - Genotoxic
952
What are examples of hazardous chemotherapy drugs?
- Cyclophosphamide - Doxorubicin - Cisplatin - Methotrexate
953
What is USP <800>?
- Standards for handling hazardous drugs in healthcare settings - Encompasses storage, compounding, administration, disposal
954
What personal protective equipment (PPE) is required for compounding chemotherapy?
- Gloves (ASTM-tested) - Gown - Eye/face protection - Respiratory protection (as needed)
955
What engineering controls are required under USP <800>?
- Biological safety cabinet (Class II) - Compounding aseptic containment isolator (CACI) - Negative pressure room
956
What is the difference between sterile and non-sterile hazardous drug compounding?
- Sterile: injectables/IVs → in cleanroom - Non-sterile: oral/crushed tablets → with containment
957
How often must personnel receive training under USP <800>?
At least annually
958
What is the purpose of the HD assessment of risk (AoR)?
- Allows institutions to implement alternatives for certain HDs (e.g., tablets) - Justify handling practices
959
What is a CSTDs role in chemotherapy administration?
- Prevent aerosolization and spillage - Improve worker safety during transfer
960
What precautions should be taken when crushing or splitting oral HDs?
- Perform in dedicated hood - Use PPE - Avoid when possible
961
What is chemotherapy spill management protocol?
- Evacuate area - Wear PPE - Use chemo-specific spill kit - Dispose in hazardous waste
962
What is the required storage for hazardous drugs?
- Labeled, separate negative-pressure room or containment area - Away from other meds
963
How are chemotherapy gowns disposed?
As trace hazardous waste if visibly contaminated
964
What are trace vs. bulk hazardous waste definitions?
- Trace: <3% remaining → yellow container - Bulk: >3% or IV bags with residual → black container
965
What organization sets chemotherapy preparation guidelines?
- United States Pharmacopeia (USP) - NIOSH - OSHA
966
What is the beyond-use date (BUD) for compounded chemotherapy?
- Determined by USP <797> and drug stability - Usually 48 hours refrigerated or shorter
967
What factors influence chemotherapy stability?
- Diluent - Temperature - Light exposure - Container
968
What drugs are light-sensitive and require protection?
- Dacarbazine - Etoposide - Anthracyclines
969
What is the Y-site compatibility issue?
- Physical/chemical reaction when drugs mix in IV line - May lead to precipitation or inactivation
970
What resources provide drug compatibility data?
- Trissel’s Handbook - King Guide - Micromedex
971
What are common diluents used in chemotherapy?
- Normal saline (NS) - Dextrose 5% (D5W) - Sterile water (for reconstitution)
972
Which drugs are incompatible with saline?
- Amphotericin B - Etoposide
973
Which drugs are incompatible with dextrose (D5W)?
- Cisplatin - Oxaliplatin
974
Why is cisplatin incompatible with D5W?
- Instability in glucose-containing solutions - Precipitates or degrades
975
Why should certain IV drugs be given via central line?
- Highly irritant or vesicant - Prevent tissue injury from extravasation
976
What is the appropriate filter size for taxanes?
0.22 micron in-line filter (non-DEHP tubing)
977
What drugs require in-line filtration?
- Taxanes - Liposomal formulations - Amphotericin B
978
What is the significance of pH in IV drug compatibility?
- Impacts solubility and stability - May affect Y-site mixing
979
What is the purpose of a final check in chemo compounding?
- Verify drug, dose, volume, label - Ensure patient safety before dispensing
980
Who performs final check of chemotherapy before release?
- Oncology-trained pharmacist - Often involves second verification
981
What barcode verification systems are used in chemo safety?
- Scanning patient and drug barcodes - Prevents administration errors
982
What are the “5 Rights” in chemo administration?
- Right patient - Right drug - Right dose - Right route - Right time
983
What is a chemotherapy timeout?
Final verbal check of critical info before administration
984
What is EMR’s role in chemo safety?
- Electronic order sets - Alerts for dose limits, allergies - Drug interaction checking
985
What are smart infusion pumps?
- Preprogrammed dose limits - Prevent infusion rate errors
986
What is double-checking and who performs it?
- Independent verification by 2 clinicians - Often nurse and pharmacist
987
What are common administration errors in chemotherapy?
- Wrong dose, route, patient - Misprogrammed pump - Incomplete orders
988
What system improvements reduce chemo errors?
- CPOE - Standardized protocols - Staff training
989
What is the NCCN Chemotherapy Order Template (COT)?
- Standardized regimen templates - Include premeds, dosing, and monitoring
990
What is ASHP’s role in chemo safety?
- Publishes guidelines for safe handling and preparation
991
What are key components of chemotherapy informed consent?
- Diagnosis and goal of treatment - Risks and side effects - Alternatives - Right to refuse
992
What is a chemotherapy order set?
- Pre-built EMR-based template - Ensures complete and accurate ordering
993
What is the ONS Chemotherapy and Biotherapy Guidelines?
- Best practice standards for oncology nurses - Covers safe handling and administration
994
What is the Oncology Nursing Society (ONS)?
- Professional org for oncology nurses - Provides certification, education, advocacy
995
What is the purpose of the APHON standards?
- Pediatric and hematology nursing guidance - Standards for safe care
996
What are competencies required for chemo administration?
- Knowledge of drug mechanisms, side effects - Safe handling - Emergency management
997
What is a chemo “roadmap”?
- Visual calendar of treatment plan - Helps patients and clinicians stay organized
998
What is the importance of documentation in chemo administration?
- Legal record - Communication - Quality assurance
999
What is patient education’s role in chemotherapy safety?
- Ensures adherence - Reduces anxiety - Promotes early toxicity reporting
1000
What are best practices for discharge counseling after chemo?
- Handling body fluids - Symptom management - When to call clinic/emergency
1001
What are unique considerations for pediatric chemotherapy dosing?
- BSA-based dosing - Organ immaturity affects clearance - Long-term effects (growth, fertility, cognition)
1002
What toxicity is more common in pediatric chemotherapy patients?
- Neurocognitive decline - Endocrinopathies - Growth delays
1003
What is vincristine’s max dose in pediatrics?
Typically capped at 2 mg to reduce neurotoxicity
1004
What is the role of methotrexate in pediatric ALL?
- CNS prophylaxis (IT or high dose IV) - Maintenance therapy
1005
What is the most common pediatric leukemia?
Acute lymphoblastic leukemia (ALL)
1006
Why are pediatric oncology protocols highly standardized?
- Maximize survival - Minimize toxicity - Based on decades of clinical trials
1007
What is the impact of chemotherapy on fertility in children?
- Risk of infertility (esp. alkylators) - Consider fertility preservation
1008
What chemo class is most gonadotoxic in pediatric patients?
Alkylating agents (e.g., cyclophosphamide, ifosfamide)
1009
What screening is recommended in long-term pediatric cancer survivors?
- Endocrine function - Cardiac monitoring - Second malignancy screening
1010
What anthracycline dose threshold increases cardiomyopathy risk?
>300 mg/m² doxorubicin equivalent
1011
What are considerations for chemotherapy in older adults?
- Comorbidities - Polypharmacy - Frailty and functional status
1012
What tool assesses geriatric fitness for chemotherapy?
- Geriatric Assessment (GA) - CARG and CRASH scores
1013
What is the CARG toxicity risk tool?
Predicts chemo toxicity risk in patients ≥65 years
1014
What are age-related changes in drug pharmacokinetics?
- ↓ Renal clearance - ↓ Hepatic metabolism - Altered volume of distribution
1015
What dose adjustments are common in elderly chemo?
- Renally cleared agents (e.g., carboplatin) - Anthracyclines (cardiotoxicity risk)
1016
What is the impact of malnutrition on chemotherapy?
- Alters drug metabolism - Increases risk of toxicity - Impairs healing and recovery
1017
What labs reflect nutritional status in chemo patients?
- Albumin - Prealbumin - Total lymphocyte count
1018
What are common GI toxicities from chemotherapy?
- Nausea - Diarrhea - Constipation - Mucositis
1019
What drugs commonly cause mucositis?
- Methotrexate - 5-FU - Melphalan
1020
What is used to prevent or treat mucositis?
- Oral hygiene protocols - Cryotherapy - Palifermin - Magic mouthwash
1021
What chemo agents commonly cause diarrhea?
- Irinotecan - 5-FU - Capecitabine
1022
How is chemotherapy-induced diarrhea managed?
- Loperamide (high dose) - Octreotide for refractory cases
1023
What chemo causes cholinergic syndrome?
Irinotecan (early-onset diarrhea + cramping, flushing)
1024
What treats irinotecan-induced cholinergic syndrome?
Atropine
1025
What is the mechanism of alkylating agents?
- DNA cross-linking → strand breakage - Cell-cycle nonspecific
1026
What is the mechanism of antimetabolites?
- Mimic nucleotides → interfere with DNA/RNA synthesis - S-phase specific
1027
What are examples of antimetabolites?
- 5-FU - Methotrexate - Cytarabine - Gemcitabine
1028
What is the mechanism of topoisomerase inhibitors?
- Interfere with DNA winding/unwinding - Cause strand breaks
1029
What drugs are topoisomerase I inhibitors?
- Irinotecan - Topotecan
1030
What drugs are topoisomerase II inhibitors?
- Etoposide - Doxorubicin - Daunorubicin
1031
What is the mechanism of microtubule inhibitors?
Disrupt mitosis by preventing microtubule function
1032
What are examples of microtubule stabilizers?
- Paclitaxel - Docetaxel
1033
What are microtubule destabilizers?
- Vincristine - Vinblastine - Vinorelbine
1034
What is a major toxicity of vincristine?
Neurotoxicity (peripheral neuropathy)
1035
What is a major toxicity of paclitaxel?
- Hypersensitivity reactions - Neuropathy - Myelosuppression
1036
What are anthracycline dose-related toxicities?
- Cardiotoxicity (cumulative) - Mucositis - Myelosuppression
1037
What is the cumulative lifetime limit for doxorubicin?
~450–550 mg/m²
1038
What drug protects against anthracycline cardiotoxicity?
Dexrazoxane
1039
What is the red urine effect from doxorubicin?
Benign discoloration due to drug color
1040
What drug class requires cold compress for extravasation?
Anthracyclines
1041
What drug class requires warm compress for extravasation?
- Vinca alkaloids - Etoposide
1042
What agents are radiation sensitizers?
- 5-FU - Cisplatin - Gemcitabine
1043
What is radiation recall?
- Inflammatory skin reaction in previously irradiated area - Triggered by certain chemo (e.g., doxorubicin)
1044
What is the mechanism of platinum agents?
- Cross-link DNA - Inhibit replication and transcription
1045
What are toxicities of cisplatin?
- Nephrotoxicity - Ototoxicity - Nausea/vomiting - Peripheral neuropathy
1046
What prevents cisplatin nephrotoxicity?
- Aggressive IV hydration - Amifostine (rarely used)
1047
What is the mechanism of 5-FU?
- Thymidylate synthase inhibitor - Blocks DNA synthesis
1048
What enhances 5-FU binding to its target enzyme?
Leucovorin
1049
What are 5-FU toxicities?
- Mucositis - Diarrhea - Myelosuppression - Hand-foot syndrome
1050
What is capecitabine and how is it activated?
- Oral prodrug of 5-FU - Activated in tumor tissue by thymidine phosphorylase
1051
What is primary chemotherapy resistance?
- Intrinsic lack of tumor sensitivity to chemo - No initial response observed
1052
What is acquired chemotherapy resistance?
- Tumor initially responds, then progresses despite treatment
1053
What are common mechanisms of chemo resistance?
- Efflux pumps (e.g., P-glycoprotein) - Altered drug targets - Enhanced DNA repair - Drug inactivation
1054
What is P-glycoprotein’s role in resistance?
- Expels drugs from tumor cells - Decreases intracellular drug concentration
1055
What classes are P-glycoprotein substrates?
- Anthracyclines - Vinca alkaloids - Taxanes
1056
What is the role of MDR1 gene in chemotherapy resistance?
- Encodes P-glycoprotein - Overexpression leads to multi-drug resistance
1057
What is the rationale for dose capping?
- Prevent toxicity in vulnerable patients - Common in obese, elderly, or pediatric patients
1058
What chemo drugs are typically capped?
- Vincristine (2 mg) - Carboplatin (based on Calvert formula, capped GFR)
1059
What is the Calvert formula for carboplatin dosing?
Dose = Target AUC × (GFR + 25)
1060
What is a typical AUC target for carboplatin in solid tumors?
- AUC 5–6 (curative intent) - AUC 4–5 (palliative intent)
1061
What labs are used to calculate GFR for carboplatin dosing?
- Serum creatinine - Age - Weight - Sex (via Cockcroft-Gault or MDRD equations)
1062
Why is creatinine capped when calculating carboplatin dosing?
- Avoid overestimating GFR in elderly or sarcopenic patients - Cap SCr at 0.7–1.0 mg/dL for safety
1063
What are signs of chemotherapy overdose?
- Pancytopenia - Mucositis - Diarrhea - Neurologic symptoms
1064
What drugs have available antidotes for overdose?
- Methotrexate → leucovorin or glucarpidase - 5-FU → uridine triacetate - Ifosfamide → methylene blue
1065
What is the first step in suspected chemotherapy extravasation?
- Stop infusion - Leave needle in place - Aspirate residual drug
1066
What are general steps in extravasation management?
- Stop infusion - Apply compress (hot/cold based on drug) - Administer antidote if available - Document incident
1067
What are specific extravasation antidotes?
- Dexrazoxane for anthracyclines - Hyaluronidase for vinca alkaloids and etoposide
1068
What is the primary danger of vesicant extravasation?
Tissue necrosis and ulceration
1069
What is the recommendation for vesicant administration route?
Prefer central venous access
1070
What is a recall reaction in chemotherapy?
- Acute inflammation in previously treated area - Triggered by subsequent chemotherapy
1071
What agents can cause recall reactions?
- Doxorubicin - Gemcitabine - Actinomycin D
1072
What are signs of infusion reactions to chemo?
- Flushing - Dyspnea - Hypotension - Fever/chills
1073
What chemo drugs are associated with high infusion reaction risk?
- Taxanes - Monoclonal antibodies (e.g., rituximab)
1074
What are steps in managing infusion reactions?
- Stop infusion - Administer antihistamines, corticosteroids, epinephrine if needed - Resume cautiously if mild
1075
What is the role of desensitization protocols?
- Enable continued use of chemo in patients with prior hypersensitivity - Gradual reintroduction in controlled setting
1076
What is intrathecal chemotherapy and its indications?
- Administered into CSF - Used for CNS prophylaxis (e.g., ALL, lymphoma)
1077
What chemo drugs are safe for intrathecal use?
- Methotrexate - Cytarabine - Hydrocortisone
1078
What is the fatal risk of intrathecal vincristine?
- Rapid neurotoxicity - Death within hours
1079
What precautions prevent intrathecal vincristine errors?
- Administer IV vincristine at separate time/site - Bold warning labels
1080
What is Ommaya reservoir used for?
- Direct intrathecal chemo delivery - Implanted into lateral ventricle
1081
What are advantages of Ommaya reservoir?
- Repeated CSF access - Reduced lumbar punctures - Better drug distribution
1082
What are risks of intrathecal therapy?
- Headache - Meningitis - Seizures
1083
What innovations improve chemo safety and efficacy?
- Liposomal formulations - Prodrug strategies - Drug-eluting devices
1084
What is the benefit of liposomal doxorubicin?
- Reduced cardiotoxicity - Prolonged circulation
1085
What are PEGylated drugs and why are they used?
- Polyethylene glycol coating - Enhances half-life and reduces immunogenicity
1086
What is the role of antibody-drug conjugates (ADCs)?
- Deliver cytotoxic drugs selectively to tumor cells via antibody targeting
1087
What are examples of ADCs used in cancer?
- Brentuximab vedotin - Trastuzumab emtansine
1088
What is an oncolytic virus in chemo?
- Virus that selectively infects and destroys cancer cells
1089
What is tumor agnostic chemotherapy?
- Targets molecular features (e.g., NTRK fusions) regardless of tumor origin
1090
What is a drug-eluting bead and its use?
- Microspheres loaded with chemo - Used in hepatic artery chemoembolization
1091
What are nanoparticle-bound chemotherapies?
- Drugs encapsulated for targeted delivery and reduced toxicity
1092
What is the purpose of oral chemotherapy agents?
- Convenience - Home-based care - Improve patient autonomy
1093
What challenges exist with oral chemotherapy?
- Adherence - Drug interactions - Monitoring
1094
What drugs are commonly used in oral form for cytotoxic chemo?
- Capecitabine - Cyclophosphamide - Temozolomide
1095
What is the pharmacist’s role in oral chemo?
- Counseling - Drug interaction checks - Adherence monitoring
1096
What chemo drugs require fasting administration?
- Capecitabine (within 30 min of meal) - Lapatinib (on empty stomach)
1097
What is a REMS program and how does it relate to chemo?
- Risk Evaluation and Mitigation Strategy - Ensures safe use of high-risk drugs (e.g., lenalidomide)
1098
What are examples of chemo drugs with REMS?
- Thalidomide - Lenalidomide - Pomalidomide
1099
Why do immunomodulatory drugs have strict REMS?
- Teratogenicity - Risk of severe birth defects
1100
What is the role of electronic chemotherapy order sets?
- Reduce errors - Standardize regimens - Include safety checks
1101
What is the purpose of chemotherapy administration checklists?
- Ensure protocol adherence - Prevent errors - Standardize workflow
1102
What are common components of pre-chemo checklists?
- Consent verification - Lab review (ANC, platelets, renal, hepatic) - Vital signs - Premedication readiness
1103
What vital signs are monitored before chemotherapy?
- Blood pressure - Heart rate - Respiratory rate - Temperature - O2 saturation
1104
What labs must be reviewed before starting most myelosuppressive chemo?
- ANC > 1500/mm³ - Platelets > 100,000/mm³ - Acceptable liver and kidney function
1105
What should be confirmed before giving chemo via central line?
- Line patency - Blood return - No signs of infection or infiltration
1106
What is the role of the double-check process before chemo administration?
- Two licensed providers verify drug, dose, route, patient identity
1107
What is patient identity verification protocol in chemo administration?
- Name - Date of birth - Medical record number - Barcode scanning
1108
What is included in post-chemotherapy monitoring?
- Infusion site check - Reaction observation - Patient education on side effects
1109
What is documented after chemotherapy is given?
- Drug name and dose - Route and rate - Time started and completed - Any adverse events
1110
What are early warning signs of an infusion reaction during chemo?
- Flushing - Rash - Throat tightness - Hypotension - Dyspnea
1111
What is the nurse’s role during chemotherapy infusion?
- Monitor patient - Manage reactions - Educate patient - Ensure accurate administration
1112
What protective measures are taken for nurses during IV chemo administration?
- PPE (gown, gloves, face protection) - Use of closed systems - Proper disposal
1113
What is PPE recommended under USP <800> for administering IV chemo?
- Double chemo-rated gloves - Impermeable gown - Eye and face protection if splashing possible
1114
What is considered a chemotherapy exposure event for staff?
- Splash or spill onto skin or mucosa - Inhalation - Needle stick injury
1115
What actions follow a chemo exposure incident?
- Decontaminate area - Report and document incident - Medical evaluation if needed
1116
What is a chemotherapy time-out?
- Final safety pause before administration - Confirms patient, drug, dose, route
1117
What are high-alert chemotherapy medications?
- Drugs with significant risk of harm if used incorrectly - Examples: vincristine, cisplatin, doxorubicin
1118
What types of errors are high-alert chemo drugs prone to?
- Wrong route (e.g., IV vs. IT) - Overdose - Labeling errors
1119
What is required labeling for vincristine to prevent IT use?
“FOR IV USE ONLY – FATAL IF GIVEN INTRATHECALLY”
1120
What systems are in place to reduce chemo-related errors?
- Barcode scanning - Smart pumps - Standardized order sets
1121
What are examples of smart infusion pump features?
- Dose error reduction software - Drug libraries - Alerts for incorrect rates
1122
What is the ASCO/ONS chemotherapy safety standard for verification?
- Two-person, independent verification at multiple stages
1123
What is the minimum interval required between training and chemo administration by nurses?
Annual competency validation
1124
What is the purpose of nursing certification in oncology (e.g., OCN)?
- Ensure specialized knowledge - Improve safety and patient outcomes
1125
What are common topics in oncology nursing education?
- Drug mechanisms - Safe handling - Toxicity management - Communication skills
1126
What are common patient education points before chemo?
- Side effects to expect - When to call the provider - Supportive care meds - Handling body fluids
1127
What is included in safe home disposal instructions for oral chemo?
- Do not crush/split - Store in original container - Return unused meds to oncology pharmacy
1128
What is the recommended storage for oral chemotherapy at home?
- Away from children and pets - Dry, cool location - Original container
1129
What are patient education strategies for adherence?
- Pill boxes - Reminder systems - Involving caregivers
1130
What counseling is provided for reproductive risks of chemo?
- Contraception use during and after treatment - Risk of birth defects - Sperm or egg preservation options
1131
What are barriers to patient adherence with chemotherapy?
- Side effects - Financial cost - Complexity of regimen - Poor understanding
1132
What patient assistance programs help with chemotherapy costs?
- Manufacturer copay cards - Foundation grants - Hospital financial support
1133
What is the role of patient navigators in oncology?
- Help patients with appointments, logistics, insurance, education
1134
What is the impact of multidisciplinary care on chemotherapy outcomes?
- Improves coordination - Reduces errors - Enhances patient satisfaction
1135
What are key components of survivorship care post-chemotherapy?
- Monitoring for recurrence - Managing late effects - Psychosocial support - Health promotion
1136
What are late effects of chemotherapy?
- Infertility - Cardiac dysfunction - Neurocognitive impairment - Second malignancies
1137
What cancer types are at highest risk of chemo-related secondary malignancy?
- Hodgkin lymphoma - Pediatric ALL - Testicular cancer survivors
1138
What agents are most associated with secondary malignancies?
- Alkylators - Etoposide - Anthracyclines
1139
What is a survivorship care plan?
- Summary of diagnosis, treatment, follow-up plan - Includes late effect screening and health tips
1140
What specialties are involved in survivorship care?
- Oncology - Primary care - Cardiology - Endocrinology - Fertility specialists
1141
What are psychosocial effects post-chemotherapy?
- Anxiety - Depression - Fear of recurrence - Body image issues
1142
What assessments screen for depression in cancer patients?
- PHQ-9 - HADS (Hospital Anxiety and Depression Scale)
1143
What is the role of social work in cancer care?
- Counseling - Resource connection - Advance care planning
1144
What spiritual concerns might arise in cancer patients?
- Meaning of illness - End-of-life fears - Faith-based decision-making
1145
What is integrative oncology?
- Combines conventional and complementary therapies - Examples: acupuncture, mindfulness, nutrition
1146
What are safety concerns with complementary therapies?
- Herb-drug interactions - Delays in standard care - Lack of regulation
1147
What is the use of acupuncture in cancer care?
- Manage nausea - Relieve pain - Reduce anxiety
1148
What is mindfulness-based stress reduction (MBSR)?
- Meditation technique to reduce stress and anxiety in cancer patients
1149
What diet recommendations are common post-chemotherapy?
- Plant-based diet - Low red/processed meat - Avoid alcohol - Maintain healthy weight
1150
What vaccines are safe in post-chemotherapy patients?
- Inactivated vaccines (e.g., flu shot) - Avoid live vaccines until immune recovery
1151
What is the purpose of chemotherapy administration checklists?
- Ensure protocol adherence - Prevent errors - Standardize workflow
1152
What are common components of pre-chemo checklists?
- Consent verification - Lab review (ANC, platelets, renal, hepatic) - Vital signs - Premedication readiness
1153
What vital signs are monitored before chemotherapy?
- Blood pressure - Heart rate - Respiratory rate - Temperature - O2 saturation
1154
What labs must be reviewed before starting most myelosuppressive chemo?
- ANC > 1500/mm³ - Platelets > 100,000/mm³ - Acceptable liver and kidney function
1155
What should be confirmed before giving chemo via central line?
- Line patency - Blood return - No signs of infection or infiltration
1156
What is the role of the double-check process before chemo administration?
- Two licensed providers verify drug, dose, route, patient identity
1157
What is patient identity verification protocol in chemo administration?
- Name - Date of birth - Medical record number - Barcode scanning
1158
What is included in post-chemotherapy monitoring?
- Infusion site check - Reaction observation - Patient education on side effects
1159
What is documented after chemotherapy is given?
- Drug name and dose - Route and rate - Time started and completed - Any adverse events
1160
What are early warning signs of an infusion reaction during chemo?
- Flushing - Rash - Throat tightness - Hypotension - Dyspnea
1161
What is the nurse’s role during chemotherapy infusion?
- Monitor patient - Manage reactions - Educate patient - Ensure accurate administration
1162
What protective measures are taken for nurses during IV chemo administration?
- PPE (gown, gloves, face protection) - Use of closed systems - Proper disposal
1163
What is PPE recommended under USP <800> for administering IV chemo?
- Double chemo-rated gloves - Impermeable gown - Eye and face protection if splashing possible
1164
What is considered a chemotherapy exposure event for staff?
- Splash or spill onto skin or mucosa - Inhalation - Needle stick injury
1165
What actions follow a chemo exposure incident?
- Decontaminate area - Report and document incident - Medical evaluation if needed
1166
What is a chemotherapy time-out?
- Final safety pause before administration - Confirms patient, drug, dose, route
1167
What are high-alert chemotherapy medications?
- Drugs with significant risk of harm if used incorrectly - Examples: vincristine, cisplatin, doxorubicin
1168
What types of errors are high-alert chemo drugs prone to?
- Wrong route (e.g., IV vs. IT) - Overdose - Labeling errors
1169
What is required labeling for vincristine to prevent IT use?
“FOR IV USE ONLY – FATAL IF GIVEN INTRATHECALLY”
1170
What systems are in place to reduce chemo-related errors?
- Barcode scanning - Smart pumps - Standardized order sets
1171
What are examples of smart infusion pump features?
- Dose error reduction software - Drug libraries - Alerts for incorrect rates
1172
What is the ASCO/ONS chemotherapy safety standard for verification?
- Two-person, independent verification at multiple stages
1173
What is the minimum interval required between training and chemo administration by nurses?
Annual competency validation
1174
What is the purpose of nursing certification in oncology (e.g., OCN)?
- Ensure specialized knowledge - Improve safety and patient outcomes
1175
What are common topics in oncology nursing education?
- Drug mechanisms - Safe handling - Toxicity management - Communication skills
1176
What are common patient education points before chemo?
- Side effects to expect - When to call the provider - Supportive care meds - Handling body fluids
1177
What is included in safe home disposal instructions for oral chemo?
- Do not crush/split - Store in original container - Return unused meds to oncology pharmacy
1178
What is the recommended storage for oral chemotherapy at home?
- Away from children and pets - Dry, cool location - Original container
1179
What are patient education strategies for adherence?
- Pill boxes - Reminder systems - Involving caregivers
1180
What counseling is provided for reproductive risks of chemo?
- Contraception use during and after treatment - Risk of birth defects - Sperm or egg preservation options
1181
What are barriers to patient adherence with chemotherapy?
- Side effects - Financial cost - Complexity of regimen - Poor understanding
1182
What patient assistance programs help with chemotherapy costs?
- Manufacturer copay cards - Foundation grants - Hospital financial support
1183
What is the role of patient navigators in oncology?
- Help patients with appointments, logistics, insurance, education
1184
What is the impact of multidisciplinary care on chemotherapy outcomes?
- Improves coordination - Reduces errors - Enhances patient satisfaction
1185
What are key components of survivorship care post-chemotherapy?
- Monitoring for recurrence - Managing late effects - Psychosocial support - Health promotion
1186
What are late effects of chemotherapy?
- Infertility - Cardiac dysfunction - Neurocognitive impairment - Second malignancies
1187
What cancer types are at highest risk of chemo-related secondary malignancy?
- Hodgkin lymphoma - Pediatric ALL - Testicular cancer survivors
1188
What agents are most associated with secondary malignancies?
- Alkylators - Etoposide - Anthracyclines
1189
What is a survivorship care plan?
- Summary of diagnosis, treatment, follow-up plan - Includes late effect screening and health tips
1190
What specialties are involved in survivorship care?
- Oncology - Primary care - Cardiology - Endocrinology - Fertility specialists
1191
What are psychosocial effects post-chemotherapy?
- Anxiety - Depression - Fear of recurrence - Body image issues
1192
What assessments screen for depression in cancer patients?
- PHQ-9 - HADS (Hospital Anxiety and Depression Scale)
1193
What is the role of social work in cancer care?
- Counseling - Resource connection - Advance care planning
1194
What spiritual concerns might arise in cancer patients?
- Meaning of illness - End-of-life fears - Faith-based decision-making
1195
What is integrative oncology?
- Combines conventional and complementary therapies - Examples: acupuncture, mindfulness, nutrition
1196
What are safety concerns with complementary therapies?
- Herb-drug interactions - Delays in standard care - Lack of regulation
1197
What is the use of acupuncture in cancer care?
- Manage nausea - Relieve pain - Reduce anxiety
1198
What is mindfulness-based stress reduction (MBSR)?
- Meditation technique to reduce stress and anxiety in cancer patients
1199
What diet recommendations are common post-chemotherapy?
- Plant-based diet - Low red/processed meat - Avoid alcohol - Maintain healthy weight
1200
What vaccines are safe in post-chemotherapy patients?
- Inactivated vaccines (e.g., flu shot) - Avoid live vaccines until immune recovery
1201
What are common side effects of cyclophosphamide?
- Hemorrhagic cystitis - Myelosuppression - SIADH - Infertility
1202
What drug is used to prevent cyclophosphamide-induced cystitis?
- Mesna - IV hydration
1203
What is a rare but serious side effect of ifosfamide?
Encephalopathy
1204
How is ifosfamide neurotoxicity managed?
Methylene blue
1205
What lab monitoring is required with high-dose methotrexate?
- Serum creatinine - Methotrexate levels - Urine pH
1206
What prevents renal toxicity from high-dose methotrexate?
- Alkalinization of urine (NaHCO₃) - Hydration - Leucovorin rescue
1207
What is leucovorin rescue?
Reduced folate used to rescue normal cells after methotrexate
1208
When is glucarpidase used?
Toxic methotrexate levels with renal dysfunction
1209
What delays methotrexate clearance?
- NSAIDs - PPIs - Penicillins - Dehydration
1210
What are hand-foot syndrome–associated drugs?
- Capecitabine - 5-FU - Liposomal doxorubicin
1211
How is hand-foot syndrome managed?
- Dose reduction/interruption - Emollients - Avoid heat/friction - Pyridoxine (limited evidence)
1212
What agent causes delayed diarrhea?
Irinotecan (via SN-38 metabolite)
1213
How is irinotecan diarrhea prevented?
- Early-onset: atropine - Late-onset: loperamide
1214
What gene polymorphism affects irinotecan toxicity?
UGT1A1*28 (reduced clearance of SN-38)
1215
What side effects are associated with cytarabine?
- Cerebellar toxicity (high dose) - Conjunctivitis - Myelosuppression
1216
How is cytarabine-induced conjunctivitis prevented?
Steroid eye drops (e.g., dexamethasone)
1217
What are signs of cerebellar toxicity from cytarabine?
- Ataxia - Dysarthria - Nystagmus - Confusion
1218
What monitoring is required for high-dose cytarabine?
Neurologic checks (baseline and ongoing)
1219
What are major side effects of bleomycin?
- Pulmonary fibrosis - Hypersensitivity - Skin toxicity
1220
What cumulative dose of bleomycin increases lung toxicity risk?
>400 units
1221
What is the bleomycin test dose?
- Initial small dose to assess for hypersensitivity - Optional, not routinely used
1222
What imaging is used to monitor for bleomycin lung toxicity?
- Chest X-ray - Pulmonary function tests (PFTs)
1223
What risk factors increase bleomycin lung toxicity?
- Age >70 - Renal dysfunction - Prior lung disease - High oxygen exposure
1224
What are side effects of anthracyclines?
- Cardiotoxicity - Mucositis - Myelosuppression - Alopecia
1225
What is the mechanism of anthracycline cardiotoxicity?
- Free radical formation - Iron-mediated damage
1226
What baseline test is required before anthracyclines?
Echocardiogram (EF assessment)
1227
What drug reduces anthracycline cardiotoxicity?
Dexrazoxane
1228
What is the difference between acute and chronic anthracycline cardiotoxicity?
- Acute: arrhythmias, pericarditis (reversible) - Chronic: cardiomyopathy (irreversible)
1229
What is the max lifetime dose of doxorubicin?
450–550 mg/m²
1230
What are symptoms of doxorubicin extravasation?
- Redness - Pain - Necrosis
1231
What is the treatment for anthracycline extravasation?
- Cold compress - Dexrazoxane IV
1232
What is the difference between conventional and liposomal doxorubicin?
- Liposomal: lower cardiotoxicity, slower clearance
1233
What is the unique side effect of liposomal doxorubicin?
Hand-foot syndrome
1234
What is the purpose of non-DEHP tubing for some chemo drugs?
Prevent drug leaching and adsorption
1235
What chemo agents require non-DEHP tubing?
- Paclitaxel - Etoposide
1236
Why is paclitaxel administered before platinum agents?
Prevents increased hematologic toxicity
1237
What is the cause of paclitaxel hypersensitivity?
Cremophor EL (solvent)
1238
How are paclitaxel reactions prevented?
- Premedication: dexamethasone, diphenhydramine, H2-blocker
1239
What are common toxicities of docetaxel?
- Fluid retention - Myelosuppression - Nail changes
1240
How is docetaxel-associated fluid retention prevented?
Dexamethasone premedication
1241
What is a unique toxicity of oxaliplatin?
Cold-induced peripheral neuropathy
1242
What should patients avoid during oxaliplatin therapy?
- Cold drinks - Cold air exposure
1243
What causes ototoxicity among chemo agents?
Cisplatin (especially at high doses)
1244
What is monitored to detect cisplatin-induced nephrotoxicity?
- Serum creatinine - Magnesium and potassium
1245
What chemo causes electrolyte wasting?
Cisplatin (Mg, K)
1246
What is amifostine and its indication?
- Cytoprotective agent - Reduces nephrotoxicity from cisplatin
1247
What chemo causes seizures as a known toxicity?
- High-dose busulfan - Ifosfamide (encephalopathy)
1248
What drug requires prophylaxis with levetiracetam or phenytoin?
High-dose busulfan
1249
What chemo causes hemolytic uremic syndrome (HUS)?
Mitomycin C
1250
What is monitored for mitomycin C toxicity?
- Hemoglobin - Platelets - Creatinine - LDH
1251
What organ is primarily responsible for metabolizing most chemotherapy agents?
Liver (via cytochrome P450 enzymes)
1252
What is the role of CYP3A4 in chemotherapy?
- Metabolizes many chemo drugs (e.g., cyclophosphamide, vincristine, paclitaxel) - Subject to drug interactions
1253
What drugs inhibit CYP3A4 and may increase chemo toxicity?
- Azole antifungals - Macrolide antibiotics - Grapefruit juice - Protease inhibitors
1254
What drugs induce CYP3A4 and may reduce chemo efficacy?
- Rifampin - Phenytoin - Carbamazepine - St. John’s Wort
1255
What is the role of pharmacogenomics in chemotherapy?
- Predicts response/toxicity based on genetic variations - Helps personalize treatment
1256
What gene variant increases risk of 5-FU toxicity?
DPD deficiency (dihydropyrimidine dehydrogenase)
1257
What test can detect risk for 5-FU/capecitabine toxicity?
DPD genotyping or phenotyping
1258
What gene impacts irinotecan metabolism?
UGT1A1*28 polymorphism
1259
What enzyme deficiency increases thiopurine toxicity risk?
TPMT (thiopurine methyltransferase) deficiency
1260
What chemo agents are affected by TPMT testing?
- Mercaptopurine - Azathioprine - Thioguanine
1261
What is the importance of pharmacokinetic (PK) monitoring?
- Ensures therapeutic drug levels - Avoids toxicity or underdosing
1262
What chemo drug is most commonly monitored via levels?
Methotrexate (especially high dose)
1263
What conditions warrant altered chemo pharmacokinetics?
- Renal or hepatic impairment - Obesity - Cachexia
1264
What is the effect of hypoalbuminemia on chemotherapy?
- Increases free drug levels - Potential for higher toxicity (esp. for protein-bound drugs like paclitaxel)
1265
What are vesicants in chemotherapy?
Drugs that can cause severe tissue damage if extravasated
1266
What are examples of vesicant agents?
- Anthracyclines - Vinca alkaloids - Mitomycin C - Dactinomycin
1267
What chemo drugs are considered irritants?
- Cisplatin - Etoposide - Carboplatin (at high doses)
1268
What is the first response to suspected extravasation?
- Stop infusion - Leave needle in place - Aspirate residual drug
1269
What compress is used for vinca alkaloid extravasation?
Warm compress
1270
What compress is used for anthracycline extravasation?
Cold compress
1271
What drug is the antidote for anthracycline extravasation?
Dexrazoxane (IV within 6 hours)
1272
What drug is the antidote for vinca alkaloid extravasation?
Hyaluronidase (subcutaneous around site)
1273
What preventative measures reduce extravasation risk?
- Use central line for vesicants - Frequent site monitoring - Staff training
1274
What is the role of sodium thiosulfate in extravasation?
Used for mechlorethamine extravasation
1275
What are common supportive medications during chemotherapy?
- Antiemetics - Growth factors - Antimicrobials - Pain control agents
1276
What antiemetics are used for highly emetogenic chemotherapy?
- 5-HT3 antagonist - NK1 antagonist - Dexamethasone - +/- Olanzapine
1277
What is the mechanism of ondansetron?
- 5-HT3 receptor antagonist - Blocks serotonin in GI tract and CNS
1278
What is the mechanism of aprepitant?
- NK1 receptor antagonist - Blocks substance P–mediated nausea
1279
What class of drugs is used for delayed nausea?
- NK1 receptor antagonists - Steroids
1280
What are common side effects of 5-HT3 antagonists?
- Headache - Constipation - QT prolongation
1281
What is the role of filgrastim in chemotherapy?
- G-CSF that promotes neutrophil recovery - Prevents febrile neutropenia
1282
What is pegfilgrastim and how does it differ from filgrastim?
- Long-acting G-CSF - Single-dose vs. daily filgrastim
1283
When is growth factor support indicated?
- Regimens with ≥20% febrile neutropenia risk - Patient risk factors (age, comorbidities)
1284
What is erythropoietin-stimulating agent (ESA) role in chemo?
- Used for anemia in palliative chemo only - Not for curative intent
1285
What are risks of ESAs in cancer patients?
- Increased thromboembolism - Shortened survival - Tumor progression
1286
What is neutropenic fever and its diagnostic criteria?
- Temp ≥38.3°C once or ≥38.0°C for ≥1 hour - ANC <500/mm³
1287
What is the empiric treatment for febrile neutropenia?
Broad-spectrum IV antibiotics (e.g., cefepime, meropenem)
1288
When are antifungals added in febrile neutropenia?
- Persistent fever after 4–7 days of antibiotics - High-risk patients
1289
What is tumor lysis syndrome (TLS)?
- Rapid tumor cell death → electrolyte abnormalities → AKI, arrhythmia
1290
What labs are elevated in TLS?
- Potassium - Phosphate - Uric acid - LDH
1291
What are risk factors for TLS?
- High tumor burden - High proliferation rate - Chemo-sensitive tumors - Preexisting renal dysfunction
1292
What are prevention strategies for TLS?
- Aggressive hydration - Allopurinol - Rasburicase (high risk)
1293
How does rasburicase work?
Converts uric acid to allantoin (more soluble)
1294
What are contraindications to rasburicase?
G6PD deficiency (risk of hemolysis)
1295
What is allopurinol’s role in TLS prevention?
- Inhibits xanthine oxidase - Prevents uric acid formation
1296
What are signs of spinal cord compression in cancer patients?
- Back pain - Motor weakness - Bowel/bladder dysfunction
1297
What is the first-line treatment for spinal cord compression?
High-dose corticosteroids (e.g., dexamethasone)
1298
What imaging is used to diagnose spinal cord compression?
MRI of spine
1299
What is the role of palliative radiation in oncology?
Symptom control (e.g., pain, bleeding, obstruction)
1300
What are common chemo-induced emergencies?
- Febrile neutropenia - Tumor lysis syndrome - Spinal cord compression - Hypercalcemia of malignancy
1301
What are the symptoms of hypercalcemia of malignancy?
- Nausea - Constipation - Confusion - Polyuria - Lethargy
1302
What cancers most commonly cause hypercalcemia of malignancy?
- Breast cancer - Lung cancer - Multiple myeloma
1303
What is the mechanism of hypercalcemia in cancer?
- PTHrP production - Bone metastases - Vitamin D secretion by lymphoma
1304
What is the initial treatment for hypercalcemia of malignancy?
- Aggressive IV hydration - Loop diuretics (after hydration)
1305
What drugs are used to treat hypercalcemia of malignancy?
- Bisphosphonates (e.g., zoledronic acid) - Denosumab - Calcitonin (short-term)
1306
How long does it take for bisphosphonates to lower calcium?
2–4 days
1307
What is the fastest acting agent for hypercalcemia?
Calcitonin (onset within hours)
1308
What are adverse effects of zoledronic acid?
- Hypocalcemia - Renal toxicity - Osteonecrosis of the jaw
1309
What labs should be checked before zoledronic acid?
- Creatinine - Calcium - Vitamin D
1310
What is SIADH in cancer?
Paraneoplastic syndrome causing water retention and hyponatremia
1311
What cancers are associated with SIADH?
- Small cell lung cancer - Head and neck cancers
1312
What are symptoms of SIADH?
- Confusion - Seizures - Headache - Nausea
1313
How is SIADH managed in cancer patients?
- Fluid restriction - Salt tablets - Loop diuretics - Vasopressin antagonists (e.g., tolvaptan)
1314
What is the danger of correcting sodium too quickly in SIADH?
Central pontine myelinolysis (osmotic demyelination)
1315
What chemo drugs can cause SIADH?
- Cyclophosphamide - Vincristine - Cisplatin
1316
What is cancer-associated thrombosis (CAT)?
Venous thromboembolism (VTE) due to cancer-related hypercoagulability
1317
What are risk factors for CAT?
- Active malignancy - Chemo - Central venous catheters - Surgery
1318
What is the preferred anticoagulant for CAT?
Low molecular weight heparin (LMWH) or DOACs (e.g., apixaban)
1319
When is warfarin avoided in CAT?
- Drug interactions - Dietary variability - Delayed onset
1320
What is the risk of DOACs in GI cancers?
Increased bleeding risk
1321
What duration of anticoagulation is typical for CAT?
- At least 6 months - Indefinite if cancer remains active
1322
What is chemotherapy scheduling based on?
- Tumor type - Drug half-life - Toxicity profile - Bone marrow recovery
1323
What is dose intensity?
Amount of drug administered per unit of time
1324
What is relative dose intensity (RDI)?
Actual dose intensity divided by planned dose intensity
1325
What RDI is typically targeted in curative regimens?
≥85–90%
1326
What is dose-limiting toxicity (DLT)?
Adverse effect preventing dose escalation or continuation
1327
What are common DLTs in chemotherapy?
- Neutropenia - Mucositis - Neuropathy
1328
What is maximum tolerated dose (MTD)?
Highest dose with acceptable level of toxicity
1329
What is a dose reduction protocol?
Predefined adjustments based on toxicity grading
1330
What grading system is used for chemo toxicity?
CTCAE (Common Terminology Criteria for Adverse Events)
1331
What is grade 3 vs. grade 4 toxicity in CTCAE?
- Grade 3: severe - Grade 4: life-threatening
1332
When are chemo delays indicated?
- Inadequate recovery (e.g., ANC, platelets) - Severe toxicity
1333
What are risks of frequent chemo delays?
- Reduced efficacy - Lower relative dose intensity
1334
What is nadir in chemotherapy?
Lowest point of blood cell counts, typically 7–14 days post-chemo
1335
What are indicators to resume chemo after delay?
- ANC > 1500/mm³ - Platelets > 100,000/mm³ - Resolution of toxicities to ≤ grade 1
1336
What is empiric dose reduction strategy in older adults?
- Start at 75–80% of full dose - Escalate as tolerated
1337
What factors guide dose adjustment in renal dysfunction?
- Creatinine clearance - Drug-specific renal metabolism
1338
What agents require renal dose adjustment?
- Cisplatin - Carboplatin - Methotrexate - Capecitabine
1339
What equation is commonly used to estimate CrCl in cancer patients?
Cockcroft-Gault equation
1340
What weight should be used in CrCl calculation for obese patients?
Adjusted body weight (ABW)
1341
What is hepatic dose adjustment based on?
- Bilirubin - AST/ALT - Drug metabolism pathway
1342
What chemo drugs require hepatic dose modification?
- Irinotecan - Paclitaxel - Anthracyclines
1343
What is the role of therapeutic drug monitoring (TDM) in oncology?
Adjust dosing based on drug levels (e.g., methotrexate, busulfan)
1344
What is the therapeutic range for methotrexate 24-hour levels?
Varies by dose, but typically <10 µM by 24 hours
1345
When is leucovorin discontinued in high-dose methotrexate therapy?
When methotrexate levels are <0.05–0.1 µM
1346
What is the purpose of pharmacokinetic-guided busulfan dosing?
Achieve target AUC for efficacy and reduced toxicity
1347
What toxicities are associated with high busulfan exposure?
- Seizures - Veno-occlusive disease - Pulmonary fibrosis
1348
What chemo drugs have non-linear pharmacokinetics?
- Methotrexate - Paclitaxel - Etoposide
1349
What is the implication of non-linear kinetics?
Small dose changes may lead to large concentration changes
1350
What is flat dosing in chemotherapy?
Fixed dose regardless of BSA (e.g., carboplatin via AUC, pembrolizumab 200 mg)
1351
What is a liposomal formulation of chemotherapy?
- Drug encapsulated in lipid bilayers - Improves distribution - Reduces toxicity (e.g., liposomal doxorubicin)
1352
What are benefits of liposomal chemo formulations?
- Prolonged circulation - Reduced cardiotoxicity - Enhanced tumor uptake
1353
What are common toxicities of liposomal doxorubicin?
- Hand-foot syndrome - Mucositis - Less alopecia and cardiotoxicity than standard form
1354
What is pegylation and its impact on chemotherapy?
- Attachment of polyethylene glycol (PEG) - Increases half-life - Decreases immunogenicity
1355
What are examples of pegylated chemotherapy agents?
- Pegaspargase - Pegfilgrastim
1356
What is the Onpro device?
- On-body injector for pegfilgrastim - Delivers dose 27 hours after chemo
1357
What is an Ommaya reservoir and when is it used?
- Implanted intraventricular port - Used for repeated intrathecal chemotherapy delivery
1358
What are risks of Ommaya reservoir use?
- Infection - Hemorrhage - Obstruction
1359
What is HIPEC in cancer therapy?
- Hyperthermic Intraperitoneal Chemotherapy - Heated chemo applied during surgery to abdominal cavity
1360
What cancers are treated with HIPEC?
- Peritoneal mesothelioma - Ovarian cancer - Appendiceal and colorectal cancers
1361
What is TACE in oncology?
- Transarterial Chemoembolization - Delivers chemo to liver tumor via hepatic artery + embolization
1362
What is a drug-eluting bead?
- Microsphere loaded with chemo (e.g., doxorubicin) - Slowly releases drug after TACE
1363
What is the goal of chemoembolization?
- Maximize tumor exposure - Minimize systemic toxicity
1364
What are potential complications of TACE?
- Post-embolization syndrome (pain, fever, nausea) - Liver dysfunction
1365
What is a clinical trial phase I?
- First-in-human - Evaluates safety, dose, and pharmacokinetics
1366
What is the purpose of a phase II clinical trial?
- Assesses efficacy in a specific cancer - Further safety evaluation
1367
What is a phase III clinical trial?
- Compares new therapy to standard of care - Large-scale efficacy and safety data
1368
What is a phase IV clinical trial?
- Post-marketing surveillance - Long-term side effects and effectiveness
1369
What is an NCI cooperative group?
- Network conducting federally funded clinical trials - Examples: SWOG, ECOG-ACRIN
1370
What is randomization in clinical trials?
- Assigning patients by chance to treatment groups - Minimizes bias
1371
What is blinding in clinical trials?
- Participants and/or researchers unaware of treatment assignment - Prevents bias
1372
What is a surrogate endpoint in oncology trials?
- A substitute for clinical benefit (e.g., PFS instead of OS)
1373
What is progression-free survival (PFS)?
Time from treatment start until disease progression or death
1374
What is overall survival (OS)?
Time from treatment start to death from any cause
1375
What is an objective response rate (ORR)?
Proportion of patients with partial or complete tumor shrinkage
1376
What is RECIST criteria used for?
Standard for measuring tumor response in solid tumors
1377
What defines a partial response per RECIST?
≥30% decrease in sum of target lesion diameters
1378
What defines progressive disease per RECIST?
≥20% increase in lesion size or new lesions
1379
What is stable disease per RECIST?
Neither sufficient shrinkage for response nor increase for progression
1380
What is tumor burden?
Total volume or size of cancer in the body
1381
What was the first chemotherapy drug?
Mustard gas derivative (mechlorethamine) in 1940s
1382
What cancer was first treated with mechlorethamine?
Lymphoma (Hodgkin’s and non-Hodgkin’s)
1383
What is the significance of the 1965 MOPP regimen?
First curative chemo for advanced Hodgkin lymphoma
1384
What does MOPP stand for?
- Mechlorethamine - Oncovin (vincristine) - Procarbazine - Prednisone
1385
What replaced MOPP as the standard for Hodgkin’s?
ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine)
1386
What is the role of ABVD in Hodgkin lymphoma?
Standard first-line regimen High cure rates
1387
What is R-CHOP used for?
First-line for diffuse large B-cell lymphoma (DLBCL)
1388
What does R-CHOP stand for?
- Rituximab - Cyclophosphamide - Doxorubicin (Hydroxydaunorubicin) - Vincristine (Oncovin) - Prednisone
1389
What is the mechanism of rituximab?
- Anti-CD20 monoclonal antibody - Causes B-cell depletion
1390
What chemo agents are derived from natural products?
- Vinca alkaloids (periwinkle) - Taxanes (yew tree) - Anthracyclines (Streptomyces)
1391
What is the significance of paclitaxel (Taxol)?
- First approved taxane - Revolutionized ovarian and breast cancer therapy
1392
What formulation improved paclitaxel safety?
Albumin-bound paclitaxel (nab-paclitaxel) – avoids Cremophor
1393
What is the source of anthracyclines?
Produced by Streptomyces peucetius bacteria
1394
What is the historical role of methotrexate in oncology?
- First chemo to induce remission in leukemia - Pivotal in choriocarcinoma treatment
1395
What is the mechanism of methotrexate?
- Inhibits dihydrofolate reductase - Blocks DNA synthesis
1396
What were early side effects of nitrogen mustard therapy?
- Bone marrow suppression - Nausea - Infections
1397
What is combination chemotherapy?
Use of multiple agents to improve efficacy and reduce resistance
1398
What principles guide combination chemo design?
- Different mechanisms - Non-overlapping toxicities - Schedule synergy
1399
What is adjuvant chemotherapy?
Given after surgery to eliminate micrometastatic disease
1400
What is neoadjuvant chemotherapy?
Given before surgery to shrink tumors and improve resectability
1401
What is the most common formula used to calculate BSA in oncology?
Mosteller formula: BSA (m²) = sqrt((height[cm] × weight[kg]) / 3600)
1402
Why is BSA used to dose chemotherapy?
- Correlates with metabolic rate and drug clearance - Standardized approach to dosing
1403
What are limitations of BSA-based dosing?
- Doesn’t account for organ function - May under- or overdose obese or cachectic patients
1404
What is flat dosing and when is it used in chemotherapy?
- Fixed dose regardless of BSA - Used with monoclonal antibodies and some targeted agents
1405
What chemo drugs are commonly flat dosed?
- Pembrolizumab (200 mg) - Nivolumab (240 mg or 480 mg) - Carboplatin (by AUC not BSA)
1406
What is dose banding in chemotherapy?
- Rounding doses to pre-defined bands - Simplifies prep and reduces waste
1407
What is dose capping and when is it used?
- Upper dose limit to reduce toxicity - Used in obese patients or for specific drugs (e.g., vincristine max 2 mg)
1408
Should chemotherapy doses be reduced for obesity?
ASCO recommends full weight-based dosing unless contraindicated
1409
What is adjusted body weight (ABW) and when is it used?
For renal dosing in obesity ABW = IBW + 0.4 × (Actual - IBW)
1410
Why is pharmacokinetics altered in obese patients?
- Increased fat mass - Altered volume of distribution and clearance
1411
What considerations apply for chemo in pediatric patients?
- Often dosed per body weight (mg/kg) in infants - BSA used in older children - Immature organ systems impact PK/PD
1412
What are common pediatric chemo toxicities?
- Growth suppression - Neurocognitive delay - Secondary malignancy
1413
What monitoring is unique for pediatric oncology?
- Growth charts - Developmental assessments - Fertility preservation
1414
What is the role of clinical trials in pediatric oncology?
- Majority of patients enrolled in cooperative group trials - Critical for advancing treatment
1415
What is the Children’s Oncology Group (COG)?
NCI-supported pediatric cancer research consortium
1416
What special considerations apply to elderly patients receiving chemo?
- Reduced organ reserve - Increased comorbidities - Polypharmacy risk
1417
What tool assesses chemotherapy tolerance in older adults?
Comprehensive Geriatric Assessment (CGA)
1418
What are goals of CGA in oncology?
- Assess function, cognition, nutrition, meds - Predict toxicity and tailor therapy
1419
What chemo toxicities are more severe in elderly?
- Myelosuppression - Neuropathy - Mucositis
1420
What is a common strategy for starting chemo in elderly patients?
Start at reduced dose and titrate as tolerated
1421
What are criteria for functional age in cancer patients?
- Activities of daily living (ADLs) - Instrumental activities (IADLs) - Performance status (ECOG/Karnofsky)
1422
What is ECOG performance status scale used for?
- Assesses patient function - Guides chemo decisions - Scale from 0 (fully active) to 5 (dead)
1423
What is Karnofsky Performance Status (KPS)?
- 100 = normal function - ≤60 = needs assistance - Used in older trials and palliative care
1424
What is the impact of chemotherapy on fertility?
- May cause infertility - Risk varies by age, drug, dose
1425
What are fertility preservation options before chemo?
- Sperm banking - Oocyte or embryo cryopreservation - Ovarian suppression (limited evidence)
1426
What cancers are treated with chemo during pregnancy?
- Breast cancer - Lymphoma - Cervical cancer (in select cases)
1427
What trimester is chemotherapy safest in pregnancy?
- Second and third trimesters - Avoid during first trimester (organogenesis)
1428
What chemo drugs are relatively safe in pregnancy?
- Cyclophosphamide - Doxorubicin - Paclitaxel (later trimesters)
1429
What chemo agents are contraindicated in pregnancy?
- Methotrexate - Lenalidomide - Vinca alkaloids (caution)
1430
What supportive meds are safe in pregnancy?
- Antiemetics (ondansetron, metoclopramide) - Low-dose steroids - G-CSF (limited data)
1431
What fetal risks are associated with chemo during pregnancy?
- Growth restriction - Preterm birth - Low birth weight - Possible neurodevelopmental impact
1432
What imaging is used to monitor fetus during maternal chemo?
- Ultrasound - Fetal echocardiography
1433
Can breastfeeding continue during chemotherapy?
No – most chemo agents are excreted in breast milk
1434
When is delivery timed around chemotherapy?
- At least 3 weeks after last cycle - Avoid neutropenia at delivery
1435
What specialists should be involved in pregnant cancer patients’ care?
- Medical oncologist - Maternal-fetal medicine - Neonatologist - Pharmacist
1436
What are ethical considerations in treating pregnant cancer patients?
- Balancing maternal benefit vs fetal risk - Informed consent - Respect for autonomy
1437
What is a pregnancy registry in oncology?
- Tracks outcomes in pregnant patients exposed to chemo - Supports safer treatment guidelines
1438
What are long-term monitoring needs for children exposed in utero to chemo?
- Growth and development - Neurocognitive testing - Cardiac monitoring
1439
What is teratogenicity?
Potential of a drug to cause birth defects during fetal development
1440
What agency classifies drugs by pregnancy risk?
FDA (previous categories A–X, now narrative format)
1441
What is the Pregnancy and Lactation Labeling Rule (PLLR)?
FDA rule replacing letter categories with narrative risk summaries
1442
What sections are included in PLLR labels?
- Pregnancy - Lactation - Females and Males of Reproductive Potential
1443
What is the role of pharmacists in chemo for special populations?
- Dose adjustments - Drug safety reviews - Counseling on reproductive risks
1444
What are common med errors in pediatric oncology?
- Decimal errors - Incorrect formulations - Weight-based miscalculations
1445
What is the role of oncology social workers for pregnant or young patients?
- Fertility support - Resource coordination - Psychosocial care
1446
How are adolescents and young adults (AYAs) defined in oncology?
Typically ages 15–39 Unique psychosocial and fertility challenges
1447
What cancers are most common in AYA populations?
- Hodgkin lymphoma - Melanoma - Testicular cancer - Sarcomas
1448
What are survivorship concerns for AYA cancer survivors?
- Fertility - Employment - Insurance - Secondary malignancies
1449
What AYA-specific cancer programs exist?
- Fertility preservation programs - Peer support groups - Dedicated AYA oncology clinics
1450
What is the benefit of multidisciplinary care for special populations?
- Integrates medical, psychosocial, and reproductive needs - Improves outcomes and quality of life
1451
What are the main risks associated with chemotherapy compounding?
- Exposure to hazardous drugs - Cross-contamination - Dosing errors
1452
What is USP <800>?
- United States Pharmacopeia standard for handling hazardous drugs - Aims to protect workers, patients, and the environment
1453
What areas are required under USP <800> for compounding?
- Negative pressure rooms - External venting - Containment primary engineering control (C-PEC)
1454
What is a biological safety cabinet (BSC)?
- A type of C-PEC - Used for preparing hazardous drugs under sterile conditions
1455
What are required PPE elements for compounding chemo per USP <800>?
- Double chemotherapy-rated gloves - Impermeable gown - Head, hair, shoe covers - Respiratory protection if needed
1456
How often must gloves be changed during compounding of hazardous drugs?
- Every 30 minutes - After contamination
1457
What documentation is required for chemo preparation?
- Compounding log - Lot numbers - Expiration dates - Personnel identifiers
1458
How are compounded chemotherapy drugs labeled?
- Drug name and dose - Route - Diluent and volume - Special handling warnings
1459
What labels are required for chemotherapy drugs?
- “Hazardous Drug – Handle with Care” - “Chemotherapy – Dispose of Properly” - Storage instructions
1460
What is the beyond-use date (BUD) of a chemo admixture?
- Depends on drug stability and sterility guidelines - Typically 24 hours refrigerated for most IV admixtures
1461
What are closed-system drug-transfer devices (CSTDs)?
- Prevent aerosol or vapor escape during drug preparation and administration
1462
When are CSTDs required per USP <800>?
- Required during administration - Recommended during compounding
1463
What are spill kits and when must they be available?
- Kits to contain chemo spills - Must be accessible in all compounding and administration areas
1464
What should be done in case of chemotherapy spill?
- Evacuate if needed - Use spill kit - Report and document - Medical evaluation if exposed
1465
How are hazardous drug spills cleaned?
- PPE use - Absorbent materials - Disposal in hazardous waste container
1466
What are examples of hazardous drug disposal requirements?
- Black bins for bulk hazardous waste - Yellow bins for trace chemo - EPA and OSHA guidelines
1467
What is the difference between black and yellow chemo waste bins?
- Black: bulk chemo waste - Yellow: trace amounts (e.g., empty bags, gloves)
1468
What is the protocol for accidental needle stick with chemo?
- Wash area - Report immediately - Follow institutional exposure protocol
1469
How is chemo waste from patients handled (e.g., urine, vomit)?
- Use PPE - Designated disposal containers - Follow local infection and hazardous waste protocols
1470
What is the standard for safe home handling of oral chemotherapy?
- Wash hands before and after - Don’t crush/split - Store away from light and children
1471
How should caregivers handle chemo-contaminated linens at home?
- Wear gloves - Wash separately - Use hot water and detergent
1472
What is the safe period for handling bodily fluids after chemo?
- Typically 48–72 hours post-dose (varies by drug)
1473
What staff training is required for chemo handling per USP <800>?
- Initial and annual competency validation - Includes PPE, spill management, compounding practices
1474
What are the requirements for chemo transport within a facility?
- Sealed in leak-proof, labeled containers - Not hand-carried in open areas - Secure, covered carts
1475
What is required for chemo storage in pharmacies?
- Designated area - Ventilated negative pressure for HDs - Clearly labeled and segregated
1476
How is drug integrity ensured during chemo storage and transport?
- Temp monitoring - Tamper-evident packaging - Secure containers
1477
What are NIOSH categories of HDs?
- Antineoplastics - Non-antineoplastics with toxicity - Reproductive risk-only drugs
1478
What drugs are NIOSH-designated HDs based on carcinogenicity?
- Cyclophosphamide - Etoposide - Melphalan
1479
How are new drugs evaluated for hazardous classification?
- Reviewed for carcinogenicity, teratogenicity, reproductive toxicity, organ damage
1480
What is an SDS and why is it important in chemo safety?
- Safety Data Sheet - Contains drug hazard information, handling, spill response
1481
What chemo-specific information is found on an SDS?
- PPE recommendations - Exposure symptoms - Emergency procedures
1482
What PPE is worn when administering IV chemotherapy?
- Double gloves - Impermeable gown - Eye/face protection if splashing is possible
1483
What is required PPE for administering oral chemotherapy?
- Single chemo-rated gloves - Gown if risk of powder/dust
1484
How is oral chemo administered in the hospital?
- Handled with gloves - Given in original packaging - Documented in MAR
1485
What is the responsibility of nurses in preventing chemo errors?
- Double-checking orders - Verifying patient identity - Monitoring for reactions
1486
What is a chemotherapy time-out?
- Final verification before administration - Confirms drug, dose, route, patient
1487
How are chemotherapy errors reported?
- Through institution’s error reporting system - May involve root cause analysis
1488
What is Just Culture in medication safety?
- Encourages error reporting without fear of punishment - Focuses on systems improvement
1489
What is ISMP’s role in chemotherapy safety?
- Provides error prevention guidelines - Advocates for standardization and education
1490
What is the ASCO/ONS chemotherapy administration standard?
- Minimum of two RN checks - Standardized education - Protocol adherence
1491
What are common chemo error types?
- Wrong dose - Wrong drug - Wrong route - Timing errors
1492
What are best practices to prevent chemo compounding errors?
- Barcode scanning - Independent verification - Limiting distractions
1493
What is look-alike/sound-alike drug confusion in oncology?
- Vincristine vs. vinblastine - Doxorubicin vs. daunorubicin
1494
How is extravasation risk minimized?
- Central line use for vesicants - Staff training - Prompt intervention
1495
What is done when a chemo infusion is interrupted (e.g., line occlusion)?
- Stop pump - Assess line and site - Document time and reason - Restart if appropriate
1496
What are considerations for chemo in home infusion settings?
- Trained personnel - Emergency access plan - Safe disposal supplies
1497
What is a chemotherapy roadmap?
- Patient-friendly treatment calendar - Outlines drugs, labs, visits, and goals
1498
What is the role of electronic order entry (CPOE) in chemo safety?
- Reduces transcription errors - Ensures standard order sets - Supports alerts and dose checks
1499
What should be documented during chemo administration?
- Start and stop time - Dose given - Adverse events - Patient status
1500
What are key performance indicators for oncology pharmacy quality?
- Error rates - Turnaround time - Compliance with protocols - Staff training completion

BCOP (4 decks)

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