Immune system and Malignancy Flashcards by Tyla Keepin

What type of vaccines should be avoided in immunocompromised patients?

live

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Examples of live vaccines

Measles, mumps, rubella (MMR combined vaccine)
Rotavirus
Smallpox
Chickenpox
Yellow fever
Nasal flu vaccine

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What are immunosuppressants used for?

Suppress the immune system and chronic inflamation.

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Examples of anti proliferative drugs?

azathioprine, mercaptopurine, mycophenolate

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Examples of calcineurin inhibitors

tacrolimus, ciclosporin

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What drugs are used in IBD?

Azathioprine, mercaptopurine, ciclosporin, methotrexate, corticosteroids

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Azathioprine- MoA

blocks purine synthesis needed for DNA/RNA/protein synthesis

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Azathioprine- side effects

blood disorders (leucopenia, thrombocytopenia, anaemia)
Pancreatitis
hypersensitivity
Nausea- take with food

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Azathioprine- monitoring (pre-screening and general)

pre screening- TMPT testing
general - FBC (weekly for 4/8 weeks, then 3 monthly)

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Azathioprine- counselling

report signs of blood disorders- unexplained bruising or bleeding and infections
If feeling nauseous then take with food

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Azathioprine- interactions

ALLOPURINOL (azathioprine is metabolised by xanthines, allopurinol is a xanthine inhibitor)
- ACEi- increases risk of anaemia
- Trimethoprim- haem toxicity
- warfarin- decreases anticoagulant effect

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How to deal with con-current use of azathioprine and allopurinol?

reduce to 1/4 of normal dose

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Mycophenolate- MoA

blocks guanosine synthesis (purine) needed for DNA synthesis

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Mycophenolate- side effects

blood disorders
hypogammaglobinemia
bronchiectasis, pulmonary fibrosis
GI effects (bleeding)
increases risk of skin cancer

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Mycophenolate- counselling

report signs of infection/bleeding
report any new and persistent cough and SOB
avoid excessive exposure to sunlight

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Mycophenolate- Cautions

recurrent infection
increased serum iG
persistent respiratory symptoms (cough,SOB)
Serious active GI disease- e.g. Ulcerative Colitis

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Mycophenolate- Cautions

recurrent infection, increased serum iG

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Mycophenolate- contraception requirements (women)

Women:
2 pregnancy tests before treatment
(8-10 days apart)
effective contraception until 6 weeks after stopping
must be part of the PPP

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Mycophenolate- contraception requirements (men)

effective contraception until 90 after stopping

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Tacrolimus- MoA

Calcineurin inhibitor (calcineurin activates T cells)

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Tacrolimus- S/E

Blood disorders
Cardiomyopathy
nephrotoxicity
photosensitivity
HYPOKALAEMIA, Increased Glucose and urea

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Tacrolimus- monitoring

Echo- hypertrophic changes (heart muscle becomes enlarged)

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Tacrolimus- counselling

avoid excess UV exposure
blood disorders
report any palpitations, SOB, chest pain (hyperK)

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Tacrolimus and ciclosporin- interactions

Enz inhibitors (toxicity)
Enz inducers
Nephrotoxic drugs- aminoglycosides, glycopeptides, Ciclosporin, methotrexate, NSAIDs
Hyperkalaemia- ACE/ARB, K-sparing, MRA, NSAID, Trimethoprim. Heparin

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Tacrolimus- MHRA advice

brand continuity

Tacrolimus/sirolimus- what ethnicity may require an increased dose?

black African or African–Caribbean

Tacrolimus- monitoring

Whole-blood tacrolimus trough concentration ECG BP Fasting blood glucose (causes increased glucose) FBC U&Es (creatinine)

Tacrolimus- contraception

exclude before treatment

Ciclosporin- MoA

calcineurin inhibitor

Ciclosporin- S/E

Eye inflammation/visual disturbances gingival hyperplasia nephrotoxicity hyperkalaemia

Ciclosporin- what food/drinks should be avoided

pomelo and grapefruit juice- enz inhibitor purple grape juice- enz inducer

Ciclosporin- monitoring

U&Es- potassium and magnesium (exam q- hyperkalaemia and hypomagnesaemia) LFT- concurrent NSAIDS FBC lipids- before and 1 month after BP- discontinue if uncontrolled

Why are cytotoxic treatments used

curative, prolong life and palliate symptoms

When can cytotoxics be used?

Neoadjuvant- before surgery or chemotherapy to shrink tumour adjuvant- added to radiotherapy/surgery to maximise treatment effects

ADV/DISADV of 1 or more cytotoxic

ADV- reduces drug resistance, increased survival rate DISADV- toxicity (increased supression)

Handling of cytotoxics (azathioprine, mercaptopurine, IV cytotoxics, finasteride)

- pregnant staff should avoid - dedicated area of pharmacy - trained staff - spills and waste disposal procedure in place - protective gear should be worn -staff exposure should be monitored

What is required for the prescribing, dispensing and administration of cytotoxic drugs?

a written protocol or treatment plan

What cytotoxics commonly cause: VTE

Tamoxifen, thalidomide, linadmonide, pomalidomide

What cytotoxics can cause: endometrial cancer

tamoxifen

What cytotoxics commonly cause: Urethral toxicity

Cyclophosphamide, infosfamide (exam q) TREAT WITH MESNA

What cytotoxics commonly cause: extravasation

vinca alkaloids, anthracyclines

What cytotoxics commonly cause: infertility in men

alkalating drugs and procarbozine

What are the 2 cytotoxics that do not cause bone marrow supression?

vincristine and bleomycin

What cytotoxics commonly cause: oral mucocytis

fluorouracil, methotrexate, anthracyclines

Bone marrow suppression: treatment of fever and neutropenia

figrastim

Bone marrow suppression: treatment of symptomatic iron deficiency anaemia

RBC transfusion erythropoetin

Hyperuricaemia (common in lymphoma and leukaemia): Treatment

allopurinol (24hours before chemo) febuxostat (2 days before chemo) rasburicase (haem cancers)

N&V Mildly emetogenic

Methotrexate vinca alkaloids flurouracil etoposide

N&V moderate emetogenic

high dose MTX Taxanes Doxorubicin Cyclophosphamide mitoxantrone

N&V Highly emetogenic

Cisplatin Dacarbazine High dose cyclophosphamide

N&V treatment: Anticipatory

lorazepam

N&V treatment: Acute <24 hours

Low risk: Dexamethasone or Lorazepam High risk: Dex+ ondansetron + Aprepitant

N&V treatment: Delayed

mod emetogenic= Dex + 5 HT3 High = Dex and Aprepitatn or Rolapitant and metoclopramide

Vinca Alkaloids- what route should be avoided

intrathecal (neurotoxicity)

Vinca Alkaloids (vincristine side effects)

bronchospasm and neurotoxicity

What is given for the treatment of methotrexate induced oral mucositis

folinic acid (calium folate)

What form of treatment must be avoided with anthracyclines

radiotherapy

Examples of anthracyclines

Xrubicin doxorubicin, daunorubicin, epirubicin, Idarubicin

Side effects of anthracyclines

red urine and caridotoxicity

Example of an anthracycline derivative

mitoxantrone

examples of alkylating drugs?

Cyclophosphamide, Ifosfamide, melphalan,

Methotrexate- Side effects

Blood disorders liver toxicity Respiratory effects- pneumonitis (cough (lasting weeks), SOB, weight loss) nephrotoxicity

Methotrexate- monitoring

FBC and renal and LFTs repeated every 1–2 weeks until therapy stabilised, thereafter patients should be monitored every 2–3 months.

What OTC products should be avoided with methotrexate

NSAIDs, aspirin penicillins, PPIs statins most antibiotics TRIMETHOPRIM

what drugs are used in MS?

interferon beta Glatiramer acetate fingolimod (PO, highly active disease) Natalizumab (rapidly evolving severe MS)

what drugs are used in breast cancer?

Early and locally advanced= tamoxifen If patient declines chemotherapy= goserelin Anastrozole and letrozole (Aromatase inhibitors)

What is used in advanced breast cancers

1. endocrine therapy- tamoxifen 3. Aromatase inhibitors (Anastrozole and letrozole & exemestane)