Malignancy Flashcards by Siobhan Doyle

What specific interaction and dose reduction is given to antiproliferative drugs?

Azathioprine and mercaptopurine are reduced to a quarter of usual dose with allopurinol

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What advantages and disadvantages does mycophenolate have compared to azathioprine?

More selective mode of action and reduces risk of acute rejection.
Risk of opportunistic infections or blood disorders may be higher

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How is tolerability to antithymocyte immunoglobulin prevented?

Pre treatment with IV corticosteroid and antihistamine. Paracetamol may be beneficial.

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What enzyme activity to antiproliferative drugs rely on? What risks does low levels create?

TPMT. Myelosuppression.

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What monitoring is required with ciclosporin

Concentration
Liver function
Potassium, magnesium
Lipids
Creatinine, BP and renal

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What advice should be given to patients on ciclosporin?

Maintain same brand. Avoid UV light

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What advice and monitoring is needed with tacrolimus and sirolimus?

Monitor blood concentrations
Avoid UV light
Exclude pregnancy before use and effective contraception needed with sirolimus during and 12 weeks after stopping
BP, ECG, glucose, electrolytes, hepatic and renal function with tacrolimus

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What advice should be given with mycophenolate?

Cough and dyspnoea may suggest bronchiectasis or pulmonary fibrosis. Pregnancy prevention programme - pregnancy tests before treatment, effective contraception up until 6 weeks after stopping. Same for male patients and partners for 90 days after stopping.
Report infection or unexplained bruising/bleeding.

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What are the different patterns of multiple sclerosis? Which don’t have treatment?

Relapsing remitting - relapses and remission periods.
Active if at least 2 relapses in last 2 years.
Highly active if continued relapse rate despite interferon beta
Rapidly evolving severe if 2 or more in 1 year and altered MRI

Primary progressive - gradual worsening
No licensed treatment - interferon beta has been used

Progressive relapsing - gradual worsening with relapses
No treatment

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What vitamin may multiple sclerosis patients be given?

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Which lifestyle choice effects progression of multiple sclerosis?

Smoking

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What is given in multiple sclerosis relapses?

Corticosteroids

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What can be advised and given for fatigue associated with multiple sclerosis?

Advice regular exercise and cognitive techniques
Amantadine
Fampridine

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What can aggregate spasticity in multiple sclerosis and what drugs can be given?

Constipation, infection, poor mobility aids, pressure ulcers,posture and pain.
Baclofen, gabapentin
Tizanidine, dantrolene
Benzodiazepines
Cannabis extract

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What should be monitored with peg interferon beta?

Signs of hepatic injury
Thrombotic microangiopathy - thrombocytopenia, hypertension, fever, CNS symptoms, impaired renal fucction
Nephrotic syndrome - oedema, proteinuria, impaired renal function.

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What monitoring is required with fingolimod?

ECG for monitoring for heart block especially at first dose. Continuous monitoring for 6 hours. Extend if anomalies.

Eye examination
Skin examination
Liver enzymes
FBC
Monitor for signs of haemophagocytic syndrome (pyrexia, asthenia, Hyponatreamia)
MRI

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What is cytokine release syndrome and what drugs can it occur with?

Characterised by severe dyspnoea

Anti lymphocyte monoclonal antibodies

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What side effect requires MRI monitoring for multiple sclerosis medication and which drugs?

Multifocal leucoencephalopathy

Natalizumab, ocrelizumab and fingolimod - monitor for signs of neurological symptoms. Alert card with Natalizumab

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How long after teriflunomide treatment can patients try to conceive?

Contraception used up to 2 years after. Can use excelerated elimination (use non oral contraception in mean time) using colestyramine or activated charcoal. Wait 1.5 months after 20mcg/l conc.

What is often done to prevent infusion related reactions?

Pre medication with corticosteroid, antihistamine and antipyretic.

What antineoplastic drugs can cause sore mouth and what can be done to prevent this?

Chemotherapy, most commonly fluorouracil, methotrexate and anthracyclines. God oral hygiene brushing teeth and rinsing 2-3 times daily. May suck ice chips with fluorouracil.

Should mouthwashes for oral mucositis be saline, antiseptic or antiinflammatory?

saline

Who is at risk of tumour lysis synddrome?

Non-hodgkins lymphoma, especially high grade/bulky, burkitt’s lymphoma, acute myeloid leukemia and occassionally solid tumours. Pre-existing hyperuricaemia, dehydration or renal impairment

What is given in hyperuricaemia

Allopurinol 24 hours before treating tumours, patient should be adequately hydrated. Febuxostat may also be used and needs to start 2 days before cytotoxics. Rasburicase can also be given if haemotological malignancy

Which cytotoxics dont cause bone marrow suppression? In which is it delayed?

vincristine and belomycin | delayed in carmustine, lomustine and melphalan

Alkylating drugs have less effect on fertility than the rest of chemotherapy. True or false.

True, and also procarbazine. But they may cause permanent male sterility.

What stages of nausea and vomiting occurence are there?

Acute - occurs within 24 hours Delayed - first occurs more than 24 hours after Anticipatory - occurs prior to dose

Which patients are more susceptible to nausea and vomiting from chemotherapy?

Under 50 years gold, anxious, motion sickness sufferers, women

State chemotherapy drugs with varying degrees of emetogenicity

Fluorouracil, etopside, methotrexate, vinca alkaloids, abdominal radiotherapy < taxanes, doxorubicin, cyclophosphamide, mitoxantrone, high dose methotrexate < cisplatin, dacarbazine, high dose cyclophosphamide

When is lorazepam used in nausea and vomiting in chemotherapy?

anticipatory symptoms and if low risk of emesis

Besides lorazepam, what other drugs are used for nausea and vomiting from chemotherapy and when?

Dexamethasone - alone for low risk or with others for higher risk 5HT3 receptor antagonists - moderate delayed with dexamethasone or high risk of acute emesis with both (NK1 also) NK1 receptor antagonist arepitant in combo for high risk for delayed or acute. Rolapitant and metoclopramide also licensed for delayed.

Which cytotoxics cause cardiac effects and what can be given instead?

Anthracyclines. Liposomal formulations do exist eg for docorubicin which reduce incidence (but cause more infusion reactions)

A patient is experiencing a burning sensation with urination on chemotherapy, which drugs could be causing, how and what can be given?

Oxazaphosphorines, cyclophosphamide, ifosfamide Urothelial toxicity > haemorrhagic cystitis Mesna May also be prevented by increasing fluid intake in days after dose.

Which drugs should not be mixed with radiotherapy regimes?

Anthracyclines

Which antineoplastics can are most associated with secondary maliganancy?

alkylating drugs

What advice and monitoring is given with methotrexate?

Full blood count, renal and liver function every 1-2 weeks until stabilised, then 2-3 monthly. Bone marrow suppression abrupt especially with increased age, renal impairment and concomitant anti folates eg trimethoprim. Withdraw with stomatitis or pneumonitis (seek attention for dyspnoea, cough or fever). Effective contraception for at least 3 months after. Report sore throat, bruising, mouth ulcers, nausea, vomiting or dark urine (blood/liver disorder) Don't take aspirin or ibuprofen over the counter.

What particular side effects are most dangerous with bleomycin and warrant discontinuation?

Progressive pulmonary fibrosis and toxicity. Suspicious x Ray indicates to stop

When should pentostatin be withheld?

Severe rash, neurotoxicity signs.

What specific side effects may occur with vinca alkaloids?

Bronchospam especially with mitomycin c and neurotoxicity - monitor for neuropathy (jaw pain, muscle spasm, constipation) especially vincristine.

How long should chemo prevention for breast cancer continue and what drugs are used?

5 years Tamoxifen for premenaupausal Anastrazole if postmenopausal

How are Menopausal symptoms controlled in women with breast cancer?

No HRT. Paroxetine and fluoxetine if not taking tamoxifen Clonidine, venlafaxine, gabapentin

What problems are associated with treating prostate cancer?

Androgen deprivation therapy. Sexual dysfunction, loss of fertility, hot flushes. Osteoporosis and fatigue. Medroxyprogesterone can be used for hot flushes.

When might bicalutamide be used in prostate cancer?

When patient willing to accept adverse impact on overall survival and gunecomastia to retain sexual function

What issues are there with protein kinase inhibitor use?

Effects on QT interval Monitoring of electrolytes and liver function Contraception Monitor for active infections and blood counts Some have effects on heart or vascular events Some have effects on driving and skilled tasks

What cautions are there with thalidomide and its analogues?

Thromboembolism, second primary malignancy, hepatitis B infection Exclude pregnancy and contraception used.. Monitor liver function

What advice should be given with tamoxifen?

Inform of risk of endometrial cancer and thromboembolism. Report sudden breathlessness, pain in calf of one leg, menstrual irregularities, discharge, pelvic pain or pressure.

What monitoring is required in somatostatin analogues?

``` Signs of tumor expansion Ultrasound of gallbladder 6-12m. Thyroid function Liver function ECG ```